OMM Exam 1 Rib Dysfunction:

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OMM


Exam 1













Rib Dysfunction:

Significance of Ribs: respiration, association with the sympathetic chain ganglion and lymphatics

Anatomy

-

24 ribs


12 on each side



Typical
Ribs

-

Ribs 3 to 9 are considered “Typical Ribs”

1.
Head

that articulates with the corresponding vertebra and the one above.

2.
Tubercle

that articulates with the corresponding transverse process

3.
Neck

4.
Angle

5.
Shaft



Atypical Ribs


Functionally, ribs 1,2, 10, 11 and 12 are considered atypical ribs

Rib 1

is short, strong, and very curved

Rib 2

is typical except for a large tuberosity that allows it to attach to serratus anterior

Rib 11

and
12

do no have tubercles and do not attach to

the sternum/costal cartilage

Rib 10

is considered atypical because it only articulates with thoracic vertebrae 10.



Other Naming Conventions

“True Ribs”



ribs 1
-
7 that articulate directly with the sternum/manubrium

“False” or “Vertebral
-
Chondral Ribs”



ribs 8 thru 10 that merge into a single
cartilaginous mass that attaches to the sternum

“Floating Ribs”



ribs 11 and 12 that do not articulate w
ith cartilage or bone anteriorly




Rib heads

join the thoracic vertebrae at the
costovertebral

articulations



ribs 2 thru 9 articulate with a demifacet on the thoracic vertebrae above and below



example, Rib 2 articulates with thoracic vertebrae one and two)



The
tubercle

of typical ribs articulate at the transverse process of it’s own thoracic
verte
brae
-

these are the
costotransverse

joints


Muscles of Rib Motion

Primary Muscles:

1.

Diaphragm

2.

Intercostal Muscles




Secondary Muscles:

1.

Scalenes

2.

Pectoralis Minor

3.

Serratus Muscles

4.

Latissimus Dorsi

5.

Quadratus Lumborum
COSTOVERTEBRAL
JOINTS
COSTOTRANSVERSE
JOINTS
T5
T6
6
th
RIB
Rib Motion



Elevation and Depression



Primary motion of Rib 1



Pretty simple, really: when you inhale, rib 1 moves up, and when you exhale, the rib
moves down



Pump handle motion




Primary motion of ribs 2
-
5



Imagine the sternum and ribs together as an old pump handle
with a mobile connection at the vertebrate.



As you inhale the pump handle goes up, and as you exhale, the
pump handle goes down.



As you inhale, that “piece” (the sternum and ribs) moves up and

out…as you exhale, it moves down and in



Bucket handle motion



Primary motion of ribs 6
-

10



Imagine that the curve of each rib is a bucket handle. When the
bucket handle is down, against the bucket, there is little room
between the bucket and the handle
. When the handle swings
upward, there space expands between the bucket and the handle.



Motions of the ribs mimic this. As you inhale, the lateral aspect
of the ribs move up and out, expanding the lateral diameter of
the thoracic cage on each side.



Cali
per motion




Primary motion of ribs 11 and 12



Imagine that the left and right ribs 11 and 12 are your thumb and index finger pinched
together. As you inhale they move farther apart (unpinch), and as you exhale, they pinch
together.

Rib(s)

Type

Primary
Motion

Muscles used to TX

1

Atypical

Elevation and
Depression

Anterior Scalene and Middle Scalene

2

Atypical

Pump Handle

Posterior Scalene, serratus anterior

3
-
5

Typical

Pump Handle

Pectoralis Minor

6
-
8

Typical

Combined Bucket
and Pump Handle

Serratus

Anterior

9
-
10

Typical

Bucket Handle

Serratus Posterior Inferior and Latissimus Dorsi

11
-
12

Atypical

Caliper

Quadratus Lumborum

**Ribs 4
-
10 have “combined motion,” some portion bucket and some pump

**
In most people, rib 5 or 6 has about equal portions
of both motions.

**Ribs 11
-
12 have some upward/downward motion during inhalation/exhalation respectively







Rib Somatic Dysfunctions

Name the dysfunction for what it likes to do:



Exhalation somatic dysfunction: ribs move easily with exhalation



Inhalation somatic dysfunction: ribs move easily with inhalation



Exhalation Somatic Dysfunction

= Inhalation Restriction



Pump handle
: ribs are stuck down in the front



Bucket handle
: ribs are stuck down and in



Caliper
: ribs are stuck in



“People who work in the
ED

are usually
Stuck Down

In

the basement”



Inhalation Somatic Dysfunction

= Exhalation Restriction

(



Pump handle
: ribs are stuck up in the front




Bucket handle
: ribs are stuck up and out



Caliper
: ribs are stuck out



“The actors
on the show
ER

were
Stuck Up


Group Rib Dysfunctions

(a.k.a. One Bad Rib)

-

If there is
one bad rib
, it prevents good function of
the other ribs around it. You need to fix the KEY RIB in order to restore physiologic balance.



Group Rib Exhalation
Dysfunctions



If a rib is stuck down
, treat the
top rib

of the group dysfunction.



Why?
The top rib is holding all the other ribs down
. In this case, you must treat the
top rib of the group dysfunction.



So…in Ex
halation Somatic Dysfunction (
Inhalation Re
striction),
TOP rib
=
KEY RIB



Group Rib Inhalation Dysfunctions



If a rib is stuck up
, treat the
bottom rib

of a group dysfunction.



Why?
The bottom rib is holding the other ribs up
. You must treat the bottom rib of
the group dysfunction.



So…In In
halatio
n Somatic Dysfunction (
Exhalation Restriction
), BOTTOM rib =
KEY RIB.

