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CHAPTER 1-PRINCIPLES
•
Facet Orientation Cervical-Backward, Upward, Medial Thoracic-Backward, Upward, Lateral Lumbar-Backward, Upward, Medial
Table 4: Fryette’s Principles Motion
Spinal Mechanics Table 1: Planes and Axes Motion
Plane
Axis
Rotation
Horizontal
Vertical
Side-bending
Coronal
AP
Sagittal
Sagittal
Horizontal
•
Table 2: Rotation
•
Left Transverse Process
Type I (Neutral)
SXRY or SYRX
Type II (Non-Neutral)
RXSX or RYSY
Right Transverse Process
Definition-impaired or altered function of related component of the somatic system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. Diagnostic Criteria-Tissue Texture Abnormality, Asymmetry, Restriction of Motion, Tenderness (TART).
Table 5: Acute vs Chronic Dysfxn
Left
Posterior
Anterior
Acute Findings
Right
Anterior
Posterior
Vasodilatation, Edema, Tenderness, Pain, Contraction, Skin Warm/Moist, Muscle Spasm, Minimal Somatovisceral changes
The point of reference for direction of rotation is a point on the anterior and superior surface of the body of the vertebra.
Table 3: Side-bending Side of SB
Concave Side
Convex Side
Left
Left
Right
Right
Right
Left
Direction
Somatic Dysfunction
•
Side of Rotation
Side-bending is tested by ing the space between two vertebral segments and pushing medially.
•
Chronic Findings Vasoconstriction, Itching & Fibrosis, Tenderness, Paresthesias, Contracture, Skin Cool/Pale, Muscle Flaccid, Frequent Somatovisceral Changes
Somatic dysfunction is named for the direction of motion, this is opposite of the direction of restriction.
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CHAPTER 2-NEUROLOGIC Autonomic Nervous System Table 6: Sympathetic Innervation Level
Splanchnic Nerve
T1-4
Collateral Ganglia Cervicothoracic, middle & superior cervical ganglia
T1-T6
Organs/Structures Innervated Head and Neck Heart and Lungs
T5-T9
Greater splanchnic nerve
Celiac ganglion
Upper GI (T5R gall bladder, T6R ducts, T7R pancreas, T7L spleen)
T10-T11
Lesser splanchnic nerve
Superior mesenteric ganglion
Lower GI (small intestine, right colon, gonads, adrenals, upper ureter)
T10-T12
Kidney
T12
Least and lumbar splanchnic nerves
T12-L2
Least and lumbar splanchnic nerves
Appendix (usually right) Inferior mesenteric ganglion
Left colon, lower ureter, bladder, uterus/ prostate, genitals
T2-T8
Arms
T11-L2
Legs
Table 7: Parasympathetic Innervation Nerve
Nucleus
Ganglion
Organs Innervates
CN3 (Oculomotor n)
Edinger-Westphal (accessory oculomotor)
Ciliary
Pupil
CN7 (Facial n)
Superior salivatory
Pterygopalatine...........> OR Submandibular...........>
Sinuses, lacrimal gland, palate Sublingual/submandibular glands
CN9 (Glossopharyngeal n)
Inferior salivatory
Otic
Parotid gland
CN10 (Vagus)
Dorsal vagal
Superior and inferior vagal
All structures in the head, neck, heart, lungs, kidneys, upper ureters, entire GI tract down to the mid-transverse colon.
S2-S4 (Pelvic splanchnic nn)
Left colon, lower ureter, bladder, uterus/prostate, genitals
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Nerve Roots Table 8: Upper Extremity and Brachial Plexus Nerve Roots Level of Exit (Disc)
Nerve Root
Sensory
Reflex
Motor
C5 Root
C4-C5 (C4 disc)
Lateral arm
Biceps
Abduction of shoulder, elbow flexion
C6 Root
C5-C6 (C5 disc)
Lateral forearm, thumb, index finger
Brachioradialis
Elbow flexion, wrist extension (most common herniation)
C7 Root
C6-C7 (C6 disc)
Middle finger
Triceps
Elbow extension, wrist flexion
C8 Root
C7-T1 (C7 disc)
Medial forearm, ring & little finger
None
Finger flexion
T1 Root
T1-T2 (T1 disc)
Medial arm
None
Finger abduction/adduction
Table 9: Upper Extremity Major Nerves Origin (Partial Origin)
Nerve
Function
Injury Commonly Results in...
