OMM Exam Review

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OMM Exam Review

10/19/2010 5:30:00 PM

Lecture 1


Physical exam of the cervical region and somatic
dysfunction


Somatic Dysfxn:

impaired or altered fxn of related components of the
somatic system


skeletal, arthroidal, myofascial

structures, and related
vascular, lymphatic and neural elements



Diagnosis is supported by visual and palpable findings:
TART

o

T: tissue texture changes

o

A: asymmetry of structure

o

R: restriction of motion

o

T: tenderness to palpation

Anatomy



Skeletal

o

7 vertebr
as of the C spine


atlas and axis are
ATYPICAL
and C3
-
C7 are TYPICAL

o

Occiput (C0)

o

Atlas (C1)



No vertebral body



Rotates around odontoid (on C2)



Palpable parts are the lateral masses


o

OA Joint: occiputoatlantal joint



2 articulations:



Occipital condyles (co
nvex)



Superior facets of C1 (concave)

o

Axis (C2)



Modified vertebral body to form the odontoid process



Palpable part is the spinous process


o

AA Joint: atlantoaxial joint



The atlas fits on top of the axis and rotates around the
odontoid process

o

Ligaments
associated with C1 and C2



Atlas and axis are joined by the
tectorial membrane
,
transverse ligament

and the
alar ligament



The
anterior and posterior longitudinal ligaments

connect the vertabra

in the vertebral column

o

Complex of occipitoatlantal and atlantoa
xial joints =
suboccipital articulation

o

Cervial spine (
C3
-
C7


typical
)



Articulations between C2
-
C7 are considered typical



No transverse processes easily palpable (except lateral
mass of C1)



C7 has a long spinous process

that you can see
when neck is flexed





Facets are in oblique plane



Discs are thicker and wedge shaped

(
45 degree angle
)



Palpable articular pillar is formed by facets



Facets
of the typical vertebrae are in

a plane that points
to eye



Rotation of typical ve
rtebrae are in this plane, so
vertebral rotation is toward the eye and not in a
horizontal plane



There are specialized synovial joints on lateral surface
of vertebrae known as
uncovertebral or uncinate
joints of Luschka

Planes of Motion: regional and segme
ntal



Planes of movement, range of motion

(cardinal spinal segmental
motions)

o

Sagittal (median)


flexi潮⽥xtensi潮



Flexion: forward or anterior bending of any segment or
region of the spine



Extension: posterior or backward bending of any
segment or region
of the spine



These motions describe the superior vertebrae in
relation to the inferior

o

Horizontal (transverse)


牯tati潮



Turning of the superior part around a longitudinal axis,
describing the motion of the ventral surface of the body
of the vertebra



Left

rotation


ventral/anterior surface rotates left,
spinous process moves right, and left transverse
process is more posterior

o

Coronal (frontal)


sidebending

(late牡l flexi潮)



Defined as right or left depending on which direction the
moving part bends in t
he coronal plane



Right


物ght c潮cavity, left c潮vexity



Left


left c潮cavity, 物ght co
n
vexity



Nomenclature

o

Positional diagnosis for a joint since we are describing
presence or absence of motion

o

Always named for the
position of the anterior aspect of
the
superior
/cephalad
bone

in relation to inferior/caudad
bone (E.g. relationship of C4 to C5)

o

Usually described in three cardinal planes


flexion/extension, sidebending L/R, and rotation L/R

o

Segmental palpation and motion diagnosis is always
named
for the mo
vement of a superior vertebrae on the
vertebrae underneath

o

Motion
preference of vertebrae is
named based on the
direction of the superior, anterior most point on the vertebral
body

o

Diagnosis is based on the direction of EASE



Gross range of motion of cervic
al spine


composite of jonts,
ligaments, muscles, etc

o

Flexion



50

degrees (able to touch chin)

o

Extension



60

degrees (able to stare directly at ceiling)

o

Lateral rotation



80

degrees ( able to rotate head until
chin is in line with shoulder

o

Lateral
flexion



45
degrees (able to lateral sidebend 45
degrees)



Segmental range of motion C
-
spine

o

50% flexion and extension at OA



Remainder is C2
-
C7

o

50% of rotation at AA



Remainder is C3
-
C7



Motion Mechanics

o

OA



Major motion is flexion and extension



Minor motion is rotation and sidebending



Occipital condyles converge anteriorly



Lateral portion of atlas articulation more cephalad
than medial portion



Rotation of occiput causes sidebending to
opposite side

o

AA



Major motion is rotation



Transverse ligament
portion of cruciate ligament
supports atlas as it rotates around odontoid process



Cephalad to caudad (uphill to downhill)
movement
accompanies this rotation

o

Typical Vertebrae (C3
-
C7)



note: see slide 44 for picture



Typical cervical joints (C2
-
C7)



This art
iculation of the undersurface of C2 on C3 is
considered a “typical” articulation



Sidebending can produce “side
-
slip” into the convexity
due to saddle shape of vertebral surfaces



Translation is opposite to the direction of
sidebending



The joints of Luschka
guide the vertebral bodies
movement in flexion/extension



Because of the sellar shape of surface, slide is in
the same direction as the motion



Flexion


anterior slide



Extension


posterior slide



The joints of Luschka

gap and compress in lateral
flexion
-
rotation limiting that motion



Typical cervical segments

o

C2
-
C7


joints of Luschka



Unciform joints, synovial joints



Assist in maintaining stability



Act as guide rails for flexion/extension, limits
translatory motion
, pro
tects against subluxation
sideways

o

C3
-
C7


typical vertebrae



2 articulatory facets (each side): 1 superior, 1 inferior
=> form the articular pillars



Sidebending and rotation are coupled motions



Slight flexion/extension



R
x
S
x



Cervical spine has
no neutral p
osition

Palpation and Diagnosis



Screen then diagnosis

o

Gross range of motion

o

Screen for TART changes

o

Individually diagnose OA and AA

o

Screen sidebending of typical cervicals with translation

o

Diagnose segmental areas of dysfunction identified with your
screen
ing



Typical cervical vertebrae



Locate articular pillars

o

Translation



Using the pads of the fingers translate the C2 vertebrae
laterally to the left, testing the motion and then
translate it laterally to the right



Is there an easy and/or resistant side?



Does this change with repeat testing with the neck
flexed?



Check all the vertebrae accordingly. Is your patient able
to discern a similar finding? Is there pain?



