Workshop: OMT Update   

 Gautam Desai, DO, FACOFP 

Richard K. Ogden, Sr. DO, FACOFP Joshua Cox, DO, FACOFP 

ACOFP FULL DISCLOSURE FOR CME ACTIVITIES Please check where applicable and sign below. Provide additional pages as necessary.

Name of CME Activity: ACOFP 52nd Annual Convention and Scientific Seminars

Dates and Location of CME Activity: March 12-15, 2015, The Cosmopolitan Las Vegas, Nevada Workshop: OMT Update Wednesday, March 11, 2015 3:00pm-5:00pmStudent Program: Rapid OMT Techniques for the Family Medicine Office Friday, March 13, 2015 10:30-Noon

Name of Faculty/Moderator: Gautam Desai, DO, FACOFP

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Gautam Desai, DO, FACOFP

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Deadline: Wednesday, February 4, 2015 SPEAKER CV AND INTRODUCTION

ACOFP 52nd Annual Convention and Scientific Seminars

1

REVIEW OF OMM

FOR THE PRACTICING

PHYSICIAN

Richard Ogden, DO, FACOFP FAAFP

Gautam J. Desai, DO, FACOFP, CPI

W. Joshua Cox, DO, FACOFP

BASICS

• T: Tissue Texture Changes:

boggy, ropey, etc

• A: Asymmetry

• R: Restriction of Motion

• T: Tenderness

2

BASICS

• Somatic Dysfunction: The naming of a somatic dysfunction describes the direction of ease, in all three planes.

• For example: The third Lumbar vertebra has a posterior transverse process on the right.

• Therefore the vertebra is right rotated (the anterior superior surface determines the direction of rotation)

LUMBAR VERTEBRA RIGHT

ROTATED

POSTERIOR

TRANSVERSE

PROCESS

3

BASICS

• Fryette’s Principles:

• If the posterior transverse process is

MORE posterior in flexion or extension,

then the somatic dysfunction is in neutral.

• In neutral (FRYETTE PRINCIPLE 1) the

rotation and the side bending go in

opposite directions (Type One Neutral

Group Opposite) TONGO

BASICS

• If the posterior transverse process becomes less posterior in flexion then it is a flexion somatic dysfunction

• If the posterior transverse process becomes less posterior in extension then it is an extension somatic dysfunction.

• These are both Fryette Principle TYPE 2

• Side bending and rotation go in the same

direction in Type 2 somatic dysfunctions

4

Nomenclature of the Somatic

Dysfunction

• In our example:

• Lumbar 3 is right rotated side bent right and in flexion so it is written L 3 F RrSr.

• If L 3 were in extension it is written

• L 3 E Rr Sr.

• If the right PTP stays the same in all three positions it is neutral L 3 N RrSl

• Typically Type 1 is a group curve and Type 2 is a single segment.

Nomenclature of the Somatic

Dysfunction

• In Type 1 treat the apex (the middle

vertebra) of the curve.

• Example: L 3 – 5 N RrSl, the 3rd lumbar

vertebra is in neutral, is rotated right and

side bent left and the vertebra to treat is L

4.

5

BASICS

• If the vertebra is side bent left then left

side bending is the direction of EASE and

it is RESTRICTED TO RIGHT SIDE

BENDING.

• If it is rotated to the right it is restricted to

rotation left.

• If it is flexed (or extended) then it is

restricted to extension (or flexion).

Patient with Sinus Infection

(Sinus Pain)

Thoracic

Duct

6

Thoracic

Duct

Thoracic Duct Release

(Direct)

FLEX THE

SUPRACLAVICULAR

FOSSA FORWARD

7

Thoracic Duct Release

(Direct)

EXTEND THE

SUPRACLAVICULAR

FOSSA

Thoracic Duct Release

(Direct)

SEQUENTIALLY SIDE BEND

THE SUPRACLAVICULAR

FOSSA RIGHT AND LEFT

8

Thoracic Duct Release

(Direct)

SEQUENTIALLY ROTATE

THE SUPRACLAVICULAR

FOSSA TO THE RIGHT

AND THE LEFT.