Long Thoracic
C5-C7
Innervates serratus anterior m
“Winging” of the scapula
Axillary
C5-C6
Innervates deltoid & teres minor mm
Deltoid atrophy
Musculocutaneous
C5-C7
Innervates arm flexors, sensory to lateral forearm
Diminished biceps reflex
Median
(C5) C6-T1
Innervates flexors of the forearm & hand. Sensory to the palmar surface (including fingernails) of digits 1-3 & part of 4
Thenar eminence atrophy
Radial
C5-C8 (T1)
Innervates forearm extensors. Sensory to back of forearm, hand, digits 1-3 and part of 4
Wrist drop, diminished triceps reflex
Ulnar
(C7) C8-T1
Innervates some flexors of the hand. Sensory to medial hand and part of digit 4, all of digit 5
Hypothenar eminence atrophy
Table 10: Lower Extremity Nerve Roots Nerve Root
Level of Exit (Disc)
Sensory
Reflex
Motor
L4 Root
L3-L4 (L3 disc)
Medial leg & foot
Patellar
Foot inversion
L5 Root
L4-L5 (L4 disc)
Dorsal surface of the lower leg & foot
None
Dorsiflexion of the toes, foot drop if injured
S1 Root
L5-S1 (L5 disc)
Lateral side of the foot
Achilles
Eversion of the foot (most common herniation)
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Table 11: Lower Extremity Major Nerves Nerve
Origin
Function
Obturator
L2-L4
Innervates adductors, sensory to small area of skin on medial thigh
Femoral
L2-L4
Innervates quads, sensory to medial & middle thigh and medial lower leg
Diminished knee jerk reflex
Lateral Femoral Cutaneous
L2-L3
Sensory to lateral thigh
Meralgia paresthetica
Posterior Femoral Cutaneous
S1-S3
Sensory to back of thigh
Sciatic
L4-S3
Innervates muscles of posterior thigh, branches into tibial and common fibular
Tibial
L4-S3
Innervates muscles of posterior leg, sensory to lateral posterior leg
Diminished ankle jerk reflex
Common fibular
L4-S2
Innervates anterior lower leg
Foot drop
CHAPTER 3-POSTURE AND GAIT Table 12: Heel Lift Therapy Type of Patient
•
Initial Lift
Increase Every 2 Weeks
Less than 5mm difference
Not treated
N/A
“Fragile” Patient (Elderly, Arthritis, Osteoporosis)
1/16” Lift
No More Than 1/16”
“Flexible” Patient
1/8” Lift
No More Than 1/16”
“Injured” Patient (Where Leg Length Was Suddenly Shortened)
•
Injury Commonly Results in...
Full Amount
N/A
The total lift height should be only ½ to ¾ of the shortness measured by the standing x-ray. A maximum of ¼” lift can be used inside the shoe. Up to ½” can be used between the patients heel and floor. If more than ½” is needed, lift must be applied to the heel and half-sole of the shoe.
CHAPTER 5-CRANIAL Flexion: • • • • • •
The SBS rises. All midline bones go into flexion. All paired bones go into external rotation. The respiratory phase is inhalation. The sacral base moves posterior (counternutation). The skull widens laterally and shortens in its A/P diameter.
Extension: • • • • • •
The SBS falls. All midline bones go into extension. All paired bones go into internal rotation. The respiratory phase is exhalation. The sacral base moves anterior (nutation). The skull narrows laterally and increases in its A/P diameter.
The Following Somatic Dysfunctions Occur at the SBS: 1. Flexion (will not cycle into extension) 2. Extension (will not cycle into flexion) 3. Torsions (left and right) 4. Sidebending rotations (left and right) 5. Vertical Strains (superior and inferior) 6. Lateral Strains (left and right) 7. SBS compression
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Table 13: Summary Chart of Bone Position Somatic Dysfunction
Greater Wings of the Sphenoid
Occiput
Temporals
Flexion
Inferior, Anterior, and Lateral Bilaterally
Inferior and Lateral Bilaterally
External Rotation Bilaterally
Extension
Superior, Posterior, and Medial Bilaterally
Superior and Medial Bilaterally
Internal Rotation Bilaterally
Left Torsion
Superior on Left, Inferior on Right
Inferior on Left, Superior on Right
Left External Rotation, Right Internal Rotation
Right Torsion
Superior on Right, Inferior on Left
Inferior on Right, Superior on Left
Right External Rotation, Left Internal Rotation
Left Sidebending Rotation
Inferior on Left, Superior on Right
Inferior on Left, Superior on Right
Left External Rotation, Right Internal Rotation
Right Sidebending Rotation
Inferior on Right, Superior on Left
Inferior on Right, Superior on Left
Right External Rotation, Left Internal Rotation
CHAPTER 6-CERVICAL SPINE Table 6-14: Motion and Positional Findings for OA Tri-axial Somatic Dysfunction
Somatic Restricted Dysfunction Motion
Translation Terminology
Transverse Process Closer to the Mandible
Transverse Process Closer to the Mastoid
If the Left Side is Most Dominant in Restriction & Tissue Changes
If the Right Side is Most Dominant in Restriction & Tissue Changes
(F)SLRR
(E)SRRL
Translates Right OR Restricted in Left Translation During Extension
Right
Left
Anterior Occiput Left
Posterior Occiput Right
(E)SLRR
(F)SRRL
Translates Right OR Restricted in Left Translation During Flexion
Right
Left
Anterior Occiput Left
Posterior Occiput Right
(F)SRRL
(E)SLRR
Translates Left OR Restricted in Right Translation During Extension
Left
Right
Posterior Occiput Left
Anterior Occiput Right
(E)SRRL
(F)SLRR
Translates Left OR Restricted in Right Translation During Flexion
Left
Right
Posterior Occiput Left
Anterior Occiput Right
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Table 15: Motion and Positional Findings For Typical Cervical Tri-axial Somatic Dysfunctions Somatic Dysfunction
Restricted Motion
(E)RRSR or ERSR
(F)SLRL
(E)RLSL or ERSL
(F)SRRR
(F)SRRR or FSRR
(E)RLSL
(F)SLRL or FSRL
(E)RRSR
Translation Terminology
May Also Be Written as...
Posterior Articular Process
Side of Most Paraspinal mm. Tightness
Translates Left OR Restricted in Right Translation During Flexion
Translates From Right to Left
Most Prominent During Flexion
Translates Right OR Restricted in Left Translation During Flexion
Translates From Left to Right
Most Prominent During Flexion
Translates Left OR Restricted in Right Translation During Extension
Translates From Right to Left
Right
Right
Most Prominent During Extension
Most Prominent During Extension
Translates Right OR Restricted in Left Translation During Extension
Translates From Left to Right
Most Prominent During Extension
CHAPTER 7-UPPER EXTREMITY 1. Extension of the upper extremity to 90 degrees. 2. Flexion of the upper extremity to 180 degrees. 3. Circumduction with glenohumeral t compression. This tests the t surfaces. 4. Circumduction with traction. This tests the t capsule. 5. Abduction (not adduction) to 90 degrees. 6. Internal rotation. 7. Pump, also called traction with caudal glide.