Now try rotation, does it correlate?

o

Diagnosis
-

Translation



Translated left = sidebent right



Translated right = sidebent left



Notice which direction the segment translates easier



T
he segment is sidebent right if it translat
es freer
to the left



The segment is sidebent left if it translates freer
to the right



If the dysfxn gets better with flexion
, then the freer
motion is flexion



If the dysfxn gets better with extension, then the freer
motion is extension



Each cervical vertebral unit from C2
-
C7 may be tested
this way (ex. C2 on C3, C3 on C4, etc.)

o

Rotation



Same starting position



Cradle head and ne
ck in your hands



Index fingers approximate ea
c
h other just lateral to the
spinous processes



Introduce a small amount of extension to localize force
to the segment being tested



Add a component of rotation by applying an anterior
force alternately to each si
de



Notice which direction the segment rotates easier

o

Diagnosis


Rotation



The segment is rotated left if it moves freer to the left



The segment is rotated right if it moves freer to the
right



If restriction of rotation is found, identify whether it is
grea
test in flexion or in extension



If the dysfxn gets better in
flexion, the freer
motion is flexion



If the dysfxn gets better in extension, the freer
motion is extension



Each cervical vertebral unit from C2
-
C7 may be tested
this way

o

Segmental motion testing



At a segmental level C2
-
C7, motion is difficult to assess
by directly flexing and extending



Extension can be induced by pressing anterior at the
segmental level



Flexion can be induced by flexing the neck to the
involved level



Screen with the lateral
translation test for side bending.
Once an area of restriction is identified try translation
with flexion, then extension

o

Nomenclature



Vertebral level (OA, AA, C2
-
C7)



Flexion or extension



Rotation (R or L)



Sidebending (R or L)

Counterstrain


See JB’s char
t for pictures

and more details



Cervial SCS

o

Cervical spine has multiple mavericj points

o

Anterior tenderpoints typically located on the most lateral
aspect of the lateral masses or slightly anterior on the lateral
masses

o

Posterior tenderpoints are found on
the occiput or associated
wit
h the tip of the spinous processes or lateral to the spinous
processes

o

STAR


sidebend toward, away rotate from tenderpoint

o

SARA


sidebend away, rotate away from tenderpoint


Lecture 2


Thoracic

spine evaluation and diagnosis


Fxns of the thorax



Shield


vessels, lymphatic’s, sympathetic chain, heart, lungs



Respiration



Pump for low pressure circuatory system

Thoracic Vertebra



Characteristics

o

Medium sized body

o

Superior and inferior articular processes

o

Facet joint in transverse
process to articulate with rib



60
degree slope

o

Facets on body to articulate with ribs

o

Sloping spinous process




o

Anatomy of thoracic vertebrae can be broken down into post
and ant
erior

parts using the
pedicle

as the dividing point.



T
he
pedicle

can also b
e referred to as the
pars
interarticularis
.

o

Anterior is the vertebral body. Spinal canal.

o

Articular processes
-

superior and inferior
. Going out
laterally the
transverse proce
sses
and medially, the
spinous process
. THINK OF THE
LAMINA

as bridging the
tr
ansverse process to the spinous process.

o

From the lateral view:
demi
-
facets for articulation with
rib heads
; a better view of the
sup and inf facets
on the
articular process
;
facet depiction on the transverse
process
.

o

Appreciate the angle of the
articular

facet
. This will change
subtly progressing cephalad and caudally


allowing for
transisitoinal zones at the cervico
-
thoracic and thoraco
-
lumbar junctions.

o

Due to the arrangement of rib heads, the circular thoracic
cage and angulation of the spinous pro
cesses, the primary
mot
ion in the thoracic spine is:
ROTATION

o

The thoracic vertebrae serve as a transition between the
cervical and lumbar vertebrae



U
pper four thoracic vertebrae are like cervical


vertically

oriented articular facets and posteriorly
dire
cted spinous processes



L
ower four thoracic vertebr
ae contain more lumbar
features


larger bodies, robust transverse and spinous
processes, and
lateral

projecting articular facets



M
iddle four thoracic vertebrae have characteristics
between these two regi
on
s



vertically oriented
articular processes and long, slender, and inferiorly
inclined spinous

processes



Anatomy

o

Scoliosis


abnormal lateral curvature of spine



May also have a rotational component

o

Kyphosis


accentuation of nml shape of thoracic spine



Palpations

o

Viscero
-
somatic reflexes



Bronchus


T2
-
4



Lung


T2
-
5



Pleura of lung


1
-
11, same level



Heart


T2
-
5, left



Stomach


T5
-
9, left



Pancreas


T6
-
9, both



Duodoenum


T7
-
10, right



Gallbladder


T9, right



Liver


T5
-
9, right



Kidney, ureter


T10
-
12, same side



Adrenals


T10
-
11, same side



Appendix


T11
-
12, ribs right



Fallopian tubes


T11
-
12, L1

o

Pre
-
ganglion sympathetics

o

Chapmans reflex points

o

Jones Strain
-
Counterstrain tenderpoints

o

Travell’s Myofascial trigger points

o

Thoracic Sympathetic Inn
ervations


May contribute to
spinal facilitation and TART changes




Heart


T1
-
T5



Stomach


T5
-
T9



Liver and gallbladder


T6
-
9



Pancreas


T5
-
11



Small intestine


T9
-
11



Colon and rectum


T8
-
L2



Kidney and ureters


T10
-
L1



Urinary bladder


T10
-
L1



Ovary and fallopian tube


T9
-
T10



Testicle and epididymus


T9
-
10, L1
-
L2



Uterus


T10
-
L1

Jones Strain
-
Counterstrain



Jone’s tenderpt


small hypersensitive pts

in the
myofascial
tissues

of the body used as
diagnostic criteria

and
treatment
monitors



Strain
-
Counterstrain

o

Indirect treatment

utilizing a myofascial tenderpt
reflective of musculoskeletal dysfxn

elsewhere in the
body

o

Relieved by placing the patient into a
position of ease

Rule of 3’s


approximate the positions of the thoracic spinous processes
re
lative to the transverse processes



T1
-
3, 12


equal



T4
-
6, 11


½ level up



T7
-
9, 10


1 level up

Freyettes Principles



Type I



When the spine is in neutral position and sidebending is
induced,
rotation and sidebending will be in OPPOSITE
directions

o

Found in

neutral

o

Occur in thoracic and lumbar regions

o

Involves long curves (
multiple segments
)

o

Rotation and sidebending are opposite

o

Make sure to check both superior and inferior

o

Example: T 2
-
4 N S
R
R
L



Type II


When the spine is flexed or extended beyond the neut
ral
position and sidebending is induced, rotation and sidebending of at
least one segment will be to the same side

o

Found in flexion or extension

o

Occur in thoracic, lumbar and cervical regions

o

Single segments (occasionally in small groups)

o

Rotation and
sidebending are to the same side (rotation
precedes sidebending)

o

Example: T 3 E Rot L Sb L




Type III


initiation of motion in any one plane will modify motion
in the other two planes

Evaluation and Diagnosis



Thoracic somatic dysfunction

o

Type (I, II, Bilat
terally extended, thoracic inlet)

o

Location (T1
-
12)