Thoracic Duct Release

(Direct)

SEQUENTIALLY

ROTATE THE

SUPRACLAVICULAR

FOSSA TO THE RIGHT

AND THE LEFT.

HOLD THE

SUPRACLAVICULAR

FOSSA INTO THE

BARRIER AND WAIT

FOR TISSUE RELEASE

9

Sub-Occipital Release (Direct)

Sub-Occipital Release

10

Arrows indicate

Direction of

Milking

Sinus Treatment

ARROWS INDICATE

DIRECTION OF

MILKING

11

Galbraith Technique “Mandibular

Tug”

ARROWS INDICATE

DIRECTION OF MILKING

Membranous Portion

Eustachian/AuditoryTube

INDICATES DIRECTION

OF MANDIBULAR TUG.

12

TMJ (TMD): Masquerades as

“I’ve got an ear infection.”

• Temporomandibular Joint Dysfunction:

Pain around the jaw joint, pain with

clenching of teeth, sometimes ringing of

the ears (tinnitus) and tenderness with jaw

motion.

• Otoscopic exam is normal.

PRE-AURICULAR

LYMPH TECHNIQUE TMJ(TMD) TREATMENT:

LYMPHATIC

13

MUSCLE ENERGY:

RESISTED MOVEMENT

IN THE DIRECTIONS OF

THE ARROWS.

TMJ(TMD)

TREATMENT

Patient with Cephalgia

OA Joint:

• major motions = flexion and extension *minor = SB and rotation

• occiput rotates and SB to opposite sides

Atlantoaxial joint

• primary = is rotation

- atlas rotates about the dens

• almost no SB or flexion/extension

Typical Cervical Segments (C2 thru 7)

• Rotation and SB usually to same side

clinically, SB and rotation to opposite sides @ times

• Modified Type II Mechanics

14

15

Cervical Spine Treatment

Occipitoatlantal Joint

– Suboccipital Release

• Myofascial Release

• Pt supine with Dr sitting facing pt

• Cup occiput and give gentle axial traction

• Wait for musculature to relax

– Usually done supine, but can do with pt

slouched in chair, or on reclining chair

Review of Muscle Energy

• Form of OMT where pt’s ms. actively used

in specific direction and v specific

counterforce from specific position

• A direct technique (engages restrictive

barrier and then carries dysfunctional

component into restrictive barrier)

16

Review of Physiology

• Postisometric Relaxation – neuromuscular bundle is in refractory state

immediately after contraction, allowing passive stretching to occur

• Reciprocal Inhibition – as one ms is contracting, antagonist is relaxing

(biceps and triceps)

Cervical Muscle Energy Treatment

OA (i.e. OA ERRSBL)

– Pt supine w Dr sitting

– Dr’s R index finger on sulcus and rest of hand

wrapped around side of neck, Dr’s L hand on top of

pt’s head

– Take to barrier: flex, SB R and rotate L

– Have pt gently straighten head vs dr’s resistance for

3-5 s

– During period of relaxation, take further into barrier

(more flexion, SB R, and rotation left)

– Repeat 3 times

17

Cervical Muscle Energy Treatment

Atlantoaxial Joint (AA)

– Fully flex head and neck (to isolate AA joint)

then rotate into barrier (side with least amount

of rotation)

– Ask pt to gently move twds neutral while dr

resists motion for 3-5 seconds

– During relaxation, move further into barrier

then repeat process until no new barriers

reached

Cervical Muscle Energy Treatment

Typical Cervicals (i.e. C3ERRSBR) – pt supine w dr sitting behind pt

– Dr’s R index finger on PTP (C3 in this case), and rest of hand wrapped around side of neck, Dr’s L hand on top of pt’s head

– Take to barrier: flex, SB and rotate left

– Have pt gently straighten head vs dr’s resistance for 3-5 s

– During period of relaxation, take further into barrier (more flexion, SB left, and rotation left)

– Repeat 3 times

18

Cervical Still’s Technique

Treatment

Typical Cervicals (i.e. C3ERRSBR)

– Pt seated with Dr standing behind pt

– Dr’s right index finger on PTP (C3 in this case), and

rest of hand wrapped around side of neck to support

(and also to use as a fulcrum)

– Dr’s left hand on top of pt’s head

– Take to where dysfunction already is, and

exaggerate: extend, SB and rotate R until feel

relaxation of tissues. This removes strain from

affected segment

Cervical Still’s Technique

Treatment

-cont • Push down head with L hand (axial compression)

• Move head away from area of dysfunction. Rotate head to L, while simultaneously SB L, and flexing c-spine. Take to the barrier, and as moving through this vector, may feel a release with monitoring hand at PTP.