Right Most Prominent During Flexion
Left
Left Most Prominent During Flexion
Left
Left Most Prominent During Extension
Table 17: Radial Head Somatic Dysfunction Somatic Dysfunction
The Seven Stages of Spencer:
Right
Restricted Motions
Most Likely Mechanism
Radial Head Anterior
Posterior and Pronation
Fall Backward on the Outstretched Hand
Radial Head Posterior
Anterior and Supination
Fall Forward on the Outstretched Hand
Table 18: Tests of the Upper Extremity Table 16: Ulnar Somatic Dysfunction Somatic Dysfunction Abducted Ulna Adducted Ulna
Carrying Angle Increased
Decreased
Wrist Increased Adduction Increased Abduction
Test
Purpose
Olecranon Process
Adson’s Test
Compression of the Subclavian Artery
Increased Medial Glide
Allen’s Test
Collateral Circulation of the Hand
Apley’s Scratch Test
Evaluate the Range of Motion of the Shoulder
Apprehension (Crank) Test
Detect Chronic Shoulder Dislocation
Drop Arm Test
Detect Tears in the Rotator Cuff Muscles
Increased Lateral Glide
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Table 18: Tests of the Upper Extremity Test
Purpose
“Empty Can” Test
Detect Tears of the Supraspinatus Tendon or Muscle
Finkelstein’s Test
DeQuervain’s Tenosynovitis (Abductor Pollicis Longus & Extensor Pollicis Brevis Tendons)
Load & Shift Test
Shoulder Instability, Anterior or Posterior
Phalen’s Test
Carpal Tunnel Syndrome
Posterior Apprehension Test
Posterior Shoulder Instability or Dislocation
Speed’s Test
Bicipital Tendinitis
Sulcus Sign
Inferior Shoulder Instability
Tinel’s Sign
Carpal Tunnel Syndrome
Yergason’s Test
Bicipital Tendinitis
CHAPTER 8 & 10-THORACIC AND LUMBAR SPINE Table 19: The “Rule of Threes” Spinous Process Location in Relation to the Vertebral Body
Transverse Process Location in Relation to the Spinous Process
T1-T3
Over the Body of the Corresponding Vertebra
The Same Horizontal Plane
T4-T6
Over the Intervertebral Space Below
About 1/2 Inch Up and Lateral
T7-T9
Over the Body of the Vertebra Below
About 1 Inch Up and Lateral
T10-T12
Over the Body of the Corresponding Vertebra
The Same Horizontal Plane
Vertebrae
7
Forward Bending (Flexion) Dysfunction Positional findings: • There is a slight separation of the spinous process from the segment below. • There is a slight approximation of the spinous process to the one above. • There is usually tenderness of the supraspinous ligament. Motion findings: • Rotation is restricted bilaterally. • Side-bending is usually restricted bilaterally. • The segment forward bends easily and is restricted in backward bending.
Backward Bending (Extension) Dysfunction Positional findings: • There is a slight separation of the spinous process from the segment above. • There is a slight approximation of the spinous process to the one below. • There is usually tenderness of the supraspinous ligament. Motion findings: • Rotation is restricted bilaterally. • Side-bending is usually restricted bilaterally. • The segment backward bends easily and is restricted in forward bending.
Neutral Somatic Dysfunction Positional findings (SXRY): • Approximation of the transverse processes on side “X”, caused by side-bending toward side “X”. • Separation of the transverse processes on side “Y”. • Posterior transverse process on side “Y”, caused by rotation to side “Y”. • Anterior transverse process on side “X”. • The spinous process may be shifted to side “X”. Motion findings: With motion testing, the segment will move in the direction of somatic dysfunction and it will be restricted in the direction opposite of the somatic dysfunction.
Table 20: Neutral Positional Diagnosis Sense of Fullness and Posterior Transverse Processes
Easy Normal (EN)
(N)SLRR
Right
EN Right or ENR
(N)SRRL
Left
EN Left or ENL
Dysfunction
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Non-Neutral Somatic Dysfunction Positional findings (R XSX): • Approximation of the transverse processes on side “X”, caused by side-bending toward side “X”. • Separation of the transverse processes on side “Y”. • Posterior transverse process on side “X”, caused by rotation to side “X”. • Anterior transverse process on side “Y”. • The spinous process may be shifted slightly to side “Y”. • These dysfunctions are generally very painful and may present with a significant amount of paravertebral muscle spasm. Motion findings: With motion testing, the segment will move in the direction of somatic dysfunction and it will be restricted in the direction opposite of the somatic dysfunction.
Table 23: Muscles Used for Inhalation Rib Somatic Dysfunction Muscle
Transverse Process Position in Extension
Dysfunction
Transverse Process Position in Flexion
FRS Left
Posterior Left
Symmetrical
FRS Right
Posterior Right
Symmetrical
ERS Left
Symmetrical
Posterior Left
ERS Right
Symmetrical
Posterior Right
CHAPTER 9-RIBS
Rib 12 Directly
Intercostales
Forced Exhalation
CHAPTER 11-THE INNOMINATES AND PUBES •
The standing flexion test will be positive on the side of the dysfunction in both innominate and pubic dysfunctions..
