Opp Spring Final Exam

Front 1

1. What is counterstrain?

Back 1

“Relieving spinal or other joint pain by passively putting the joint into its position of greatest comfort.”

“Relieving pain by reduction and arrest of the continuing inappropriate proprioceptor activity. This is accomplished by markedly shortening the muscle that contains the malfunctioning muscle spindle by applying mild strain to its antagonists”

Front 2

2. Who developed counterstrain?

Back 2

Developed by Lawrence Jones, D.O.

Front 3

3. How would you describe counterstrain to a patient?

What type of technique is it?

Back 3

Counterstrain is based on finding tender points associated with somatic dysfunction.

Then positioning patient to eliminate tenderness at the tender point.

Is an passive indirect technique

Accomplished by positioning away from the restrictive barriers

Front 4

4. What is the physiology behind counterstrain?

Back 4

Decrease gamma gain: "...stop inappropriate proprioceptor activity... shortening the muscle that contains the malfunctioning muscle spindle by applying a mild strain to its antagonist." (Jones)

Front 5

5. What is another way to describe the physiology behind counterstrain?

Back 5

This is an indirect technique that employs the Muscle spindle reflex. This reflex responds to rate and changes of intrafusal fiber length.

Hypershortening the extrafusal fibers by bringing the origin and insertion of the muscle mass closer together, decreases the length of the intrafusal fibers and relaxes them. This relaxation phase is followed by a slow return to neutral in order to allow the CNS to reset the gamma gain activity in the spindle to a new lower level.

The end result of counterstrain on the muscle spindle fibers is a turning down of the gamma gain.

Remember: Position of ease, slow return after 90 seconds.

Front 6

6. What are tenderpoints?

Back 6

Are small, discrete, tense and edematous

They are the size of a finger tip and exquisitely tender

They DO NOT radiate pain else where

If a tender point results from a viscerosomatic reflex, tenderness returns within minutes or hours after treatment.

Pressure it takes to blanch a nail bed

Front 7

7. What are the rules for finding and holding the tenderpoints?

Back 7

1. First find the point
2. Gross position
3. Fine tune to 2/3 better
4. Monitor the tenderpoint at all times
5. Do not release it
6. Do not put constant pressure on it

Front 8

8. What are some general rules for utilizing counterstrain?

Back 8

1. Posterior TP’s generally require extension
2. Anterior TP’S generally require flexion
3. Close to the midline – flex or extend
4. The more lateral it is, the more sidebending and less flexion and extension
5. HOLD FOR 90 SECONDS
6. RELEASE SLOWLY
7. Remember the patient remains passive throughout this procedure
8. Return the patient to a neutral position and reassess the tenderpoint
9. Tenderness should have disappeared or should be at least 70% improved

Front 9

9. What are the indications for counterstrain?

Back 9

1. Acute or chronic somatic dysfunctions
2. Somatic dysfunctions with a neural component like a hypershortened muscle
3. As primary treatment or in conjunction with other approaches
4. Somatic dysfunctions in any area of the body

Front 10

10. What are the absolute contraindications for counterstrain?

Back 10

Absence of somatic dysfunction

Lack of patient consent and/or cooperation.

Also, metastatic carcinoma and uncontrolled infection

Front 11

11. What are the relative contraindications for counterstrain?

Back 11

1. Patient who cannot voluntarily relax
2. Severely ill patient
3. Vertebral artery disease
4. Severe osteoporosis

Front 12

12. What are some post treatment reactions that the patients may have?

Back 12

Pain, usually in antagonist muscles several hours after treatment

Self limited and well tolerated

Front 13

13. What counterstrain positions should we look out for?

Back 13

1. Avoid positions that do not relieve pain
2. Avoid positions that cause discomfort, dizziness, panic, neurogenic pain
3. Avoid extreme hyperrotation or hyperextension of the cervical spine
4. Avoid extreme forward bending of the thoracolumbar spine in osteoporosis patients
5. Use caution with RA (ligament instability)

Front 14

14. What is the main motion of the lumbar spine?

Which way are the facet joints facing?

Back 14

Main motion is flexion and extension.

Facets are oriented backward and medial.

