Transcript Work Related Somatic Dysfunction

Work Related Somatic
Dysfunction
Stuart Williams D.O.
Associate Professor
OMM Dept
Sedentary Posture
• Leads to exaggeration of normal sagittal
plane curves.
– Ex: increased lordosis in cervical spine
– Ex: increased kyphosis in T spine
OA Joint
Supine Direct ME – Flexion SD
• Pt is supine & DO at head of
table
• Support lateral masses of
atlas between index finger &
thumb
• Use other hand to grasp pt’s
head and induce extension
of the occiput to restrictive
barrier
• Instruct pt to “Nod your chin
toward your throat” while DO
offers isometric counterforce
& localizes to the OA joint
• Instruct pt to relax & engage
new restrictive barrier
• Repeat steps 3-4 times &
recheck
OA Joint
Supine Direct ME – Extension SD
• Pt is supine & DO at head of
table
• Support lateral masses of
atlas between index finger &
thumb
• Use other hand to grasp pt’s
head and induce flexion of
the occiput to restrictive
barrier
• Instruct pt to “Raise your
chin upward” while DO offers
isometric counterforce &
localizes to the OA joint
• Instruct pt to relax & engage
new restrictive barrier
• Repeat steps 3-4 times &
recheck
Seated Cervical Motion Test:
•
•
•
•
•
Can do both actively and passively.
A. Forward Bending (sup & inf division)
B. Backward Bending (sup & inf division)
C. Sidebending
D. Rotation (sup & inf division)
• Look for: ROM, resistance to motion, unilateral
restriction of motion.
Cervical Screening and
Diagnostic Tests; Cervical
Soft Tissue Review
David Russo, PRF
Department of Osteopathic Manipulative Medicine
Modified by Stuart F. Williams D.O.
November 6, 2001
•
Cervical Spine Range of
Motion
Rotation
– 50% occurs at AA
joint, 50% rest of Cspine
– Should be able to
bring chin to
shoulder
– approx. 90 degrees
each directions
Cervical Spine Range of Motion
• Flexion/Extension
– total range 90 degrees
each direction
OA Sagital Plane Somatic
Dysfunction
• Forward Bending (Flexion SD)
– condyles have moved posterior in relation to C1
– space between occiput and C1 feels deeper
– patient looks like chin is tucked
• Backward Bending (Extension SD)
– condyles move anterior in relation to C1
– space between occiput and C1 feels shallower
– patient looks like chin is sticking out
Pinch Technique for Sagittal
Plane OA Dysfunction
• Examiner sitting at
patient’s side
• Stabilize tubercle of
C1 with thumb and
forefinger
• Cradle occiput in
other hand
• Rock occiput
forward and back
• Appreciate quality
of movement
Cradle Technique for OA Dx
• Hands cradle occiput
with fingertips of index
and middle fingers over
occipital articulation
• Test right and left
translation (sideslippage)
• May also check forward
and backward bending
• Somatic dysfunction
named for the way the
segment wants to move
– Opposite of the restriction
Pinch Technique for Sagittal
Plane OA Dysfunction
• Examiner sitting at
patient’s side
• Stabilize tubercle of
C1 with thumb and
forefinger
• Cradle occiput in
other hand
• Rock occiput
forward and back
• Appreciate quality
of movement
Cradle Technique for OA Dx
• Hands cradle occiput
with fingertips of index
and middle fingers over
occipital articulation
• Test right and left
translation (sideslippage)
• May also check forward
and backward bending
• Somatic dysfunction
named for the way the
segment wants to move
– Opposite of the restriction
Somatic Dysfunction of the AA
Joint
• Somatic dysfunctions occur in left and
right rotation of the AA joint
– Inspection
• head may be deviated to left or right
– Palpation
• Transverse process of atlas may feel posterior
(closer to the mastoid process) on side of rotation
– Motion testing
• Preference for rotation in one direction; limitation in
opposite
Atlanto-axial Joint
• The anatomy of the
AA joint dictates its
motion
• The AA joint moves in
rotation only & makes
up 50% of cervical
rotational motion
• There is a little bit of
“wobble” but it is
CLINICALLY
INSIGNIFICANT
Somatic Dysfunction of the AA
Joint
• Motion testing
– Forward bend
patient’s head to
“lock-out” lower
vertebrae
– Rotate left, rotate
right
– Somatic dysfunction
is named for the way
the vertebrae wants
to move
Functional Anatomy
• Atypical vertebrae
– Motion named for superior
vertebra on inferior vertebra
– Atlas (C1) on axis (C2)
• Anatomy dictates motion