Other Notes on Rib Dysfunction



Ribs are often seen as extensions of the thoracic vertebrae, and are therefore highly
susceptible to dysfunction when there is thoracic somatic
dysfunction



When encountering rib dysfunction, screen for and treat thoracic dysfunction fist


this
will often correct of improve the rib dysfunction



Rib Dysfunction & the Circulatory System



Rib 1 dysfunction can compress the subclavian artery (thoracic o
utlet syndrome) or
subclavian vein



Each rib has an intercostal vein and intercostal artery associated with it



Rib dysfunction can affect respiration and diaphragmatic function


decreasing the
effectiveness of the lymphatic system



Rib Dysfunction & the Ner
vous System



Rib 1 dysfunction can compress the cervical plexus



Each rib has a nerve associated with it



The sympathetic chain ganglion lie anterior to the rib heads

Muscle Energy Treatment



Goals:



Increase rib motion



Improve respiratory function



Decrease
Pain



Improve lymphatic drainage for the thorax and lungs



Improve medication access to affected lung(s)

What You Need to Know



Name the ribs: are they typical, atypical, true, false, etc.



What muscles are used to treat a dysfunction at that rib?



How do you n
ame a rib somatic dysfunction?



How do you find the KEY RIB?



What sympathetic innervations can rib dysfunctions influence?



How can muscle energy techniques be applied to rib dysfunctions?



PRACTICE, PRACTICE, PRACTICE!


Sacrum Dysfunction I & II
:

Recommended Reading: Foundations Chps 52, pp 778
-
782, 768
-
769 (**walking cycle)

Sacrum



Formed by the union of 5 modified vertebrae



Costal elements, vertebral arch, and centrum develop within a cartilaginous model


these
elements combine by age 8



Epiphysea
l plates separate adjacent sacral segments



These fuse sequentially beginning with the lowest segments working their way up



The upper 2 segments fuse about age 7
-
8 as do the sphenoid and occiput



Completion of bony fusion by age 25 (synchronous with the SBS)

Osteology/Articulations



Wedge shaped bone divergence anterior convergence posterior



Articulates with the 5
th

lumbar superiorly, the coccyx inferiorly, and 2 pelvic (innominate bones)
through the “L” shaped sacroiliac articulations


Sacroilliac Joint



2 ar
ms (1 short, 1 long) form “L” shape
joint



Both diarthrodial & synovial joint



Significant variability



Adaptive changes in the third decade
due to:

o

Gravitational stress

o

Increased size & # of ridges

o

Thickened Capsule

o

Accessory articulations


Anatomic Relatio
nships



Stability depends on: muscular, neural,
ligamentous relationships



Parallel joint surface



Self
-
locking



Form closure



surface contact

o

The anatomy of the individual joint and the
demands of gravity placed on it, define the
FORM CLOSURE of a particula
r joint

o

The SI joint becomes stable in part based on its
structural orientation



Force closure:

ligamentous, muscles & fascia

o

Depends upon activation of muscles across the joint system

o

Compressive forces & congruency between two surfaces of a joint provide
the friction to
enhance stability

o

Joint stability on the basis of dynamic force closure via the trunk, arm, and leg muscles
that can compress it


the cross
-
like configuration



Crossing musculature includes:



Latissimus dorsi



Thoracolumbar fascia



Gluteus m
aximus



Iliotibial tract



Linea alba



External abdominal
obliques



Transverse abdominals



Piriforms



Rectus abdominis



Internal abdominal oliques



Ilioinguinal ligament



Thoracolumbar fascia:

load transfer between lat’s & opposite glutes

“Fascioligamentous stocking


o

Formed by: thoracolumbar fascia, hamstring
-
sacrotuberous ligament complex (functional
and anatomical connection to sacrotuberous and inferior S
-
I ligament)

o

Integral role in intrinsic S
-
I stability

Sacral Plexus

o

Sciatic nerve passes through the posterior aspect of the hip & has a variable relationship with the
piriformis as illustrated

o

Some question exists as to whether it’s a physical pressure or chemical irritation that causes
sciatica with piriformis lesions

o

Sa
cral Plexus

o

Formed by the:

Lumbosacral trunk (ventral rami of L
4

& L
5
)
,
The first 3 sacral ventral
rami, & a portion of the 4
th

o

Innervates motor & sensory for
:

LEs & pelvis
,
Parasympathetic fibers to left colon & pelvic
organs

Sacral Motion



Dynamic interpl
ay between pelvis and sacrum to allow the normal activities of motion including
walking



Major axes around which sacral motion: Vertical axis, Horizontal (
superior and middle
transverse)
, Right and Left Oblique



Somatic Dysfunction: impaired motion around an

axis





Axes of Motion

o

Superior Transverse Axis
-

t
he hypothetical Axis around which the sacrum moves during
respiration. Involuntary sacral motion which occurs during Cranial sacral
flexion and extension
occurs around this axis
(Second Sacral Segment)

o

Middle Transverse Axis
-

the functional axis of sacral nutation and counternutation in the
standing position.

o

Flexion (Forward Bending) and Extension (Backward Bending) occur around this
axis

o

Inferior Transverse axis

-

the functional axis of motion at the inferior auricular surface of SI
joint and is the axis of motion of the ilia on the sacrum

o

Vertical Axis promontory
: rotational axis

o

Oblique Axes

o

Occur as normal part of lumbopelvosacral
motion during the walking cycle

o

Occur due to multiple forces:



Sidebending of L5 at the upper portion of the sacrum, restricting normal sacral
flexion and extension



Pirformis

tension on the lower arm of the sacral joint, causing a pivot point and
restriction




Sacral Motion

Forward Bending and Sacral Base



From a standing position as you forward bend(with legs locked) to about 45 degrees the sacral
base nutates around a tran
sverse axis ( it flexes forward).