Table 24: Innominate Dysfunction
Muscle
Acts Upon
Scalenes
Ribs 1-2
Pectoralis Minor
Ribs 3,4,5,(6)
Serratus Anterior
Ribs 6,7,8,9,10
Latissimus Dorsi
Ribs 9,10,11,12
Quadratus Lumborum
Rib 12 Indirectly
Intercostales
Forced Inhalation
Findings
Anterior Rotation
ASIS inferior, PSIS superior
Posterior Rotation
ASIS superior, PSIS inferior
Superior Shear
ASIS superior, PSIS superior
Inferior Shear
ASIS inferior, PSIS inferior
Innominate Inflare
ASIS closer to the umbilicus
Innominate Outflare
ASIS further from the umbilicus
Table 25: Pubic Dysfunction Dysfunction
Table 22: Muscles Used for Exhalation Rib Somatic Dysfunction
Acts Upon
Quadratus Lumborum
Dysfunction
Table 21: Non-Neutral Positional Diagnosis
8
Findings
Superior Shear
Pubic tubercle superior
Inferior Shear
Pubic tubercle inferior
Pubic Adduction
Distance between the pubic tubercles is decreased
Pubic Abduction
Distance between the pubic tubercles is increased
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CHAPTER 12-THE SACRUM Table 26: Sacral Somatic Dysfunction Dysfunction
Seated Flexion Test
Spring Test
Sphinx Test
Sacral Base Findings
ILA Findings
L on LOA
Positive right
Negative
More symmetrical
Right anterior
Left posterior & inferior
R on ROA
Positive left
Negative
More symmetrical
Left anterior
Right posterior & inferior
R on LOA
Positive right
Positive
Less symmetrical
Right posterior
Left anterior & superior
L on ROA
Positive left
Positive
Less symmetrical
Left posterior
Right anterior & superior
Sacral Base Anterior
Positive bilaterally (may appear negative)
Negative
N/A
Anterior bilaterally
Posterior bilaterally & even
Sacral Base Posterior
Positive bilaterally (may appear negative)
Positive
N/A
Posterior bilaterally
Anterior bilaterally & even
Left Sacral Margin Posterior
Left posterior
Left posterior & even
Right Sacral Margin Posterior
Right posterior
Right posterior & even
Left Unilateral Sacral Flexion
Positive left
Negative
More symmetrical
Left anterior
Left posterior & markedly inferior
Right Unilateral Sacral Flexion
Positive right
Negative
More symmetrical
Right anterior
Right posterior & markedly inferior
Left Unilateral Sacral Extension
Positive left
Positive
Less symmetrical
Left posterior
Left anterior & probably superior
Right Unilateral Sacral Extension
Positive right
Positive
Less symmetrical
Right posterior
Right anterior & probably superior
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CHAPTER 13-THE LOWER EXTREMITY Somatic Dysfunction of the Hip t The major motions (with the knee extended) and their approximate ranges are: • Flexion- 80 to 90 degrees. • Extension- 25 to 35 degrees. • Abduction- 45 to 55 degrees. • Adduction- 25 to 35 degrees. • Internal rotation- 30 to 40 degrees. • External rotation- 40 to 50 degrees. The ranges will be different if the knee is bent. Somatic dysfunction may also occur in the minor motions of the hip t. Those motions are: • Anterior glide- occurs with external rotation. • Posterior glide- occurs with internal rotation.
Table 27: Tests of the Lower Extremity Test
Somatic Dysfunctions of the Fibular Head • Fibular head anterior. • Fibular head posterior. Fibular head posterior dysfunction may cause compression of the common fibular (peroneal) nerve.
Upper Motor Neuron Dysfunction
Barlow’s Test
Hip Stability
Erichsen’s Test
Sacroiliac Pathology
Galeazzi’s (Allis) Test
Congenital Hip Dislocation Ages 3-18 mos.
Homans’ Sign
Deep Vein Thrombophlebitis
Lachman’s Test
Anterior Cruciate Ligament
Ludloff’s Sign
Traumatic Separation of the Lesser Trochanter of the Femur
McMurray’s Test
Meniscal Tears
Ober’s Test
Iliotibial Band/Fascia Lata Dysfunction
Ortolani’s Test
Congenital Hip Dislocation in a Newborn
Patrick’s (FABER or FABERE) Test
Hip t Pathology
Posterior Drawer Test
Posterior Cruciate Ligament
Thomas Test
Contraction of the Iliopsoas Muscle
Thompson’s Test
Ruptured Achilles Tendon
Trendelenburg Test
Gluteus Medius Muscle (Superior Gluteal Nerve)
Table 27: Tests of the Lower Extremity Test
Purpose
Purpose
Babinski’s
Somatic Dysfunction of the Knee t Dysfunction may occur in the major motions of flexion and extension, or in any of the minor motions listed below: • Medial and lateral glide. • Anterior and posterior glide. • Internal rotation with anteromedial glide. • External rotation with posterolateral glide.
10
Anterior Drawer Test
Anterior Cruciate Ligament
Valgus Stress Test
Medial (Tibial) Collateral Ligament
Anterior Drawer Test of the Ankle
Anterior Talofibular and Calcaneofibular Lig.
Varus Stress Test
Lateral (Fibular) Collateral Ligament
Apley’s Compression Test
Knee Meniscal Injury
Apley’s Distraction Test
Knee Ligamentous Injury
Copyright 2002 Steven L. Simmons, DO. All Rights Reserved. Internet Copy. WWW.DRSIMMONS.NET
The “Cram” Pages These pages are packed full of high-yield info organized for quick review. It is intended to help you pick up a few extra questions after you have completed a more thorough study. DON’T RELY ON THIS EXCLUSIVELY TO GET YOU THROUGH THE BOARDS! You need to do a more extensive review to do well.