Rib somatic dysfxn

o

Type (inhaled or exhaled)

o

Location



Upper (ribs 1
-
4)



Middle (ribs 4
-
8)



Lower (ribs 9
-
12)

o

Pump or bucket



Thoracic examination

o

Observation



Posture



Breathing

o

Palpation



Global screen (GROM)



Directed soft tissue screen



Paraspinal red reflex


changes in paraspinal
musculature



Paraspinal hypertonic

changes



Segmental screen



Springing



Palpatory diagnosis


pt seated or prone

o

Screen



Run fingers along paraspinal

muscles assessing for
TART



Palpate along spinous processes assessing for midline
orientation and proximity



Spring at costo
-
trasverse jxn or midline on spinous
processes

o

Segmental motion testing



Place finger pads on transverse processes (tp)



Engage the vertebra to the left and right
by pushing on
the L tp and then engage the right side by pressing on
the R tp => engaging rotation



Check with the segment in flexion and extension



Check movement of spinous process relative to one
above and below with active flex and ext.



Inhale


extensio
n



Exhale


flexion



Documentation

o

Segment involved

o

N, F, E

o

Direction of sidebending and rotation

o

**remember: if B/L flex or ext then no Sb or Rot involved


Lecture 3


Osteopathic Examination of the Lumbar Spine


Incidence



85% of the general population will

have low back pain

o

2
-
5% of the general pop. yearly reports low back pain



Back pain occurs in 35% of adolescent athletes



Overise back injuries are prone to recurrence

o

26% males, 33% females



27% of back pain in adults is due to musculoskeletal strains

Anato
my



Vertebrae are built for support of heavy loads ina fairly neutral
plane



Allows for a fair amount of flex and ext



Less of sidebending and rotation due to sagittal orientation of facets

Facet / Posterolateral complex



Comprised of:

o

Bony facets

o

Joint betwee
n facets



Articular surfaces



Ligaments/capsule surrounding joint

o

Neural foramina anteriorly

o

Lamina

o

Ligamentum flavum



Usually produces localized sharp pain with loading that may radiate

Lumbar spinal mechanics



L
-
spine

o

Narrowing of intervertebral foramen

o

Ante
rior disc becomes taut

o

Facets slide up



L
-
spine flexion

o

Nucleus deforms posteriorly

o

Interveterebral foramen enlarge

o

Facets slide up



L
-
spine sidebending

o

Facet on the opposite side slides up

o

Facet on the same side slides down

o

Disc flattens on the ipsilateral

side



L
-
spine rotation

o

Same side facet joint opens in distraction

o

Disc is compressed

o

Vertebra translates to the same side

Barrier concept


see diagrams on slides 15, 16, and 17



Anatomic barrier



Physiologic barrier



Pathologic barrier

o

This is where the comp
laint lies

o

This is where you will be working with your patients

Mechanics

(REFER TO THORACIC LECTURE FOR SPECIFICS ON TYPE I AND II
MECHANICS)



Lumbars

o

Just like thoracics

o

Follow Type I mechanics in neutral position



Maintained by large groups of vertebrae

o

Follow Type II mechanics in non
-
neutral position



Inhale


flexi潮



Exhale


extensi潮



Maintained by short restrictors

o

This is the rule in nml mechanics and dysfxn



Lumbosacral mechanics

o

Sacrum and lumbar spine

spine move in opposite directions

o

Lumbar flexion


sacral extension

o

Lumbar extension


sacral flexion

Lumbar examination



Range of motion

o

Patient seated / standing

o

Screen with fingers

o

Note skin changes, tenderness and prominece differences


TART

o

Hone in on these areas for further examinati
on



GROM



Single segment motion



Pt either prone or seated

o

Anteriorly compress the R tp (inducing left rotation)

o

Then repeat for left

o

Repeat rotation test with flexion, then extension, and
compare to neutral

o

Findings



If the motion is roughly the same in both
flexion and
extension


Neutral, Type I



If the motion is more restricted in flexion or extension


F or E, Type II



The flexion/extension component of the positional
diagnosis is the plane in which the restriction lessened
(or moves more freely)

Red Flags i
n low back pain



Major trauma mechanism



Age > 50 or <20



History of cancer




Cauda equina symtpoms

o

Saddle anesthesia

o

New onset bladder/bowel dysfxn

o

Severe or rapidly progressive neurological symptoms



Cons
t
itutional symptoms

o

Fever

o

Chills

o

Unexplained weight
loss

o

Recent bacterial infection

o

IV drug abuse

o

Immune suppression

o

Severe night time pain

Indications for treatment



Adjust muscle tone



Return ROM



Produce joint mobilization



Improve respiratory and or circulatory fxn



Return symmetry

Contraindications



Absolute

o

No somatic dysfxn present

o

Lack of patient consent or cooperation



Relative

o

Pt who cannot voluntarily relax

o

Severely ill pt

o

Vertebral artery disease

o

Severe osteoporosis

Strain
-
Counterstrain


See JB

s guide


Lecture 4


Intro to Treatment of the
Lymphatics


Osteopathic philosophy



Illness is often caused by mechanical impediments to nml flow of
body fluids and nerve activity



Removal of mechanical impediments allows optimal blody fluid flow,
nerve fxn and restoration of heath

History of lymphatics



1653


lymph
atic system first described by Olaf Rudbeck, professor
of medicine at Uppsala University in Sweden



1890s


A.T. Still first doc to emphasize lymphatic treatment for
health maintenance



1904


Frederic Millard, D.O. studies lymphatic’s

o

published Applied Anat
omy of the Lymphatis in 1922



1926


C. Earl Miller, D.O. first described the lymphatic pump
technique



1929


William Galbreath technique for mandibular and middle ear
drainage



Frank Chapman, D.O. developed a series of “neurolymphatic
reflexes”


chapman’s
points

Lymphatic System



Continuous network of filters and drainage which help remove
toxins



Passive system


relies on arterial pressure, muscle contraction,
thoracoabdominal and pelvic diaphragms, system of one way valves



