Quarter One Basics of Osteopathic Medicine Osteopathic Medicine o A complete system of medical care with a philosophy that combines

s the needs of the patient with the current practice of medicine, surgery and obstetrics, that emphasizes the interrelationship between structure and function and that has an appreciation of the bodys ability to heal itself Osteopathic Philosophy o A concept of health care supported by expanding scientific knowledge that embraces the concept of the unity of the living organisms structure and function Four Osteopathic Principles o The person is a unit of body, mind and spirit o The body is capable of self-regulation, self-healing and health maintenance o Structure and function are reciprocally interrelated o Rational treatment is based on an understanding of the above principles Mission Statement of A.T. Still o To find health should be the object of the doctor. Anyone can find disease. Osteopathic Physician o A person with full, unlimited medical practice rights who has achieved the nationally recognized academic and professional standards within their country to practice diagnosis and treatment based upon the principles of osteopathy Somatic Dysfuntion o Impaired or altered functioning of related components of the somatic system: skeletal, arthrodial, and myofascial and related vascular, lymphatic and neural elements Disrupts the unity of body, mind and spirit Impairs the bodys capability for self-regulation, self-healing and health maintenance Disrupts the reciprocal interrelationship between structure and function Rational treatment requires considering the significance of the impact of somatic dysfunction in the individual patients ability to maintain health and wellness o Acute: immediate or short-term impairment or altered function Characterized by: vasodilation, edema, tenderness and pain o Chronic: impairment of altered function of related components of the somatic system Characterized by: tenderness, itching, fibrosis, paresthesias, tissue contraction TART o Tissue texture change: palpable evidence of disturbed physiology in the paraspinal tissues o Asymmetry: difference in position of body landmarks o Restriction of Motion: resistance to movement in one direction & relative freedom of movement in the other direction o Tenderness: pressure applied & patient reports discomfort, flinches or has a facial change HIPROT o History: ask questions o Inspection: observation o Palpation: hands on o Range of Motion: active, passive o Other Tests Barrier End Feel Range of Motion o Active motion permitted during active use of muscles o Passive motion permitted with passive movement o Accessory Movement small involuntary movement independent of muscle action, affects voluntary range of motion o Glides movements of one surface in relation to another without rotational movement Motion Barriers o Limit to motion in defining barriers the palpatory end-feel characteristics are useful

Restricted Barrier: will alter the expected barrier end feel for a given structure Assessed by motion testing May have associated TTA, asymmetry and tenderness Boney Anatomic o Limited by bone, hard o E.g. elbow Tendonous Anatomic o Limited by the tension of the tendon, elastic o E.g. ankle dorsiflexion Ligamentous Anatomic o Ligaments prevent excessive glide of the joint, firm and abrupt o E.g. Anterior/Posterior Cruciate (b/w femur or tibia and knee) Soft Tissue Anatomic o Stops secondary to tissue approximation, soft o E.g. feeling biceps when flexing/extending Empty End Feel o Guarding, patient voluntarily limits the motion secondary to pain Ideal Postural Alignment Anterior/Posterior: levelness of eyes, ears, shoulders, scapula, iliac crest, great trochanters o Coronal Plane o Look for scoliosis Lateral View: plumb bob through: ankle, mid knee, greater trochanter, mid shoulder, ear o Sagittal Plane o Look for increased/decrease spinal curvature Movement o Observe walking and look for abnormal gait o Limp, lean, one leg/foot turns out, space of arm from body, etc Tissue Texture Abnormalties A palpable change in tissues from skin to periarticular structures Includes: bogginess, thickening, stringiness, ropiness, firmness, increased/decreased temperature and moisture Is any combination of the following: vasodilation, edema, flaccidity, hypertonicity, contracture, fibrosis o As well as, itching, pain, tenderness and paresthesias Tests for Tissue Texture o Red Reflex drag fingers along paraspinal muscles, watch for areas that remain red longer after other areas resolve o This is hyperemia the skin has been stimulated by friction o Reflex is great in degree and duration in an area of acute somatic dysfunction as compared to an area of chronic somatic dysfunction o Commonly observed in the paraspinal area Screening for Spinal Dysfunction Springiness Test o Demonstrates Type I physiologic Motion: thoracic and lumbar Axes and Cardinal Planes of Motion Planes and Axes of Motion o Coronal: Sidebending o Sagittal: motion around transverse axis, flexion and extension o Transverse: motion around a vertical axis, rotation Spine: three columns o One of vertebral bodies and discs o Two of articular facets and processes Spinal Mechanics o Simple One plane o

 In thoracic and lumbar, occurs with flexion and extension Compound Multiple planes Links sidebending and rotation Sagittal plane position dictates the motion pattern that occurs Vertebral Anatomoy, Physiologic Spinal Motion, Rule of 3s Vertebrae: Review Structures o Vertebra Prominens: C7 o Scapular Spine: T3 o Inferior Angle of Scapula: T7 o Iliac Crests: L4-Male, L5-Female o Sacral Dimples/Base: L5 not in everyone Neutral Mechanics o Weight bearing occurs through the bodies and discs o Posterior columns are relatively non-functioning Nonneutral Mechanics o Occurs when sagittal plane motion exceeds the neutral range o Posterior elements and facets dictate motion Principle 1 Compound Motion o Neutral, Type I, occurs in the usual upright posture o With sidebending, rotation should occur in the opposite direction o Occurs in three Principle 2 o Nonneutral, Type II, signigicant sagittal plane involvement, flexion or extension beyond normal range o Rotation must precede sidebending in the same direction o Single segment These are all normal motions Rule of Threes o T1-3, spinous process at same level o T4-6, spinous process level down o T7-9, spinous process 1 level down o T10 1 level; T11 level, T12 same level Spinal Somatic Dysfunction Neutral Only record asymmetric motion Done in the prone position Rotation Sidebending Flexion/Extension normal Nonneutral Done in an upright position Rotation and Sidebending in same direction Flexion/Extension not normal o Passive and Active ROM Passive the patient is not helping Active the patient does the movement Unit 2: Osteopathic Manipulative Techniques I review techniques in the KM OMT Dosing Limited by patients ability to respond; must take into account for the patients body changes OMT Indications Somatic Dysfunction: the indication

 To enhance homeostatic mechanisms, using the musculoskeletal system OMT Contraindications Soft Tissue skin disorders, acute muscular strains, ligamentous, tendon sprain/inflammation, bone fractures, infections in organs, deep venous thrombosis HVLA unstable anatomy at or near the somatic dysfunction, patient refusal, joint infections, severe muscle spasm, sprain, osteoporosis Muscle Energy infection or tear in muscle, fracture or dislocation in joint, instability of cervical spine, joint swelling, unresponsive patient Characteristics of Techniques Direct o Restriction taken to restrictive barrier, in one or more planes of motion o Use activating forces to carry the dysfunction through the barrier o Soft tissue, Articular, LVMA, Myofascial Release, Muscle Energy, HVLA Indirect o Restriction taken away from restrictive barrier, move joints/tissues in direction of ease o Release due to inherent forces, tensions gradually relax o Muscle Counterstrain; Joint Capsule Balanced ligamentous, functional technique Definitions OMT therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that have been altered by somatic dysfunction Homeostasis maintenance of static or constant conditions in the internal environment; the level of well-being of an individual maintained by internal physiologic harmony that is the result of a relatively stable state or equilibrium among the interdependent body functions Somatic Dysfunction impaired of altered function of related components of the somatic system: skeletal, arthrodial and myofascial structures and their related vascular, lymphatic and neural elements Somatovisceral Reflex localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures Viscerosomatic Reflex - localized visceral stimulation producing patterns of reflex response in segmentally related somatic structures Somato-somatic Reflex muscle spasm around spine causes increased somatic input to spinal cord which in turn causes increased input back to the muscle Viscero-visceral Reflex diseased organ causes increased afferent sympathetic input to spinal cord which in turn causes increased efferent input back to that organ or another organ Spinal Facilitation Maintenance of a pool of neurons in a state of partial or subthreshold excitation; less afferent stimulation is required to trigger the discharge of impulses The Segment a spinal segment which through somatic or visceral dysfunction has become hypersensitive and consequently hyper reactive o Produces state of high sympathetic activity (sympathotonia) o Susceptible to input from all body parts from emotions to the viscera o Produces chaos in the spinal cord and interrupts normal functioning o Increased tone from a diseased organ is sent to the spinal cord level of innervations o Somatic nerves are stimulated at that level and increased muscle tone is palpable Somatic Relationships to Sympathetic Function T1-4: head and neck T1-6: heart and lungs T2-8: upper extremity and esophagus T5-9: upper GI system T10: kidney T10-11: middle GI system; ovaries and testes T11-L1: upper ureter T11-L2: lower extremity T12-L2: bladder, lower GI system, uterus and prostate