CHAPTER 1-PRINCIPLES
•
Facet Orientation Cervical-Backward, Upward, Medial Thoracic-Backward, Upward, Lateral Lumbar-Backward, Upward, Medial
Table 4: Fryette’s Principles Motion
Spinal Mechanics Table 1: Planes and Axes Motion
Plane
Axis
Rotation
Horizontal
Vertical
Side-bending
Coronal
AP
Sagittal
Sagittal
Horizontal
•
Table 2: Rotation
•
Left Transverse Process
Type I (Neutral)
SXRY or SYRX
Type II (Non-Neutral)
RXSX or RYSY
Right Transverse Process
Definition-impaired or altered function of related component of the somatic system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements. Diagnostic Criteria-Tissue Texture Abnormality, Asymmetry, Restriction of Motion, Tenderness (TART).
Table 5: Acute vs Chronic Dysfxn
Left
Posterior
Anterior
Acute Findings
Right
Anterior
Posterior
Vasodilatation, Edema, Tenderness, Pain, Contraction, Skin Warm/Moist, Muscle Spasm, Minimal Somatovisceral changes
The point of reference for direction of rotation is a point on the anterior and superior surface of the body of the vertebra.
Table 3: Side-bending Side of SB
Concave Side
Convex Side
Left
Left
Right
Right
Right
Left
Direction
Somatic Dysfunction
•
Side of Rotation
Side-bending is tested by ing the space between two vertebral segments and pushing medially.
•
Chronic Findings Vasoconstriction, Itching & Fibrosis, Tenderness, Paresthesias, Contracture, Skin Cool/Pale, Muscle Flaccid, Frequent Somatovisceral Changes
Somatic dysfunction is named for the direction of motion, this is opposite of the direction of restriction.
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CHAPTER 2-NEUROLOGIC Autonomic Nervous System Table 6: Sympathetic Innervation Level
Splanchnic Nerve
T1-4
Collateral Ganglia Cervicothoracic, middle & superior cervical ganglia
T1-T6
Organs/Structures Innervated Head and Neck Heart and Lungs
T5-T9
Greater splanchnic nerve
Celiac ganglion
Upper GI (T5R gall bladder, T6R ducts, T7R pancreas, T7L spleen)
T10-T11
Lesser splanchnic nerve
Superior mesenteric ganglion
Lower GI (small intestine, right colon, gonads, adrenals, upper ureter)
T10-T12
Kidney
T12
Least and lumbar splanchnic nerves
T12-L2
Least and lumbar splanchnic nerves
Appendix (usually right) Inferior mesenteric ganglion
Left colon, lower ureter, bladder, uterus/ prostate, genitals
T2-T8
Arms
T11-L2
Legs
Table 7: Parasympathetic Innervation Nerve
Nucleus
Ganglion
Organs Innervates
CN3 (Oculomotor n)
Edinger-Westphal (accessory oculomotor)
Ciliary
Pupil
CN7 (Facial n)
Superior salivatory
Pterygopalatine...........> OR Submandibular...........>
Sinuses, lacrimal gland, palate Sublingual/submandibular glands
CN9 (Glossopharyngeal n)
Inferior salivatory
Otic
Parotid gland
CN10 (Vagus)
Dorsal vagal
Superior and inferior vagal
All structures in the head, neck, heart, lungs, kidneys, upper ureters, entire GI tract down to the mid-transverse colon.
S2-S4 (Pelvic splanchnic nn)
Left colon, lower ureter, bladder, uterus/prostate, genitals
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Nerve Roots Table 8: Upper Extremity and Brachial Plexus Nerve Roots Level of Exit (Disc)
Nerve Root
Sensory
Reflex
Motor
C5 Root
C4-C5 (C4 disc)
Lateral arm
Biceps
Abduction of shoulder, elbow flexion
C6 Root
C5-C6 (C5 disc)
Lateral forearm, thumb, index finger
Brachioradialis
Elbow flexion, wrist extension (most common herniation)
C7 Root
C6-C7 (C6 disc)
Middle finger
Triceps
Elbow extension, wrist flexion
C8 Root
C7-T1 (C7 disc)
Medial forearm, ring & little finger
None
Finger flexion
T1 Root
T1-T2 (T1 disc)
Medial arm
None
Finger abduction/adduction
Table 9: Upper Extremity Major Nerves Origin (Partial Origin)
Nerve
Function
Injury Commonly Results in...