We would die w/in 24 hours from t
oxin buildup if it stopped fxning



Organized lymphatic tissue

o

Spleen

o

Thymus

o

Tonsils

o

Appendix

o

Visceral lymph tissues (GI, pulmonary, liver)

o

Lymph nodes



Collecting ducts

o

Largest trunks drain into the venous system

o

Left thoracic duct


drains into left
subclavian vein



Drains 75% of body’s lymph

o

Right thoracic duct


drains into right subclavian vein



Drains 25% of lymph from the upper right quadrant of
body



Terminal drainage sites used to diagnose regions of tissue
congestion

o

Supraclavicular space


head
and neck

o

Posterior axillary fold


a牭

o

Epigastric area


abd潭en and chest

o

Inguinal area


l潷e爠ext牥mity

o

Popliteal area


leg

o

Achilles tendon


f潯o

Lymph fluid



Ultrafiltrate that leaks out of arterial capillaries into the interstitium

and back into lymphatic bessels



Consists of

o

Lymphocytes

o

Protein and salts

o

Postprandial water

o

Soluble fats

o

Clotting factors

o

Bacteria and smaller viruses

Fxns of Lymphatic System



Maintain
fluid balance

o

Avg. of

30L of fluid filters out of capillaries every day

o

90% is resorbed

o

10% is resorbed by the lymphatic system



Purification and cleansing of tissues



Defense



B and T cell lymphatic systems



Nutrition

o

Approx 50% of all plasma proteins are carried here

o

Nutrient
binding

o

Fats, cholesterol, chylomicrons

Pathophysiology



Poor fxn



Congestion



Edema

Superficial and Deep nodes



Superficial (palpable)



cervical, axillary, supraclavicular,
epitrochlear, inguinal



Deep (non
-
palpable)



intrathoracic, intraabdominal, pelvic,
d
eep cervical

Cervical Nodes


know the names of each



OMT and Lymphatic Techniques

(See Lab Handout for directions on how to
perform these techniques)



Two broad based categories of lymphatic techniques

o

Removing restrictive barriers

o

Promote and augment th
e flow of lymph



Goal: increase venous and lymohatic return

o

Balance the system to restore fxn

o

Removing edema

o

Proper fluid dynamics

o

Increased resorption of fluids

o

Increased circulation and respiration

o

Decreased proteins in the interstitium

o

Facilitation from
a more beneficial pH balance

o

Maintain proper immune response



Sequencing treatment

o

Release of th
e

central lymphatic system should be
accomplished first, followed by release of periphery



This decreases the chance of exceeding the
system’s innate 7 mm Hg max. increase in
capability of handling increase flow

o

Begin by releasing the thoracic inlet, then abdominothoracic
diaphragm, then pelvic diaphragm

o

Lymphatic treatments should be accomplish
ed by a r
e
lease of
all respiratory restrictions
,

as well as restrictions of muscles,
joints, and the abdomen



Techniques to remove restrictive barriers and promote and
augment flow

o

Open thoracic inlet



removes restrictive impediments



Many neurovascular str
uctures pass through here



This is the first area to address



Indications


any dysfxn or lymp congestion caused or
exacerbated by fascial tone asymmetry



Contraindications


do not use if pt has painful,
severely restricted motion of shoulder

o

Rib raising



r
educes hypersympathetic activity to the
lymphatic vessels and mobilization of the ribs enhances
respiration



Sympathetic chain lies anterior to rib heads



Affecting these produces systemic effects



Thoracic duct closely associated with this area



Cysterna chil
i is a dilation of the thoracic duct at its
inferior pole


drains all the lower extremities, pelvis
and abdomen

o

Doming abdominal diaphragm



improves the ability of
this major fibromuscular
diaphragm to produce effective
pressure gradients between thoraci
c and abdominal cavities,
therefore promoting and augmenting flow

o

Ishiorectal fossa release



improves the ability of the
pelvic diaphragm to produce effective pressure gradients
between pelvic and thoracic cavities, therefore promoting and
augmenting lymp
hatic flow

o

Correcting somatic dysfxns in areas of concern



removes restrictive barriers

o

Lymphatic pump techniques



promotes and augments
lymphatic flow



Thoracic



Improves the ability of this structure to produce
effective pressure gradients



Pelvic



Pectoral traction



Assists in opening thoracic inlet



Encourages venous and lymphatic return through
the right lymphatic and thoracic ducts



Helps to expand fascial barriers



Pedal



Plantar flexion or dorsiflexion



Helps pelvic diaphragm move



Hepatic and splenic

techniques

o

Direct pressure techniques



promotes and augments
lymphatic flow

Lymph flow in the thoracic duct



Abdominal pump


increased from 1.57 +/
-

0.20 to a peak of 4.80
+/
-

1.73 during treatment



Thoracic pump


increased from 1.20 +/
-

0.41 to 3.45 +/
-

1.61



Physical activity


increased from 1.47 +/
-

0.33 to 5.81 +/
-

1.30

Contraindication
s to Lymphatic techniques



Osseous fractures



Malignancy


esp. primary lymphatic cancers



Bacterial infections with a temperature

of 102F or greater


antibiotic control should be implemented first to reduce the chance
of seeding and encouraging a generalized body infection


Lecture 5


general survey and vital signs


General survey



Begins with the first moment of patient encounter



Apparent
state of health



acutely or chronically ill, sick, frail,
fit, healthy



Level of consciousness



is the pt awake, alert, and responsive
to you and others in the environment



Signs of distress


clutching chest, pallor, diaphoresis, labored
breathin
g, wheezing, cough



Pain



wincing, sweating, protectiveness of painful area, facial
grimacing, unusual posture favoring one limb or body area



Skin



pallor, cyanosis, jaundice, rashes, bruises



D
re
ss, personal hygiene, grooming


appropriate to the
temperat
ure and weather? Clean, properly buttoned and zipped?
How does it compare with clothing worn by people or comparable
age and social group?



Facial expression



observe at rest during conversation (specific
topics), during physical exam, and in interaction w
ith others. What
for eye contact. Is it natural? Sustained and unblinking? Averted
quickly? Absent?



B
o
dy and breath odor



fruity odor of diabetes or scent of
alcohol? (CAGE questions)



P
osture, gait, motor activity



what is the patient’s preferred
posture? Preference for sitting up
-

left
-
sided heart failure, leaning
forward with arms braced in


chronic obstructive pulmonary
disease. Is the patient restless or quiet? How often does the patient
change position? How fa
st are the movements?

Height



Measure in stocking feet



Is the pt unusually short or tall?



Is the build slender or stocky?



Is the body symmetric?



Note the general body proportions and look for any deformities.



Examples of abnormalities

o

Very short stature: Tu
rners Syndrome, childhood renal
failure, achondroplastic and hypopituitary dwarfism

o

Long limbs in proportion to trunk: hypogondaism and
Marfan’s Syndrome

o

Height loss: osteoporosis and vertebral compression fractures

Weight



Is the pt emaciated, slender,
plump, obese, or somewhere in
between?