• Then release compression, and take pt to neutral

• Retest

19

Patient with Pneumonia, Bronchitis,

Congestive Heart Failure

• Thoracic Duct Technique

• Thoracic Pump

• Rib Raising

• Pedal Pump

• Treat Thoracic spine T 1 – 6

(Sympathetics to lungs and heart)

Patient with Pneumonia, Bronchitis,

Congestive Heart Failure

• THORACIC PUMP

PATIENT CROSSES

ARMS ACROSS CHEST FOR

ATTENTION TO GENDER

SENSITIVITY

PATIENT INHALES AGAINST

GENTLE RESISTANCE OF

PHYSICIAN’S HANDS, GENTLE

OSCILLATORY MOVEMENT

AS PATIENT EXHALES. REPEAT

SEVERAL TIMES AND ON LAST

ANTICIPATED INHALATION THE

PHYSICIAN QUICKLY REMOVES

HANDS FROM CHEST AND THE

PATIENT INHALES MORE

FORCIBLY

20

Patient with Pneumonia, Bronchitis,

Congestive Heart Failure

• THORACIC SPINE TREATMENT T 1– T 6

ARROWS INDICATE

DIRECTION OF

PERPENDICULAR STRETCH

MYOFASCIAL RELEASE TO

TREAT THORACIC

SYMPATHETIC

INNERVATION

TO LUNGS AND HEART

Patient with Pneumonia, Bronchitis,

Congestive Heart Failure

ARROWS INDICATE THE

ANTERIOR AND LATERAL

AND CEPHALAD DIRECTION

OF THE FINGERTIPS LIFTING

THE RIBS.

RIB RAISING IS BOTH A LYMPHATIC AND

SYMPATHETIC INHIBITORY TECHNIQUE.

21

RIB RAISING: CAN BE PERFORMED

SUPINE OR SEATED.

ARROWS POINT

TO SYMPATHETIC

GANGLIA

ANTERIOR TO

RIB HEAD

22

ARROWS POINT TO LYMPH

NODES ANTERIOR TO RIB

HEADS.

Patient with Pneumonia, Bronchitis,

Congestive Heart Failure

ARROWS INDICATE THE

CEPHALAD/CAUDAL

OSCILLATORY MOVEMENT

APPROXIMATELY 100

CYCLES PER MINUTE.

23

The Patient With LBP

The Patient With LBP

24

The Patient With LBP

Lumbar Examination

• Pt either prone or

seated

• Anteriorly compress

right transverse process

– Inducing a left rotation

• Then repeat for the L

– Inducing right rotation

• Repeat rotation test with

flexion, then extension,

and compare to neutral

25

Lumbar Examination

• If motion roughly same in both

flexion & extension

– then neutral dysfunction

– follows Type I mechanics

• If motion more restricted in flexion

or extension

– then flexion/extension

dysfunction

– follows Type II mechanics

• Flexion / extension component of

positional diagnosis is the plane in

which restriction lessened (or

moves more freely)

Perpendicular release

– Pt is prone with Dr standing at side of table,

on opposite side of dysfunction.

– Place thumb and thenar eminence on the

paravertebral muscles.

– Keeping elbows locked in extension, push

downward and laterally on paravertebral

muscles.

– Maintain this pressure for 3 seconds,

allowing for release of muscle tension.

26

Long axis distraction of lumbar

musculature

– Pt prone with Dr standing at side of table, on opposite side of dysfunction.

– DO’s hands placed in crossed pattern on affected muscles, with 1 hand at superior aspect and other hand at inferior aspect of muscles to be treated.

– Gentle pressure maintained, and then a stretch placed on affected muscles by distracting your hands apart until maximal tension develops.