Counterstrain A system of diagnosis and treatment that considers the dysfunction to be a continuing, inappropriate strain reflex; fixed by specific directed positioning about the point of tenderness to achieve the desired therapeutic response o To treat the strain, it is countered by reintroducing the original strain (point of ease) Tenderpoints: small, discrete hypersensitive areas w/in the myofascial structures that result in localized pain Locations: Midline (on spinous process or inferolateral) or Lateral (on transverse process) o Upper Pole L5: b/w L5 spinous process and PSIS Multifidus muscle, treat s if is it transverse process Postions o Midline pure extension o Inferolateral rotate away, sidebend away, extend (always rotate towards with lumbars) o Transverse rotate towards, sidebend away, extend Soft Tissue Technique (Direct) Use lateral stretching, linear stretching and deep pressure to monitor tissue response o Traction/stretching, kneading, inhibition, can combine several Balanced Ligamentous (Indirect) Rotate Towards, Sidebend Towards, Extend/Flex towards direction Muscle Energy (Direct) Patients muscles are actively used on request from a controlled position, in a specific direction Indications: specific motion restriction, joint motion loss or muscle hypertonicity Contrations: shortening and/or development of tension in muscle o Concentric: muscle contraction results in approximation of attachments o Eccentric: legthening of muscle during contraction There are three common types of muscle contractions used o Isometric: increase in tension w/out change in muscle length Force of doctor and patient equal; sustained gentle pressure Origin and insertion are maintained in a stationary position and muscle is contracted against the resistance o Isolytic (Eccentric): contraction against a resistance while forcing the muscle to lengthen Force of doctor greater (through restrictive barrier) Muslce is lengthened while the patient is contracting Used for treatment of fibrotic or chronically shortened myofascial tissues o Isotonic: approximation of muscle origin and insertion w/constant muscle tension Force of doctor much less than patients (very gentle) With gentle contraction against the agonist muscle, there is a reflex relaxation of the muscles antagonistic group Used to lengthen a muscle shortened by cramp or acute spasm Patien contracts *TOWARDS* the barrier Technique: rotate, sidebend and flex/extend away (except for isotonic) Success: accurate diagnosis, patient at initial point of resistance, unyielding counterforce from patient, patient is repositioned at new restrictive barrier HVLA (Direct) A rapid, therapeutic force of brief duration that travels a short distance w/in the anatomic range of motion of a joint, that engages the restrictive barrier in one or more planes of motion to elicit release of restriction Engage restrictive barrier, and then carry dysfunction component through the barrier, using force Indications: Articular Somatic Dysfunction (firm distinct articular barrier, abrupt or hard end feel) Apply enough force for a response but not to overwhelm patient Treatment Sequence Know TART, HIPROT, etc Plan of Intervention: what doesnt move? What direction will it move? How doesnt it move? Consider all three planes of motion

Quarter Two Sacral Dx Screening Tests are first o Backward bending: positional asymmetry of the bases are compared Positive: if the findings become more asymmetric in the sphinx position The positive side is then posterior, the other side is NOT anterior o Spring Test: springing on the lumbosacral junction Positive: if there is very little motion or the movement is painful o ASIS compression: apply posterior pressure on one ASIS while stabilizing the other Test both sides Positive: named for side with restricted motion o Four Pole Motion Test: to find various motion Push base anterior and inferolaterally, push ILA anterior and superolaterally Record positive/negative/mild motion This is to infer the axis of sacral motion o Standing/Seated Flexion: for dysfunctions affecting the sacrum/sacroiliac joint Diagnoses o Bilateral Sacral Flexion Tissue texture change over the SI joint Negative spring test Deep sulci, sacral base anterior, sacral apex posterior (all bilaterally) ILA is level, motion testing restricted Tight sacrotuberous ligaments o Bilateral Sacral Extension Tissue texture change over the SI joint Positive spring test Shallow sulci, base posterior, apex anterior (Bilaterally) Base motion testing restricted ILA level Sacrotuberous ligaments relaxed o Sacral Margin Posterior (Vertical axis rotation) Positive Backward Bending Test, ILA level superior/inferior Anterior side: deep sulcus, base anterior, ILA anterior, relaxed ligament, + motion Posterior side: shallow sulcus, base posterior, ILA posterior, tight lig, - motion o Sacral Rotation on Same Oblique Axis (For right side) R base anterior, R sulcus deep, Backward Bending is negative Good motion at right sacral base, poor motion at left ILA L ILA is posterior and slightly inferior, L ligament is tight o Sacral Rotation on Opposite Oblique Axis (Findings for right) Right base posterior, right sulcus shallow Backward Bending is Positive Poor motion at right base, good motion at L ILA L ILA is anterior and slightly superior, L lig loose o o Unilateral Sacral Flexion (Sacral Shear) (for Left side) Tissue texture over SI joint, negative backward bending test Left base anterior, left sulcus deep Left ILA very inferior, slightly posterior ASIS/seated flexion positive on left Motion testing of left ILA is restricted o Unilateral Sacral Extension Tissue texture over SI joint, Positive backward bending test Right base posterior, right sulcus shallow Right ILA very superior and slightly anterior ASIS/seated flexion positive on the right Motion testing of Right base is restricted Sacral Tx; see the Q2 syllabus, these are the techniques listed in the notes Dont forget all the BLT stuff where you stick your hand under the butt, I mean sacrum, of your patient just move with the dysfunction (i.e. if its anterior push anteriorly, etc) Bilateral sacral flexion Kimberly 194 C Bilateral Sacral Extension Kimberly 199 C