If pt is obese, is the fat distributed evenly or is it concentrated

over
the trunk, the upper torso, or around the hips?



Examples of abnormalities:

o

Generalized fat in simple obesity

o

Truncal fat with relatively thin li
mbs: Cushing’s Syndrome and
metabolic syndrome

o

Causes of weight loss: malignancy, diabetes mellitus,
hyperthyroidism, chronic infection, depression, diuresis and
successful dieting

Body Mass Index

(BMI)



Derived from two surveys: the National Health Examina
tion Survey
(1969
-
1970) and the National Health and Nutrition Examination
Survey (1970
-
1990)

Methods to Calculate Body Mass Index (BMI)

Unit of Measure

Method of Calculation

Weight in pounds,

height in inches

(1)Body Mass Index Chart

(see table on p.
91)

(2)
Weight (lbs) x 700
*


Height (inches)



Height (inches)


Weight
in kilograms,

height in meters
squared

(3)
Weight (kg)


Height (m
2
)

Either

(4) “BMI Calculator” at website
www.nhlbisupport.com/bmibmicalc.htm

Classification

of Overweight and Obesity by BMI


Obesity
Class

BMI (kg/m
2
)

Underweight


<18.5

Normal


18.5
-
24.9

Overweight


25.0
-
29.9

Obesity


I

30.0
-
34.9

II

35.0
-
39.9



Extreme

obesity

III

>
40



Affected by muscle mass
:

o

More muscle > BMI, but still healthy
(overestimates)

o

Low muscle mass, nml BMI, but may not be healthy
(underestimates)



Waist circumference

o

Place measuring tape snugly around waist

o

Good indicator of ab fat which is another predictor of your risk
for developing chronic disease

o

Men > 40 inches


highe爠物sk

o

Women > 35 inches


highe爠物sk



Overweight ppl may be at risk for:

o

Type II diabetes

o

Coronary heart disease or stroke

o

Metabolic syndrome

o

Certain types of cancer

o

Sleep apnea

o

Osteoarthritis

o

Gallbladder disease

o

Fatty liver disease

o

Pregnancy
complications



Adults with a BMI of 25 or higher are at risk for premature death
and disability

Vital signs


blood pressure, heart rate, respiratory rate, temperature (pain
is 5
th

and smoking status is questionable)



Blood pressure (optimal conditions)

o

Avoi
d smoking or drinking caffeinated beverages 30 minutes
prior

o

Ensure room is quiet and comfortably warm

o

Seated in chair with feet on floor for at least 5 minutes

o

Arm should be free of clothing

o

Palpate the brachial artery and position arm so that the
brachia
l artery is at the level of the heart



Too high


BP may be lower



Too low


BP may be elevated

o

Measurement



Center cuff over brachial artery with lowver border
about 2.5cm above the antecubital fossa



Secure cuff snugly and position pts arm so that is
slightl
y flexed at the elbow



Palpate radial artery and inflate the cuff until you
cannot feel it. Add 20mm Hg to that pressure



Deflate and wait 15
-
30 sec



Place bell of stethoscope lightly over brachial artery and
inflate the cuff to pressure previously determined



Deflate slowly at 2
-
3 mm Hg/ sec (Korotkoff sounds)



The point where you hear the first two
consecutive beats is systolic



Disappearance point is diastolic (some ppl have a
condition called aortic regurgitation in which the
sound will not disappear)



Read
both Systolic and Diastol
ic

to the nearest 2mm Hg
and wait 2 minutes to repeat

(if it differs more than 5
mm Hg take additional readings)



Initial measurements should be taken in both arms
(may differ 5
-
10 mm)



Pressure differences more than 10
-
15 mm Hg may
be
found in subclavian steal syndrome and aortic dissection

o

Blood pressure cuff



Width: 40% of upper arm circumference (12
-
14 cm in
adults)



Length: 80% of upper arm (encircle arm)



If the cuff is too small the pressure will be elevated



If the cuff is too lar
ge the pressure will be lower on a
small arm and higher on a large arm



Standard cuff is 12X13 cm appropriate for arm
circumferences up to 28 cm

o

Ascultatory gap



Silent interval that may be present between the systolic
and diastolic BPs (typically seen in el
derly pts)

o

Orthostatic blood pressure



Measure BP and HR with pt supine, then have the pt
stand up, wait 3 minutes and repeat



Nml systolic BP drops slightly or remains unchanged,
diastolic rises slightly



Orthostasis: systolic BP drops >20mm Hg or diastolic
BP drops > 10 mm Hg




Pulse

o

Radial pulse is commonly used to asses HR

o

If the rhythm is regular and the rate seems nml count the
rate for 30 sec and multiply by 2



Respirations

o

Observe the rate, rhythm, depth, and effort of breathing

o

Count number of
respirations in 1 minute either by watching
their chest rise or lightly placing stethoscope over trachea

o

Abnormalities



Nml rate is 14
-
20 breaths per minute (adults) and
up to 44 in infants



Bradypnea (slow)



May be secondary to causes as diabetic coma,
drug

induced respiratory depression, and
increased intracranial pressure



Tachypnea (rapid, shallow)



Number of causes such as restrictive lung
disease, pleuritic chest pain, elevated diaphragm



Cheyne
-
Stokes Breathing



Periods of deep breathing alternate with apn
ea


children and aging ppl may do this



Other causes: heart failure, uremia, drug
-
induced
respiratory depression



Hyperpnea, hyperventilation



Causes: exercise, anxiety, metabolic acidosis



Kussmaul breathing is deep breathing due to
metabolic adidosis

(may b
e fast, nml or
slow)



Ataxic breathing (Biots Breathing)



Unpredictable irregularity


may be shallow or
deep, and stop for short periods



Causes: respiratory depression and brain damage
(typically at the medullary level)



Temperature

o

Average oral temp: 37C (9
8.6F), which fluctuates (35.8C


37.3C)



Use glass or electronic thermometer

o

Rectal temp. is higher than oral by about 0.4C


0.5C, but the
difference is variable



Pt lies on one side with hip flexed, stick lubricated
thermometer in anal canal about 3
-
4 cm

o

A
xiallary temp. is lower than oral by about 1C and is less
accurate

o

Tympanic temp is typically 0.8C higher than oral temp



Make sure the infrared beam is aimed at the tympanic
membrane



Uses core body temperature

SOAP Note

(Refer to Lab Handout or Slides 34
-
4
4 for example)



Useful in longitudinal care



Useful for other practitioners who care for your pt.



