Transcript Techniques for Practical 1

Techniques for Practical 1
Year One
Block 2
Cervical, Thoracic, Shoulder, Elbow,
Wrist
Opponen’s Roll
 Grasp first digit (thenar emin.)
and fifth digit (hypothenar
emin.) with each hand
 Contact pisiform and
navicular (scaphoid) bones
with thumbs
 Extend wrist, abduct and
laterally rotate first digit with
counterforce over hypothenar
area
 Use thumbs to stretch at
boney contact points the
transverse carpal ligament in
lateral/medial direction
Treatment for Abduction Somatic
Dysfunction of the Wrist
 Doctor and patient facing each
other, seated or standing
 Doctor grasps patient’s wrist
and places it into pronation
and abduction
 Doctor moves patient’s wrist
from the original position in
abduction to and just past the
adduction barrier in a smooth
gentle motion.
Treatment for Adduction Somatic
Dysfunction of Wrist
 Doctor and patient facing
each other, seated or
standing
 Doctor grasps patient’s
wrist and places it into
pronation and adduction
 Doctor moves patient’s
wrist from the original
position in adduction to
and just past the abduction
barrier in a smooth, gentle
motion
Direct, Articulatory – Wrist Ab-/Ad-duction S/D
• Grasp pronated wrist
and contact posterior
surface joint margin
with thumbs
• Apply traction and carry
wrist into direction of
dysfunction
• Gently articulate toward
the restricted barrier
with low to medium
velocity and medium
amplitude.
Treatment of Flexion Somatic Dysfunction
 Patient seated, doctor standing or sitting facing
patient.
 Doctor grasps the patient's wrist with the doctor’s
thumbs on the dorsal aspect of the wrist, pressing
on the dysfunctional bone.
 The doctor may reinforce the pressure of the
treating thumb by adding pressure with the other
thumb.
 The doctor’s hands wrap around the wrist to
contact the palmar aspect of the patient’s hand.
 The patient’s wrist is initially held in flexion
 A simple repeated motion is carried out, moving
the wrist from flexion to extension, while
maintaining pressure over the displaced
carpal bone.
Treatment of Extension Somatic Dysfunction
Patient seated, doctor standing or
sitting facing patient.
Doctor grasps the patient's wrist with
the doctor’s thumbs on the dorsal
aspect of the wrist, resting on the
dysfunctional bone.
The doctor’s hands wrap around the
wrist so that the index fingers can press
on the dysfunctional bone.
The patient’s wrist is initially held in
extension.
A simple repeated motion is carried out,
moving the wrist from extension to
flexion, while maintaining pressure over
the displaced carpal bone.
Squeeze w/Circumduction
(4760.11A)
• Place heel of both hands
over radiocarpal region of
carpal bones & interlace
fingers
• Attempt to distract fingers
while squeezing fingers
together
– Causes the heel of each
hand to squeeze
together
• Circumduct wrist in circular
or figure eight fashion
Radioulnar Interosseous Membrane,
Direct Method
• Pt. sits and physician stands in front
• Hold supinated forearm in palms of both
hands with physician thumbs crossed over the
anterior surface of the pt. forearm with the
interosseous dysfunction between the
thumbs.
• Contact the lateral side of the ulna with one
thumb and the medial side of the radius with
the other thumb
Muscle Energy technique continued
• Pt. is instructed to “turn palm downward”
while physician offers isometric counterforce.
PRONATION!!
• Maintain counterforce 3-5 seconds and both
pt. and physician simultaneously relax
• Take up the slack and repeat (usually 3x)
• RECHECK YOUR FINDINGS!!
Tx: Radial Head Posterior- Direct
Muscle Energy
• Correct Abduction or Adduction
first
• Contact the posterior aspect of
radial head with thumb of lateral
hand
• Grasp distal radius and ulna
and engage barrier with forearm
supination & wrist extension
• Patient attempts to pronate (Dr.
resists)
• Relax, engage new barrier
– Dr.’s thumb and supination
force will move radial head
anterior
Thumb on anterior
distal radius
supinate
*
Tx: Radial Head AnteriorDirect Muscle Energy
• Grasp the hand on
the side of the
dysfunction
contacting the
dorsal aspect of the
distal radius with
the thumb
Tx: Radial Head Anterior, continued
• The physician’s
other hand is palm
up with the thumb
resting against the
anterior and medial
aspect of the radial
head
• The physician
pronates the
patient’s forearm
to the edge of the
restrictive barrier.