This is in part due to the bracing of the sacrospinous ligaments as well as the increasing
posterior
-
superior pull of the erector spinae muscles on the posterior portion of S1



L5 flexes forward, the sacrum will foreword be
nd/flex/nutate

Backward Bending

o

As l5 continues to flex past 45 degrees continued nutation of the sacrum will be resisted by
ligamentous bracing. Counternutation will be encouraged by the pull of the erector spinae m. as
well as shifting center of gravity
of L5 on S1

Torsion

o

Occurs around an oblique axis formed by restricted motion at the lower arm of the sacrum on
one side and the contralateral sacral base on the other


Lumbosacral Mechanics

o

L5 and S1 move in opposite directions in the transverse plane
(typically)

o

If L5 rotates to the right then the sacrum will rotate to the left

o

The sacrum seems to have more effect on L5 as opposed to L5 affecting sacrum

o

Forward Bending

o

Lumbar spine regionally extends & sacrum regionally flexes

o

nutation

o

Backward Bendin
g

o

Opposite of above

Somatic Dysfunction

o

Dysfunction is when one of the normal
motions of the sacrum does not reverse and is maintained

o

Dysfunctions which maintain normal axes normally found in the walki
ng cycle are termed
physiologic

Physiologic
dysfunctions occur around an axis (occur during normal walking cycle)

o

Dysfunctions which do not occur around an axis are non
-
physiologic. Non physiologic
dysfunctions should be corrected first


Non physiologic dysfunctions do not occur around an
axis (uni
lateral dysfunctions)


Dysfunctions are names by the preference of motion around an axis using the anterior sacral bases
as a reference poi
nt

Dysfunction

Description/Findings

Image

Torsions


(
oblique axis
)

-

Most common dysfunctions

-
-

L5 rotates opposite

of sacral base



Forward


L on L

R on R

Left on Left

Right on Right


SeFT

+ R

+ L


Sacral Sulci:

Deep R

Deep L

ILAs:

Shallow L

Shallow R

Spring Test

(
-
)

(
-
)

Sphinx Test

Less
asymmetry

Less
a
sy
m
metry

Backward


R on L

L on R


Right
on Left


Left on Right


SeFT


+ R

+ L

Sacral Sulci

Shallow R

Shallow L

ILAs

Deep L

Deep R

Spring Test

(+)

(+)

Sphinx Test

More
asymmetry

More
asymmetry

Rotations

(oblique axis)

-

L5 rotates in the same directions as the
sacral base



Flexions
(transverse axis)

Unilateral


Deep sulcus & prominent ILA on same
side as positive seated & standing flexion
tests

-

Spring Test (
-
)





Bilateral


REALLY,
REALLY

rare!!


Can be seen
during
pregnancy



DRAMATICALLY reduced ROM to lumbar
flexion.


Symmetric SeFT & StFT


Bilaterally deep sulci & prominent ILA.


Spring test (
-
)

-

Sphinx Test: decreased asymmetry

-

Sacral rock test (+)



Extensions
(no axis)

Unilateral


Rare



Deep sulcus &

prominent ILA on same
side, but OPPOSITE side of dysfunction
(per SeFT & StFT)

-

Spring response
(+)



Bilateral


REALLY,
REALLY

rare!!!



DRAMATICALLY reduced ROM to lumbar
extension.


Symmetric SeFT & StFT.


Bilaterally shallow sulci & depressed ILA.


Spring test (+)

-

Sphinx Test: more asymmetry



Osteopathic Examination of the Sacrum

o

Lateralizing Test



which side is the dysfunction??

o

Standing (StFT)



Pt is standing.



Place your hands on the iliac crests bilaterally, and your thumbs should fall righ
t
into the area of the PSIS. Move your thumbs to the inferior notch of the PSIS.



As patient bends forward, monitor thumbs


whichever
side

moves cephalad first
(and usually the farthest) is dysfunctional.

o

Seated (SeFT)



Pt is seated, with feet flat on floor, knees spread a bit, so hands can pass freely in
middle.



Place hands as in standing flexion test, pt bends forward at waist.



Interpretation of results same as in standing flexion test.

o

Static Landmarks
:

o

Pt. Supine: AS
IS, Umbilicus, Pubic Ramus

o

Pr. Prone: Iliac crest, PSIS, Ischial tuberosity



Sacral Sulci (Sacral Base)



Shallow (posterior) or Deep (anterior)



Inferior lateral angles (ILAs)



Anterior or Posterior



Superior or Inferior



Need to check all four corners to arrive

at the
static position of the sacrum



Sacrotuberous Ligament

o

Functional Test



extension or flexion

o

Spring

Test



Pt is prone.



Place hand on lumbosacral junction.



Apply moderate pressure anteriorly.



If L
-
S spine allows motion, test is (
-
), but could be a fl
exion (fwd) dysfunction.



If L
-
S spine resists motion, test is (+), indicating an extension (bwd) dysfunction.



Can mimic findings via respiration.

o

Sphinx Test (Backbending)



If sulcus depth asymmetry (or ILA asymmetry)improves

with lumbar extension
the sacrum is nutated or forward bent/flexed



If sacral sulcus asymmetry(or ILA asymmetry) becomes more prominent with
extension of the lumbars, then the
sacrum

is backward bent/ extended

Treatment

Forward Sacral Torsions

(L on L tx

in image)

1.