Sacral Margin Posterior Kimberly 203 C Sacrum Same rotation/same axis Kimberly 207 E Sacrum Rotation/Opposite Axis Kimberly 212 C Unilateral Sacral Flexion (Sacral Shear) 213 A, 214 B Unilateral Sacral Extension 216 A Pelvic Dx Standing Flexion test: for finding dysfunctions originating in the pelvis or lower extremity o Place thumbs on inferior slope of PSIS, follow forward bending movement o Positive Test: side demonstrating most cephalad terminal motion o Three possibilities: pelvis/sacral dysfunction, contralateral tight hamstrings, ipsilateral tight hamstrings the latter two are a false negative and positive, respectively Seated Flexion test: find sacral/pelvic dysfunctions w/o the lower extremity factor o Same technique as standing flexion test o ASIS compression test see under sacral diagnosis Diagnoses o Innominate Rotation all is rotated in one direction, posterior with hip flexion and anterior with hip extension, dysfunction on side positive for flexion tests Innominate Rotation Anterior Side ASIS is anterior and inferior, side PSIS is superior and posterior Complaints: SI pain, ipsilateral hamstring tightness and spasm, sciatica Tissue texture changes: ipsilateral ILA and iliolumbar ligament tightness Innominate Rotation Posterior Side PSIS posterior and inferior, Side ASIS superior Complaints: SI, Inguinal or groin pain b/c of rectus femoris dysfunction, and medial knee pain due to Sartorius dysfunction Tissue texture changes: at ipsilateral sacral sulcus and inguinal ligament o Innominate Shears all is shifted up or down, no rotation, small amt of glide occurs with abduction or adduction, dysfunction on positive flexion test side Innominate Shear Superior Side Iliac crest, ASIS and PSIS superior Complaints: SI or pelvic pain Tissue texture changes at the ipsilateral SI joint and ipsilateral pubes Innominate Shear Inferior Side Iliac crest, ASIS and PSIS inferior Complaints and tissue texture changes same as superior shear o Innominate Flare all is rotated medially or laterally around a vertical axis, inflare occurs w/internal hip rotation and outflare occurs w/external rotation, positive flexion side Inflare and Outflare Complaints: pelvic or SI pain Tissue texture changes: muscular tension anteriorly with an outflare, and posteriorly with an inflare o Pubic Shears ASIS and PSIS are equal, but pubes are not, found on positive flexion side Superior, generally very painful o Pubic compressions bilateral pubic tenderness, may be reflexive of L5 dysfunction Pelvic Tx Anterior Rotation 222B Posterior Rotation 218C Superior Shear 225A Inferior Shear Im pretty sure its similar to 226A Inflare 226A Outflare 227A Superior Pubic Shear 187A Inferior Pubic Shear 189A Anterior Pubic Shear 192A Pubic Compression 191A Sacral Mechanics Dont forget: body unity, structure/function, self-healing/self-replacing and that treatment is the application of these principles! Landmarks o Base Left, right or both; anterior/posterior; pure landmark

Sulcus right, left or both; deep/shallow; relationship b/w it and PSIS; affected by innominate dysfunction; mixed landmark o ILA right, left or both; anterior/posterior; superior/inferior; pure landmark Development o Embryonic plate to primitive streak to Hensens node o Segmentation, then differentiation, then craniocaudal ossification o Postnatal asymmetry of the adult: its articulations occur through growth and ossification of is occurs when strains are present Lumbar sacralization o Lumbosacral synostosis; lumbosacral articulation o This is when L5 becomes part of the sacrum Sacral Lumbarization o This is when S1 resembles a lumbar vertebrae Nerves o S1-S4, and S5 (para and sympa we know this from anatomy!) o Sciatic nerve ventral rami of L4-S3, exits through greater sciatic foramen With variation can cause great pain Myofascial Structures piriformis, coccygeus, iliacus, psoas, multifidus, gluteals, erector spinae hamstrings, abdominals o Function there are no direct muscular attachments b/w the sacrum and ilia Motions result from the actions of the muscles, the sacrum simply couples the forces of the lower extremity and axial spine Sacrum and SI joints relieve twisting on the pelvic ring Motion result of regional mechanical forces o About an oblique axis result of motion occurring about a vertical and transverse axis (aka an AP axis) Left or right o Transverse axis Superior, middle or inferior o Vertical axis o Anterior/Posterior Axis o Dynamic motion of sacrum and pelvis occurs in gait o Gait Shifting one leg causes oblique axis ipsilaterally to shift (stance leg) Contralateral leg is in swing phase Toe off, innominate anteriorly rotated, carry sacral base anterior Heel strike, weight begins to shift and then switch axes o innominate posterior So, sacrum moves through its physiologic motion: L/L to neutral to R/R back to neutral and so on and so forth o Breathing Spinal curves flatten with inhalation Spinal curves increase with exhalation Lateralization; (see above for explanations) Standing Flexion Test Seated Flexion Test ASIS Compression Test Backward Bending Test Springing Test Counterstrain; See Q2 packet for additional explanations AL1 medial ASIS, push medial to lateral AL2 medial AIIS, push medial to lateral AL3 lateral AIIS, push lateral to medial AL4 inferior AIIS, push inferior to superior AL5 anterolateral pube, push anterior to posterior Iliacus (psoas, iliopsoas) 7 cm medial to ASIS, and deep, palpate anterior to posterior Pectineus (inguinal) lateral aspect of pubic tubercle at attachment of inguinal ligament and pectineus muscle Gluteus minimus anterior inferior attachment of g. minimus at superior femur LPL5 2 cm inferior to PSIS Piriformis midway b/w the ILA and the trochanter High ilium 2 to 3 cm lateral to PSIS at iliolumbar ligament attachment on the iliac crest G. Medius (Lateral PL3 and PL4) upper, outer portion of the g. medius muscle o 1 medial superior medial gluteal o

o 2 lateral lateral gluteal G. Maximus (MPSI, FISI) push anteromedial into ILA at a point 10 cm inferior and slightly lateral to the PSIS Coccygeus (HIFO) lateral sacrococcygeal junction at the attachment of the coccygeus muscle L5 Sacral Torsion normal physiologic coupled mechanics b/w the sacrum and L5 involves rotation in opposite directions (aka: torsion) o Forward Torsion: LSR on LOA w/L5 NSLRR or RSR on ROA w/L5 NSRRL o Backward Torsion: RSR on LOA w/L5 NSRRL or LSR on ROA w/L5 NSLRR When L5 rotation in the same direction as the sacrum, it is termed maladapted or uncompensated Cervical Mechanics Functions of the C-spine o Protects spinal cord, protects lower part of medulla, allows for orderly exit of medulla and high mobility, transfers weight of the head from a 2-column support at the OA to a 3 column support at C2 & distally Cervical Nerves st o 1 exits b/w the occiput and atlas, each goes above the vertebrae, etc o C8 is b/w C7 and T1 Cervical Musculature o Rectus capitus major and minor, obliquus capitus superior and inferior (suboccipital ) Nerve reflex keeps head level when neck rotates/side bends o Sternocleidomastoid: tells CNS where the head is in relationship to the body (dizziness) o Transversospinalis: E and R head to opposite side o Semispinalis capitus: locates articular column, E and R to same side o Longus coli: flexor of the cervical spine on anterior surface st nd o Anterior/Middle scalene: attaches to 1 rib; Posterior scalene: attaches to 2 rib Typical Cervical Vertebra: C2-7 (the inferior division) o Spines bifid, C7 spine is the longest (vertebral prominens) o Body is saddle shaped on superior surface, lateral contours have uncinate processes that fit in the inferior surface of cervical vertebra above joints of Luschka o Joints of Luschka: guides motions (especially side bending) to allow SB and rotation to the same side Non-synovial joint: no rheumatoid arthritis, but it can degenerate and hypertrophy Articular processes fit together and form the R & L articular processes o Transverse Processes: cradles a cervical nerve, which passes posterior to the vertebral artery (the artery is in the transverse foramen) Disk Herniation: posterior herniation prevented by posterior longitudinal ligament Nerve Root Compression: mostly occurs from degeneration of joints of luschka and osteoarthritis of synovial joints at intervertebral foramen Vertebral artery o Backward bending, sidebending and rotation all to the same side place vascular flow at risk on the opposite side of the neck Palpation o First find articular processes which form the R and L articular columns (2 to 3 cm from the spinous processes) o At the lateral edge of the semispinalis capitus muscle Cervical Diagnosis Motion of typical Cervicals (C2-C7) o Sidebending and rotation is to same side o Extension and flexion can be up to 45 degrees, make up for 50% of the motion o Diagnosis At articular process, move the lateral aspect medially from each side to see which way it likes to sidebend, and push from posterior to anterior to see which way it likes to rotate Flex and extend and name for preference Superior Cervical Divison: OA and AA joints o OA joint: convex occipital condyle facets fit into atlas Hypoglossal nerve is in hypoglossal canal and vagus is in jugular foramen Diagnosis Flexes 45 degrees, extends 45 degrees; SB and R in opposite directions Screening test: shelf method (pull base of skull superiorly on each side) Use V method to sidebend, rotate and check flexion/extension Name for way it likes to go o Atlas (C1) No spinous process, anterior and posterior arch w/tubercle No vertebral body, large lateral mass w/concave superior articular facets