Long Thoracic
C5-C7
Innervates serratus anterior m
“Winging” of the scapula
Axillary
C5-C6
Innervates deltoid & teres minor mm
Deltoid atrophy
Musculocutaneous
C5-C7
Innervates arm flexors, sensory to lateral forearm
Diminished biceps reflex
Median
(C5) C6-T1
Innervates flexors of the forearm & hand. Sensory to the palmar surface (including fingernails) of digits 1-3 & part of 4
Thenar eminence atrophy
Radial
C5-C8 (T1)
Innervates forearm extensors. Sensory to back of forearm, hand, digits 1-3 and part of 4
Wrist drop, diminished triceps reflex
Ulnar
(C7) C8-T1
Innervates some flexors of the hand. Sensory to medial hand and part of digit 4, all of digit 5
Hypothenar eminence atrophy
Table 10: Lower Extremity Nerve Roots Nerve Root
Level of Exit (Disc)
Sensory
Reflex
Motor
L4 Root
L3-L4 (L3 disc)
Medial leg & foot
Patellar
Foot inversion
L5 Root
L4-L5 (L4 disc)
Dorsal surface of the lower leg & foot
None
Dorsiflexion of the toes, foot drop if injured
S1 Root
L5-S1 (L5 disc)
Lateral side of the foot
Achilles
Eversion of the foot (most common herniation)
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Table 11: Lower Extremity Major Nerves Nerve
Origin
Function
Obturator
L2-L4
Innervates adductors, sensory to small area of skin on medial thigh
Femoral
L2-L4
Innervates quads, sensory to medial & middle thigh and medial lower leg
Diminished knee jerk reflex
Lateral Femoral Cutaneous
L2-L3
Sensory to lateral thigh
Meralgia paresthetica
Posterior Femoral Cutaneous
S1-S3
Sensory to back of thigh
Sciatic
L4-S3
Innervates muscles of posterior thigh, branches into tibial and common fibular
Tibial
L4-S3
Innervates muscles of posterior leg, sensory to lateral posterior leg
Diminished ankle jerk reflex
Common fibular
L4-S2
Innervates anterior lower leg
Foot drop
CHAPTER 3-POSTURE AND GAIT Table 12: Heel Lift Therapy Type of Patient
•
Initial Lift
Increase Every 2 Weeks
Less than 5mm difference
Not treated
N/A
“Fragile” Patient (Elderly, Arthritis, Osteoporosis)
1/16” Lift
No More Than 1/16”
“Flexible” Patient
1/8” Lift
No More Than 1/16”
“Injured” Patient (Where Leg Length Was Suddenly Shortened)
•
Injury Commonly Results in...
Full Amount
N/A
The total lift height should be only ½ to ¾ of the shortness measured by the standing x-ray. A maximum of ¼” lift can be used inside the shoe. Up to ½” can be used between the patients heel and floor. If more than ½” is needed, lift must be applied to the heel and half-sole of the shoe.
CHAPTER 5-CRANIAL Flexion: • • • • • •
The SBS rises. All midline bones go into flexion. All paired bones go into external rotation. The respiratory phase is inhalation. The sacral base moves posterior (counternutation). The skull widens laterally and shortens in its A/P diameter.
Extension: • • • • • •
The SBS falls. All midline bones go into extension. All paired bones go into internal rotation. The respiratory phase is exhalation. The sacral base moves anterior (nutation). The skull narrows laterally and increases in its A/P diameter.
The Following Somatic Dysfunctions Occur at the SBS: 1. Flexion (will not cycle into extension) 2. Extension (will not cycle into flexion) 3. Torsions (left and right) 4. Sidebending rotations (left and right) 5. Vertical Strains (superior and inferior) 6. Lateral Strains (left and right) 7. SBS compression
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Table 13: Summary Chart of Bone Position Somatic Dysfunction
Greater Wings of the Sphenoid
Occiput
Temporals
Flexion
Inferior, Anterior, and Lateral Bilaterally
Inferior and Lateral Bilaterally
External Rotation Bilaterally
Extension
Superior, Posterior, and Medial Bilaterally
Superior and Medial Bilaterally
Internal Rotation Bilaterally
Left Torsion
Superior on Left, Inferior on Right
Inferior on Left, Superior on Right
Left External Rotation, Right Internal Rotation
Right Torsion
Superior on Right, Inferior on Left
Inferior on Right, Superior on Left
Right External Rotation, Left Internal Rotation
Left Sidebending Rotation
Inferior on Left, Superior on Right
Inferior on Left, Superior on Right
Left External Rotation, Right Internal Rotation
Right Sidebending Rotation
Inferior on Right, Superior on Left
Inferior on Right, Superior on Left
Right External Rotation, Left Internal Rotation
CHAPTER 6-CERVICAL SPINE Table 6-14: Motion and Positional Findings for OA Tri-axial Somatic Dysfunction
Somatic Restricted Dysfunction Motion
Translation Terminology
Transverse Process Closer to the Mandible
Transverse Process Closer to the Mastoid
If the Left Side is Most Dominant in Restriction & Tissue Changes
If the Right Side is Most Dominant in Restriction & Tissue Changes
(F)SLRR
(E)SRRL
Translates Right OR Restricted in Left Translation During Extension
Right
Left
Anterior Occiput Left
Posterior Occiput Right
(E)SLRR
(F)SRRL
Translates Right OR Restricted in Left Translation During Flexion
Right
Left
Anterior Occiput Left
Posterior Occiput Right
(F)SRRL
(E)SLRR
Translates Left OR Restricted in Right Translation During Extension
Left
Right
Posterior Occiput Left
Anterior Occiput Right
(E)SRRL
(F)SLRR
Translates Left OR Restricted in Right Translation During Flexion
Left
Right
Posterior Occiput Left
Anterior Occiput Right
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Table 15: Motion and Positional Findings For Typical Cervical Tri-axial Somatic Dysfunctions Somatic Dysfunction
Restricted Motion
(E)RRSR or ERSR
(F)SLRL
(E)RLSL or ERSL
(F)SRRR
(F)SRRR or FSRR
(E)RLSL
(F)SLRL or FSRL
(E)RRSR
Translation Terminology
May Also Be Written as...