Patient lays on oblique axis side



flex to L
-
S joint.

2.

Rotate patient’s upper body to same side as torsion

a.

this position reverses torque through the sacrum to induce
opposite rotation.

3.

Drop legs off table & begin ME tx sequence

(pt tries to pus
h feet up
toward ceiling against resistance)

a.

Can add respiratory efforts for extra efficacy


maintain
i
nhalation

while pushing
for flexion or forward torsions & vice versa.

** Keep in mind alternative treatment options: pt can lie down with oblique axis u
p and rotate
backwards (upper body facing up) and push feet down toward floor against resistance

Backward Sacral Torsions

(L on R tx in image)

1.

Lie patient
down on oblique axis side

& flex to level of L
5
-
S
1
.

2.

Rotate upper body in the same direction as the
sacrum is rotated

&
stabilize.

3.

Have patient push knee up toward ceiling as you resist with an
isometric force for 5 seconds.

a.

For an additional assist, have patient
maintain
exhalation

while pushing

Unilateral Sacral Flexion

1.

Patient prone, physician on dys
functional side.

2.

Place the
thenar eminence of the treating hand over the sacral
apex

of the dysfunctional side of
the sacrum.

3.

Abduct ipsilateral leg until motion is felt by the palpating hand (~
20

), & then internally rotate the leg.

4.

Instruct pt to

inhal
e fully & hold it.

5.

Exert a downward pressure over the sacral apex while

pt. exhales,

resisting sacral flexion.

6.

The pressure is maintained for 3


5 seconds while
gapping the SI
joint on the side of the dysfunction.


a.

This may be accomplished by bending the patient’s knee 90


& gently internally rotating the patient’s abducted leg.

7.

Repeat above 2
-
3 times & recheck.

Unilateral Sacral Extensions

1.

Patient prone, physician on dysfunctional side.

2.

Place the
thenar

eminence of the treating hand over the sacral
base

of the dysfunctional side of
the sacrum.

3.

Abduct ipsilateral leg until motion is felt by the palpating hand (~
20

), & then internally rotate the leg.

4.

Instruct pt to
exhale fully & hold it.

5.

Exert a downwar
d pressure over the sacral base while
pt.
inhales,

resisting sacral extension.

6.

The pressure is maintained for 3


5 seconds while
gapping the SI
joint on the side of the dysfunction
.

a.

This may be accomplished by bending the patient’s knee 90


& gently i
nternally rotating
the patient’s abducted leg.

7.

Repeat above 2
-
3 times & recheck.

Bilateral Sacral Flexion

1.

Patient prone, physician on dominate eye side.

2.

Place the
thenar eminence of the treating hand over the sacral
apex
.

3.

Abduct both legs until motion is f
elt by the palpating hand (~ 20

), & then internally rotate the
legs (gaps SI joints).

4.

Instruct pt to inhale fully & hold it.

5.

Exert a downward pressure over the sacral apex while
pt. exhales,

resisting sacral flexion.

6.

The pressure is maintained for 3


5 s
econds
while gapping the SI joints bilaterally


a.

This may be accomplished by bending the patient’s knee 90


& gently internally rotating
the patient’s abducted leg.

7.

Repeat above 2
-
3 times & recheck.


Bilateral Sacral Extension

1.

Patient prone, physician on
dominate eye side.

2.

Place the
thenar eminence of the treating hand over the sacral
base

.

3.

Abduct both legs until motion is felt by the palpating hand (~ 20

), & then internally rotate the
legs.

4.

Instruct pt to exhale fully & hold it.

5.

Exert a downward pressure over the sacral base while
pt.

inhales,

resisting sacral extension.

6.

The pressure is maintained for 3


5 seconds while
gapping the SI joints bilatarally
.

a.

This may be accomplished by bending the patient’s knees 90


& gently int
ernally rotating
the patient’s abducted legs.

7.

Repeat above 2
-
3 times & recheck.

A Few Helpful Hints

1.

If the Sacral Sulcus is deep on one side and the ILA is shallow on the opposite side there is an
Oblique axis

2.

If the sacral sulcus is deep on one side and t
he ILA is shallow on the same side there is no axis
and it must be a unilateral

3.

The flexion test will never be on an axis. If you have a left oblique axis the flexion test should be
positive on the right.

4.

If you have a unilateral then the flexion test shou
ld be on the side of the unilateral

5.

If you have a negative Spring Test or a negative Sphinx test your dysfunction must be a forward
bent problem(L/L,R/R ,unilateral sacral flexion, bilateral flexion

6.

If you have a positive Spring or Sphinx Test then the pr
oblem must be backward bent

(L/R,R/L,unilateral sacral extension,bilateral sacral extension

7.

Inhalation will cause the sacrum to slightly backward bend

(extend)

8.

Exhalation will cause the sacrum to slightly forward bend

(flex)













Segmented
Facilitation
:

Definition:

a spinal cord segment in which the activity of the interneuronal pool has been altered from
its normal activity


Embryology

o

Neural Tube
: homogenous, no longitudinal differentiation

o

Dorsal Root:

sensory or primary afferent fibers

derived from neural crest cells migrating away
from the
dorsal ridge

o

Ventral Root
:
ventral root axons

derived from
ventral potion of neural tube

o

Spinal Nerve
: combo of dorsal and ventral roots at level of intervertebral disc

o

Somite
:

repetitive segments gi
ving rise to dermatomes (skin), myotomes (muscle), sclerotomes
(vertebrae)

o

Therefore the spinal nerve relaying at C6 carries info from its dermatomal pattern
(thumb, lateral upper limb); myotomal distribution (mm it innervates, biceps,
brachioradialis for
example) and sclerotomal distribution (tip of acromion, medial border
of humerus).

o

Lack of segmentation in the spinal cord, this overlap seen with dermatomes, myotomes,
scleratomes allows for spread of info coming from primary afferents to multiple levels

above and below relative to where they enter.

o

Thereby, facilitation of the spinal cord, is NOT restricted to a specific segment. The input
comes in to a particular segment, but from there can travel up or down the cord via
interneuronal pathways .