• Tell the patient to
supinate and use
an isometric force.
• Hold 3-5 seconds,
stop and relax.
• Take up the slack to
the new restrictive
barrier.
• Repeat 3-5 times
• RECHECK
FINDINGS!!!
Dx of Ulnar Abduction and abduction motion
testing
• Pt seated/ Dr. Standing
• Dr. contacts patient’s elbow and
wrist
• at elbow - thenar eminence to
medial aspect of olecranon and
finger to lateral condyle - apply
force with finger to thenar
• (+) extending arm from elbow
while attempting adduction is
met with resistance (olecranon
will not laterally glide) Pt may
experience pain and crepitus may
occur as the olecranon seats in the
olecranon fossa.
Tx of Ulnar Abduction with Medial Glide SD:
Direct Technique - Ariticulatory - 4741.11B
 Patients elbow flexed ~ 90o with
Dr firmly grasping distal forearm
from lateral aspect
 Dr. grasps the elbow with thenar
eminence on medial margin of
olecranon and fingers on lateral
condyle
 apply lateral and slightly superior
force at medial contact and
adduction force at distal forearm
 Take arm into full Extension in a
sweeping motion applying the
same forces above.
Tx of Ulnar Adduction with Lateral Glide SD:
Direct Technique - Articulatory - 4742.11B
 Pt seated/Dr standing
 Patients elbow slightly flexed ~
90o. Dr firmly grasps distal
forearm from medial aspect
 Dr. grasps the elbow with thumb
or thenar eminence to lateral
margin of olecranon
 apply medial and slightly superior
force at lateral contact and
abduction force at distal forearm
engaging the barrier.
 Take arm into full extension in a
sweeping motion applying the
same forces above.
Sternoclavicular Dysfunction Assessment
• ABduction (IG)/ADduction (SG)
1. DO at head of table, patient
supine
2. DO monitors medial clavicle area
3. Patient shrugs their shoulders.
Both clavicles should move into
Abduction, and the medial
clavicles should move inferiorly
4. In the absence of trauma, the
dysfunctional (restricted) clavicle
stays superior at the SC
jointNamed an ADduction
somatic dysfunction (superior
glide)
Example of a superior left SC jo
Sternoclavicular Dysfunction Assessment
• Horizontal Flex (PG)/Horizontal Ext (AG)
1. DO at head of table, patient supine
2. Monitor the medial clavicle
3. Patient reaches toward the ceiling with
their arms. Their scapulae should come
off the table. Both clavicles should move
into horizontal flexion, and the medial
clavicles should move posterior (posterior
glide)
4. In the absence of trauma, the
dysfunctional (restricted) clavicle stays
anterior at the SC jointNamed a
horizontal extension (anterior glide)
somatic dysfunction
Example of an anterior S
SC Joint – Articulatory method
• Thumb on medial
clavicle with caudad
pressure
• Patient’s arm brought in
a “backstroke” pattern –
towards flexion through
adduction and abduction
and then ending up in
extension
• Reassess
AC joint – Articulatory method
• DO grasps patient elbow or
forearm from behind
• DO monitors lateral edge of
clavicle anteriorly with finger
pads
• DO applies anterior/inferior
pressure on the lateral side of
the clavicle with thumb, flexes
the patient’s elbow and extends
and adducts the humerus to gap
the AC joint
• DO further extends the shoulder
and a circulatory articular sweep
is applied – carry the elbow
posteriorly  superiorly 
anteromedially while
maintaining adduction and
capsular tension
• Recheck
Spencer Technique
The seven stages of motions are: 4. Traction with
circumduction on straight
1. Engage GH extension barrier
arm
with elbow flexed
2. Engage GH flexion barrier with  Start small circles, then
gradually increase size
the elbow flexed
 Clockwise and
3. Circumduction with
counterclockwise
compression
5. Engage abduction barrier
• Start small circles, then
gradually increase size
• Clockwise and
counterclockwise
• May also do ME of IR/ER
barriers
6. Internal rotation with
elbow flexed
7. GH pump with distraction
and compression along
straight arm
2
1
3
4
5
6
7
Myofascial release of the T spine
Myofascial release of the Scapula
Anterior TP 1-2 tx
Ant TP 3-6 tx
Ant TP tx T 7-9
Posterior midline TP tx
Post lateral TP tx
Suboccipital Inhibition
Objective: decrease
suboccipital (SO) muscle
tone
1) doctor at head of table;
patient supine.