Posterior Articular Process
Side of Most Paraspinal mm. Tightness
Translates Left OR Restricted in Right Translation During Flexion
Translates From Right to Left
Most Prominent During Flexion
Translates Right OR Restricted in Left Translation During Flexion
Translates From Left to Right
Most Prominent During Flexion
Translates Left OR Restricted in Right Translation During Extension
Translates From Right to Left
Right
Right
Most Prominent During Extension
Most Prominent During Extension
Translates Right OR Restricted in Left Translation During Extension
Translates From Left to Right
Most Prominent During Extension
CHAPTER 7-UPPER EXTREMITY 1. Extension of the upper extremity to 90 degrees. 2. Flexion of the upper extremity to 180 degrees. 3. Circumduction with glenohumeral t compression. This tests the t surfaces. 4. Circumduction with traction. This tests the t capsule. 5. Abduction (not adduction) to 90 degrees. 6. Internal rotation. 7. Pump, also called traction with caudal glide.
Right Most Prominent During Flexion
Left
Left Most Prominent During Flexion
Left
Left Most Prominent During Extension
Table 17: Radial Head Somatic Dysfunction Somatic Dysfunction
The Seven Stages of Spencer:
Right
Restricted Motions
Most Likely Mechanism
Radial Head Anterior
Posterior and Pronation
Fall Backward on the Outstretched Hand
Radial Head Posterior
Anterior and Supination
Fall Forward on the Outstretched Hand
Table 18: Tests of the Upper Extremity Table 16: Ulnar Somatic Dysfunction Somatic Dysfunction Abducted Ulna Adducted Ulna
Carrying Angle Increased
Decreased
Wrist Increased Adduction Increased Abduction
Test
Purpose
Olecranon Process
Adson’s Test
Compression of the Subclavian Artery
Increased Medial Glide
Allen’s Test
Collateral Circulation of the Hand
Apley’s Scratch Test
Evaluate the Range of Motion of the Shoulder
Apprehension (Crank) Test
Detect Chronic Shoulder Dislocation
Drop Arm Test
Detect Tears in the Rotator Cuff Muscles
Increased Lateral Glide
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Table 18: Tests of the Upper Extremity Test
Purpose
“Empty Can” Test
Detect Tears of the Supraspinatus Tendon or Muscle
Finkelstein’s Test
DeQuervain’s Tenosynovitis (Abductor Pollicis Longus & Extensor Pollicis Brevis Tendons)
Load & Shift Test
Shoulder Instability, Anterior or Posterior
Phalen’s Test
Carpal Tunnel Syndrome
Posterior Apprehension Test
Posterior Shoulder Instability or Dislocation
Speed’s Test
Bicipital Tendinitis
Sulcus Sign
Inferior Shoulder Instability
Tinel’s Sign
Carpal Tunnel Syndrome
Yergason’s Test
Bicipital Tendinitis
CHAPTER 8 & 10-THORACIC AND LUMBAR SPINE Table 19: The “Rule of Threes” Spinous Process Location in Relation to the Vertebral Body
Transverse Process Location in Relation to the Spinous Process
T1-T3
Over the Body of the Corresponding Vertebra
The Same Horizontal Plane
T4-T6
Over the Intervertebral Space Below
About 1/2 Inch Up and Lateral
T7-T9
Over the Body of the Vertebra Below
About 1 Inch Up and Lateral
T10-T12
Over the Body of the Corresponding Vertebra
The Same Horizontal Plane
Vertebrae
7
Forward Bending (Flexion) Dysfunction Positional findings: • There is a slight separation of the spinous process from the segment below. • There is a slight approximation of the spinous process to the one above. • There is usually tenderness of the supraspinous ligament. Motion findings: • Rotation is restricted bilaterally. • Side-bending is usually restricted bilaterally. • The segment forward bends easily and is restricted in backward bending.
Backward Bending (Extension) Dysfunction Positional findings: • There is a slight separation of the spinous process from the segment above. • There is a slight approximation of the spinous process to the one below. • There is usually tenderness of the supraspinous ligament. Motion findings: • Rotation is restricted bilaterally. • Side-bending is usually restricted bilaterally. • The segment backward bends easily and is restricted in forward bending.
Neutral Somatic Dysfunction Positional findings (SXRY): • Approximation of the transverse processes on side “X”, caused by side-bending toward side “X”. • Separation of the transverse processes on side “Y”. • Posterior transverse process on side “Y”, caused by rotation to side “Y”. • Anterior transverse process on side “X”. • The spinous process may be shifted to side “X”. Motion findings: With motion testing, the segment will move in the direction of somatic dysfunction and it will be restricted in the direction opposite of the somatic dysfunction.
Table 20: Neutral Positional Diagnosis Sense of Fullness and Posterior Transverse Processes
Easy Normal (EN)
(N)SLRR
Right
EN Right or ENR
(N)SRRL
Left
EN Left or ENL
Dysfunction
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Non-Neutral Somatic Dysfunction Positional findings (R XSX): • Approximation of the transverse processes on side “X”, caused by side-bending toward side “X”. • Separation of the transverse processes on side “Y”. • Posterior transverse process on side “X”, caused by rotation to side “X”. • Anterior transverse process on side “Y”. • The spinous process may be shifted slightly to side “Y”. • These dysfunctions are generally very painful and may present with a significant amount of paravertebral muscle spasm. Motion findings: With motion testing, the segment will move in the direction of somatic dysfunction and it will be restricted in the direction opposite of the somatic dysfunction.
Table 23: Muscles Used for Inhalation Rib Somatic Dysfunction Muscle
Transverse Process Position in Extension
Dysfunction
Transverse Process Position in Flexion
FRS Left
Posterior Left
Symmetrical
FRS Right
Posterior Right
Symmetrical
ERS Left
Symmetrical
Posterior Left
ERS Right
Symmetrical
Posterior Right
CHAPTER 9-RIBS
Rib 12 Directly
Intercostales
Forced Exhalation
CHAPTER 11-THE INNOMINATES AND PUBES •
The standing flexion test will be positive on the side of the dysfunction in both innominate and pubic dysfunctions..