Front 15

15. What are the important spinal ligaments?

Back 15

1. Interspinous
2. Supraspinous
3. Ligamentum flavum

Front 16

16. Where does the anterior longitudinal ligament attach and insert?

Back 16

Anterior longitudinal goes from the base of the occiput to the anterior sacrum

Front 17

17. Where does the posterior longitudinal ligament attach and insert?

Back 17

Posterior longitudinal ligament goes from posterior body of the axis down to the sacrum

Front 18

18. Iliolumbar ligament

Back 18

Attaches to the transverse processes of L4 & L5 and the iliac crest

First ligament to become tender with lumbar posture changes, and this pain commonly refers to the groin.

Tender area 1” superior & lateral to PSIS on the crest

Increase stability at the lumbosacral junction

Commonly strained in traumatic injuries

Front 19

19. What does the stork test do?

Back 19

If positive, it indicates a pars interarticularis fracture

Front 20

20. What is spondylosis?

Back 20

Is anterior lipping of the vertebral bodies that are associated with degenerative disc disease.

Front 21

21. What is spondylolisthesis?

Back 21

Bilateral fracture of pars interarticularis with forward slippage of a vertebral body over the one directly below it

Positive vertebral step-off sign (while palpating the spinous processes you feel a forward displacement of that spinous process).

Front 22

22. What is spondyloysis?

Back 22

Fracture of the pars interarticularis of the vertebral arch.

Front 23

23. How do you grade spondylolisthesis?

Back 23

Based on the displacement on the vertebra below

I - 0% - 25%
II - 25% - 50%
III - 50% - 75%
IV - 75% or greater

Front 24

24. Latissimus dorsi

Origin, insertion, innervation, action

Back 24

Origin:
Humerus

Insertion:
T7-12,Iliac crest, Thoracolumbar fascia

Action:
Humerus motion and raises body to arms during climbing

Innervation:
Thoracodorsal nerve (C6-8)

Front 25

25. What are the erector spinae muscles?

Back 25

Iliocostalis
Longissimus
Spinalis

Going from Lateral to medial “I Love Spaghetti”

Front 26

26. Multifidus origin and insertion

Back 26

Multifidus

Origin:
Spinous process

Insertion:
Transverse Process

Front 27

27. Rotatores origin and insertion

Back 27

Rotatores

Origin:
Upper posterior Transverse Process

Insertion:
Lower border of the lamina of the vertebra above it

Front 28

28. Quadratus lumborum

Origin, insertion, innervation, action

Back 28

Origin:
Inf. border of 12th rib and tips of lumbar transverse processes

Insertion:
Iliolumbar ligament & iliac crest

Action:
Extension and sidebending

Innervation:
T12,L1-4 ventral rami

Front 29

29. Iliopsoas muscle

Origin, insertion, innervation, action

Back 29

Composed of psoas major and iliacus

Origin:
T12-L5 vertebral bodies

Insertion:
Lesser trochanter

Action:
Primary flexor of the hip

Innervation:
Femoral nerve
(L1-L3)

Front 30

30. Where are the anterior lumbar tender points?

Back 30

L1 Medial to ASIS

L2-L4 on AIIS in counterclockwise order:
L2:medial to AIIS
L3: lateral to the AIIS; press medially L4: inferior to the AIIS; press cephalad.

L5 is 1 Cm lateral to pubic symphysis on the pubic ramus

Front 31

31. Where are the posterior lumbar tender poitns?

Back 31

The tender point lies at the inferolateral aspect of the spinous process or laterally on the transverse process of the dysfunctional segment

Front 32

32. Where is the iliacus tenderpoint, and what is the indication for treatment?

Back 32

This procedure is appropriate for somatic dysfunction of the iliacus muscle.

The tender point lies 2 to 3 cm caudal to the point halfway between the ASIS and the midline, deep on the side of the dysfunction

Front 33

33. Lumbar spinal cord levels

Back 33

In T-spine and L-spine the nerve roots emerge below the corresponding vertebra

Therefore disc herniation b/w L3 and L4 will effect the L4 nerve root.

