1. Techniques for Practical 1

2. OA Somatic Dysfunction
Sagittal Plane
Forward bending
Backward bending
Multiple Plane
Rotation
Side-Slippage (Sidebending)
Forward/backward bending

3. OA Sagittal 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

4. OA Joint Supine 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

5. OA Joint Supine 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

6. Pinch Technique for Sagittal Plane OA Flexion and Extension
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

7. Multiple Plane Somatic Dysfunction of OA joint
Because of the ANATOMY of the condyles, the OA side-bends and rotates to opposite sides in either flexion or extension
OA (F) or (E) SL RR
OA (F) or (E) SR RL
Brain attempts to keep the “eyes level on the horizon” at all cost
OA asymmetries are compensated by activating the sub-occipital mm

8. Multiple Plane Somatic Dysfunction of OA joint
Inspection
“Is this patient’s head on straight?”
Look for deviation of the chin and tip of nose from the mid-line position

10. Somatic Dysfunction of the AA Joint
Motion testing
Forward bend patient’s head to “lock-out” lower vertebrae
Rotate left, rotate right
Compare, assess, diagnose...

11. Diagnosis of the AA
Test seated active & passive motion. (regional scanning)
Test supine motion specific to AA.
Flex head beyond 45o, then rotate patient’s head passively.
Supine, inspect & palpate. T-A-R-T!!!
C1 lateral masses located between mastoid process and ramus of mandible.
Supine, localized motion testing of the AA
Compare right verses left rotation.
***And remember!!! -- Somatic dysfunction at the AA joint is descriptive only of the motion of the atlas on the axis (C1 on C2) *** = AA left rotation or AA right rotation
FOR EXAMPLE:
Usual findings (eg. Left rotation)
Transverse process and lateral mass of C1 (Atlas) are posterior on L  tip near mastoid process
Transverse process and lateral mass of C1 (Atlas) are anterior on R  tip near angle of mandible
MOTION present to L (L rotation)
Diagnosis:
AA left rotation: AARL or AA right rotation: AARR

12. Direct, Muscle Energy of AA- 4231.11B
Forward bend head to >45o
To lock out lower cervicals
MCP joint of the index finger contacts lateral mass of atlas (C1) on posterior rotated side
Rotate into barrier (maintain flexion)
Sweeten with SB
Instruct patient to turn his/her head the opposite direction against your force - use isometric force for 3-5 sec.
Upon relaxation, engage the new barrier & repeat M.E. 2-3 more times
MCP joint = metacarpal-phalangeal joint
Remember  Obliquus capitus inferior (suboccipital muscle)
origin: SP C2
insertion: TP C1
function: rotate C1 to same side

13. Supine-Direct-ME C3 NRLSL
Reach under spine to contact the convex side.
Pull with fingers to induce Right Sidebending (reverse the curve)

14. ME for Typical
Cervical
RLSL

16. Jones Strain-Counterstrain Anterior C1 Tender Point
A.k.a the OA joint TP
High on posterior ascending ramus of mandible
Contact TP & rotate away 90º
Find it, fold it, hold it, recheck!
REVIEW!!!

18. Indication for Treatment This procedure is appropriate for somatic dysfunction at C3 to C7. Tender Point Location The tender point lies at PC3 to PC7 posterolateral, at lateral surface of the articular process associated with the dysfunctional segment (Fig. 9.36). Treatment Position
The physician extends the head and neck to the level of the dysfunctional segment with minimal to moderate side bending directed at the segment and minimal to moderate rotation away (Figs. 9.37, 9.38, 9.39, 9.40, PC3, PC3, PC6, and PC6, respectively).
The physician fine-tunes.
PC3 TP- eSaRA

19. Myofascial release of the T spine

20. Myofascial release of the Scapula

21. Anterior TP 1-2 tx

22. Ant TP 3-6 tx

23. Ant TP tx T 7-9

24. Posterior midline TP tx

25. Post lateral TP tx

26. Spencer Technique The seven stages of motions are:
1. Engage GH extension barrier with elbow flexed
2. Engage GH flexion barrier with the elbow flexed
3. Circumduction with compression
Start small circles, then gradually increase size
Clockwise and counterclockwise
May also do ME of IR/ER barriers
4. Traction with circumduction on straight arm
Start small circles, then gradually increase size
Clockwise and counterclockwise
5. Engage abduction barrier
6. Internal rotation with elbow flexed
7. GH pump with distraction and compression along straight arm
Kimberly Manual, p
Direct articulatory/ME

27. 1 2 3 4 5 6 7

28. Sternoclavicular Dysfunctions
Sternoclavicular joint motions:
Superior/Inferior glide
Movement in the frontal (coronal) plane
Also called ADduction/ABduction
Anterior/Posterior glide
Movement in a horizontal (transverse) plane
Also called horizontal extension/horizontal flexion
Rotation on its long mechanical axis
Anterior (internal)/Posterior (external)
Joint motions are coupled
ABduction (IG) is coupled with posterior (external) rotation
ADduction (SG) is coupled with anterior (internal) rotation
Frame of reference for ABd/ADd, horizontal flex/ext is lateral end of clavicle
Frame of reference for sup/inf glide, ant/post glide is medial (sternal) end of clavicle
Frame of reference for rotation is the superior surface of clavicle