Lumbar Muscle Energy Treatment

i.e. L3ERRSBR)

– Pt seated w dr standing behind pt

– Dr monitoring PTP with 1 hand

– Have pt clasp hands behind head

– Take to barrier: flex, SB and rotate left

– Pt gently straightens back vs dr’s resistance for 3-5 s

– During period of relaxation, take further into barrier

(more flexion, SB left, and rotation left)

– Repeat 3 times

27

Patient With Knee Pain: History Of Inversion Ankle Injury: Posterior

Fibular Head

PLANTAR FLEXION, INVERSION

Injury

DISTAL FIBULA (LATERAL MALLEOLUS)

MOVES ANTERIOR

FIBULAR

HEAD

MOVES

POSTERIOR

Muscle Energy Posterior Fibular

Head

omurtlak.bloguez.com

RESISTED DORSIFLEXION

OF ANKLE CAUSES THE

FIBULAR HEAD TO MOVE

ANTERIOR (EXTENSOR

HALLUCIS LONGUS AND

ANTERIOR TIBIALIS

FIBERS CONTRACTING)

28

29

Counterstrain Steps

1. Find a significant tenderpoint

2. Establish a pain scale

3. Wrap the patient around the tenderpoint

4. Reduce pain by 70% with small arcs of motion

5. Hold for 90 seconds

6. Passively return patient to neutral

7. Recheck the tenderpoint

Flexion Ankle

Counterstrain • This is reverse of

extension force.

Tenderpoint is high

in the front of the

ankle in a depression

medial to the big

extensor tendon.

30

Flexion Ankle

Counterstrain-Treatment • Exert force under

the ball of the

foot. (can be

reinforced by

physician’s chest)

Fine tune with

slight rotation.

(Flexed) Calcaneus (FCALC)

• Anteromedial plantar surface of the calcaneus

• Common TP in plantar fasciitis

31

Flexed Calcaneus: FCALC

• Place the prone pt’s dorsal foot on your thigh

• Use your cephalad hand to induce anterior force on calcaneus while pressing pt’s shin against your thigh

• Use te heel of your hand to press ball of foot toward the calcaneus while monitoring the point with index finger

• Combined motion will plantarflex the foot

MFR of Plantar Fascia

• Place thumbs of both fingers on sole of

pt’s foot

• Move thumbs in superior and lateral

direction, while maintaining steady

pressure

• Continue until you feel tissues relax

32

Ilio-Sacral Somatic Dysfunction

Standing Flexion Test

• Static: PSIS bilaterally should be at same

level-not asymmetrical

• Pt standing, physician at eye level of PSIS

and patient slowly bends forward.

• PSIS that moves farthest / first is positive

side.

Patient with Hip and Sacral Pain:

Standing Flexion Test Determines side of Iliosacral

Somatic Dysfunction

• Static Heights: PSIS bilaterally should be

level. Record which is lower/higher

BEFORE HAVING THE PERSON

FORWARD BEND.

• Indicative of an upslip or downslip (shear)

33

SHADED AREA

INDICATES

PLACEMENT OF THUMB

UNDER

THE PSIS

RECORD WHICH

PSIS MOVES

FIRST /

FARTHEST.:

INDICATES SIDE

OF DYSFUNCTION.

ARROWS INDICATE THE

DIRECTION OF ALTERNATING

COMPRESSION TO FIND THE

HARD END FEEL TO VERIFY THE

SIDE OF SOMATIC

DYSFUNCTION

ASIS OR PELVIC

COMPRESSION TEST

34

ANTERIOR ROTATION ILIUM:

ASIS AND MEDIAL MALLEOLUS

LOWER ON THE SIDE OF POSITIVE

STANDING FLEXION TEST.

ANTERIOR INNOMINATE ROTATION

•

MUSCLE ENERGY CORRECTION OF ANTERIOR INNOMINATE ROTATION

ARROW 1 SHOWS THE DIRECTION OF THE PHYSICIAN’S FORCE AGAINST

THE PATIENT’S ACTIVATING FORCE, WHICH IS SHOWN BY ARROW 2.

AFTER THE PATIENT RELAXES, THE PHYSICIAN CONTINUES TO ENGAGE

NEW BARRIERS UNTIL NO NEW BARRIERS ARE ENCOUNTERED.