Used throughout the healthcare community



Used in short notes for patient encounters and for extended full
history and physical exams



Format

o

S: subjective



History only: chief complaint, hx of present illness,
symptoms in paragraph form, hx in bullet form



OLD CARTS

o

O: objective



what y潵 see



Physical examination: general appearance, system
headings, osteopathic findings, lab

o

A: assessment



Differential diagno
sis in order of likelihood (min of 3)

o

P: plan



Therapeutic plan, notice of intent to perform prohibited
exam or forgotten exam



MOTHRR



Medicines


name, dose, frequency



Osteopathic treatment


Dx, OMM



Testing


labs be specific



Humanistic issues


can they comply with plan



Referrals


when necessary



Return visit


indicate when to come back or
when to call ER





LECTURE MATERIAL FROM FIRST EXAM THAT IS RELEVANT TO THIS
MATERIAL


Lecture 2

Homeostasis



Maintenance of static or constant conditions in

the internal
environment



The level of well
-
being of an ind. maintained by internal physiologic
harmony that is the result of a relatively stable state of equilibrium
among the interdependent body fxns

Allostasis



Remaining stable by being variable



Allostat
ic load

o

Coined by McEwen and Steller in 1993

o

The physiological costs of chronic exposure to fluctuating or
heightened neural or neuroendocrine response that results
from repeated or chronic stress

o

Explains how frequent activation of the body’s stress
respo
nse, essential for managing acute threats, can in fact
damage the body in the long run



Disease is a symptom or sign of the level of one’s life

o

The body’s abnormal response to nml stress

o

An abnormal response to an abnormal internal stress

o

Body’s reaction to

an environmental external stress

TART



Tissue texture changes



Asymmetry of structure



Restriction of motion



Tenderness to palpation

Tissue Texture Changes



Acute

o

Articular mobility


sluggish, guarded motion, range restricted

o

Myofascial


flaccidity and then

contraction

o

Vascular


heat, erythema and/or edema

o

Neural


skeletal pain, visceral irritation



Chronic

o

Mobility


limited range, quality good

o

Myofascial


fibrosis

o

Vascular


constriction (cool, dry, blanched)

o

Lymphatic


edema, congestion

o

Neural


tenderness, paresthesia, itching, symathicotonia,
visceral effects

Restriction of Motion



Motion

o

Nml vs abnml

o

Voluntary vs involuntary



Motion Barriers

o

Physiologic

o

Anatomic

o

Restrictive



Motion


a change of position with respect to a fixed system or
an
act or process of a body changing position in terms of direction,
course and velocity



Types

o

Inherent


spontaneous motion of every cell, organ, system
and their component units within the body

o

Respiratory

o

Physiologic


changes in position of body struct
ures within the
nml range

o

Active


movement produced voluntarily by a pt.

o

Passive


motion induced by the doc while pt remains passive
or relaxed



Nml

o

Range of nml active motion occurs b/n the physiologic
barriers

o

Nml joint has a midline or a neutral pt wit
hin its range of
motion



Motion Loss

o

Occurs in the range of nml physiologic motion



Motion Barrier

o

Limit to motion

o

Defining barriers


palpatory end feel characteristics are
useful



Quality of Motion

o

Clue to evaluating motion characteristics of somatic dysfxn

o

Motion is asymmetric

o

Ease and bind



Bind


restriction in one direction



Ease


freer motion in other direction



Physiologic Barrier

o

End pt of nml physiologic motion

o

Range of nml active motion occurs b/n physio barriers



Anatomic Barrier

o

End pt of permitted
passive movement

o

Motion beyond the anatomic barrier damages anatomic
structures



Restrictive Barrier (aka pathologic barrier)

o

End pt of permitted motion in somatic dysfunction

o

Movement towards the restrictive barrier exhibits bind

o

When treating you must shi
ft the midline



The midline is going to be where the muscles are most
supple

Somatic Dysfxn



In one way or another an area of somatic dysfxn is an area of
abnml motion



We use the barrier concept in palpating and diagnosing areas of
abnml motion



Diagnosis

o

Tis
sue texture changes ( or abmnlty)

o

Asymmetry

o

Restriction of motion

o

Tenderness



Asymmetry and restricted range of motion occur as a result of
somatic dysfxn that created a restrictive barrier



Motion loss is maintained by the restrictive barrier



Classification

of somatic dysfxn

o

By duration



Acute



Immediate



Short term



Chronic



Prolonged

o

By etiology



Primary (usually traumatic)



Sudden trauma, postural imbalance



Microtrauma and repetitive trauma



Secondary



Compensation for primary or MSK problem



Reflex response to
visceral or emotional

o

By motion



In an area of dysfxn and restriction, we name the
dysfxn by what motion remains
-
> the direction the
structure can still move towards

o

By location (and or number)



Single component



Single vertebral unit



Rib, fibular head, inno
minate at the SI joint



Multiple components



Several vertebrae in a group



Tarsal bones, pelvic girdle



OMT

o

Therapeutic application of manually guided forces to improve
physiologic fxn and or support homeostasis that may have
been altered by somatic dysfxn

o

Var
iety of techniques



Two major factors determine choice of technique



Ability of pt to respond to treatment



Ability of doc to perform the technique

o

Direct technique



Positioning in the direction of the restrictive barrier



Activation force is applied



Movement
thru restrictive barrier



Soft tissue



Direct myfascial



Articulation



Muscle energy



Thrust



HVLA


hi velocity, lo amplitude

o

Indirect technique



Positioning away from the restrictive barrier



Move tissues in a direction that is freer



Release by inherent forces



I
ndirect myfascial release



Counterstrain



Facilitated positional release



Fxnal technique



Ligamentous release



Balanced ligamentous release



Ligamentous articular strain



Cranial

o

Treatment models



Structural Model



Biomechanical adjustment and mobilization of
joi
nts



Remove restrictions and limitations of motion in
soft tissue and myofascial structure to enhance
freedom of motion



Respiratory Circulatory Model



Improve diaphragm restrictions in the body



Metabolic Model



Enhance self healing and self regulatory
mechanism of body



Enhance energy expenditure and exchange



Enhance immune fxn



Neurologic Model



Attain autonomic balance and address neural
reflex activity, remove facilitated segments,
decrease afferent nerve signals and decrease pain



Behavioral Model



Impro
ve to biopsychosocial aspects of the health
spectrum including emotional balancing and
compensatory mechanisms



Role of limbic system in perception of pain



Depression and musculoskeletal pain


Lecture 3

The medical interview



Comprehensive


for new pts



Prob
lem oriented


pts with a specific complaint



By the end of the interview 2 judgments need to be made

o

Clinical


focus on diagnosis and treatment

o

Practical


focus on the “right thing to do” for the pt.