Long transverse processes anterior to mastoid process of temporal bone; no trough for nerve Transverse Ligament: attaches to the tubercle on medial side of each lateral mass Secures odontoid process b/w it and anterior arch (AO joint) o Axis (C2) Has a vertebral body w/superior part extending cephalad as the odontoid process st 1 spinous process in cervical area, no disk b/w the atlas and axis o Atlas + Axis = four Joints 1 and 2: right and left AA synovial joints, this is whats manipulated Convex inferior facets of atlas sit on convex superior 3 and 4: alanto-odontal joints Anterior b/w dens and anterior arch of atlas and posterior b/w dens and transverse ligament of atlas For a rotational pivot AA movement: only rotation, 45 degrees in each direction Diagnosis: use V to stabilize and name it for the way it likes to go Cervical Treatment General Aspects o Patients respond better with: heat, hydration, low pH o Treatment numbers in Kimberly Manual 39A, 40A, 40B, 47A, 69B, 70A, 71B, 72D, 73A, 74B, 74C, 75B, 76A, 78A, 79B, 79C, 80D, 81A, 82B HVLA o If more than one plane is involved, all are involved; direct barrier should have slight springiness, if it is painful, all 3 planes arent localized: Do not thrust o Thrust is about 1/8 to at the barrier o If you try to put R and SB both to the barriers, the localization will be lost o Upper typicals (C2 and 3) respond better to the rotational method Rotate to opposite side, and sidebend up to lock out lower vertebrae o Lower typicals: respond better to sidebending method Sidebend to opposite side, then rotate back to lock out upper vertebrae o OA sidebent left, rotated right Contact right posterior occiput posterior to, but no on mastoid process Cradle head w/left hand move to opposite sides, adjust flexion/extension HVLA thrust medially, anteriorly and superiorly o AA left rotation Cradle head in hands, contact left lateral mass of atlas w/lateral margin of left index finger Rotate head to opposite side, use SLIGHT flexion/extension if needed Apply HVLA rotational thrust through lateral mass Muscle Energy o For success: consider indications and contraindications, set up favorable to you, soft tissue preparation Precise localization needs, adjust sagittal plane first for Type II dysfuction, good patient instructions, good relaxation b/w efforts o OA Flexion Support posterior arch, use other hand to induce extension of occiput Have patient nod head against resistance, relax and then move to new barrier o AA left rotation Contact both lateral masses of atlas with margin of index fingers Extend head over fingers, rotate AA (right) to barrier Have patient turn head left against resistance Relax, move to new barrier o OA sidebending Left, rotation right Support arch with V hold Grasp head, adjust flexion and extension, sidebend occiput right and rotate left to engage barrier Have patient turn head right against resistance or look right Relax, move to new barrier Indirect method Special Tests Cervical DeKleyns Test: patient is extended and rotated to assess vascular adequacy before manipulation Spurlings Test: for cervical compression Cervical Counterstrain Anterior Cervical

AC1: posterior surface of ramus of mandible, push posterior to anterior & midway b/w ramus and mastoid process on transverse process of C1, push lateral to medial SARA o AC2-6: anterior surface of transverse process FSARA; AC3 may sometimes need ESARA o AC7: 2 cm lateral to the medial end of the clavicle (Clavicular head of the SCM) FSTRA o AC8: Medial end of clavicle (Sternal head of SCM) FSARA Posterior Cervical o PC1/inion: optional, usually right or left side protuberance, can be midline FSTRA o PC1: 3-4 cm lateral to midline in muscle mass (lateral) & posterior arch of C1 (medial) E, maybe SARA o PC2: 2 cm lateral to midline below occiput (lateral) & on C2 spinous processes/just lateral (medial) E, maybe SARA o PC3: on inferior aspect of C2 spinous processes or just lateral FSARA, sometimes may need ESARA o PC4-7:on inferior aspect of C3-6 spinous processes of the named vertebrae above ESARA o PC8: on inferior aspect of C7 spinous processes or just lateral (Medial) & on posterior tip of transverse process deep in trap muscle belly (lateral, optional) ESARA Quarter Three Cranial Anatomy Considerations Cranial Landmarks and Structures o Anterior Landmarks Nasal bones, intranasal suture, nasion, glabella, metopic suture (in frontal bone), inferior concha, superior orbital foramen, inferior orbital foramen, maxilla, anterior nasal spine, upper/lower midincisional lines, superior/inferior alveolar processes o Lateral Landmarks Zygoma (sutures: frontozygomatic, sphenozygomatic, zygomaticotemporal), Zygomatic arch, TMJ, temporal process of the zygoma, coronoid process of the mandible, external auditory meatus, parietal notch, mastoid process of the temporal bone, asterion (occiput + parietal + mastoid portion of the temporal bone), inion, sphenoid (sutures: sphenosquamous, frontosphenoid, sphenoparietal), pterion (frontal + parietal + sphenoid + temporal) o Superior Landmarks Bregma, Coronal suture, sagittal suture o Posterior Landmarks Lambda, Lambdoidal suture, Wormian bone o Inferior Landmarks Basion, Opisthion, Inion, Occipital condyles o Le Fort Fractures Type I: through the inferior nasal septum, maxillae above the teeth and zygomaxillary suture Type II: through the bridge of nose, lacrimal area, the inferior orbital foramen and zygomaxillary sutural area Are more pyramidal in shape and involve in inferior orbital rim Type III: through the nasofrontal, frontomaxillary suture, medial wall of the orbit, ethmoid bones, floor of the orbit, lateral orbital wall, zygomaticofrontal junction, zygomatic arch Moves intranasally through the base of the ethmoid, vomer and ptergoid plates Called a craniofacial dissociation, may be CSF rhinorrhea present Basic Anatomy of the Bones *NO COMPOSITES LISTED (THE PARTS OF THE BONES) o Basicranium Cartilaginous neurocranium is made up of the inferior portions of the temporal, sphenoid, occipital bones and the midline nasal septum Ethmoid is the only bone of the base entirely of endochondral origin o Sphenoid Bone From the midline basilar cartilage and membranous vault Has a body and lesser/greater wings, also pterygoid processes