Table 24: Innominate Dysfunction
Muscle
Acts Upon
Scalenes
Ribs 1-2
Pectoralis Minor
Ribs 3,4,5,(6)
Serratus Anterior
Ribs 6,7,8,9,10
Latissimus Dorsi
Ribs 9,10,11,12
Quadratus Lumborum
Rib 12 Indirectly
Intercostales
Forced Inhalation
Findings
Anterior Rotation
ASIS inferior, PSIS superior
Posterior Rotation
ASIS superior, PSIS inferior
Superior Shear
ASIS superior, PSIS superior
Inferior Shear
ASIS inferior, PSIS inferior
Innominate Inflare
ASIS closer to the umbilicus
Innominate Outflare
ASIS further from the umbilicus
Table 25: Pubic Dysfunction Dysfunction
Table 22: Muscles Used for Exhalation Rib Somatic Dysfunction
Acts Upon
Quadratus Lumborum
Dysfunction
Table 21: Non-Neutral Positional Diagnosis
8
Findings
Superior Shear
Pubic tubercle superior
Inferior Shear
Pubic tubercle inferior
Pubic Adduction
Distance between the pubic tubercles is decreased
Pubic Abduction
Distance between the pubic tubercles is increased
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CHAPTER 12-THE SACRUM Table 26: Sacral Somatic Dysfunction Dysfunction
Seated Flexion Test
Spring Test
Sphinx Test
Sacral Base Findings
ILA Findings
L on LOA
Positive right
Negative
More symmetrical
Right anterior
Left posterior & inferior
R on ROA
Positive left
Negative
More symmetrical
Left anterior
Right posterior & inferior
R on LOA
Positive right
Positive
Less symmetrical
Right posterior
Left anterior & superior
L on ROA
Positive left
Positive
Less symmetrical
Left posterior
Right anterior & superior
Sacral Base Anterior
Positive bilaterally (may appear negative)
Negative
N/A
Anterior bilaterally
Posterior bilaterally & even
Sacral Base Posterior
Positive bilaterally (may appear negative)
Positive
N/A
Posterior bilaterally
Anterior bilaterally & even
Left Sacral Margin Posterior
Left posterior
Left posterior & even
Right Sacral Margin Posterior
Right posterior
Right posterior & even
Left Unilateral Sacral Flexion
Positive left
Negative
More symmetrical
Left anterior
Left posterior & markedly inferior
Right Unilateral Sacral Flexion
Positive right
Negative
More symmetrical
Right anterior
Right posterior & markedly inferior
Left Unilateral Sacral Extension
Positive left
Positive
Less symmetrical
Left posterior
Left anterior & probably superior
Right Unilateral Sacral Extension
Positive right
Positive
Less symmetrical
Right posterior
Right anterior & probably superior
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CHAPTER 13-THE LOWER EXTREMITY Somatic Dysfunction of the Hip t The major motions (with the knee extended) and their approximate ranges are: • Flexion- 80 to 90 degrees. • Extension- 25 to 35 degrees. • Abduction- 45 to 55 degrees. • Adduction- 25 to 35 degrees. • Internal rotation- 30 to 40 degrees. • External rotation- 40 to 50 degrees. The ranges will be different if the knee is bent. Somatic dysfunction may also occur in the minor motions of the hip t. Those motions are: • Anterior glide- occurs with external rotation. • Posterior glide- occurs with internal rotation.
Table 27: Tests of the Lower Extremity Test
Somatic Dysfunctions of the Fibular Head • Fibular head anterior. • Fibular head posterior. Fibular head posterior dysfunction may cause compression of the common fibular (peroneal) nerve.
Upper Motor Neuron Dysfunction
Barlow’s Test
Hip Stability
Erichsen’s Test
Sacroiliac Pathology
Galeazzi’s (Allis) Test
Congenital Hip Dislocation Ages 3-18 mos.
Homans’ Sign
Deep Vein Thrombophlebitis
Lachman’s Test
Anterior Cruciate Ligament
Ludloff’s Sign
Traumatic Separation of the Lesser Trochanter of the Femur
McMurray’s Test
Meniscal Tears
Ober’s Test
Iliotibial Band/Fascia Lata Dysfunction
Ortolani’s Test
Congenital Hip Dislocation in a Newborn
Patrick’s (FABER or FABERE) Test
Hip t Pathology
Posterior Drawer Test
Posterior Cruciate Ligament
Thomas Test
Contraction of the Iliopsoas Muscle
Thompson’s Test
Ruptured Achilles Tendon
Trendelenburg Test
Gluteus Medius Muscle (Superior Gluteal Nerve)
Table 27: Tests of the Lower Extremity Test
Purpose
Purpose
Babinski’s
Somatic Dysfunction of the Knee t Dysfunction may occur in the major motions of flexion and extension, or in any of the minor motions listed below: • Medial and lateral glide. • Anterior and posterior glide. • Internal rotation with anteromedial glide. • External rotation with posterolateral glide.
10
Anterior Drawer Test
Anterior Cruciate Ligament
Valgus Stress Test
Medial (Tibial) Collateral Ligament
Anterior Drawer Test of the Ankle
Anterior Talofibular and Calcaneofibular Lig.
Varus Stress Test
Lateral (Fibular) Collateral Ligament
Apley’s Compression Test
Knee Meniscal Injury
Apley’s Distraction Test
Knee Ligamentous Injury
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