S
p
inal Cord Segments

-

made up of three parts:

1.

peri
pheral sensory via dorsal root

2.

central neural circuits

3.

efferent system via the ventral root.

SPINAL CORD

o

gray matter in middle, white matter on pe
riphery;
opposite in cerebrum

o

Gray indicates where the cell b
odies live, white
contains ascending

and descending spinal
tracts

o

Areas of importance when discussing spinal facilitation
include the DORSAL COLUMNS AND THE VENTRAL/LATERAL/DORSAL
HORNS

SPINAL NERVES:

composed of dorsal and ventral root contributions
.

o

Have dorsal and ventral rami. Ventral ramus has white (pre
-
gangionic) and gray (post
-
ganglioinic) rami communicantes serving sympathetic chain ganglia; as well as serving
peripheral skeletal muscle (body wall, limbs, perineum).

o

Dorsal ramus innervates t
he posterior musculature (iliocostalis, longissimus, spinalis), the
capsule surrounding the articular facet and interspinous/supraspinous ligaments.

DORSAL ROOT:


o

carries sensory, or primary afferent, fibers. First order cell
-
bodies in dorsal root ganglion
, 2
nd

order cell bodies in spinal cord.

o

Central fibers take information from dorsal root ganglion to spinal cord synapsing on cell bodies
(interneurons) in lateral horn, ventral horn, dorsal horn, dorsal column.

VENTRAL ROOT:

composed of efferent (motor
action) fibers. Cell bodies in ventral horn.


Ventral R
amus

o

has white (pre
-
ganglionic) and gray (post
-
ganglionic) rami communicantes serving sympathetic
chain ganglia; as well as serving peripheral skeletal muscle (body wall, limbs, perineum).

Dorsal

ramus


o

innervates the posterior musculature (iliocostalis, longissimus, spinalis, intertransverserii), the
capsule surrounding the articular facet and interspinous/supraspinous ligaments.


Primary Afferent Fibers


Sensory

&
Processing

A
-
afferent

(ex. A
-
a
lpha, A
-
beta)

Sensory

Processing

o

Encapsulated Endings

o

Pacinian, Meissner’s corpuscles, muscle spindle organs,
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楮v潬o敤⁷楴栠
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o

Meissner’s

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瑯⁡捣c浭潤慴攠er敳獵e攠e汴lr慴楯湳i

o

Large Myelinated

o

Low threshold for activation

o

Play a role in touch and proprioception

o

Line labeled

o

E
ach primary sensory neuron is coupled to a limited
number of central neur
ons preserving the fidelity of the
signal


after awhile, we aren’t cognisent of the shirt on
our shoulder, unless we think about it. We’ll see how
瑨楳⁶慲楥猠晲潭⁴桥⁢
-
慦晥f敮琠獹獴敭t

o

Local muscle postural reflexes
and ascending systems

o

Direct input
to
ventral

horn
and
lateral

horn of spinal cord

o

Collateral input to dorsal horn
modulates activity of B
-
afferent system

o

Ascending pathways to get
info to cerebral cortex and
cerebellum


Under normal circumstances: they
inhibit (downplay) B
-
afferent
activity in spinal cord and WDR
response


B
-
afferent

(ex. C fibers, a
-
delta)

Sensory

Processing

… SPECIAL!

o

Non
-
encapsulated endings

o

Most common type of sensory nerve endings


浯獴s
晲敱略湴汹⁦潵湤⁩ ⁳ i測⁤整散e⁴ 浰敲慴畲攬
浥捨慮楣慬⁳i業畬椬⁐䅉N

o

Small, lightly or un
-
myelinated = high threshold (not an
immediate perception of pain

o

Responsible for nociception


p慩渠浥獳慧楮a



Sp楮慬a
捯cd⁲eg楳i敲猠慣
tivity coming in, but it’s our
br慩渠n桡琠
瑥汬猠l猠獯s整桩湧⁩猠h慩湦n氮

o

Activated by noxious stimu
li (PAIN) in soma or viscera

o

Helps set up and maintain somatic dysfunction via
reflex loops and peptide release, centrally and
peripherally

o

General adaptive response: mechanism out body uses to
compensate for stressors (emotion, physical, viral,
traumatic)

o

Neuroendocrine
-
immune network = central player in
adaptive response (it incorporates the hypothalamic
-
pituitary
-
adrenal axis)

o

Frequency coded: changing the rate of firing will
result in a different perception

o

Local circuitry of spinal
segment


坄W
業i慣a

o

Fibers terminate in
dorsal

and
lateral

horns of spinal cord

o

Responsible for activation of
WDRs

(wide dynamic range
neurons)
; excessive activation
leads to FACILITATION

o

Ascending pathways via
anterolateral system

o

Neurosecretory function

o

B
-
afferents h
ave capability
to release pro
-
inflammatory
cells peripherally in
response to spinal cord
messaging

Dorsal Horn Neurons

Interneuronal Pool in Dorsal Horn

o

Low threshold mechanoreceptor neurons

o

High threshold nocieceptor specific neurons

o

WIDE DYNAMIC RANCE N
EUROSN (WDRs)


focus on these!!

