BLOCK ONE
Practical One Material
TART
o Tissue texture changes, Asymmetry, Restriction of motion, Tenderness
Types of end feel:
o Hard – bone hits bone (ex: elbow extension)
o Soft Tissue Approximation – tissue hits bone (ex: knee flexion)
o Stretch – tissue can’t go any further (ex: finger extension)
Abnormal End Feel
o Early Muscle Spasm – protective spasms after injury
o Late Muscle Spasm – chronic
o Hard Capsular – frozen shoulder (abrupt halt to movement)
o Soft Capsular – synovitis (doesn’t want to go through normal range of motion due to swelling)
Can palpate:
o Tissue movement - feeling skin vs. muscle
o Deep Palpation – feeling muscle vs. bone
o Fascial Changes – feeling stretches w/ heat, plus or minus pressure
Standing Screening Exam
o Posterior Landmarks (22)
Start head to feet (looking at asymmetries in the coronal plane)
(head position (tilted, rotated), mastoid processes, earlobes, cervical spine curves,
cervical spine mass, slope of shoulder, acromion, spine of scapula [ridge at the
top], inferior angle of the scapula [point at the bottom], medial scapular border
[the medial shoulder blade], lumbar/thoracic curves, lumbar/thoracic muscle
mass, arms symmetrical to thorax, fingertip level, iliac crests, PSIS, gluteal
muscles and folds, greater trochanters [most lateral bone of the femur], thighs
[symmetry/direction], calves [symmetry/direction], Achilles tendon, position of
the feet [symmetry in direction/ankle angle]
o Anterior Landmarks (14)
Eye level, earlobe level, rotation or angulation of the head, face, neck muscles (scalenes
[small muscles in the middle] and sternocleidomastoids [larger muscle from earlobes to
the front bottom neck]), shoulder level (acromion, clavicles, joints), levels of fingertips,
rib cage rotation/angulation, sternum xiphoid, iliac crest heights, ASIS, greater
trochanter, patella, medial malleoli, medial longitudinal arches [inner arch of foot]
AROM of the lower spine
o Flexion at the hips
Bend forward, count inches from fingertips to ground
o Extension at the hips
Lean backwards, measure the angel from vertical
o Sidebending
Lean to the left, then right measure distance form fingertips to ground
Active rotation of the thoracic/lumbar spine
o Have the patient sit & cross their arms, rotate spine as far as they can to the left, then right (if
head is rotating as well, measuring the active rotation of cervical/thoracic/lumbar)
Cervical spine range of motion
o Passive range of motion
Flexion/extension
1 hand braces the shoulders, the other hand is on top of the head doctor moves
head forward & backward (90 degrees)
Want fingeres 3, 4, & 5 over T1, T2, and T3; index finger over C7 can feel C7
moving, but T1 should be still (lets you know you’re measuring cervical, not
thoracic
Rotation
Use one hand to rotate the head to the left, then right (~90deg)
Sidebending
Bending to the left and right (~45deg)
Shoulder
o Flexion – raising straight up to the sky (~180deg)
o Extension – arm straight behind you (~90deg)
o Vertical abduction – raising arm laterally up to above your head (palms facing outside)
o Vertical adduction – bring arms back down towards body
o Horizontal abduction – holding arm horizontally out in front of you moving away from body
(adduction – towards the body)
o External rotation of the shoulder hold your arm in an L shape in front of you and rotate up
towards the sky (high-five)
o Internal rotation of the shoulder rotating down
Elbow
o Flexion = palm toward your shoulder
o Extension = going back down
Forearm
o Want to have elbow at 90deg angle by chest, Pronation & Supination
Wrist
o Flexion, Extension, Abduction, Adduction
Hip
o Flexion – knee bent, pulling in towards chest (but don’t want pelvic rotation)
Can also do with leg straight
**pt is supine
~90deg
o Internal/External rotation
Can be supine or prone
If prone, lay flat, bent knee, when pushing knee in towards middle internal (when knee
is in outer direction = external)
If prone, put one hand over sacrum to monitor spinal rotation
Knee
o Flexion = foot to butt (normal is about one fistful away)
Dorsaflexion = toes towards the sky
Plantarflexion = toes planted in the ground
Inversion of foot = turning bottom of your foot in
Eversion of foot = turning bottom of your foot out
SOMATIC DYSFUNCTION:
o Impaired or altered function of related components of the somatic (body
framework) system; skeletal, arthrodial, and myofascial structures, and
related vascular, lymphatic and neural elements.”