29. A P A P Posterior Rotation External Rotation Horizontal Flexion
MEDIAL A P
LATERAL
LATERAL
MEDIAL A P
Posterior Rotation
External Rotation
Horizontal Flexion
Posterior Glide
ABduction
Inferior Glide
As the clavicle ABducts laterally, there is a downward (inferior) glide at sternal end
As the clavicle ADducts laterally, there is an upward (superior) glide at the sternal end
ABduction/inferior glide and posterior/external rotation are linked
ADduction/superior glide and anterior/internal rotation are linked
MEDIAL A P
LATERAL
LATERAL
MEDIAL A P
ADduction
Superior Glide
Anterior Rotation
Internal Rotation
Horizontal Extension
Anterior Glide

30. Sternoclavicular Dysfunction Assessment
ABduction (IG)/ADduction (SG)
DO at head of table, patient supine
DO monitors medial clavicle area
Patient shrugs their shoulders. Both clavicles should move into ABduction, and the medial clavicles should move inferiorly
In the absence of trauma, the dysfunctional (restricted) clavicle stays superior at the SC jointNamed an ADduction somatic dysfunction (superior glide)
Example of a superior left SC joint

31. Sternoclavicular Dysfunction Assessment
Horizontal Flex (PG)/Horizontal Ext (AG)
DO at head of table, patient supine
Monitor the medial clavicle
Patient reaches toward the ceiling with their arms. Their scapulae should come off the table. Both clavicles should move into horizontal flexion, and the medial clavicles should move posterior (posterior glide)
In the absence of trauma, the dysfunctional (restricted) clavicle stays anterior at the SC jointNamed a horizontal extension (anterior glide) somatic dysfunction
Example of an anterior SC

32. SC Joint – Articulatory method
Thumb on medial clavicle with caudad pressure
Patient’s arm brought in a “backstroke” pattern – towards flexion through adduction and abduction and then ending up in extension
Reassess

33. AC joint – Articulatory method
DO grasps patient elbow or forearm from behind
DO monitors lateral edge of clavicle anteriorly with finger pads
DO applies anterior/inferior pressure on the lateral side of the clavicle with thumb, flexes the patient’s elbow and extends and adducts the humerus to gap the AC joint
DO further extends the shoulder and a circulatory articular sweep is applied – carry the elbow posteriorly  superiorly  anteromedially while maintaining adduction and capsular tension
Recheck

34. Carrying Angle
Left: Adduction of the ulna (#1), will cause the radius to be pulled proximal (#2). This will result in abduction of the wrist (#3).
Right: Abduction of the ulna (#1) will cause the radius to be pushed distal (#2). This will result in Adduction of the wrist (#3)

35. Dx of Ulnar Abduction and abduction motion testing
Pt seated/ Dr. Standing
Dr. contacts patient’s elbow and wrist
at elbow - thenar eminence to medial aspect of olecranon and finger to lateral condyle - apply force with finger to thenar
(+) extending arm from elbow while attempting adduction is met with resistance (olecranon will not laterally glide) Pt may experience pain and crepitus may occur as the olecranon seats in the olecranon fossa.

36. Tx of Ulnar Abduction with Medial Glide SD: Direct Technique - Ariticulatory - 4741.11B
Patients elbow flexed ~ 90o with Dr firmly grasping distal forearm from lateral aspect
Dr. grasps the elbow with thenar eminence on medial margin of olecranon and fingers on lateral condyle
apply lateral and slightly superior force at medial contact and adduction force at distal forearm
Take arm into full Extension in a sweeping motion applying the same forces above.

37. Tx of Ulnar Adduction with Lateral Glide SD: Direct Technique - Articulatory - 4742.11B
Pt seated/Dr standing
Patients elbow slightly flexed ~ 90o. Dr firmly grasps distal forearm from medial aspect
Dr. grasps the elbow with thumb or thenar eminence to lateral margin of olecranon
apply medial and slightly superior force at lateral contact and abduction force at distal forearm engaging the barrier.
Take arm into full extension in a sweeping motion applying the same forces above.

38. Tx: Radial Head Posterior- Direct Muscle Energy
Correct Abduction or Adduction first
Contact the posterior aspect of radial head with thumb of lateral hand
Grasp distal radius and ulna and engage barrier with forearm supination & wrist extension
Patient attempts to pronate (Dr. resists)
Relax, engage new barrier
Dr.’s thumb and supination force will move radial head anterior
Thumb on anterior distal radius
supinate *

39. Tx: Radial Head Posterior, continued
Repeat 3-5 times
RECHECK YOU FINDINGS!!

40. Tx: Radial Head Anterior- Direct Muscle Energy
Grasp the hand on the side of the dysfunction contacting the dorsal aspect of the distal radius with the thumb

41. Tx: Radial Head Anterior, continued
The physician’s other hand is palm up with the thumb resting against the anterior and medial aspect of the radial head
The physician pronates the patient’s forearm to the edge of the restrictive barrier.
Tell the patient to supinate and use an isometric force.
Hold 3-5 seconds, stop and relax.
Take up the slack to the new restrictive barrier.
Repeat 3-5 times
RECHECK FINDINGS!!!