PHYSICIAN MAY INSERT UPTURNED HAND ALONG POSTERIOR ISCHIAL

TUBEROSITY TO AUGMENT CORRECTIVE POSTERIOR ROTATION.

1

2

35

POSTERIOR ROTATION ILIUM:

ASIS AND MEDIAL MALLEOLUS

HIGHER ON THE SIDE OF POSITIVE

STANDING FLEXION TEST.

POSTERIOR INNOMINATE ROTATION

Muscle Energy Correction of Posterior

Innominate Somatic Dysfunction.

BLUE ARROW INDICATES

PHYSICIAN FORCE TO

CORRECT DYSFUNCTION

BLACK ARROW INDICATES

THE DIRECTION OF THE

PATIENT’S FORCE AGAINST

THE PHYSICIAN.

36

Muscle Energy Correction of Posterior

Innominate Somatic Dysfunction.

• Physician resists

patient flexing hip for

3 – 5 seconds, the

patient relaxes and

the physician

engages the new

barrier.

• The cycle is repeated

until no new barriers

are encountered.

Arrow 1: Physician force

Arrow 2: Patient force

2 1

INNOMINATE IN-FLARE AND

OUT-FLARE

ASIS

DISTANCES

FROM THE

XIPHOID

ARE

MEASURED

ON SIDE OF POSITIVE STANDING FLEXION

TEST: ASIS NEAR MIDLINE, INFLARE, IF

FARTHER THEN IT IS AN OUTFLARE.

37

Treatment of an Innominate Downslip

(Inferior Shear)

• www.stockphotopro.com/photo-thumbs-2/stockpho... The patient is lying with the

affected side up, and the

physician applies a caudal

force against the patient’s ischial

tuberosity during deep

inspiration and as the patient

exhales, the physician engages the

new barrier until no new barrier

Is encountered. The patient is

re-assessed

Treatment of Superior Innominate

Shear (Upslipped Innominate)

Pt and physician

positioned as in

photo

physician Internally

Rotates the hip

and exerts

axial traction to the

barrier. Pt

attempts to

elevate hip for

3 – 5 seconds,

relaxes and the

cycle is repeated

until no new

barriers and the pt

is re-assessed

www.mhhe.com/.../illustrations/ch25/25-24.jpg

Black Arrow Indicates

Traction Caudally

38

Treatment of Innominate Out-Flare

• img.medscape.com/pi/emed/ckb/sports_medicine/... Patient is supine as in

photo. Physician applies

Adducted force and

Patient resists by

Abducting the hip for

3 – 5 seconds,

then relaxes and the

Physician engages the

new barrier. This

continues until no new

barriers are encountered

and the patient is

re-assessed.

Physician force

Patient force

Treatment of Innominate In-Flare

• www.hwbf.org/hwb/conf/alex47/pat1.jpg Patient placed in position

noted in photo (Fabere’s

Test position). Patient

attempts to adduct the

left leg ( arrow 2 ) and

the Physician resists

(arrow 1) for 3 – 5 seconds

then the patient relaxes,

and the cycle is repeated

until no new barriers

are encountered

1 2

39

Sacro-Iliac Somatic Dysfunction

Diagnosis: Seated Flexion Test

• Patient is seated on the

table, feet supported,

physician is behind the

patient, at eye level to the

PSIS, thumbs contacting

the undersurface of the

PSIS.

• Patient forward flexes

and physician notes the

side that moves first and

farthest.

scoliosis.org

ARROWS INDICATE THE

DIRECTION OF ALTERNATING

COMPRESSION TO FIND THE

HARD END FEEL TO VERIFY THE

SIDE OF SOMATIC

DYSFUNCTION

ASIS OR PELVIC

COMPRESSION TEST

40

Treatment of Ilio-Sacral or Sacro-Iliac

Somatic Dysfunction:

Balanced Ligamentous Tension • Patient seated on side of table, physician seated

on chair facing patient.

• Physician applies pressure on the patella through the femur to SI joint testing each side individually.

• The physician maintains the pressure on the side of ease while the patient flexes forward & backward; rotates right & left at the waist; and side bends right & left. The patient remains in all of the planes of ease until the physician feels a release.

• The Sacro-Iliac joint is then re-tested.