WDRs

o

Convergence

o

Receive from A
-
afferents, B
-
afferents;
somatic and visceral

o

Send to other interneurons; brainstem via anterolateral tract

o

Large receptive fields; often referring to flank of animal


o

Plasticity

o

Voltage
-
dependent response properties

o

“Wind Up”

o

Recap: located in deep dorsal and lateral horns, when activated by B
-
afferents


whether
coming from soma or viscera


will lead to segmental facilitation

SUMMARY


BOTTOM LINE!

o

B
-
Afferents + WDR = Segmental
Faciliation

o

Reflex Arc that Develops = Tart findings, visceral or somatic disease


Spinal Facilitation

Consequences

o

Self
-
sustaining loop b/w sensory afferent originating in periphery, spinal cord interneurons,
and ventral horn motorneurons
/or to sympathetic chain ganglia via white rami
communicantes

o

Incoming information can
SPREAD

above and below incoming spinal segment


and two
separate primary sites can converge at common meeting ground

o

Altered output from the ventral and lateral horn


effect on paravertebrals and peripheral
musculature

o

Vasomotor effects, red reflex, tissue texture changes

o

TART findings, acute vs chronic

Somato
-
Visceral Reflex

o

Localized somatic stimulation producing patterns of reflex response in segmentally related
visc
eral structures.

o

Info originally coming from soma


skeletal muscle


has an effect on viscera

o

How?

o

B
-
afferents from soma, interacting with WDRs, which may also be receiving info from
viscera; WDRs synapse with sympathetic pre
-
ganglionics supplying viscera

o

Reasearch:

o

Miranda A, et al. Altered visceral sensation in response to somatic pain in the rat.
Gastroenterology. 2004 Apr;126(4):1082
-
9.



noxious somatic afferent input from the hid limb facilitates visceral hyperalgesia as
measured by increased colore
ctal distention.

o

Sato Y, et al. Reactions of cardiac postganglionic sympathetic neurons to movements of
normal and inflamed knee joints. J Auton Nerv Syst. 1985 Jan;12(1):1
-
13.



repetitive passive motion of an inflamed knee caused an increase in blood pr
essure
and inferior cardiac nerve activity (Passive movements in the normal working
range of the joint did not influence the activity of ICN units. However, noxious joint
movements, particularly of inflamed joints, led to pronounced excitation of ICN
units

accompanied by rises in blood pressure.)

Viscero
-
Somatic Reflex

o

Localized visceral stimuli producing patterns of reflex response in segmentally related
somatic structures

o

(Noxious) sensory info coming from viscera


gut
-

has an impact on skeletal muscl
e



o

What fiber carries this kind of “noxious sensory” information?

o

Seen at paraspinal level AND in Chapman’s points

o

How ?

o

Afferent fiber, central synapses in dorsal horn, WDR activation: results in referred pain;
sympathetic involvement results in vasomot
or changes, ventral horn involvement results
in paraspinal changes

o

Research

o

Stawowy M, et al. Somatosensory changes in the referred pain area in patients with
cholecystolithiasis. Eur J Gastroenterol. 2005 Aug;17(8)865
-
70.



Cholesytolithiasis leads to s
ignificant hyperalgesia in the somatic area, where pain
was referred to during the acute attacks (right costal margin). Sensitivity and pain
thresholds tested via pinprick, pinching, heat, cold, pressure, electrical stimulation.

o

¨Nicholas AS, et al. A s
omatic component to myocardial infarction. Br Med J (Clin Res Ed).
1985 July 6;291(6487):13
-
17.



those in group with hx of prior mi had significantly higher incidence of tissue
texture changes confined almost entirely to the upper thoracics (T1
-
4). Contro
l
group low incidence of thoracic paraspinal asymmetry.

Chapman’s Reflex

o

Initially described as a ganglioform contraction that blocks lymphatic drainage

o

Cause inflammation in tissue distal to blockage

o

Probable concurrent involvement of sympathetic nervous

system

o

Acute Palpatory Characteristics

o

Tender, nonradiating, may be pinpoint

o

Anterior
-
may differ depending on location

o

Posterior
-
”ganglioform contraction” may be buried in dysfunctional tissue

o

Chronic Palpatory Characteristics

o

Nontender or less tender

o

Ant
erior
-
generalized increased tension

o

Posterior
-
paraspinal areas (ropiness,stringy)



Viscero
-
Visceral Reflex

o

Localized visceral stimuli producing patterns of reflex response in segmentally related
visceral structures

o

Ex: sensory info from one diseased org
an can adversely effect another

o

How

o

Autonomics

o

B
-
afferents

o

Segmental spread/overlap

o

Research

o

Intestinal
-
intestinal reflex: seen within the enteric nervous system.


refer to
Foundations, chapter 5, Autonomic Nervous system

o

Wang G, et al. Pelvic nerve inpu
t mediates descending modulation of homovisceral
processing in the thoracolumbar spinal cord of the rat. Gastroenterology. 2007 Nov;
133(s):1544
-
53.



input from colorectal distention carried on pelvic n project to l
-
s and those carried
on hypogastric to t
-
l dorsal horn neurons


study found that input over the pelvic
nerve modulates the response of t
-
l spinal neurons to colorectal distension
through a supraspinal loop and that increasing t
-
l processing, increases visceral
hyperalgesia.

