Block 2 OMM Spring OMS1 2010

1. Find most significant tender point
2. Establish scale (10 = start)
3. Monitor tenderness, tissue texture
4. Passively move patient toward ease, until pain reduced 70% or more
5. Maintain for 90 seconds, rechecking every 30 seconds, monitor
6. Slowly return PASSIVE patient to pretreatment position, maintain contact with point
7. Re-evaluate for resolution of tenderness and tissue abnormality at tender point.

1) Both can be located in muscle (though tender points not necessarily)
2) Locally tender
3) Elicits jump sign when pressed

NO associated pain pattern, located in muscles tendons ligaments and fascia, NO radiating pattern when pressed, taut band is NOT present, twitch response is NOT present, dermographia NOT present, Jones felt a tender point was a MANIFESTATION of a dysfunction, muscle treated by SHORTENING

Patient presents with characteristic pain pattern, elicits a radiating pain pattern when pressed, present within a taut band of tissue, elicits twitch response with snapping palpation, dermographia of skin over point, Travell felt pathology WAS the trigger point, muscle treated by stretching spraying and injection.

Impaired or altered function of related components of the somatic system (body framework): skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elementss

An area of skin innervated by sensory fibers from a single spinal nerve.

A group of mesenchymal cells emerging from the ventromedial part of a mesodermic somite and migrating toward the notochord.

The place where an alpha motor neuron pierces the investing fascia of a muscle to innervate a muscle

Indirect, passive technique.

Phase 1 – use subjective tenderness from patient to guide treatment
Phase 2 – use your developing palpatory skills to identify and monitor the tissue texture abnormalities of the tender point and correlate them with the patient’s reported tenderness.

1. Normal
2. Production of Strain
3. Reaction to Strain
4. Dysfunctional Resting State
5. Counterstrain Treatment
6. Post-Treatment

A normal muscle is stretched and strain is produced, creating pain and a sudden panic shortening of that longer muscle. This results in stretch inhibition of the agonist muscle, and reflex contraction and sustained hypertonus (facilitated spindles) of the antagonist.

The muscles are gently stretched, reproducing the situation that caused the strain, but allows for a resetting reflex, forcing the antagonist muscle down to zero firing. When brought back to normal position passively, there is no stretch inhibition or reflex contraction. SD is resolved.

Frontal Headache: C1;
Periorbital Headache: C2;
Occipital to Vertex Headache: C4;
Temporal Headache: C2
Generalized Headache: C5

Whiplash - C1-C2, C7-C8, T1-T2
Earache, Tinnitis, Vertigo - C3
Maxillary Sinus Pain - C2
Lower Neck Pain - C6-C8
Cervical Motion Restriction - any C

Upper Back Pain - T1-T6
Precordial Pain - AT3-6, ribs, interspace
Fatigue - T5-T6
Cystitis - AT11, L4

Heartburn - AT5
Epigastric Pain - AT7-8
Umbilical Pain AT9-10
Diarrhea or Constipation pain AT9-10

Shoulder pain/numbness - AT1-5
Finger pain - C6-8, T1
Elbow pain - T1
Lower Back pain - T9-T12

Prior to release of the muscle, the operator will sense warmth at the tender point.

An atypical strain point

Stoic patient - one who reports no pain or change in pain with positional movements, one has to rely on feel of tissue rather than patient feedback.

Acute/chronic SD, SD with neural component like hypertonic myofascial tissue, as a primary treatment or combined with other techniques, SDs in many areas of the body.

Patients who cannot voluntarily relax, are severely ill, vertebral artery disease, severe osteoporosis

20-30% of patients experience a reaction, general soreness, usually after their first treatment, appears 1-48 hours after treatment. Resolves in 1-2 days. Treating 6 or less tender points reduces the risk of reaction.

Avoid painful motions, avoid recreating the injury, avoid extremes of motion, do not test motions that produced pain or restriction before treatment, stay well hydrated (7-10 glasses of water), avoid dehydrating liquids.

Patient followup should be within 3-7 days at first, increasing distance between treatments as patient improves. Only one treatment may be necessary, but may take 6-10 over 2-3 months.