Soft tissue manipulations. Indications
o Reduce tension, Stretch/increase elasticity, Improve circulation (lymphatic & venous drainage),
Stimulate stretch reflex in hypotonic muscles, Helps patient relax & reduce guarding, Can make
other manipulations more effective once relaxed, Improve physician-patient relationship
Soft Tissue Techniques
o Cervical Region
Forward Bending (Bilateral Fulcrum), supine
Patient supine, doctor at the head of table, doctor’s arms crossed under the head &
hands are placed palm down on the patient’s anterior shoulder region,
longitudinally stretch the cervical paravertebral musculature in a rhythmic (or
sustained) manner
When done, reassess for improvement of tension
o Also helps w/ circulation
Contralateral Traction (supine)
Pt lies on their back, physician is on the side of the table opposite the side of the
neck they’ll be palpating; cephalad hand lies on the pt’s forehead to stabilize it;
caudad hand will reach around to touch the cervical paravertebral musculature
with the pads of the fingers; will draw the paravertebral muscles ventrally
producing minimal extension of the cervical spine; then re-evaluate the tissue
tension
Suboccipital Release (supine)
pt supine, physician at head of the table; pads are in immediate contact w/ the
suboccipital region in contact w/ the trapezius and its immediate underlying
musculature; apply gentle anterior and cephalad pressure; hold for a few seconds,
release (can do rhythmically for up to 2 min, until feel tissue texture changes, or
sustain for 30 sec – 1 min)
a good use for this is tension headaches
o Thoracic
Upper Thoracic w/ Shoulder Block; Lateral Recumbent
pt’s in the lateral recumbent position; physician at side of the table facing the pt;
put caudad hand underneath shoulder (put pads of fingers on the medial aspect of
the paravertebral muscles overlying the thoracic transverse processes); cephalad
hand is in contact with the anterior portion of the shoulder to provide effective
counter force. Drape the pt’s arm over your arm; physician’s caudad hand exerts a
gentle force ventrally to engage the soft tissues & laterally to create a
perpendicular stretch of the thoracic paravertebral musculature; hold for a few
sec’s & then release slowly; repeat these steps in a kneading fashion; at the end
re-evaluate the tension.
Prone Pressure
Lateral Recumbent Position of the Lumber Region
Foot: Longitudinal Arch Spring
Structural Exam
o Looking for somatic dysfunction; incorporate TART
o Static and dynamic evaluations
o Gait
Observation while walking
Looking at the body’s motions (is the motion symmetrical?)
Feet – foot position (toe in, tow out) heel to toe weight transfer
Knees: knock knee (valgus), bowlegged (varus)
Hip motion - lateral and vertical
HAT: (Head Arms Torso) – arm swing, side to side excursion, head movement
Proprioception/balance – squat down to the floor, observe motion up & down (TART)
Also have stand on one leg w/ eyes open; allow them to stand for 10-15 sec.
observe for declination (wobble) then repeat w/ other leg (TART)
Trendelenberg sign: while they’re holding one knee up, observe the hip. Should rise
slightly, if it drops may have hip dislocation, gluteus medius weakness, fractured femoral
head, or severe coxa vara
o Lateral observation
Cervical lordosis
Thoracic kyphosis
Lumbar lordosis
Sacral kyphosis
Gravitational line
Rotation of the pelvis
Knees flexed or hyperextended?
o Midgravitational Line for lateral screening exam (7 things)
External auditory canal
Lateral head of the humerus
3rd lumbar vertebra
Anterior 3rd of the sacrum
Greater trochanter of the femur
Lateral condyle of the knee
Lateral malleolus
Standing Flexion Test
o Measuring which PSIS moves first when the patient bends over
Hip Drop Test
o Have pt bend one knee, measure which PSIS moves further lumbar convexity on that side
o Assessing passive lumbar sidebending
Standing Tests
o Pelvic Side Shift (passive)
Pt standing, put one hand on the contralateral shoulder & the other hand on the hip
Translate the pelvis by pushing with the hip hand
Side that moves more is the positive side (if it moves more to the left, lumbar spine
sidebent left)
Seated Tests
o Seated flexion test
Pt sitting, feet apart lean forward while physician is feeling PSIS first one that
moves is positive on that side
o Acromion Drop Test
Testing thoracic sidebending (passively)
Pressure down on acromion on one side
Aim for inferior scapula on opposite side
Have other hand feeling both sides of the spine
Retest on other side
Note which side resists – has least motion
Sidebending restricted on that side
Upper extremity ROM: Hands over head, dorsum approximated. Observe for restriction of motion,
asymmetry
Supine & Prone Exam
Practical 2 Material
Counterstrain- How we diagnose and treat a pts somatic dysfunction by using/monitoring a tender point
and using spontaneous tissue release
o Mechanisms of Treatment: Want to shorten myofascial tissues around tender point to normalize
function. Promotes down regulation of pro-inflammatory mediators.
o Mechanisms of Dysfunction: Impaired ligament-strain inhibits/stimulated muscle contraction.