– Primarily rotation, providing
50% total cervical rotation
– 45° rotation in either
direction
– Minor side-slipping, though
clinically unimportant
Functional Anatomy
• Atlas (C1)
– No Spinous process
– No Body (fell to become dens on Axis)
– Lateral masses (transverse process)
• Between angle of mandible and mastoid
• Transverse foramen hold vertebral artery and sympathetic plexus
• Acts as a lever for muscles to rotate head
• Axis (C2)
– First spinous process
– Dens (odontoid process) formed from “body” of Atlas
– Lateral masses also hold vertebral artery and sympathetics
• AA Joint
– No intervertebral disc
– Inferior articular facets of atlas are concave
– Superior articular facets of axis are convex
Atlas (C1)
Concave Surfaces
Anterior Articulation
of Dens
Dens (Odontoid Process)
Axis (C2)
Convex Surfaces
Functional Anatomy
• Atlas (C1)
– No Spinous process
– No Body (fell to become dens on Axis)
– Lateral masses (transverse process)
• Between angle of mandible and mastoid
• Transverse foramen hold vertebral artery and sympathetic plexus
• Acts as a lever for muscles to rotate head
• Axis (C2)
– First spinous process
– Dens (odontoid process) formed from “body” of Atlas
– Lateral masses also hold vertebral artery and sympathetics
• AA Joint
– No intervertebral disc
– Inferior articular facets of atlas are concave
– Superior articular facets of axis are convex
Functional Anatomy
• Atlas (C1)
– No Spinous process
– No Body (fell to become dens on Axis)
– Lateral masses (transverse process)
• Between angle of mandible and mastoid
• Transverse foramen hold vertebral artery and sympathetic plexus
• Acts as a lever for muscles to rotate head
• Axis (C2)
– First spinous process
– Dens (odontoid process) formed from “body” of Atlas
– Lateral masses also hold vertebral artery and sympathetics
• AA Joint
– No intervertebral disc
– Inferior articular facets of atlas are concave
– Superior articular facets of axis are convex
Indications For Treatment
•
•
•
•
•
Restore loss of range of motion
Improve function of upper extremity
Relieve pain or spasm in neck or UE
Relieve cephalgia (headache)
Facilitate lymphatic drainage from head into
thorax
• Balance ANS
– Parasympathetics mediated by Vagus n.
– Sympathetics mediated by cervical ganglia
Somatic Dysfunction
• S/D occurs in rotation of AA joint
– Rotation around vertical axis in transverse plane
– AA Rotated Left or Right
• Inspection
– Head deviated to right or left
– Chin not quite midline
• Palpation
– Transverse process of atlas may feel posterior or closer to
mastoid process on rotated side
– Transverse process of atlas may feel anterior or closer to
mandible on opposite side of rotation
• Motion-testing
– Preference for motion in one direction, restriction in other
– Active or passive
Regional Scanning
• Active Testing
– Patient seated, rotates
head to right and left
– Tests total motion of
typical and atypical
cervicals
• Passive Testing
– Patient relaxes while
operator takes neck
into rotation
– Should have more
motion than active
Motion Testing
• Localize motion to AA joint
– Forward bend head past 45°
– Takes advantage of Fryette’s 3rd
principle
– “Locks out” typical vertebrae
• Test isolated AA joint
– Passively rotate patient’s head
right and left
– Compare degree of movement
• Should be 45° in each direction
– Pay attention to end feel
• Normal direction should be springy
• Restricted direction should feel
tighter
Palpatory Diagnosis
• Landmarks
– Lateral masses of C1 located
between mastoid process and
angle of mandible
– Example: AA rotated left
• Left lateral mass posterior,
approximates with mastoid
process
• Right lateral mass anterior,
approximates with angle of
mandible
• Localized motion testing
– Locate C1 lateral masses
– Compare motion
Supine, Direct, ME
•
•
•
•
•
Contact lateral mass of C1 on
rotated (posterior) side with MCP
joint of index finger
Forward bend head to 45°
Rotate into barrier
Sweeten with sidebending (takes
advantage of Fryette’s 3rd Principle)
Instruct patient to turn head in
opposite direction against your
force
– Use isometric force for 3-5 sec
– Takes advantage of obliquus
capitus inferior m.
•
Upon relaxation, engage new
barrier
– Small corrections to maintain
localization
– Repeat 2-3 times until corrected
Screen the Area
•
•
•
•
•
Observe. TART.