MPSI - Midpole Sacroiliac
FISI - Flarein Sacroiliac

ILA - Iliacus
SI points - Sacroiliac

PIR - Piriformis

SI points - Sacroiliac

HISI - High Ilium Sacroiliac
HIFO - High Ilium Flareout

ING - Inguinal

Thoracic spine, Lumbar spine, lower extremities

Iliacus now includes the psoas and iliacus points.

Iliacus - 1/3 distance to midline from the ASIS
Psoas - 2/3 distance to midline from the ASIS

Anterior

It is found on the anterior surface of the pubic ramus, where the medial thigh intersects the pubic ramus, lateral to the pubic tubercle.

Anterior

It is found on the superior aspect of the pubic ramus, at the attachment of the inguinal ligament.

Anterior

Patient lays supine, ankles crossed over knee of physician, ankle on treatment side against the knee. Patient relaxes thighs to allow knees to fall laterally.

Physician induces flexion and external rotation

Patient lays supine, physician brings knee on treatment side cephalad, carefully monitoring point.

Physician induces flexion and a little external rotation if needed.

Patient lays supine, with knees crossed and treatment leg resting on the physician's knee.

Physician induces flexion and internal rotation.

Flexion

It is on the superior-medial aspect of the PSIS

Posterior

The HISI is on the lateral side of the PSIS

Posterior

PL3 is about halfway between PL4 and the PSIS
PL4 is halfway between the greater trochanter and the iliac crest, and in line with the PSIS at the posterior aspect of the tensor fascia lata.

Gluteus medius

UPL5, HISI, PL3, PL4

Patient lays prone, physician brings leg into extension, with some external rotation and adduction.

Patient lays prone, physician brings leg into extension, with some abduction.

Patient lays prone and physician extends the treatment leg, with some external rotation and abduction or adduction.

MPSI, FISI, HIFO

It is directly below the PSIS and at the level of the ILA.

Posterior

The FISI point is also called the MPSI point, and is located directly below the PSIS and at the level of the ILA.

Posterior

Patient lays prone, physician abducts the leg, with some extension or flexion.

HIFO is located on the lateral side of the coccyx.

Posterior

Patient lays prone, physician extends an appropriate amount and adducts the leg.

Posterior

MPSI, FISI, LPL5, PIR,

LPL5 is 2cm below the PSIS, on the inferior aspect.

Posterior

Patient lays prone, physician usually seated beside patient on treatment side, flexes treatment leg off edge of table and internally rotates and adducts if necessary.

PIR is located halfway between the ILA and the greater trochanter, in the middle of the piriformis muscle.

Posterior

Patient lays prone, physician usually is seated on treatment side of patient, and flexes the knee off the table, with some abduction and internal rotation.

Anterior to posterior, 2-3 inches deep

Anterior to posterior
LI - medially
ING - superiorly

Inferior and lateral

lateral to medial, posterior to anterior

lateral to medial, some posterior to anterior

Press at a 45 degree angle, lateral to medial

Posterior lateral to anterior medial

Superior and posterior to anterior

There are three layers of living membrane: dura mater, arachnoid mater, pia mater;

Each layer has differing strengths and structure, supports the CNS rostrally to caudally.

The RTM folds back on itself to form internal straps...
...between the two halves of the brain
...between the brain and pituitary
...between the cerebrum and cerebellum

Pia mater - a thin membrane adhering directly to the cells of the CNS
Arachnoid mater - a complex layer of spiderweb-like filaments that contain CSF - and lies between the dura mater and pia mater.
Dura mater - the outer layer that adheres to the bone and to itself to form venous sinuses, the diaphragma sellae, tentorium, and falx.

Falx Cerebri, Falx Cerebelli, Diaphragma Sella, Anterior Dural Girdle

Transverse sinus, straight sinus, superior petrosal sinus, inferior petrosal sinus, cavernous sinus, spheno-parietal sinus

Sutures: Coronal, Frontal/Metopic, Lambdoid, Sagittal
Fontanelles: Anterior, Posterior, Posteriolateral/Mastoid, Anterolateral/Sphenoidal
Eminences: Parietal, Frontal

Vault bones are the plates of bones that make up the skull

Each starts at an ossification system, bones grow by radiating outward, and collide with one another to push the skull wider apart.

"Boss" or "eminence" of adult bones are the old ossification centers.