2) Pads of fingers just
beneath superior nuchal
line in the SO tissues
3) Lift head slightly so its
entire weight is supported
on fingers
Kneading
•
•
•
•
Objective: Relax the cervical
paravertebral muscles (PVM).
1) doctor standing on patient’s
side; patient supine.
2) With caudad hand, reach across
patient and cup PVM; Place
cephalad hand on pt’s forehead
4) Push head away from you, then
pull up and laterally on PVM tissue
letting head roll back toward you.
Forward bending stretching
Objective: Stretch posterior
cervical tissues
1) doctor at head of table; patient
supine.
Cross forearms and place them
behind pt’s head with fingertips
on pt’s shoulders.
Exert slow forward bending stretch
until a restrictive barrier is
engaged, slowly increase to next
barrier
Trapezius Stretch
Objective: Relax the
trapezius muscle
1) Patient supine, doctor at
head of table
2) Stabilize one shoulder
with opposite hand
3) With free hand contact
same side of head as
stabilized shoulder and
introduce GENTLE stretch
Longitudinal Stretching
• Objective: Relax the
paravertebral muscles (PVM).
•
•
•
•
1) doctor at head of table; patient
supine.
2) palmar surfaces of fingers of
both hands under the neck near
spinous processes
3) lift PVM with fingers and draw it
toward you (cephalad = toward
head)
4) release and carry tissue away
from you (caudally = toward tail)
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
Pinch Technique for Sagittal Plane
OA Flexion and Extension
• 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
Multiple Plane Somatic Dysfunction of OA
joint
• Because of the ANATOMY of the condyles, the OA
side-bends and rotates to opposite sides in either
flexion or extension
– OA (F) or (E) SL RR
– OA (F) or (E) SR RL
• Brain attempts to keep the “eyes level on the
horizon” at all cost
• OA asymmetries are compensated by activating the
sub-occipital mm
Multiple Plane Somatic Dysfunction
of OA joint
• Inspection
– “Is this patient’s
head on straight?”
– Look for deviation
of the chin and tip
of nose from the
mid-line position
Somatic Dysfunction of the AA
Joint
• Motion testing
– Forward bend patient’s
head to “lock-out” lower
vertebrae
– Rotate left, rotate right
– Compare, assess,
diagnose...
Diagnosis of the AA
1.
2.
Test seated active & passive motion. (regional
scanning)
Test supine motion specific to AA.
Flex head beyond 45o, then rotate patient’s
head passively.
3.
4.
Supine, inspect & palpate. T-A-R-T!!!
C1 lateral masses located between mastoid
process and ramus of mandible.
Supine, localized motion testing of the AA
Compare right verses left rotation.
Diagnosis:
AA left rotation: AARL or AA right rotation: AARR
Direct, Muscle Energy of AA- 4231.11B
Forward bend head to >45o
To lock out lower cervicals
MCP joint of the index finger contacts
lateral mass of atlas (C1) on posterior
rotated side
Rotate into barrier (maintain flexion)
Sweeten with SB
Instruct patient to turn his/her head the
opposite direction against your force use isometric force for 3-5 sec.
Upon relaxation, engage the new barrier
& repeat M.E. 2-3 more times
Supine-Direct-ME
C3 NRLSL
• Reach under spine to
contact the convex
side.
• Pull with fingers to
induce Right
Sidebending (reverse
the curve)
ME for Typical
Cervical
RLSL
Supine-Indirect- Resp. Force
C3 N(F)RLSL
• Bilateral contact at
articular pillars
• Head supported on
forearm/heel of hand
• Adjust in all 3 planes
for greatest ease
• Add respiratory force
or inherent force for
activation
Jones Strain-Counterstrain
Anterior C1 Tender Point
A.k.a the OA joint TP
High on posterior
ascending ramus of
mandible
Contact TP & rotate
away 90º
Find it, fold it, hold it,
recheck!
REVIEW!!!
Indication for Treatment
This procedure is appropriate for
somatic dysfunction at C3 to C7.
Tender Point Location
The tender point lies at PC3 to PC7
posterolateral, at lateral surface of the
articular process associated with the
dysfunctional segment (Fig. 9.36).
Treatment Position
The physician extends the head and
neck to the level of the dysfunctional
segment with minimal to moderate
side bending directed at the segment
and minimal to moderate rotation
away (Figs. 9.37, 9.38, 9.39, 9.40, PC3,
PC3, PC6, and PC6, respectively).
The physician fine-tunes.
PC3 TP- eSaRA