To make these judgment we need to develop 2 histories

o

History of the person


personal narrative or illness story

o

History of the symptoms


causal account of systems,
processes and symptoms or “disease story”

o

Usually the history of the symptoms ends up in chart, but the
other defines the doc
-
pt relationship

O
pen and Closed Questions



Use open questions to hear the story



Ask more specific questions to begin to fill in the detail



Yes

no questions

Doorway Note


1 min



Write down pt age, setting, chief medical complaint if given, vitals



Use of empathy begins
before you enter the room

o

Includes congruence (genuineness), unconditional positive
regard (acceptance of communicated experience w/o
judgment or criticism) and assurance of understanding

Once in room



Initiation and self
-
introduction (1
-
2 min)



The chief co
mplaint (2 min)

o

Clarify

o

Write down the CC in the pts words verbatim



Establishing Understanding and Concluding


Lecture 4

Somatic dysfxn



Impaired or altered fxn of related components of the somatic (body
framework) system: skeletal, arthroidal, and myofasci
al structures,
and related vascular, lymphatic and neural elements

Structural Diagnosis



Observation



Palpation

o

Info


tissue changes



Temp



Texture



Surface humidity



Elasticity



Turgor



Tissue tension



Thickness



Shape



Irritability



Motion

o

Communication


pt and
doc

o

Treatment

o

Layers



When palpating we are contacting skin but feeling
through



Skin



Superficial fascia



Deep fascia



Muscle



Bone and joint



Anatomical layers



Skin



Epidermis



Dermis



Fascial Layers



Superficial



Deep



Muscle



Bone

Skin



Palpatory information

o

Temp

o

Flu
id status

o

Oily/dry


measure of autonomous nervous tone



Skin drag



Red reflex

Subcutaneous


fascial layers



Superficial

o

Structure



Cxn tissue make up: fibroelastic tissue and adipose
tissue



Pacinian corpuscles



Lymph, blood vessels, nerve trunks

o

Fxn



Deep
pressure reception



Insulation



Mobility



Temperature regulation



Deep

o

Structure



Cxn tissue



Dense irregular fibroelastic



Contains: muscles, organs, vessels

o

Fxn



Wrap



Support



Protects



Compartmentalizes



Subserous



Properties

o

Viscosity



Rate of deformation under a
load



Capability to yield under continual stress

o

Elasticity



Ability to recover its shape after deformation

o

Plasticity



Ability to retain a shape attained by deformation

Muscular Layers



Palpatory info

o

Tension/ spasticity

o

Acute injury



Softer



Hot



Edematous



Painful

o

Chronic



Hard



Cold



Ropey



Sore

Jones’ Strain
-
Counterstrain



Tender points vs Trigger points

o

Tenderpt (Lawrence Jones, DO): found in muscle or
attachment of muscle; manifestation of somatic dysfxn
elsewhere in the body (no pain elsewhere)

o

Triggerpt (Ja
net Travell, MD): histological changes w/in a
muscle that are palpable and cause pathology and
musculoskeletal pain and parasthesias further from site of
actual trigger pt location (triggers pain)



Mechanism of strain
-
counterstrain

o

Tenderpt arises when abnm
l muscle tone is maintained
through an inappropriate strain reflex

o

Passively placing the pt into a position of ease (POE) which
allows for resetting of the neural components involved in the
“strain reflex”


trying to relax gamma loop

o

Nml resting tone is a
chieved, resulting in balance in the
muscular system, skeletal system, neural and vascular
systems



Contraindications

o

Absolute



No somatic dysfxn present



Lack of pt consent or cooperation’s

o

Relative



Pt who cannot voluntarily relax



Severely ill pt



Vertebral
artery disease



Severe osteoporosis



Tenderpts for lower extremity

o

Lateral trochanter



Location: along the iliotibial band distal to the greater
trochanter



POE: pt supine, moderate abduction of the thigh, slight
flexion

o

Iliacus



Location: deep in fossa of ala
of ilium, 2 in medial and
slightly below ASIS



POE: marked bilateral flexion and external rotation of
the hips with the knees flexed



Tenderpts for upper extremity

o

Levator scapulae



Location: superior, medial border of the scapula at the
attachment of the lev
ator scapulae



POE: pt supine or seated, glide the scapula superiorly
and medially to shorten the mm

o

Medial epicondyle



Location: medical epicondyle (attachment of pronator
teres and common flexor tendon



POE: flexion, marked pronation and slight adduction of

the forearm with slight flexion of the wrist


Lecture 5


History of pt



Should give the diagnosis 90% of the time



Listen to pts story and guide them through the history



Expand and clarify

o

After taking history direct patient to areas that seem most
significant

o

Clarify each symptom to a more specific fact


focused
questions

o

Include the timing and chronology of the problem

Symptoms



Each one should be thoroughly questioned



Build evidence for and against each one and focus on problems that
are pertinent



Keep patient focused in a gentle manner



Keep pts concerns and relationship w/ you in focus

Disease/Illness distinction



Disease


what doc uses to explain problem, uses what he/she
learns to come up with a diagnosis



Illness


pts experiences of all the asp
ects of the disease, including
effects on relationships, fxn and sense of well
-
being

Negotiating the plan



Learning about the disease and conceptualizing the illness fives you
the ideas to decide what further eval. You need for treatment



Helps build rapport

Closing and follow
-
up



Let pt know that the end of the interview is near



Ask if he/she has further questions



Make sure they understand the problem



Always give follow
-
up instructions



Review further eval., treatments, and follow
-
up at the end

7 attributes of

a symptom



Location


where is it? Does it radiate?



Quality


what is it like?



Quantity or severity


how bad? Ask on a scale of 1
-
10 for pain



Timing
-

when did/does it start? How long does it last? How often
does it come?



Setting in which it occurs


env
ironmental, personal activities,
emotional rxns



Remitting or exacerbating factors


is there anything that makes it
better or worse?



Associated manifestations


have you noticed anything else that
accompanies it?