Squamous bone - when bone forms within the membrane of the Dura. Thin, with few fenestrations or foramina.

Basilar bone: also called basement bone, thick, with many foramina

They both have a basilar portion (basi-occiput) and a squamous (temporal squama) portion - each bone contributes to the cranial base and the vault.

As the bones grow, they drag out the dura, stretching it, which is important for keeping the sinuses patent.

Crista galli (center) - lateral to that, the Lesser Wings (one on each side) - even more lateral, the petrous portions (one on each side)

Crista galli - the anterior/posterior pole
Clinoid processes - anterior/inferior pole
Petrous ridges - lateral poles
Sacrum - caudal pole
Occiput - posterior pole

Falx cerebri - superior and inferior sagittal sinuses
Falx cerebelli - occipital sinus
Tentorium cerebelli - transverse sinus
Great vein of Galen
Sutherland's fulcrum - straight sinus
Confluence of sinuses
Sigmoid sinus
Cavenrous sinus

Straight sinus
Confluence of sinuses
Transverse sinus
Sigmoid sinus
Cavernous sinus

Inferior sagittal sinus and great vein of Galen

Across the skull from the inion, it collects blood from the occipital, straight, and superior sagittal sinuses

Transverse and petrosal sinuses, which are sent to the jugular vein via the sigmoid sinus

It is located at the pituitary gland (nestled around it) and drains into the petrosals.

Confluence of sinuses to the sigmoid sinus.

The dura is continuous with the internal layer of cranial dura.
It is firmly attached to the foramen magnum C2, C3, and S2.
It becomes the denticulate ligament that surrounds the exiting nerve root

C2, C3, S2

Move the contralateral piece in the opposite direction to enhance motion in the desired direction

The straight sinus remains static - it transmits tension without motion.

S2, C2 and occiput are usually rotated and sidebent together. They are also corrected together (as opposed to treating each individually)

SBS rises
Pulling anterior sacrum rostrally (L5-S1 goes posterior)
Inferior sagittal sinus drops
Straight Sinus remains still
Head widens
Glabella moves towards Inion

Sutures exist and are patent throughout life

Joints take work to create and maintain

Only reason to maintain them is for motion

No suture = no motion (cranial synostosis)
Complex suture = complex motion
Bone in a suture = distorted motion

Do not form until the bones meet in infancy
Interdigitate with each other
Change bevel with each other

Hypermobility = speculated to cause wormian bones
Normal motion = produces beveled sutures
Hypomobility = produces ankylosis

bones inter-digitate at sutures, and lesions release along sutural lines. Treat each bone in detail, focus on the sutures & their bevels

bones can only do what the membranes in which they live permit. Sutures & their bevels are less important than accessing membranous restrictions

Extension

*Midline bones only flexion or extension*

(forgot, look up)

Inferior

External Rotation

Posterior and Superior

1) Central nervous system (CNS) inherent motility
2) Cerebral spinal fluid (CSF) rhythmic fluctuations
3) Intracranial and intraspinal membranes (dura) inherent mobility
4) Articular mobility of the osseous cranial bones
5) Sacrum involuntary articular mobility relative to the ilia

Frontals - RTMs
Parietals - RTMs
Temporals - Occiput
Zygoma - Temporal bones
Maxillae - Vomer bone

Others: Palatines, nasals, lacrimals, inferior conchae, ethmoid (lateral masses)

Sphenoid*
Occiput*
Ethmoid (median plate)
Vomer
Sacrum

The parallel transverse axis

Superior

They rotate in the same direction

Ethmoid and occiput rotate one way, sphenoid in the other

The SBS rises

Inhalation phase of the PRM is correlated with Flexion

The SBS falls

Exhalation phase of the PRM is correlated with Extension

Patient supine, operator seated and the four fingers along the side of the head on each side.

Digit 2 - the greater wing of the sphenoid
Digit 3 - temporal bone zygomatic arch
Digit 4 - behind the ear on the temporal bone mastoid process
Digit 5 - lateral angle of the occiput

a functional as well as anatomical integrative relationship within the primary respiratory mechanism that directly connects the cranium to the sacrum (The occiput, C2, C3, and Sacrum).