Somato
-
Somatic
Reflex

o

Localized somatic stimuli producing patterns of reflex response in segmentally related
somatic structures

o

Ex. Withdrawal of hand after contact with a hot surface

o

How

o

B
-
afferents carry to dorsal horn, WDRs activate, synapse with ventral motor neuron,

output to related musculature

o

Research


refer to Foundations Chp 10

Common Viscero
-
Somatic Reflex Pattern
s

Thyroid

C7
-
C8


Pancreas

T6
-
9, both

Bronchus

T2
-
4

Kidney, Ureters

T10
-
12, same side

Lung

T2
-
5

Ovaries

T12
-
L1, same side

Pleura

T1
-
11, same side

Adrenals

T10, L1, Same side

Heart

T2
-
5, left

Appendix

T11
-
12, ribs right

Stomach

T5
-
9, left

Uterus

L4 and 5, both sides

Duodenum

T7
-
10, right

Bladder, Prostate

L3
-
5

Gallbladder

T9, right

Colon

L1
-
5

Liver

T5
-
9, right

Rectum

L4
-
5


Fallopian
Tubes

T11
-
12, L1


V
-
S: Palpatory Findings

Acute

Chronic

o

Increase in skin temp and moisture

o

Cutaneous hyperesthesia

o

Red reflex

o

Increased subq fluid (boggy)

o

Increased mm contraction

o

Motion testing may feel like a hard rubber
band


“firm springyness

o

Trophic changes in skin


cool, dry

o

Increased thickening of skin and subq tissues
(boggy turns fibrotic)

o

Localized mm contraction involving 2 or
more segments

o

Motion testing feels like hard barrier


Spinal Facilitation
:

o

Initiated by excessive activity of
the B
-
afferent fiber system

o

B
-
afferents relay on WDRs

o

Self
-
sustaining circuit


A REFLEX LOOP
-

between primary afferents (from soma or


viscera), spinal cord interneurons and motorneurons projecting back to periphery

o

Changes in musculature and skin are p
alpable!

o

What Can We Do??

“Rule of the artery is supreme”

o

Address the structure, so that there may be improved function of the tissues surrounding
or in proximity of that structure.



Optimal arterial supply



Proper venous and lymphatic drainage



Appropriate
neural responses

o

Treat damaged tissue, be it viscera or soma. Address the dis
-
ease


medicinal, surgical.


How Does Somatic Dysfunction get There?


Introduction to Soft Tissue Techniques

Functions of Soft Tissue:

o

Postural

o

Muscles, tendons, ligaments, fas
cia

o

Support

o

Muscles, tendons, ligaments, fascia

o

Circulatory

o

Arteries, veins, lymphatics, muscles

o

Transport

o

GI, UG, etc.

o

Protective

o

Skin, mucous membranes


Fascia:

o

Mesoderm derivative

o

Fibers

o

Collagen



Main protein in connective tissue



High tensile strength



Main component in cartilage, ligaments, tendons, bone, teeth



Helps strengthen vessels, cells and skin



Many types discovered

o

Elastin



Can be stretched and return to original position



Abundant in areas where expansion and relaxation occur



Lungs



Vessels



Bladde
r



Skin



Body stops producing in teens



Affected by aging, tobacco, UV

o

Ground substance

o

Support and bind cells together

o

Provide a medium for the exchange of materials



Gel like



Hydrophilic (attracts water)



70% of connective tissue is water



Age reduces
hydration



Injury or constant tension can

also reduce water content

o

Connective tissue properties

o

Manufactures and secretes substances

o

Plasticity and adaptability

Functions of Fascia

o

Mechanical

gives rise to
support, compartmentalization
, and
conduits
.

o

Metabolic

gives rise to
diffusion

which has already been mentioned when discussing gel

properties, and to
energy storage

in the concept of elastic potential energy.

o

Immunologic

has been addressed earlier as well, plus the additional concept of acting as

a

physical barrier.

General Properties of Fascia



determined by its structure

o

Viscosity

o

Rate of deformation under a load

o

Capability to yield under continual stress

o

Elasticity

o

Ability to recover its shape after deformation

o

Plasticity

o

The ability to
retain a shape attained by deformation

Fascia Mechanical Concept


Compartmentalization



3D System

o

It is important to think and visualize the body as a 3
-
dimensional model. This model creates a
tube
-
within
-
a
-
tube arrangement. This arrangement is importa
nt for allowing the body and its
regions to work more fully as a unit; and it provides protection as well, due to barrier,
immunologic, and pressure
-
related support.

o

Remember that fluid is a big part of fascia and yet is essentially non
-
compressible, thus

allowing for the distribution of forces over a large surface area and thus minimizing damage to
any given focus. This distribution of forces is linked to a term called
Tensegrity

which is a lecture
topic in of itself. Keep in mind too, the spaces b/w fa
scial layers, which are often lost in the
cadaveric specimen, but can play a huge role when treating patients.

Types of Fascia

o

Extraperitoneal (Subserous)

o

Covers, supports and lubricates organs

o

Deep

o

Compartmentalization

o

Facilitates, limits and directs moti
on

o

Superficial

o

Insulates

o

Stores energy

o

Skin mobility

Soft Tissue Approach to OMT

o

Procedure directed toward tissues other than skeletal elements

o

Usually involves lateral stretching, linear stretching, deep pressure, traction and/or
separation of muscle
origin and insertion

o

Monitor tissue response and motion changes by palpation

Types of Soft Tissue

o

Lateral Stretch

o

Longitudinal Stretch

o

Deep Pressure

o

Separation of O & I

Purpose of Soft Tissue Techniques:

o

Diagnostic

o

Therapeutic

o

Sole intervention

o

Prepares s
oft tissue for other techniques

o

Enhance well being of tissues

Soft Tissue Technique Effects

o

Mechanical

o

Stretches skin, fascia, muscles to enhance their motion, pliability, and function