Open
-
ended to focused questions



Using
questioning that elicits a graded response



Asking a series of questions, one at a time



Offering multiple choices for answers



Clarifying what the pt means



Encouraging with continuers



Using echoing

Pain scale



0
-
1


no pain



2
-
3


mild



4
-
5


discomforting


mo
derate



6
-
7


distressing/ severe



8
-
9


intense/very severe



10


unbearable

Sign vs. Symptom



Sign

o

Objective evidence of disease esp as observed and
interpreted by the doc rather than pt

o

What you see



Symptom

o

What pt reports

How to characterize symptoms



OLD
CARTS

o

Onset

o

Location

o

Duration

o

Character

o

Aggravating/associated factors

o

Relieving factors

o

Temporal factors

o

Severity

PMHX/PSHX



Childhood illness



Adult illness



Immunization history



Health maintenance/screening tests

Meds



Current rx name, dosage and how often



OTC, dosage and how often



OC’s



Herbal/complimentary

Allergies



Type and symptoms



Mild, moderate, severe



Side effect vs. allergy

Family HX



Siblings, parents, grandparents



Age and health



Documents presence or absence of specific illness



Illness of history rel
ated to CC

Personal Hx



Edu level



Home situation



Lifestyle



STOP

o

Sexual history

o

Travel history

o

Occupational history

o

Pattern of eating

Review of Systems (ROS)



General symptoms



Skin, hair, nails



Head and neck



Lymph nodes



Chest and lungs



Breasts



Heart and blood

vessels



Peripheral vasculature



Hematologic



GI



Endocrine



Females


menses, pregnancies



Males


puberty onset, difficulty with erections, emissions,
testicular pain, libido, infertility



GU



Musculoskeletal



Neurologic



Psychiatric

SOAP Note


HX only


Lecture
6

Posture Balance



Optimal postural balance

o

Perfect distribution of the body mass around the center of
gravity

o

Compressive forces are balanced by tensile forces with
minimal muscular energy expenditure

o

A condition of optimal distribution of body mass in rel
ation to
gravity



Postural imbalance

o

Ideal body mass distribution is not achieved



Compensation

o

Result of the pt homeostatic mechanisms working through the
entire body unit to maintain fxn and all postural lines
maximally



Decompensation

o

Postural homeostatic
mechanisms overwhelmed


occurs in
all cardinal planes

o

Despite continuous homeostatic attempts, the fxn and/ or
postural lines are not maintained

Aspects of posture



Dynamic interaction of two forces: gravity and the strength of the
individual

o

Base of suppo
rt



All structures from feet to skull



Distribution of weight depends on



Energy requirements for homeostasis



Integrity of musculoligamentous structures



Compensation that structures have on visual
and/or balance fxns of the body

o

Group curves



Refers to the seg
mental spinal column involving
multiple vertebral units



Anterior
-
posterior (AP)



Kyphosis


spinal curve with the convexity
“looking posterior” and the concavity “looking
anterior



Primary kyphosis is thoracic



Lordosis


spinal curve with the convexity
“look
ing anterior” and the concavity “looking
posterior”



Primary lordosis


cervical and lumbar



Lateral (side
-
to
-
side)

o

Optimal posture



Balanced configuration of body



Static and dynamic



Structural



Dynamic



Clinical observation



Compensation is the counterbalancing of any change or
defect of structure or fxn

Compensated Posture



Homeostatic mechanisms working through the entire body to
maximize fxn



Occurs in all three planes of body motion



Keeps the body balanced and the eyes level



Static and dynamic postures are influenced by and influence soft
tissue fxn and interaction

Mechanics of compensatory group curves



Unilateral muscle contraction creates concavity ( short
-
term,
resolves w relaxation)



Long term anatomic adaptation associate
d with positional change
(tissue change over time)

Compensatory curves



Compensatory changes often named according to group curve

o

Sagittal plane


kyphotic or lordotic

o

Lateral curves


scoliosis

Structural examination



Gait eval.



Postural eval.

o

Postural exam



Analysis of static postural alignment in upright weight
-
bearing position



Eval of selective soft tissue tensions



Palpatory exam and segmental motion testing is vital to
understanding structure
-
fxn interrelationships

o

Eval



Provides information about the body



Postural muscles



Capability to adjust homeostasis



Presence and type of group curves



Location of postural spinal crossovers



Clues to TART changes



Clues to areas of somatic dysfxn



Insight into structure
-
fxn relationships

o

Posture


Anterior view



Head
carriage


rotation of side
-
bending in relation to
shoulders



Shoulder levelness



Rib cage configuration



Sternal deformities



Pectus carinatum, pectus excavatum



Clavicular deformities or elevation



Supraclavicular fossae


depth or fullness



Linea alba hair pat
terns



Iliac crest heights



ASIS



Patellae



Tibial tuberosities



Upper extremities



Internal/external rotation



Antecubital fossae for angles of fullness



Body space

o

Lateral view



AP cervical, thoracic and lumbar curves for inc. lordosis
or kyphosis



Gravitational l
ine


should be thru external aud.
Meatus, AC joint, greater trochanter, lateral malleolus



Sway in pelvis? Rotation in pelvis?



Knees flexed or hyperextended?



Head carriage


anterior?
-
> seen with thoracic
kyphosis

o

Posterior view



Angulation

of head carriage


mastoid



Level of shoulders, scapulae



Symmetry of paraspinal muscles



Carrying angle of elbows



Waist creases



Lower extremity external or internal rotation



Achilles tendon



Check fullness


indicative of hypertonicity or
hypotonicity



Body s
pace



Palpate



Mastoid



Level of shoulders



Inferior border of scapulae



Iliac crests



PSIS



Trochanters



Unilateral fullness left and right muscle
groups indicative of
hypertonicity/hypotonicity



Achilles tendon



Arches of feet



Tension and height



Regional exam



Stat
ic palpation



Dynamic palpation/motion testing



Segmental exam

Transitional zones


areas of the axial skeleton where structural changes
significantly lead to fxnal changes



Commonly referred to as transitional areas or junctions

o

Craniocervical (
occipitocervical)



Zone: OA



Transverse Diaphragm: tentorium cerebelli

o

Cervicothoracic



Zone: CT



Transverse Diaphragm: thoracic inlet/simpson’s fascia



C7
-
T1

o

Thoracolumbar



Zone: TL



Transverse Diaphragm: abdominal diaphragm



T10
-
L1

o

Lumbosacral



Zone: LS



Transve
rse Diaphragm: pelvic diaphragm



L5
-
S1



Accommodative



Occipito
-
atlantal jxn

o

Transitional area



Craniocervical jxn



Occipito
-
atlantal



Tent cerebrelli



Thoracic inlet

o

Cervicothroacic

o

Thoracic inlet / Simpson’s fascia



Thoracolumbar jxn

o

Thoracolumber

o

Abdominal
diaphragm



Lumbosacral jxn

o

Lowest transitional area

o

Keystone of the musculoskeletal stress pattern

o

Foundation upon which the spine is balanced and is
dependent upon



Stability



Equilibrium



Fxn of thoracic cage

Adam’s Test



Ask pt to bend forward at waist



Monit
or for symmetry of thoracic area



Observe for spinal line as well as rib hump

Standing flexion test (StFT)



Pt standing



Place our hands on the iliac crests bilaterally and your thumbs
should fall right into the area of the PSIS


move thumbs slightly
inferio
r to PSIS



Monitor thumbs as pt moves





10/19/2010 5:30:00 PM



10/19/2010 5:30:00 PM