Articulations: both parietals, temporal and palatines, the frontal ,vomer, ethmoid and occiput bones Functions Anterior, middle and posterior cranial fossa, part of the orbit Houses the pituitary Allows passage of cranial nerves Directs movement of the bones of the face o Occipital Bone In four parts at birth Articulations: both parietals and temporal, sphenoid and atlas Functions Forms posterior cranial fossa, posterior attachment for RTM Supports brainstem Primary motion influence on temporal and sacrum Fascial Relations: midline dura, posterior dural septa, cervical & paravertebral fascia o Temporal Bone Derived from the midline basilar cartilage and intramembranous ossification Functions of the Squamous Portion Completes enclosure of the tympanic membrane Forms lateral portion of the calvarium and the cranial articulation for the mandible Provides attachment for the temporalis and master muscles The Petrous Portion: formed in cartilage, ossifies from multiple centers Functions of the Petrous Portion Transverse buttress of the cranium Encloses, stabilizes otovestibular organ and the carotid artery Attachment for the tentorium, aponeurosis of the pharynx and the styloid process and ligaments Forms the lateral part of the jugular foramen Types of functional articulations Petrobasilar harmonic, tongue in groove Petrojugular gomphosis Occipitomastoid irregular Squamous squamous Sphenotemporal SS pivot Temporal mandibular diarthrosis Bone Relations All cranial nerves except for I, II and XII Brain, meningeal septa, foregut-Eustachian tube and major vessels of the brain Vulnerable Structures Vestibular apparatus, labyrinth, Eustachian tube, TMG, temporal bone imbalance, temporal bone and dura, petrobasilar portion, glenoid fossa and styloid process, CN III, IV, VI, CN V1, Gassarian ganglia, CN IX, X, XI, petrosphenoid ligament, tentorium cerebella, Internal auditory meatus, meckels cave, jugular foramen Reciprocal Tension Membrane o Component of the Primary Respiratory Mechanism o Unit of function composed of spinal and cranial dura, allows and limits motion o Attaches to bones of the vault, holding them together w/constant tension o Allows for change of shape of the vault, while maintaining constant volume Anatomy o Dural Membranes though membrane in two layers Endosteal (outer): internal periosteum of the cranial bones, contiguous through the sutures and foramen to external periosteum Meningeal (visceral): surrounds brain and spinal cord, provides tubular sheaths for cranial nerves which continues as the epineurium once outside the skull

Falx Cerebri, Tentorium Cerebelli, Falx Cerebelli Main Poles of Attachment (RTM) Anterior/superior: crista galli Anterior/inferior: clinoid processes of sphenoid Lateral: petrous ridges of temporal bones and mastoid angles of parietals Posterior: internal occipital protuberance and transverse ridges o Spinal Dura Endosteal dura blends with the Peri-Cranium at the Foramen Magnum Meningeal Dura descends inferiorly to form a loose sheath around the spinal cord Attachments: circumference of the foramen magnum, posterior surfaces of C2 and C3, nd posterior surface of 2 sacral segment, descending to the sacro-coccygeal ligament The CORE LINK! Btw the cranium and sacrum Pathologic motion is the cranium is reflected in the sacrum, and vice versa Functions o Inhalation Tentoria: flatten and move anterior, petrous ridges move superiorly/anterolaterally Falx Cerebri: shifts slightly forward following the arc of its sickle Lowers inferiorly, curves under (posterior) at crista galli Greater wings of sphenoid: lateral, anterior and inferior movement Lateral angles of occiput: lateral, anterior and inferior movement Spinal Dura: pulled superiorly and S2 This moves the sacral base posterior and superior Straight Sinus an dsutherland Fulcrum: shift anterior Venous sinuses: move from a V-shape to a more ovoid shape for increased drainage o

Sutherland Fulcrum: point of function located in the region of the straight sinus Suspended: moves but stays on RTM Automatic: with the motion of the RTN Shifting: moves up and down the straight sinus Fulcrum: point of rest around which motion occurs (SUSPENDED AUTOMATIC SHIFTING FULCRUM) o Exhalation: wasnt covered, but is simply all opposite! Strains of the RTM o Will distort in proportion to traumatic force o Due to the inelasticity of connective tissue o Force will cause change according to direction and amount if resilency is exceeded o Sutherland Fulcrum will accommodate to rebalance the tensions o Alterations/somatic dysfunctions can by palpated In dura: membranous articular strains In Body: ligamentous articular strains Clinical Application including Entrapment Neuropathy and Techniques Vulnerable points of Cranial Nerve Entrapment Neuropathy o Neuropathies and Type Neurapraxia: Sunderland 1 injury Transient physiologic block or conduction loss w/out axonal change, recovery is quick Pain, no or minimal wasting, numbness, proprioception affected Axonotemesis: Sunderland 2 and 3 injuries Disruption of axon and myelin sheath motor w/architecture preserved, regeneration occurs at 1-3 mm/day Pain, sensory and motor paralysis, atrophy after 6 weeks, sympathetic loss Neurotmesis Disruption or transaction, scarring, prolonged severe compression, neuroma formed, recovery in months, but needs surgery No pain except at neuroma, muscle wasting, complete sensory/motor/sympa loss o Cranial Nerve: I (olfactory) How it becomes entrapped: excessive medial compression of ethmoid notch or orbital plates, unilateral or bilateral trauma How to diagnose/test for this: Loss of Smell, so test smell o Cranial Nerve: II (Optic)

How it becomes entrapped: shift of greater wings of sphenoid result in hyperopia and shift backwards may result in myopia How to diagnose/test for this: Loss or distortion of vision, diplopia, test visual acuity and fields Evaluate Orbit Bones: frontal, maxillary, palatine, lacrimal, ethmoid, zygoma, sphenoid Common Disorders: Cephalgia, retro-orbital pain, visual field defect, myopia, somatic dysfunction of head, cervical, thoracic, lumbar or sacral areas Cranial Nerve: III, IV, VI (for motor-eye motions) How it becomes entrapped: III: at superior orbital fissure, as it crosses the attached border or the tent in the cavernous sinus IV: as it pierces the free border of the tent and petrous ridge of the temporal VI: petrosphenoid ligament, and at the fibroosseus tunnel by the dorsum sella How to diagnose/test for this: double vision, strabismus, accommodation, test range of eye movements, Test bones of orbit Common Disorders: trauma (strabismus, paralysis, plagiocephaly, somatic dysfunction) Cranial Nerve: VII (Facial) How it becomes entrapped: dural sheath is heavy at the internal acoustic meatus and vulnerable to shifts in position of the occiput or temporal bone; local edema can result in compression neuropathy at the styloid foramen; organs of equilibrium are vulnerable to alterations in temporal bone position How to diagnose/test for this: paralysis, weakness, no/poor taste; test facial expression and taste, external rotation of temporal and sphenoid bones Function losses: CN VII and VIII, peripheral motor, hyperacusis, some taste and salivation, peripheral motor only Common Disorders: Facial Palsy Pathways cross, so the other side is effected Can be central (supranuclear) or Peripheral (infra-nuclear Bells) Cranial Nerve: VIII (Vestibulocochlear) How it becomes entrapped: Same as for the Facial Nerve (see above) How to diagnose/test for this: hearing deficit, tinnitus, vertigo, otitis media and interna, evaluate temporal and sphenoid bones Common Disorders: Vertigo, hearing loss, trauma Cranial Nerve: V (Trigeminal) *This nerve is Mixed* How it becomes entrapped Rectus Capitus Posterior minor: traction of the myodural bridge and C1-3 and C2-3 Entrapment of C2 or C3 by trapezius and/or other muscles/fascia Nociceptive influence from zygapophyseal joints, IV discs, tendonitis and dural traction Influence from altered firing patterns from CN V, X or XI How to diagnose/test for this: anesthesia, trigeminal neuralgia, plagiocephaly; evaluate temporal (petrobasilar) and sphenoid Places where pain occurs TMJ: treat stylomandibular ligament and both bones affected Lesser occipital nerve: from ventral rami C2/C3, palpable at occipital grove o Pain pattern different from greater occipital and auricular nerves Rectus Capitus Posterior Minor and Occipital Nerve pathways: attach to dura and pulls it away, causing pain during cranial extension Greater Occipital Nerve: from dorsal rami of C2/C3, pierces trapezius near the superior nuchal line, find it 2 cm lateral to the inion at the superior nuchal line and medial to the occipital artery Cranial Nerve: V3 (Mandibular branch of Trigeminal Nerve) Migraine Cephalgia Premonitory Phase: migraine attack of hours to a day; fatigue, concentration problems, neck stiffness, sensitivity to light/sound, nausea, blurred vision, yawning Migraine Aura: a progressive neurologic deficit or disturbance w/complete recovery o Visual disturbances (see zig-zags), sensory symptoms (unilateral hand to arm to face or cutaneous allodinia), motor weakness (unilateral), speech problems Headache Phase: attacks last up to 72 hours, have unilateral location, pulsating quality, moderate to severe pain, aggravation by physical activity (need at least 2) o Nausea/vomiting, photophobia, phonophobia Entrapment: large vessels, pial vesseals dura matter and large venous sinuses are innervated by the trigeminal ganglion and upper cervical dorsal roots