o

Circulatory

o

Movement of fluids through vessels and tissue more
efficiently

o

Neurologic

o

Stimulatory or inhibitory

o

Analgesic

o

Release endogenous opioids

o

Modulate spinal reflex pathways

o

Decreased stimulation of nerve endings with correction of somatic dysfunctions

Soft Tissue Treatment Indications

o

Move fluids

o

Relieve lymphatic congestion

o

Decrease muscle spasm

o

Release fascial restrictions

o

Diagnose

o

Break up adhesions

o

Promote healing

o

Increase ROM

o

Increase immune response

o

Decrease pain

o

Prepare tissues for other treatment

Soft Tissue Rx

o

Patient fac
tors

o

Age

o

Disease

o

Type/degree of injury

o

OMT history

o

Other factors

o

Time

o

Location

o

Physician skill

o

Reassess tissues

o

Perform technique until desired response

Key Points

o

Patient relaxed

o

Physician relaxed

o

Do not push into bone

o

Avoid snapping over hypertonic
muscles

o

Use finger pads, thenar or hypothenar eminences

o

Avoid rubbing skin

o

Use leverage when possible

Techniques







MFR of Lower Extremity:

Set Up

o

Pt supine with the leg and thigh to be treated off the table.

o

The physician clasps their hands together behind the tibia. The thenar eminences contact the
medial and lateral aspects of the popliteal fossa, making sure that no contact is made with the
popliteal fossa itself.

o

The physician stabilizes the patient’s f
oot b/w their own legs by placing the pt’s ankle b/w
their thighs.

o

The patient’s thigh is elevated slightly off the table.

Procedure

o

Traction is applied through the physician’s grasp, primarily by leaning backward, so that the
patient feels it in the p
osterior thigh, hip capsule, SI joint and T
-
L junction (in this ascending
order). If the traction is uncomfortable for the patient, then readjust the forces or the direction of
traction. If traction can only be felt at hip capsule or SI joint, then that
is the starting point

o

Once the proper amount of traction is obtained (and this may need to be modified as the
tissues release), move the patient’s knee into flexion and extension by moving your knees into
flexion and extension and observe the impact it h
as on the thigh, hip capsule, SI joint and T
-
L
junction.

o

Add an
abduction/adduction component to the thigh by moving your torso left and right.

o

Add a rotational component to the femur by sidebending your torso left and right.

o

Add an adduction/abduction c
omponent to the lower leg by moving your knees toward the
table and away from the table

***With each motion observe the effect this has on the thigh, hip capsule, SI joint and t
-
l junction.

Your goal is to make the hip capsule, SI joint and T
-
L junction fe
el at ease. This will be accomplished in an
ascending order. You may need to modify your positioning as the tissues begin to unwind and you may
need to start the set
-
up again in order to engage and effect the higher levels.



PPC Neuro















Cran
ial Nerve & Reflexes Exam

Neurological History

Neurological Exam

Mental Status

Exam:

Mental Status
Exam



Key element of neurological functioning


Exam for a
bnormal states of thought, affect,
perception, cognition



Meaningful within the context of the rest
of the physical exam



Reflects brain’s ability to perform various tasks that relate to communication, homeostasis, etc



All elements originate from neuronal activity in the CNS just as other neurological functions
(motor, sensory, etc) do



Integral part of a
complete physical exam



Various parts of PE may be expanded or contracted



NOT the MMSE



Observation and examination of brain functioning is the goal



Complications and/or Limitations



Attempting to derive information about brain functioning through observation

of
behavior and responses to tasks, etc



Looking at brain functioning through overlay of learned re
sponses, behavior, dynamics



Examination remains science with art

Components of Mental Status Exam



General Observations (least physiologically correlated, but

important)

o

Diffuse physiologic functions but important due to engrained social and cultural norms.
Ex: social greetings

o

Demographic data


age, sex, appearance

o

Speech

o

Psychomotor activity level and behavior

o

Eye contact

o

Level of alertness and orientation



M
ood and Affect

o

Two useful analogies



Mood as internal sensation and affect as outward presentation



Mood as prevailing weather system and affect as what we see outside (temporal
relationship)

o

Mood is generally reported by the patient but with qualification

o

Affect is observed



Range



Stability



Appropriateness








NORMAL Range

CONSTRICTED/BLURRED

LABILE





Thought

o

Pieces of information from internal or external sources
-

“building blocks”

o

Accurate representations of reality v. delusions and
characteristic patterns

o

Description of thought (amount, preoccupation)

o

Suicidal/homicidal ideation

o

Thought Process



Mechanism by which simplistic thoughts are linked to form more complex
thoughts for the purpose of communication



Associations are the “glue”
between the building blocks



Normal


logical and goal directed





Abnormal


loose







Abnormal
-

tangential








Perception

o

Internalization of environmental stimuli


data input

o

Normal


representative interpretation

o

Abnormal


hallucinations (der
ived de novo), illusions (misinterpretation of stimuli)



Memory

o

Physiologic memory



Temporarily organized



Differential loss with memory disorders

o

Useful construct of recent and remote memory



Cognitive Functioning

o

Concentration

o

Attention span

o

General fund of

knowledge/intellect



Only an estimate which provides context

o

Abstraction ability



Ability to manipulate information in the absence of concrete stimulus

Summary



Mental status is a component of the neurological condition of the pt



Examination of mental status

is an integral component to any good physical examination



Mental status is contextual to the overall condition of the pt so only has meaning within the
context of a more complete examination



General appearance, mood and affect, thought, perception and cog
nitive functions are the basic
components of the mental status examination