Achieved through the dural column

The core link uses the mobility of the intracranial and intraspinal membranes, and the involuntary mobility of the sacrum between the ilia.

Formed from four distinct embryological parts - squamous portion with subparts - interparietal, supraocciput - there are two condylar portions, and two basilar portions.

7th or 8th year

The sacrum rotates about the transverse respiratory axis - at the tip of the spinous process of the second sacral segment.

With occiput flexion phase, the base of the sacrum moves posteriorly about the primary axis and slightly superior

Extension phase moves the base slightly inferior and anterior

Inability to latch and suck, frequent emesis, bradycardia, torticollis (neck to one side), irritability, colic, opisthotonis (can't lay flat)

An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique.

To restore pain-free movement to the musculoskeletal system in postural balance.

Decreased mechanical efficiency/increased joint stress
Facilitation of spinal segments
Soft tissue contractures (overuse, disuse)
Decreased ROM
Pain

Soft tissue techniques help prepare the area of SD for treatment

Osteopathic medicine, Chiropractic medicine, Physical therapy

a low velocity/moderate to high amplitude technique where a joint is carried through its full motion with the therapeutic goal of increased range of movement.

The activating force is either a repetitive springing motion or repetitive concentric movement of the joint through the restrictive barrier.

A low velocity/moderate amplitude technique where the restrictive barrier is engaged repeatedly to produce an increased freedom of motion.

Thrust - HVLA

Springing - Decreased force application, repeated addressing of barrier

Articulatory - low velocity/moderate amplitude

Low Velocity, High Amplitude - Increased force more slowly

High velocity Low amplitude, Thrust, Mobilization, Impulse, Crunch, Cracking, Popping

Direct action, passive

Specific joint restriction (ROM)

Hard barrier

Cancer
Mild-moderate osteoporosis
Neurological disease (cerebral palsy, Parkinson's, etc)
Extremes of age - Toddlers, Geriatric patients

Vertigo or loss of consciousness with cervical extension and rotation, indication of vertebral artery occlusion
"Rubbery" quality of soft tissue restriction
Pathologic instability of the O/A joint (ie RA, Down Syndrome/Trisomy 21)
Suspicion of a fracture
Septic joint
Vasculitis, Bursitis, History of CVA
Metastatic bone disease

Immediate increase in the range and freedom of motion

1/8 inch

1) Prepare dysfunctional joint by relaxing associated soft tissue.
2) Place dysfunctional joint against its restrictive motion barrier(s) and lock out all other motion.
3) Apply activating force to restrictive motion barriers while maintaining the locking out of other motion. Force is variable! Never “shotgun”.
4) Hold position briefly after the thrust before return to neutral.
5) Re-evaluate joint motion.

Movement within a synovial joint that is independent of, and cannot be introduced by, voluntary muscle contraction

Essential for normal, pain free, nonrestricted movement of the particular articulation

Patient must be relaxed.
Therapist must be relaxed. Therapeutic grasp must be painless, firm, and protective.
One joint is mobilized at a time.
One movement in a joint is restored at a time.
In performance of movement, one aspect of joint is moved upon the other, which is stabilized.
Extent of movement is not greater than that assessed in the same joint on opposite unaffected limb.
No forceful or abnormal movement must ever be used.
The manipulative movement is a sharp thrust, with velocity, to result in approximately 1/8” gapping at the joint.
Therapeutic movement occurs when all of the “slack” in the joint has been taken up.
No therapeutic maneuver is done in the presence of joint or bone inflammation or disease (heat, redness, swelling, and so on).

Reduce hypertonicity

Allow for increased resiliency of tissues surrounding the dysfunctional joint.

Relaxation and reassurance to the patient

Treatment is localized to a single joint.

“Shotgun” to a generalized area of the spine is inappropriate and may be harmful.

Force should never replace skill!!!

Applied quickly over a short distance
Motion at joint is only about 1/8”
Excessive force is never a substitute for specificity.
Excess force should not be used in the hope that the joint will move.