42. Radioulnar Interosseous Membrane, Direct Method
Pt. sits and physician stands in front
Hold supinated forearm in palms of both hands with physician thumbs crossed over the anterior surface of the pt. forearm with the interosseous dysfunction between the thumbs.
Contact the lateral side of the ulna with one thumb and the medial side of the radius with the other thumb

43. Muscle Energy technique continued
Pt. is instructed to “turn palm downward” while physician offers isometric counterforce. PRONATION!!
Maintain counterforce 3-5 seconds and both pt. and physician simultaneously relax
Take up the slack and repeat (usually 3x)
RECHECK YOUR FINDINGS!!

45. Squeeze w/Circumduction (4760.11A)
Place heel of both hands over radiocarpal region of carpal bones & interlace fingers
Attempt to distract fingers while squeezing fingers together
Causes the heel of each hand to squeeze together
Circumduct wrist in circular or figure eight fashion

46. How to Diagnose Flexion or Extension Somatic Dysfunction of the Wrist
Have patient flex and extend the wrist-look for freedom of motion and restriction of motion.
Passively move the patient’s wrist in Flexion and Extension-see how far it can move in either direction and how it feels.
Where it moves more easily is the diagnosis (the motion it is “stuck in”).
Where it is restricted represents the restrictive barrier.
Dx: Flexion SD or Extension SD

47. Treatment of Flexion Somatic Dysfunction
Patient seated, doctor standing or sitting facing patient.
Doctor grasps the patient's wrist with the doctor’s thumbs on the dorsal aspect of the wrist, pressing on the dysfunctional bone.
The doctor may reinforce the pressure of the treating thumb by adding pressure with the other thumb.
The doctor’s hands wrap around the wrist to contact the palmar aspect of the patient’s hand.
The patient’s wrist is initially held in flexion
A simple repeated motion is carried out, moving the wrist from flexion to extension, while maintaining pressure over the displaced carpal bone.
Flexion Somatic Dysfunction = Dorsal Carpal Dysfunction
The Nicholas text says that traction is not needed for this technique. However, if you want to use traction, you can try it and see how it works for you. If you choose to use traction, realize that it will only be a small amount

48. Treatment of Extension Somatic Dysfunction
Patient seated, doctor standing or sitting facing patient.
Doctor grasps the patient's wrist with the doctor’s thumbs on the dorsal aspect of the wrist, resting on the dysfunctional bone.
The doctor’s hands wrap around the wrist so that the index fingers can press on the dysfunctional bone.
The patient’s wrist is initially held in extension.
A simple repeated motion is carried out, moving the wrist from extension to flexion, while maintaining pressure over the displaced carpal bone.
There is no Nicholas reference for this technique, but it is basically the reverse of the previous one. It is in kimberly Sitting Direct HVLA

49. How to Diagnose
Have the patient adduct and abduct the wrist – look for differences from side to side
You move the patient’s wrist in abduction and adduction – check for how far it can move in either direct AND how it feels
Where it moves more easily is the diagnosis.
Where it is restricted represents the restrictive barrier.
DX: Abduction SD vs Adduction SD
Have the students walk through these motions with me

50. Treatment for Abduction Somatic Dysfunction of the Wrist
Doctor and patient facing each other, seated or standing
Doctor grasps patient’s wrist and places it into pronation and abduction
Doctor moves patient’s wrist from the original position in abduction to and just past the adduction barrier in a smooth gentle motion.
the picture shows the final position of the wrist and hand
no nicholas reference

51. Treatment for Adduction Somatic Dysfunction of Wrist
Doctor and patient facing each other, seated or standing
Doctor grasps patient’s wrist and places it into pronation and adduction
Doctor moves patient’s wrist from the original position in adduction to and just past the abduction barrier in a smooth, gentle motion
the picture shows the final hand position. Note that these 2 treatments are HVLA treatments, but they don’t follow the usual rules for HVLA. usually with HVLA we place the patient right up against the barrier and make a very small, quick thrust. In these 2 cases, we start away from the barrier and make larger, but still quick, thrusts toward the barrier.
no nicholas reference

52. Direct, Articulatory – Wrist Ab-/Ad-duction S/D
Grasp pronated wrist and contact posterior surface joint margin with thumbs
Apply traction and carry wrist into direction of dysfunction
Gently articulate toward the restricted barrier with low to medium velocity and medium amplitude.

53. Opponen’s Roll
Grasp first digit (thenar emin.) and fifth digit (hypothenar emin.) with each hand
Contact pisiform and navicular (scaphoid) bones with thumbs
Extend wrist, abduct and laterally rotate first digit with counterforce over hypothenar area
Use thumbs to stretch at boney contact points the transverse carpal ligament in lateral/medial direction