Ilio-Tibial Band Somatic Dysfunction

• Diagnosis is made with patient supine with knee flexed and foot flat on table.

• Physician lifts the patient’s foot and places it on the table lateral to the contra-lateral thigh.

• Pain along the ITB is pathognomonic.

• Ober’s Test:

• Patient is lying lateral recumbent, involved side up and physician abducts the involved hip and gently releases it.

• Inability to smoothly let leg drop down is a positive test.

41

Ilio-Tibial Band Somatic Dysfunction:

Myofascial Release

• Patient is supine with knee flexed and foot flat

on table.

• Physician lifts the patient’s foot and places it on

the table lateral to the contra-lateral thigh.

• The physician then strokes proximally from

lateral knee to greater trochanter.

• May also engage the ITB with perpendicular

stretch and wait for tissue creep.

Piriformis Syndrome

• Diagnosis is made by history of nerve pain

in the deep buttock and radiating laterally

down the posterior hip and thigh, stopping

at the knee.

• Also, there is a tender point in the mid-

posterior gluteal area.

42

Piriformis Syndrome:

Still’sTechnique • Patient is supine, physician standing at the

Ipsilateral side.

• Physician’s cephalic hand monitors in the gluteal area the piriformis tender point and with the caudal hand grasps the ankle, flexes the knee and fully abducts the hip.

• Both of the physician’s hands guide the foot over the midline FIRST then the knee and then the ankle is returned to the original side and the physician internally rotates the hip which is then held in extension as the knee is fully extended.

PIRIFORMIS:

EXTERNAL ROTATOR

AND ABDUCTOR OF

THE HIP.

PIRIFORMIS

43

UPPER EXTREMITY: ELBOW

POSTERIOR RADIAL HEAD SOMATIC

DYSFUNCTION

• FALL FORWARD ON OUTSTRETCHED

HAND (FOOSH)

• GENERALLY CAUSES THE FOREARM

TO PRONATE AND THE RADIAL HEAD

THEN GLIDES AND STAYS POSTERIOR

UPPER EXTREMITY: ELBOW

ANTERIOR RADIAL HEAD SOMATIC

DYSFUNCTION

• FALL BACKWARD ON OUTSTRETCHED

HAND

• GENERALLY CAUSES THE FOREARM

TO SUPINATE AND THE RADIAL HEAD

THEN GLIDES AND STAYS ANTERIOR

44

SUPINATION:

RADIAL HEAD

GLIDES

ANTERIOR

PRONATION:

RADIAL HEAD

GLIDES

ANTERIOR

POSTERIOR RADIAL HEAD: SUPINATE THE FOREARM

TO THE BARRIER. PATIENT TRIES TO PRONATE AGAINST THE PHYSICIAN.

HOLD 3-5 SECONDS, PATIENT RELAXES, AND PHYSICIAN ENGAGES

THE NEW SUPINATION BARRIER AND THE PROCESS IS REPEATED

UNTIL NO NEW BARRIERS. PRESSURE USING THE PHYSICIAN’S

THUMB ON THE POSTERIOR RADIAL HEAD PUSHING IT ANTERIORLY

AUGMENTS THE TREATMENT.

SUPINATION:

RADIAL HEAD

GLIDES

ANTERIOR

PRONATION:

RADIAL HEAD

GLIDES

ANTERIOR

ANTERIOR RADIAL HEAD: PRONATE THE FOREARM TO

THE BARRIER.

PATIENT TRIES TO SUPINATE AGAINST THE PHYSICIAN. HOLD 3-5

SECONDS, PATIENT RELAXES, AND PHYSICIAN ENGAGES THE NEW

PRONATION BARRIER AND THE PROCESS IS REPEATED UNTIL NO

NEW BARRIERS. PRESSURE USING THE PHYSICIAN’S THUMB ON THE

ANTERIOR RADIAL HEAD PUSHING IT POSTERIORLY AUGMENTS THE

TREATMENT.

45

WRIST SOMATIC DYSFUNCTION

FLEXION

• With wrist flexion

there is dorsal glide of

the carpal bones.