When stimulated, this releases vasoactive neuropeptides resulting in neurogenic inflammation, which causes vasodilation and plasma protein extravasation, resulting in migraine pain o Cranial Nerve: IX (glossopharyngeal) How it becomes entrapped: at the jugular foramen affected by malposition of the occiput and temporal bones How to diagnose/test for this: difficulties swallowing, excessive gag reflex, evaluate temporal, occiput, occipitomastoid suture o Cranial Nerve: X (Vagus) How it becomes entrapped: see IX above How to diagnose/test for this: numerous dysfunctions, trauma to occiput, temporal bones; evaluate OA, AA, temporal and occiput o Cranial Nerve: XI (Accessory) How it becomes entrapped: see IX above How to diagnose/test for this: weakness/paralysis, torticollis, trauma to cervical/occiput/temporal; evaluate those bones o Cranial Nerve: XII (hypoglossal) How it becomes entrapped: condylar compression and intraosseous strain leading to compression at the hypoglossal canal At birth: canal is vulnerable at birth from rotation of the squamous portion of the occiput distorts the condyles This results in dysfunctional feeding and tongue action How to diagnose/test for this: dysphagia, tongue function; test tongue motions, evaluate occiput (condyles), upper C-spine Treatment Holds o The Vault Hold: greater wing of sphenoid, anterior to the tragus, mastoid region and lateral occiput; palms on the top of the head o The Becker Hold: greater wing of sphenoid, occiput; palm rests down towards table o The Fronto-Occipital Hold: greater wings of the sphenoid and frontal, palm under occiput o The Bilateral Temporal Hold: temporal bones o The Unilateral Temporal Hold: zygomatic arch, external ear canal; free hand for treatment Treatment Techniques o Diagnosis: SBS, Dural Strains, peripheral lock, intraosseous strains, abnormal fluid fluctuation, other somatic dysfunctions in the body o Goals of Treatment Normalize nerve function, counteract stress, eliminate circulatory stasis, normalize CSF fluctuation, release membranous tension, correct cranial articular dysfunctions, modify gross structural patterns Contraindications: acute intracranial hemorrhage, intracranial aneurysm, herniation of medulla oblongata, recent skull fracture o Balanced Membranous Tension: most commonly used, balances RTM Most neutral position possible under all factors responsible for existing pattern of motion Must be maintained while following the PRM through its cycles Balance point is at the Sutherland fulcrum Can shift in response to injury/strain Attention directed to automatic, shifting, suspension fulcrum Refinements in securing the point of BMT Choice of permitted motion: exaggeration, direct, disengagement, opposite physiologic motion, molding Innate forces: CSF fluctuation, respiratory cooperation Being of assistance to the patients indwelling, self-healing forces: physician guided and directed, synchronize w/and augment motion present, sense health already present and support it, figure out best treatment priorities o Disengagement Techniques Impacted/compressed sutures: bevel changes/compressed SBS Separate the opposing surface then find point of BMT Parietal Lift: addresses superior-inferior strains in the RTM Sutures: parietal outer table beveled at expense of temporal bone

Parietal notch sometimes restricts superior motion of parietal bone Bevel changes determines location of axis Hand Placement nd rd th o 2 , 3 and 4 fingers contact inferior border of each parietal bone near (but superior to) the parietal temporal suture), cross thumbs Technique o Approximate fingers of hands towards each other Internally rotates inferior border of parietals o Carry parietals posterior to disengage parietal notch o Carry parietals superior to point of BMT (pay attention to Sutherland fulcrum) o Gently release after tension relaxes Frontal Lift: addresses anterior-posterior strains in the RTM Sutures: lateral angles, lesser wing of sphenoid Axis of rotation: may function as paired bones in regard to motion, determine location by bevel changes Hand Placement o Hypothenar eminence on lateral angles of frontal bone, fingers interlaced w/fingers of opposite hand Technique o Approximate thenar eminences o Lift frontal bone anterior Disengages, frontal-parietal suture and frontal bone from lesser wing of sphenoid o Carry to point of BMT, paying attention to Sutherland fulcrum o Gently release at relaxation

CV4 Stay medial to occipitomastoid sutures w/thenar eminences Contact lateral angles of squamous occiput and gently compress them by the weight of the head Encourage exhalation phase of PRM, wait for motion to resume, then release Can perform on temporal, parietals and sacrum Fluid Technique: Venous Sinus Release To improve venous drainage, helpful for headaches or a hard, rigid head from SBS compression Contact positions hold until softening, warmth and inherent motion are felt Inion Over occipital sinus Occiput toward foramen magnum condylar decompression Transverse sinuses Inion Sagittal sinus sagittal suture and metopic suture Fluid Technique: V-spread Commonly used at occipitomastoid suture, only needs a few ounces of pressure Can synchronize w/phases of CRI Technique On restricted side: index and middle fingers gap suture On opposite side, diagonally across from suture, place index finger o Direct CSF w/impulse to restricted suture Frontal/Maxillary Lift Contact lateral angles of frontal bone with one hand and lateral angles of maxilla with other hand Encourage internal rotation of both bones and gently lift both bones anterior Allow for unwinding, and when they go into external rotation, release pressure Spenobasilar Synchondrosis Decompression Use becker hold, and gently resist 3-4 cycles

Once a still point is reached, then lift the greater wings of the sphenoid bone anterior, allowing for dural unwinding Then release anterior pressure and recheck for normal motion o Stacking Technique For each step, encourage the motion in the direction of preference Flexion/Extension Superior/Inferior Vertical Strain motion Left and Right Lateral Strain Motion Left and Right Torsion Motion Left and Right Sidebending/Rotation motion Lastly, decompress SBS and follow motion as it unwinds o Condylar Decompression Place pads of fingers posterior to occipital condyles Apply gentle posterior, superior and lateral traction by moving elbows together and leaning back o Direct Release of Occipitomastoid Suture internal rotation of temporal bone Externally rotate temporal bone to barrier; also flex occiput to barrier Move posterior medial with tension to externally rotate Have patient hold their breath in inhalation Glide the structures through the barrier at exhalation o Exaggeration of Physiologic Motion of the Temporal Bones Mastoid processes are gently compressed medially and posterior during inhalation phase of PRM Motion is symmetrically slightly exaggerated during external rotation of the temporal bones and allowed to return during the internal rotation phase Physiologic Motion and Cranial Strain Patterns Physiologic Motion o Sphenoid Composite Horizontal axis through the center of the body Flexion w/inhalation, extension w/exhalation o Occiput Composite Horizontal axis above the jugular process at the level of the SBS o Temporal Bone Composite Motion guided and influenced by the occiput Axis is from the jugular surface to the petrous apex below the petrous ridge Moves like a wobbly wheel Cranial Strain Patterns o Flexion and Extension normal movement, the simplest somatic dysfunctions are variants of this Flexion is Ernie and Extension is Bert! o Most dysfunction is defined by what occurs at the SBS, although not all are caused by SBS problems o Primary Respiratory Mechanism Inhalation: flexion of midline bones, external rotation of paired bones Exhalation: extension of midline bones and internal rotation of paired bones o SBS Strain Patterns Torsions The sphenoid and occiput are rotated in opposite directions around an AP axis Named for position of the greater wing of the sphenoid Paired bones around cephalad wing are in external rotation wide orbit/prominent eye Paired bones around the caudal occiput are also in external rotation Hand motions (for left torsion) th o L hand rotate posterior, L index finger superior, L 5 digit inferior (occiput moving caudally) and other hand is opposite Sidebending/Rotation From traumatic force to side of the head at the level of the SBA Causes opposite rotation of the sphenoid and occiput around vertical axes and rotation in the same direction around an AP axis Named for wide side, which is convex: anterior (internal rotation), posterior (external)