Pregnancy, guarding, pain, arthritis, elderly, children

Breaking a vacuum
Gapping the joint
Release of a nitrogen bubble
Electrical discharge
Breaking hydrodynamic fluid

Sounds does not equal success
Sound may be produced from a different joint
Barrier may be overcome without any sound
Sound is harmless as well as necessary

May equate sound with a successful treatment (incorrect)

Some fear that sound means something has broken or fractured (also incorrect, generally)

Soft tissue technique pre-treatment
Localize restricted joint in all planes
Respiratory cooperation
Redirection of attention of the patient
Mild traction
Double thrust
Post-thrust pause
Adjust the treatment to fit the patient AND your skill level

Accurate diagnosis
Consider possible complications
Ask permission to treat**
Listen with your hands
Emphasize SPECIFICITY
SD with joint restriction is an indication for thrust techniques - not pain
SD often coexist with other diseases so look at whole patient

Atypical in structure and motion - OA, AA, C1-C2

Typical in structure and motion - Typical motion and structure - C2-C3, through C7-T1

Sidebending - less than 10 degrees - C6-T1
Rotation about 8-12 degrees, peak at C3-C5
Flexion/extension - 8-20 degrees, peak at C5-C6

80-90 degrees of rotation to each side
45 degrees lateral flexion on each side
130 degrees total flexion/extension

It moves backwards, upwards, and medial. Anterior rotation is toward the eyes.

C3-C6 - mid-cervical vertebrae have small lateral joints. They provide stability to the cervical spine by limiting lateral side slip

Sidebending and rotation should be in the same direction.

1/3

Flexion - fix the left facet and flexion of the right facet will lead to left rotation and sidebending

Extension - fix the right facet and extend the left facet leading to left side bending and rotation

Rotation

15-22 degrees

Rotation mostly

Some sidebending may occur but it is also coupled with rotation

The right facet flexes and becomes sidebending and rotation left.

C1-C2 level - intimal tear with extension and rotation - on the vertebral artery. Especially with too much force.

Rectus capitis posterior minor
Rectus capitis posterior major
Superior oblique muscle of the head
Inferior oblique muscle of the head
Rotatores cervicis - longus, breves
Longissimus capitis
Semispinalis capitis
Splenius capitis, cervicis

Longus colli muscle
Scalenes muscles (anterior, middle, posterior)

Sternocleidomastoid
Levator scapulae muscle
MIddle scalene muscle
Anterior scalene muscle

Treat the upper T spine and ribs before treating the cervical spine
Check anterior and lateral muscles and fascia for dysfunction
Pain in upper thoracic may be from brachial plexus irritation
Trust intuition and be cautious in face of possible nerve root involvement
Order appropriate tests and/or consults in face of cervical neuropathy and trauma.

Check for motor weakness, sensory deficit, and reflex changes

C5 - anterior middle arm and forearm
C6 - lateral forearm to thumb
C7 - index and middle finger
C8 - medial forearm, 4th and 5th fingers

Dorsal scapular nerve

C5

Suprascapular nerve

C5 and C6 from the superior trunk of the right brachial plexus

Lateral pectoral nerve

C5, C6, C7 - from the joining of the superior and middle trunks at the lateral cord of the right brachial plexus

Musculocutaneous nerve

C4, C5, C6, C7 from one of the terminal branches of the lateral cord in the right brachial plexus

Axillary nerve

C5, C6 from one of the terminal branches of the posterior cord in the right brachial plexus

Radial nerve

C5, C6, C7, C8, T1 from one of the terminal branches of the posterior cord in the right brachial plexus

Median nerve

C5, C6, C7, C8, T1 from the combined terminal branches of the posterior and medial cords in the right brachial plexus

Ulnar nerve

C7, C8, T1 from one of the terminal branches of the medial cord in the right brachial plexus

Thoracodorsal nerve

C6, C7, C8 from the posterior cord in the right brachial plexus

Subscapular nerve

C5, C6 from the posterior cord of the right brachial plexus

Medial pectoral nerve

C8, T1 from the medial cord of the right brachial plexus.