• BLACK ARROW

• INDICATES DORSAL

• CARPAL GLIDE

WRIST SOMATIC DYSFUNCTION:

EXTENSION • www.emedx.com/apex/apex_exercise_images/apex

P

U

PURPLE ARROW INDICATES WRIST EXTENSION, DARK ARROW

INDICATES VENTRAL GLIDE.

46

WRIST SOMATIC DYSFUNCTION:

• FLEXION SOMATIC DYSFUNCTION:

PHYSICIAN RESISTS PATIENT’S

ATTEMPT TO FLEX WRIST FOR 3 – 5

SECONDS AND WHEN PATIENT

RELAXES THE PHYSICIAN ENGAGES

THE NEW EXTENSION BARRIER AND

CONTINUES UNTIL NO NEW BARRIERS

ARE ENCOUNTERED.

WRIST SOMATIC DYSFUNCTION:

• EXTENSION SOMATIC DYSFUNCTION:

PHYSICIAN RESISTS PATIENT’S

ATTEMPT TO EXTEND WRIST FOR 3 –

5 SECONDS AND WHEN PATIENT

RELAXES THE PHYSICIAN ENGAGES

THE NEW FLEXION BARRIER AND

CONTINUES UNTIL NO NEW BARRIERS

ARE ENCOUNTERED.

47

WRIST SOMATIC DYSFUNCTION:

Articulatory Technique

• The patient’s wrist is held between both of the physician’s thenar eminences and the physician’s fingers are then interlaced and the patient’s wrist is then moved through a figure-of-eight pattern with the patient’s elbow unsupported to allow gentle distraction of the radiocarpal joint.

• After several cycles the wrist is then re-assessed.

Carpal Tunnel Syndrome

• History of hand paresthesias, especially the thumb, index, long, and radial aspect of the ring finger. Symptoms worsen at night and during pregnancy due to compression of median nerve.

• Positive Phalen’s test

• Both wrists maximally flexed and place dorsum to dorsum for one minute.

www.seattlecentral.edu/.../phalens

_test.gif

48

Carpal Tunnel Syndrome

(cont.)

• Tinel’s sign:

drwolgin.co

m/images/c

arpal%20tu

nnel%20tin

els.jpg

Carpal Tunnel Syndrome

Treatment

1

2

3

1: Palmar Carpal Ligament

2: Transverse carpal ligament

3: Median nerve

49

Carpal Tunnel Syndrome

Treatment

Wrist is extended and thumbs are placed

at the location of the short lines, and

compressing force is maintained as the

thumbs sweep out in the directions of the

arrows. This maybe be repeated until

tissue softening is accomplished.

50

Pt with GI Complaints

Constipation, abdominal pain, flatulence

Check iliotibial bands (Chapman’s)

Soft tissue to lumbothoracic and

lumbosacral areas

• Addresses levels of sympathetics

Iliotibial band release

– Pt supine with affected hip and knee flexed to place

foot on the affected side flat on the table.

– Dr standing at side of table facing pt.

– DO places one hand on the knee to stabilize.

– Other hand placed on lateral aspect of knee and

pressure applied to the depth needed to affect the

dysfunctional tissue

• Use heel of hand, or flat part of hands

– Stroke up lateral aspect of thigh to greater

trochanter, maintaining pressure on the IT band.

51

Thoracolumbar Diaphragm

Myofascial Tx

• Pt supine with dr at side of table

• Dr places 1 hand over right ribs 7 -10 and

the other hand contacts the left ribs 7 -10

in the midaxillary line

• Induce SB, noting restrictive barriers

Thoracolumbar Diaphragm

Myofascial Tx

• Induce transverse plane motion (rotation)

noting restrictive barriers

• Apply direct myofascial release technique

to barriers found

• After release of tissues, reassess region in

same manner as above

52

Mesenteric Cecal Lift

• Pt supine with knees bent

• Dr places heel of right hand on caudad

part of RLQ

• Push cecum cephalad

• Listen with hands and await tissue

softening

53

Doming the Diaphragm

• Pt supine with Dr standing, facing pt’s head

• Dr places hands on pt’s lower ribs, with thumbs under costal margin

• As pt inhales, exert cephalad force on diaphragm

• As pt inhales, resist caudad motion with thumbs

• Continue for 3-4 cycles