Treatment by shortening of myofascial structures to normalize neuronal activity, circulation of
inflammatory mediators.
o Mechanism Theories: Proprioceptive-Contraction of a muscle to prevent injury, this causes
sudden lengthening and defensive contraction. The opposing muscle contractions leads to tender
points. Sustained abnormal metabolism-injury in tissue that alters body causing loss of nutrients
and results in sensitized nerves, edema and tenderness.
o Contraindications? Relative-If pt cannot relax, ill, osteoporosis, position is not tolerated, cannot
communicate. Absolute- Cannot tolerate position, no dysfunction, lack of consent, exacerbation
of life threatening symptoms.
o More medial pain? Flexion and extension. More lateral pain? Sidebending and rotation.
BLT: Definition- Ligaments- osteopathic lesions that involve joints, Creates balanced tension- use of
ligaments to maintain lesion, Edythe Ashmore- Hold exaggeration on joint, reverse force. History- Want
to reduce tension, Still used indirect and traction techniques, Lippincott-use of ligaments for
maintenance of lesion. Mechanism-Find neutral Restore function-loosen and shorten muscles and
readjust to permit return to normalcy, Barriers-anatomic (torn tissue), physiologic (AROM), elastic
(between two), Restrictive barrier can change normal midline. Contraindications- Somatic dysfunction
of articular or myofascial basis, fracture, malignancy. Safety-extremely safe, diagnosis and Treatment-
For ligaments restore normal range of motion and decrease restriction. Find the most looseness by
allowing the patient relax, disengage, exaggerate (move in direction of injury). Balance and wait
FRP: Definition- Indirect myofascial release by placing component into neutral position and
diminishing tension. Korr-increased gain in gamma motor neuron activity. History- Simplar and less
traumatic treatment developed by schiowitz. Mechanism- Indirect technique to find least tension to
reduce strain. Always return to neutral. Contraindications- Joint instability, herniated disc, sprains or
strains, congenital anomalies. Diagnosis-TART and Treatment-For hypertonic muscles, use
compression, distraction and torsion, move away from barrier. Use tissue texture treatment, short
treatment, add motion to treatment.
Counterstrain for Lumbar Spine and Sacrum
o Palpate overlying the inferior aspect of the lumbar region L 1-5. Also palpate the lateral regions.
o Common lumbar tender points include: PL1-5 spinous process (eEStRa), PL1-3 Transverse
process(eEStRa) and quadratus lumborum(EAbdEr). (See Lab 8 lecture for pictures)
o Make sure to hold tender point entire time! Posterior Lumbar Region- two ways to treat lower
back pain. Use of EAddRA, extend hip, adduct the leg and externally rotate the hip or EStRa,
grasp ASIS on side of tender point, induce extension and rotation of pelvis toward tender point,
while lumbar rotates away.
o Common Pelvic tender points include: Upper (EAddIr/Er) and lower(FIrAdd) pole L5, High
ilium sacroiliac (EAbEr), high ilium flare out (Eadd), Gluteus medius posterior L3;L4(EErAb),
piriformis(FAbdIr/Er).
o Posterior pelvic region Lower pole-treatment of lower back pain or pelvic pain. Flex knee and
hip 90degrees, internal rotation of hip and adduction of knee.
o Posterior pelvic region Upper pole- treat when pt has lower back and pelvic pain. Palpate the
superior medial aspect of the posterior superior iliac spine. Extend and adduct the hip, then
switch between internal and external rotation based on patient’s needs.
o Posterior pelvic region, high ilium sacroiliac- treatment for pain in buttock associated with
quadratus lumborum or glutes. Palpate superior or lateral to PSIS and medially towards PSIS.
Extend, abduct and externally rotate the hip.
o Posterior pelvic region high ilium flare out- treatment for pain in lower medial portion of glutes.
Palpate on lateral aspect of ILA. Extend and adduct the hip.
o Posterior pelvic region, PL3;PL4 lateral gluteus medius-treatment for pain below iliac crest
while walking/getting up. Palpation of PL3 or PL4. Extend and abduct the hip, then internal or
external rotation based on pt.
o PPR, piriformis- Treatment for pain in buttock and posterior thigh. Palpation of midpoint
between ILA and greater trochanter. Pt leg off the table, flexed, abducted and externally rotated.
Can also do in lateral recumbent position.