Long thoracic nerve

C5, C6, C7 - short branches before the nerves become the superior, posterior, and medial trunks of the right brachial plexus

Avoid HVLA
Treat with indirect methods
Muscle energy applied gently can be appropriate and effective depending on the severity of the problem

1) Accurate Diagnosis
2) Place segment at the "firm edge" of the barrier
3) Patient rests comfortably in your hands
4) Doctor initiates motion ASAP once reaching the barrier
5) Vector of the thrust determined by whether doing side bending or rotatory thrust
6) Perform a quick thrust through the barrier, from the barrier, no wind-up
7) Re-evaluate
8) Use gentle soft tissue (briefly)

#1 risk: stroke - primarily as a result of combining rotation with extension

Tear of the vertebral artery between C1 and C2

No diagnosis was listed
No evidence of engagement of barrier
Extension and rotation

Trisomy 21 (AA is instable, get X-rays)
Spondyloarthropathies (Ra, AS)
Chiari Malformation - type I, generally asymptomatic during childhood, manifests with headaches and cerebellar symptoms
Metastatic cancer, multiple myeloma
Atherosclerosis of the vertebral arteries (or elsewhere - caution)

Physician is in a hurry, frustrated
Ignoring red flags
Doing OA-HVLA without "soft-tissue" prep first and last
Substitute strength for precision
Do not localize to the true barrier
Patient is guarded, anxious, tense
Physician not present and mindful

Benefits exist for headache and neck pain
Harm occurs infrequently
More spontaneous risk of VBA embolization than with manipulation treatments
Provocative tests are unreliable
Risk factors - rotational HVLA implicated
Conclusion: HVLA is effective and relatively safe (compare to NSAIDS, other treatment modalities)

25%

20% acquire A-A instability

Screen for cervical spine flexion and extension views - some recommend annual screenings

The sudden autonomic discharge and reset may be too much for them

Patient does not want or cannot tolerate HVLA
Muscle spasm, exacerbation
Herniated disk with nerve root compromise
Patient does not have head control
Primitive reflexes
Cancer with metastatic risk
Paget's dx, parathyroid problems, fracture
Arterial plaques
Spasticity/contracture
Vascular compromise
Acute condition that may exacerbate (asthma)
Osteoporosis
Hemophilia or anticoagulants
Lens implants or Marfan's/MVPS
Litigious patient

10-20% of those hospitalized for GI complications of NSAID use die
1997 estimated death rate from NSAID complications in patients with arthritis was equivalent to deaths from AIDS
Costs from associated GI complications is greater than 2 billion per year

Cervical long axis kneading and stretching

Cervical transverse push pull treatment

Inspection/Observation
Active/Gross motion testing
Palpation
Passive/Segmental motion testing including lateral translation test and rotation test
Neuro-vascular testing
Other considerations?

Check skin for changes in color, lesions, etc.
Look for asymmetry of position and muscular tone
Note changes in AP and lateral curves or weight bearing line

Check TART - check anterior, posterior, and lateral muscles as well as upper T spine and ribs
Check patient lying supine - the sub-occipital region, the posterior articular pillar region, as well as areas lateral to the pillars.
Make a segmental diagnosis

With patient seated...
Rotate left and right
Side bend left and right
Touch chin to chest (flex)
Look to ceiling (extend)

*Palpate/feel as they perform these motions - have patient perform actively, and physician also tests passive motion*

Directed by the findings from TART and the screening exam...
Check side bending, rotation, and flexion/extension

In the space between the tip of the mastoid process and the angle of the jaw

Inferior and posterior medial to the mastoid tip

Obliquus capitis superior
Obliquus capitis inferior

Rectus capitis posterior minor

Rectus capitis posterior major
Obliquus capitis inferior

Test rotation of the atlas about the axis

Sit at supine patient's head, monitor the lateral masses of the atlas, flex the entire c-spine to isolate other c-spine motion, back off slightly to localize at the A-A
Test Right and Left rotation and note any restriction or difference

Lateral translation test done with finger pads on the articular pillars
Test rotation by pressing on articular pillars
Test in neutral, flexed, and extended positions and note/label dysfunctional segments by position of ease

1) Patient supine, physician at head of table
2) Palms on each side of the patient's head, contact the right lateral mass of the atlas with the MPJ of the right index finger
3) Hold head and flex head and neck fully, and then slightly back off flexion at C1 while maintaining flexion in rest of cervical spine
4) With the MPJ contacting the atlas the physician rotates the AA joint to the restrictive barrier
5) With a quick, short thrust physician rotates C1 left through the barrier
6) Recheck