Check the 1st ribs, spring ribs. Check fascia
Hand on neck/shoulder: muscle tension
Screen CT transverse processes
?Common compensatory pattern: SB right
Rotated right (OPP pages 46-47)
– OA CT TL LS: L/R/L/R
– Why is Non neutral SD uncommon at the CT
junction?
• (assigned OPP 516-529)
CT junction sagittal plane
dysfunction
• Often multiple segments involved
– Dowager’s Hump for multiple flexed segments
• Diagnostic findings for sagittal plane SD
– Tissue texture changes
– Alteration in relationship of spinous processes
– Restiction in opposite sagittal plane motion
– Rotation and Sidebending are restricted
– Tenderness over the supraspinous ligament
CT junction sagittal plane
dysfunction
• Often multiple segments involved
– Dowager’s Hump for multiple flexed segments
• Diagnostic findings for sagittal plane SD
– Tissue texture changes
– Alteration in relationship of spinous processes
– Restiction in opposite sagittal plane motion
– Rotation and Sidebending are restricted
– Tenderness over the supraspinous ligament
Posture & Landmarks
• Normal Sagittal Curves:
– Cervical lordosis
• Concave posterior
– Thoracic kyphosis
• Convex posterior
– Lumbar lordosis
• Concave posterior
– Fused Sacrum is
• Convex posterior
POSTURAL XRAYS MAY BE APPROPRIATE
Sagittal Plane
Gravitational line
– Posterior to apex of coronal
suture
– External auditory meatus
– Humeral head
– Middle of L3 vertebra
– Femoral head
– Posterior to mid-knee/at axis
– (Slightly) Anterior to lateral
malleolus
• Center of gravity for the entire
body is ~5 cm anterior to 2nd
sacral vertebra. Used to evaluate the
A-P (anterior-posterior) curves of the
spine
Increased kyphosis/lordosis
Sagittal Plane
Gravitational line
– Posterior to apex of coronal
suture
– External auditory meatus
– Humeral head
– Middle of L3 vertebra
– Femoral head
– Posterior to mid-knee/at axis
– (Slightly) Anterior to lateral
malleolus
• Center of gravity for the entire
body is ~5 cm anterior to 2nd
sacral vertebra. Used to evaluate the
A-P (anterior-posterior) curves of the
spine
Increased kyphosis/lordosis
“ Transition Zones”
• Areas Where Curves Reverse
• Commonly susceptible to somatic
dysfunction
– Occipitocervical (OA),
cervicothoracic(CT),
thoracolumbar (TL), and
lumbosacral (LS) junctions.
– Boney changes in the vertebrae,
muscular changes, and fascial/soft
tissue changes.
– Also look at the apex of the curves
for dysfunction
“ Transition Zones”
• Areas Where Curves Reverse
• Commonly susceptible to somatic
dysfunction
– Occipitocervical (OA),
cervicothoracic(CT),
thoracolumbar (TL), and
lumbosacral (LS) junctions.
– Boney changes in the vertebrae,
muscular changes, and fascial/soft
tissue changes.
– Also look at the apex of the curves
for dysfunction
Physiologic Curves
• Compensatory
changes in one
sagittal plane curve
results in changes to
other curves
– e.g. Increased lumbar
lordosis-> increased
thoracic kyphosis and
cervical lordosis
• Secondary Curves
Lordosis
Kyphosis Decreased Curves
Assess TART changes
• Junctional areas, also called transitional
regions, may be considered from a
minimum of two segments
• OA junction: OA AA C2
• CT junction: C7-T1
• TL junction: T10-L1
• LS junction: L5-S1
• Lateral Screen
• C - Spine
» Increased or decreased lordosis?
• T - Spine
» Increased or decreased kyphosis
• L - Spine
» Increased or decreased lordosis
• Weight-bearing line through
»
»
»
»
»
Ext auditory meatus
AC joint
Body of L3
Greater trochanter
Anterior to lateral malleolus
Not aligned means postural
decompensation
View
Cervical-Thoracic-Lumber
Curves
• Cervical Motion Test (Passive)
– FB and BB (approx 90 each direction)
» Test motions in superior and inferior division.
» Positive test  lost motion (<90 ).
 Must determine if loss is in superior or inferior
division.
1. “Tuck Chin”  FB (45 )
OA motion
2. “Untuck Chin”  BB (45 )
Cervical Motion
FB/BB
Cervical Motion
Saggital Plane: OA
Cervical Motion Test
– Rotation (90 each direction)
» Tests both superior and inferior division
» Positive test  lost motion (<90 ).
 Must determine if loss is superior or inferior
division (Best done with patient supine).
Cervical Motion: Rotation