Front 34

34. Where does the spinal cord terminate?

Back 34

Between L1 and L2

Posterior longitudinal ligament narrows in the lumbar region

Front 35

35. Where do most disc herniations occur?

Back 35

90-80% of disc herniations occur between L4 and L5 or L5 and S1

Front 36

36. What are the red flags for a potentially serious underlying cause for low back pain?

Back 36

1. Recent significant trauma, or milder trauma age >50
2. Unexplained weight loss
3. Unexplained fever
4. Immunosuppression
5. History of cancer
6. Intravenous (IV) drug use
7. Osteoporosis
8. Prolonged use of corticosteroids
9. Age >70
10. Focal neurologic deficit progressive or disabling symptoms
11. Duration greater than 6 weeks

Front 37

37. What does the straight-leg raising test do?

Back 37

Evaluate for sciatic nerve compression

Positive test will causes pain secondary to sciatic nerve compression (b/c dorsiflexion stretches the sciatic nerve)

Normal leg can be raised to 70-80deg of hip flexion

False positive due to tight hamstrings (will not cause pain when you dorsiflex foot)

Front 38

38. What does the Thomas test do?

Back 38

Assesses for flexion contracture of the hip which is usually caused by Iliopsoas spasm

Negative test patients opposite leg will remain flat on the table

Positive test patients opposite leg will lift off the table

Front 39

39. What does the Trendelenberg test do?

Back 39

Assesses for gluteus medius muscle strength

Patient instructed to lift leg off floor

Positive test patients pelvis falls

Negative test patients pelvis stays level

Front 40

40. Where are the anterior thoracic tenderpoints?

Back 40

T1 is at the bottom of the suprasternal notch

T2 is on the front of the manubrium

Lower thoracic have lateral tenderpoints

Front 41

41. Where are the posterior thoracic tenderpoints?

Back 41

Follows the spinous and the transverse processes

Front 42

42. What is the ECOP definition of counterstrain?

Back 42

An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by an associated myofascial tender point, is treated by using a position of spontaneous tissue release while simultaneously monitoring the tender point.

Front 43

43. What are the characteristics of tenderpoints?

Back 43

Specific discrete areas of local tenderness about the size of a finger tip

No radiation of pain

Usually unilateral, but can be bilateral

Can be found both anteriorly and/or posteriorly

Area of patient’s pain may not be where the physician finds the tenderpoint

Front 44

44. What is a myofascial trigger point?

Back 44

Myofascial trigger point is an hyperirritable point that may refer (trigger) pain and other symptoms both locally and to distant areas.

Autonomic phenomena may also be referred from certain muscles.

Front 45

45. What are the referred phenomena of trigger points?

Back 45

Pain
Increased motor unit activity (spasm)
Hypersecretion
Proprioceptive disturbances

Front 46

46. What is a Chapman point?

Back 46

A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunction or pathology

Front 47

47. What is Jones strain counterstrain?

Back 47

Indirect technique aimed at reducing the gamma gain on a structure (muscle, ligament)

FIND IT
FOLD IT
HOLD IT

Front 48

48. What are the six proposed effects of counterstrain?

Back 48

1. Normalize muscle hypertonicity
-reduce GAMMA gain
2. Normalize fascial tension
3. Reduce joint restriction by decreasing muscle tone
4. Increase blood circulation due to reduction of spasm
5. Decrease pain- normalize thresholds
6. Increase strength- no joint spasm to work against

Front 49

49. An 83 year-old female presents with a 6 week history of cervico-thoracic pain. You notice she has an increased kyphosis in her upper back region. What special conditions and precautions must you consider before treatment?

Back 49

Degenerative discs of cervical spine

Spondylosis

Front 50

50. Where is a common area of pain resulting from whiplash?

Back 50

Trapezius

Front 51

51. Where are the anterior cervical tender points located?

Back 51

The typical cervical tenderpoints are located on the anterolateral tip of the articular pillars of the cervical vertebrae on in the lateral muscle mass.

C1 has an atypical tender point located high on the posterior edge of the ascending ramus of the mandible. This is close to the tip of the transverse process of C1.

The tenderpoint for C7 is located on the superior surface approx 1 inch lateral to the medial end of the clavicle.

Front 52

52. Where are the posterior cervical tenderpoints located?

Back 52

The posterior cervical tenderpoints are generally located on the interspinous ligaments between the spinous processes or slightly medial or lateral to them, or on the articular pillars more laterally.