Hand motions (for right SBR) o Right hand will feel fuller and wider, but be more caudad (fingers spread apart) Vertical Strains From traumatic force to the inferior aspect of the occiput or superior aspect of the sphenoid Results in rotation in the same direction around respective transverse axes Named for position of basisphenoid Superior sphenoid moves in flexion while occiput is in extension, inferior sphenoid is in extension when occiput is in flexion Hand Motions th o Index fingers move inferiorly, 5 digits move superiorly Lateral Strains (parallelogram of head) From a traumatic force to the side of the head either anterior or posterior to the SBS Named for position of basisphenoid Hand Motions (for right LS) o Fingers of right hand anterior, fingers of left hand posterior SBS compressions From and anterior-posterior compressive force, can be from long term psychological trauma Hand motions o Fingers of both hands approximate, Flexion/Extension cycles limited o Bowling ball head

Sacrum Midline bone, moves in flexion and extension Dysfunctions can affect cranial motion and vice versa, through the force transmitted up the spine and through the dural connections Bilateral sacral flexion: sacrum maintains craniosacral extension resulting in extension preference of cranial mechanics I.e. during pregnancy o Visual Recognition Facial bone motion is drive by sphenoid motion Temporal bones and mandible are determined by occipital motion Parietals are influenced by both sphenoid and occiput The Five Components of the Cranial Concept The Inherent Motility of the Brain and Spinal Cord o Brain involuntarily and rhythmically moves, CNS coils and uncoils o Expansive Phase Inhalation/Flexion rd Neural Axis shortens towards junction of 3 ventricle and lateral ventricles Spinal cord shortens and is drawn upward, cerebral hemispheres unfold Brain substance becomes thin and compact, but ventricles dilate o Contractile Phase Extension/Exhalation o CNS, PNS and Fascia are al continuous, and the motion is palpable through the whole body Fluctuation of CSF o Highest known element, fluid w/in a fluid, juice in the electric battery, vital to CNS metabolism o Produced by choroid plexus o Fluctuates w/in the cranium, spinal cord and dural sheaths (a near closed container subarachnoid space) o Inhalation Ventricles/SA space increase CSF production > absorption Intracranial volume increases, skull widens transversely o Exhalation Ventricles/SA space decrease CSF absorption > production Intracranial volume increases, skull narrows transversely

Mobility of the Intracranial and Intraspinal Membranes o Tentorium, falx cerebri and spinal dura to S2 make an anatomical restraint o Membranes form a functional unit called the Reciprocal Tension Membrane (RTM) Articular Mobility of the Cranial Bones o Anatomic response to the physiologic motion to accommodate cyclic fluctuations resulting from CNS motility, fluctuation of CNS volume and fluctuation of intracranial blood volume o Cranial sutures are the consequence of embryonic development Conn. tissue, blood vessels, free nerve endings, stretch receptors and autonomics o Suture: two bones joined w/intervening fibrous tissue Squamous: beveled and overlapped squamous temporoparietal, sphenosquamous Serrate: saw tooth, interlocking hinge sagittal suture Squamoserrate: saw tooth and bevel coronal suture, lambdoidal suture Can be irregular occipitomastoid, parietomastoid Harmonic: smooth gliding maxillolacrimal, vomersphenoid, sphenopalatine Gomphosis: peg and socket petro jugular Synchondrosis: union of two bones w/intervening cartilage SBS, stylohyoid o SBS Flexion SBS rises, angle b/w sphenoid and basioocciput becomes more acute Increase in coronal plane and shortening in the sagittal plane Occurs w/midline bones o SBS Extension SBS flattens, angle b/w sphenoid and basioocciput becomes less acute Narrowing in coronal plane and lengthening in the sagittal plane Occurs w/midline bones o Physiologic Motion of Paired Bones Said to internally and externally rotate (extension and flexion, respectively)

Involuntary Mobility of the Sacrum b/w the Ilia o Passive motion, dictated by dural elements at S2, called the core link o Flattens with inhalation, extends with exhalation Contraindications to Treatment Acute Intracranial Hemorrhage o May significantly change intracranial fluid pressure dynamics, and may interrupt tenuous progress of clot formation Intracranial aneurysm Herniation of medulla oblongata Recent Skull Fracture Note: Plagiocephaly and the Complete Exam are not included on this little study guide. This starts on page 99 of the packet. Quarter 4 Rib Cage General Anatomy Sibsons Fascia covers the superior orifice, is considered the C-T diaphragm Inferior orifice is covered by the abdominal diaphragm, which attaches to the xiphoid process, and T6-L3 Sympathetic control: T1-6 nerve roots exit from T-spine, synapse at sympathetic chain and innervate heart/lungs o Chain ganglia are anterior to rib heads and often influenced by rib somatic dysfunction Ribs slant downward (from posterior to anterior) Functions: protection, breathing, lymphatic and venous pump Relationships: Sternal notch at T2, Sternal angle at T4, xiphoid at T9, umbilicus at L3,4 o Rib 2 attaches at sterna angle, rib 8 just inferior to scapula, rib 7 is last one to directly contact the sternum Typical Ribs 2-7, join anteriorly to costal cartilage, then costochondral joints o Costochondritis is a non-synovial joint problem, often on the left side 8-10, join condral mass at synovial costochondral joints All ribs costotransverse and costovertebral synovial joints; rib attaches to its vertebral body and the one above Transverse Axis: PUMP HANDLE; midclavicular line of rib 2-5 o Inhalation: posterior angle moves inferiorly, anterior moves superiorly AP Axis: BUCKET HANDLE; midaxillary line of ribs 6-10

o Intercostals space separates with inhalation (rib moves lateral and superior) Diagnosis o Pain with respiration: rib SD o Coughing? Usually exhalation SD o Name for preference of rib motion, start with springing ribs and feeling for resistance and tenderness Treatments: both indirect or direct o If group of ribs is inhaled, treat inferior rib first, if exhalaed treat superior rib first o ME for exhalation SD: ribs 3-5 use P. Major, 6-9 use serratus anterior and 10-12 use latissimus dorsi Atypical Ribs Costosternal joint of rib 1 is a synchondrosis; 11 & 12 are floating ribs, no costochondral or costosternal articulations Rib 1 o Elevates with inhalation, may be from muscle spasm of anterior and middle scalene o Depresses with exhalation, most likely from trauma Ribs 11 and 12 o Have a pincer/caliper motion, where the ribs move posteriorly, laterally and slightly superior w/inhalation o Lat pulls them away from iliac crest, narrowing interspace; quad lumborum pulls 12 down to iliac crest and widens 11s intercostals space Diagnosis o Rib 1: look at levelness of thumbs on costotransverse articulations; 1 cm lateral to T1 and slightly superior o Ribs 11 & 12: patient is seated or prone, feel for widths of intercostals spaces and directions of rib tips Sternum Manubrium, sterna body and xiphoid process: can all flex/extend, rotate and sidebend All are named for point on the anterior/superior aspect of the manubrium or sterna body This is usually treated indirectly (or directly) and generally after the thoracics and ribs Thoracic Inlet st T1, right and left 1 ribs and manubrium; right and left lymph ducts need unhindered passage for drainage Functional: T1-4, 1 and 2 bilaterally and manubrium o SD affecs somatic, parasympathetic and sympathetic nerves, Sibsons fascia and great vessels Diagnosis: generally rotates and sidebends the same way, may have flexion/extension st o Sidebending: check 1 rib, push inferior on shoulders Fascial Preference: steering wheel hold (palm of hand on sternum and manumbrium) o Rotation: compare depths of infraclavicular space, coracoclavicular angles (posterior on side of rotation) and springiness of ribs Facial Preference: Steering wheel hold (thumbs over superior aspect of first rib head, fingers below clavicles contacting ribs 1 and 2) or same as sidebending check translation o Flexion/Extension Fascial Preference: Steering wheel hold, translate superior and inferior Rib Counterstrain (see p. 26 for a nice chart) Anterior axillary line vertical line from anterior axillary fold Posterior axillary line vertical line from posterior axillary fold Midclavicular line vertical line from midpoint of clavicle Anterior (Depressed) Rib Tenderpoints a positional diagnosis o AR1: on first costal cartilage beneath the clavicle adjacent to the sternum nd o AR2: Medial (6-8 cm lateral to rib 2), Lateral (on lateral 2 rib, high in the axilla) o AR3-10: along anterior axillary line, on the anterior chest wall Need 120 seconds for these treatments o Treatments Ribs 1 & 2: Supine; Neck flexion, cervical rotation toward and cervical sidebending toward Ribs 3-10: Seated; thoracic and cervical flexion, STRT Opposite knee from side of diagnosis under arm o How do we get these? Depressed ribs are typically exhaled, from coughing, bending forward and lifting Posterior (Elevated) Rib Tenderpoints a motion preference diagnosis