1) Support patient's head and neck with arm
2) MCPJ placed on the posterior aspect of the articular pillar
3) Introduce rotation to the barrier with your MCPJ
4) Flex or extend to the barrier
5) Side bend the cervical spine to direction of ease to lock out the other cervical vertebrae
6) With patient relaxed, thrust from the barrier with a quick short impulse through the barrier
7) Place patient in neutral and recheck

1) Patient supine, physician at head
2) Physician places MCPJ on lateral margin of restricted articular pillar, and pushes the articular column to induce sidebending and rotation toward restriction
3) Support head and neck for counterforce and rotation
4) Physician flexes or extends the neck as needed to localize to the dysfunctional segment
5) Rotate the spine to ease to lock out the rest of the vertebrae
6) With patient relaxed, from the barrier, thrust with a quick short impulse through the barrier
7) Place patient in neutral and recheck

Chronic headaches

Neurovascular symptoms of thoracic outlet syndrome

The lateral portion of the anterior arm and portions of the shoulder and superior anterior chest

The lateral edge of the arm and the thumb

The lateral portion of the posterior arm and portions of the posterior shoulder. Also the 2nd and 3rd digits.

The medial portion of the posterior arm and portions of the posterior shoulder. Also the 4th and 5th digits.

The more medial portion of the anterior arm, and portions of the chest inferior to that innervated by C5. Also, portions on the posterior shoulder below those innervated by C8.

Alteration of the motion of the SBS that leads to non-physiologic motion of the primary respiratory mechanism

Usually occurs from cranial trauma

May also be manifested through trauma in other parts of the body (particularly the pelvis)

All the cranial bones - both midline as well as pared bones but is referenced to the Sphenoid's relationship to the Occiput

Torsion (Right or Left)
Lateral Strain (Right or Left)
Vertical Strain (Superior or Inferior)
Sidebending Rotations (Right or Left)
Sphenobasilar Symphysis Compression

They can be present individually or in combinations

No, each strain pattern has a unique, identifiable palpable configuration.

A single transverse axis

A single transverse axis, just superior to the jugular processes

Flexion of midline bones
Rising of the SBS
External rotation of the pared bones

Sphenoid greater wings and Occiput lateral angles progress inferiorly

Temporal bone squamous portions widen anterior-laterally

Extension of midline bones
Lowering of the SBS
Internal rotation of the pared bones

Sphenoid greater wings and Occiput lateral angles move superiorly

Temporal bone squamous portions narrow posterior-medially

Primarily a single anterior-posterior axis

By the most superior sphenoid base and the greater wing

Digits 2 and 5 of one hand move in the opposite (superior or inferior) direction relative to Digits 2 and 5 of the other hand

Usually an inferior or superior force vector directed on the outer anterior or posterior quadrant of the cranium

Specifically digits 2 and 5 will be superior on the left side

Two transverse axes - one through the body of the Sphenoid, and another superior and posterior to the jugular processes of the occiput

It is named for the most superior sphenoid base

The #2 digits on both hands move superior or inferior relative to the #5 digits on both hands.

Usually an inferior or superior force vector directed along the midline either at the anterior or posterior aspects of the cranium

They both rotate in the same direction (dysfunctional motion - should be opposite motion)

Two superior-inferior axes, through the sphenoid body and foramen magnum
One anterior-posterior axis through the body of the sphenoid, basion, and opisthion

It is named by the side of cranial convexity - so which ever one bulges out the most (essentially named opposite of sidebending)

Digits 2 and 5 on one hand move apart (concave side), while digits 2 and 5 on the other hand move together (the convex side)

Usually a lateral force vector directed at the level of and perpendicular to the sphenobasilar symphysis (SBS).

Two superior-inferior axes through the sphenoid body and the foramen magnum

Defined by bilateral digits #2 moving in opposite left or right directions relative to bilateral digits #5.

A lateral force vector directed at either the left or right anterior or left or right posterior lateral quadrants of the cranium

Absence of primary respiratory mechanism flexion and extension.
A hard dense amorphous mass with complete absence of perceived cranial motion (bowling ball)
An abnormal increase in cranial motion or alternating strain patterns, such as lateral or torsion strains

A force vector applied either to the anterior or posterior midline aspects of the cranium, directed through the SBS