Work Related Somatic Dysfunction

1. Work Related Somatic Dysfunction Stuart Williams D.O. Associate Professor OMM Dept

2. Sedentary Posture Leads to exaggeration of normal sagittal plane curves. Ex: increased lordosis in cervical spine Ex: increased kyphosis in T spine

3. OA JointSupine 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

4. OA JointSupine 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

7. 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.

8. 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

10. Cervical Spine Range of Motion Rotation 50% occurs at AA joint, 50% rest of C-spine Should be able to bring chin to shoulder approx. 90 degrees each directions

11. Cervical Spine Range of Motion Flexion/Extension total range 90 degrees each direction

12. 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

13. 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

14. Cradle Technique for OA Dx Hands cradle occiput with fingertips of index and middle fingers over occipital articulation Test right and left translation (side-slippage) May also check forward and backward bending Somatic dysfunction named for the way the segment wants to move Opposite of the restriction

15. 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

16. Cradle Technique for OA Dx Hands cradle occiput with fingertips of index and middle fingers over occipital articulation Test right and left translation (side-slippage) May also check forward and backward bending Somatic dysfunction named for the way the segment wants to move Opposite of the restriction

17. 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

18. 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

19. 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

20. 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

21. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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

33. 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

37. Posture & Landmarks Normal Sagittal Curves: Cervical lordosis Concave posterior Thoracic kyphosis Convex posterior Lumbar lordosis Concave posterior Fused Sacrum is Convex posterior

38. Sagittal PlaneGravitational 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

39. Sagittal PlaneGravitational 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

40. � 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 Transitional zones - where antomic structure changes create the potentional for the greatest functional change What do we know about the apex of the curve in a group, type I dysfunction?Transitional zones - where antomic structure changes create the potentional for the greatest functional change What do we know about the apex of the curve in a group, type I dysfunction?

41. � 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 Transitional zones - where antomic structure changes create the potentional for the greatest functional change What do we know about the apex of the curve in a group, type I dysfunction?Transitional zones - where antomic structure changes create the potentional for the greatest functional change What do we know about the apex of the curve in a group, type I dysfunction?

42. 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

43. 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

44. 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

46. I.B.2.A-C. Posture-Lateral ViewCervical-Thoracic-Lumber Curves

47. 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? )

48. Cervical MotionFB/BB

49. Cervical MotionSaggital Plane: OA

50. 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).

51. Cervical Motion: Rotation