PR1: beneath margin of upper trapezius on the posterior arm of the first rib PR2-10: on posterior aspect of rib at the rib angle Need 120 for these (and the PR1 seated technique) o Treatments Rib 1 Seated; ESaRt, using opposite knee as diagnosis to rest arm on Supine; cervical extension, SART Ribs 2-10: Seated; thoracic and cervical flexion with SARA Same knee as side of diagnosis under arm o How do we get these? Typically inhaled, from coughing/sneezing, leaning back/lifting, smoking COPD Treatments for Typical/Atypical Ribs and Thoracic Inlet See page 13 of the packet for a full listing. Have fun Lymphatic Considerations Terminal lymphatics and surrounding structures o Single layer of squamous endothelial cells w/adjacent overlapping edges; junctions function as valves o No intraluminal valves, no smooth muscle, anchoring filaments loosely tether cells to surrounding tissues Anatomy o Right Duct: right hemicranium, right upper extremity, heart and lobes of lung (minus LUL) o Left Duct: Everything else Functions of the system o Maintain physiologic environment, organize homeostatic mechanisms of the body o Maintain low interstitial oncotic pressure and subatmospheric hydrostatic pressure creating a vacuum o Maintain blood volume and a dry interstitium, defend against infection and tumor growth o Process and remove cellular products o Normal 24 hour flow is 2-4 L o Edema (accumulation of interstitial fluids) caused by lymphatic obstruction is called LYMPHEDEMA Causes of increased interstitial fluid o Increased filtration pressure, decreased oncotic pressure gradient across capillary, increased capillary permeability, inadequate lymph flow, combo of the above Factors influencing lymph movement o Extrinsic: contraction of muscles, exercise, OMT, Pulsation of arteries, Respiratory movement to increase negative thoracic pressure o Intrinsic: smooth muscle contraction, interstitial fluid pressure Causes of tissue congestion o Etiologic agents: intrinsic (genetic) or acquired (nutritional, infectious, ischemic, chemical, trauma) Response to pathologic agents o Normal: hypertrophy, hyperplasia, atrophy, metaplasia o Cell injury: all organ injury starts with molecular or structural alterations in cells Somatic Dysfunction (review!) o Impaired or altered function of related components of the body framework Diaphragms effect on thoracic duct o Cysterna Chyle: compressed during exhalation, driving its contents to the heart; dilates during inhalation o Ampulla: at termination of duct at left subclavian or jugular vein Empties with inhalation (secondary to negative intrathoracic pressure) and is refilled from the duct with Diagnostic Considerations: paraspinal tissue texture, collateral ganglia tightness, chapmans points, SD Signs of congestions: feel for fullness and bogginess o Supraclavicular, posterior axillary folds, epigastric, inguinal, popliteal, Achilles tendon, head/neck, arm, chest/abdomen, thigh/leg, ankle/foot o Spinal dysfunction has a great effect on visceral function, especially from C7-T1 Common Compensatory Patterns and Respiratory Circulatory Model o Spinal Transistion Zones OA: craniocervical junction, tentorium cerebella is diaphragm

o o

 CT: cervicothoracic, thoracic inlet TL: thoracolumbar, respiratory diaphragm LS: lumbosacral, pelvic diaphragm o A compensated pattern involves alternating fascial patterns o Tend to have greatest effects on visceral function and are areas of significant biomechanical influence of neural tissue; may be the key to ones dysfunction Therapeutic Considerations o Techniques must be individualized, nociceptive input has greatest impact on autonomic reflex Successful treatment impacts neurologic and vascular function Anatomical Considerations o Need more than the names of the structures, also need relationships w/surrounding structures Lymphatic Treatment o Improves restrictions to lymphatic flow larger lymphatic vessels and terminal lymphatic capillaries o Augments lymphatic flow o Basic Sequence: terminal drainage sites first, flow techniques last A (more complicated) Treatment Sequence for Lymphatics o Rib raising and/or paraspinal inhibition, significant spinal dysfunction (esp. uncompensated areas), thoracic inlet release, abdominal diaphragm doming (+ any significant remaining rib cage dysfunction), free local/regional fascial restrictions, local/regional fluid augmentation (effleurage/regional pumps) and systemic/generealized fluid augmentations (lymph pumps) Relative contraindications o Osseous fractures, bacterial infections when temp is >102, carcinoma o Opportunity costs Dont waste time, but dont neglect it you can improve the health of appropriate patients Figure out appropriateness based on palpatory evaluation and diagnosis Outcome Measures: thoracic duct flow can be measured, heart rate, aortic pressure, cardiac output Interventions: thoracic pump, abdominal pump, pedal pump o Treatments should last at least 30 seconds and be repeated twice once TDF is returned to baseline Diagnosis Basics o Patient should be supine o Palpate for fullness and bogginess: supraclavicular, posterior axillary fold, epigastric, inguinal (just medial to femoral artery), popliteal area and Achilles tendon (b/w malleoli and Achilles tendon) o Diagnosis spinal transitional zones OA: articular (OA, AA, SBS) and fascial (suboccipital) CT: articular (anatomic TI and functional TI) and fascial (TI, upper sterna and supraclavicular) TL: articular (L1-3, Ribs 7-12, Xiphoid process) and fascial (lower rib cage rotation) LS: articular (L5, sacrum, innominates) and fascial (pelvic rotation, pelvic floor tightness) Treatments for Lymphatics: see pp. 45 and/or 58 for the complete lists (they are the same) Rib raising techniques o Free restrictions of T-spine and rib cage o Improve respiratory excursion of the rib cage: minimizing amt. of work needed for expansion during respirations o Improves lymphatic pumping mechanism of the Thoracic cage o Reduces constriction of larger lymph vessels (Autonomic/sympathetic/lymphatic relations) o Sympa chain is just anterior to rib heads, and the ganglia can be affected by lifting the heads o Technique may be stimulatory, but results in decreased or normalized activity of the sympathetic By adjusting tissues, you can rebalance the sympathetic chain Measured Sympathetic Activity o Salivary a-amylase specific measure of sympa activity; it does not correlate w/changes in cortisol levels o Aymlase levels DECREASED significantly following rib raising o Parasympa rates (salivary flow) and Cortisol levels (HPA axis) did not significantly change