C2-C7 rotation and sidebending
to same side
restrictive barrier
within physiologic barrier
anatomic barrier
limit of passive motion, moving past will cause damage
stay away
physiologic barrier
limit of active motion
HVLA Rules
Stay AWAY from the anatomic barrier
Don't confuse Stabilizing and Thrusting hands
Lock-out
Don't wind up!
Thrust is VERY Low Amplitude
Think (Hey! Very Low Amplitude)
Stay AWAY from the anatomic barrier
cervical HVLA thrusting hand
MCP on post T.P.
Keep a straight line between MCP and elbow
HVLA stabilizing hand
Opposite side of head/neck from Thrusting
Equal and opposite force to Thrusting hand
NEVER initiates movement
HVLA lockout
Sidebend the one below towards, rotate the target away
If Thrusting C3 Rr Sr:
Doc will want to rotate C3 LEFT (into the barrier)
Fryette's 3rd will cause C3 to SB left as well
To keep C4 from rotating LEFT with C3:
Translate C4 LEFT (thus SB C4 to the Rig
HVLA axes of motion
we treat 2 out of the 3 functional planes for safety
joint that inhibits cervical sidebending
joints of Luschka
Fryette's 3rd Principle
Movement in one plane limits movement in another plane
Why you don't 'wind up' in HVLA
'Winding up' will not engage the golgi tendon and the hypertonic muscle will not relax
HVLA Thrust
Fast and Short
About 2-3 degrees of rotation
Neck Circumference 16" --- 400mm
2 degrees of rotation will rotate the neck 2mm
Vertebral body Circumference 4" --- 76mm
2 degrees of rotation will rotate the V.B. 0.42mm
May not sound like much, but recall tha
Normal cervical spine motion
OA F/E 45 degrees (50% of C spine, OA is opposite SB and R are in opposite direction)
AA rotates 45 degrees (50% of C spine)
C2-C7 F/E, R/SB 45 degrees (50% of C spine)
Cervical:- SB and rotation are in the same direction
only fryette's law in effect for
HVLA Safety Guidelines
Be aware of possible complications
Make an ACCURATE diagnosis
A palpatory examination is a prerequisite for treatment
Listen with you hands and fingers
If it doesn't feel right, back off and collect more data
If the barrier doesn't feel right, don't thrus
HVLA Relative Contraindications
-Mild to moderate strain or sprain
-Mild osteopenia or osteoporosis
-Osteoarthritic joints with moderate motion loss
-Rheumatoid disease other than in the spine (
absolute for us, relative for boards
)
-Minimal disc bulge and/or herniation with radicular
HVLA Absolute Contraindications
Joint instability
Severe osteoporosis
Metastasis
Osteoarthritic joint w/ ankylosis
Severe discogenic spondylosis w/ ankylosis
Osteomyelitis
Infection of the tissues
Joint replacement
Severe herniated disc w/ radiculopathy
Congenital anomalies such as Klip
Muscle tension headache
Etiology:
Skeletal muscle contraction
Reflex vasodilatation of extracranial vessels
Usually bilateral
Described as fullness, tightness, or pressure
Rarely associated with nausea/vomiting
Sleep disturbances
Decreased serotonin in the brain (susceptible to
Functions of thoracic cage
Protection
Movement: assists with respiration
Interconnection
Thoracic cage components
Thoracic vertebrae(12), ribs (12), and sternum
clavicle are scapula are considered upper extremity
anterior landmark: sternal notch
T2
anterior landmark: sternal angle
T4
anterior landmark: xiphoid
T9
anterior landmark: umbilicus
L3/L4
posterior landmark: sup angle of scapula
T2
posterior landmark: spine of scapula
T3/T4
posterior landmark: inf angle of scapula
T7
true typical rib articulations
4: VB above, VB below, TP, sternum
VB articular facets
BUM
BUL
BM
head and neck sympathetics
T1-4
heart/lungs sympathetics
T1-6
upper extremity sympathetics
T2-8
Foregut sympathetics
T5-9
Midgut sympathetics
T10-11
Hindgut sympathetics
T12-L2
thoracic spine divisions
Upper: T1-T4
Middle: T5-T8
Lower: T9-12
typical vertebrae
...
atypical ribs
anyone w a 1 or 2 in the name: 1, 2, 10, 11 and 12
Atypical vertebrae
one whole facet on T1, 10, 11, 12
no facet on TP of T11 or T12
corresponds to atypical ribs
rule of 3's
T1 - T3: SP is at the same level as tip of the TP
T4 - T6: SP is one half vertebral level below the tip of the TP
T7 - T9: SP is one full vertebral level below the tip of the TP
T10: SP is one full vertebral level below the tip of the TP
Follows rules of
range of motion of thoracic spine
Rotation : greatest motion
Sidebending : 2nd greatest motion
Flexion: 2nd least motion
Extension: least motion
overall has least motion of each spine area (cause of VB height to disc height - VB much taller than disc)
facilitation
read pages in Digiovanna
period example
thoracic outlet
clavicle, 1st ribs, and scapula
stenosis affects ulnar nerve
anatomical thoracic inlet
Manubrium, 1st ribs bilaterally & T1
functional thoracic inlet
Manubrium with Angle of Louis, first two ribs bilaterally, and T1-4
true ribs
1-7
Direct sternal attachment
false ribs
8-10
Synchondroses to costochondral cartilage of rib 7
floating ribs
11-12
No sternal attachment
typical ribs
3-9
pump handle rib motion
check
aka elephant trunk
ribs 1-5
movement in sagittal plane and transverse axis
Caudad (Expiratory) motion is usually from
Intercostal mucles
The weight of the remainder of the rib cage
The elastic recoil of the ribcage
The ribs usually move as a unit.
A
bucket handle rib motion
check
aka chicken dance
ribs 6-10
movement in coronal plane and AP axis
With inhalation, the lateral aspect of the rib moves cephalad
Results in an increase of transverse diameter of the thorax.
Predominantly found in lower ribs, increasing in motion from
caliper rib motion
check
aka crab claws
ribs 11 and 12
movement in transverse plane and vertical axis
characterized by single joint motion
analogous to internal and external rotation
rib somatic dysfunction
movement or position of one or several ribs is altered or disrupted
presents as pain with respiration
palpate ribs on both sides, compare, also check with respiration
inhalation rib dysfunction
rib is stuck in inhalation or stuck up
inhalation motion is more free, exhalation motion more restricted
doesn't want to go into exhalation thus pt complains of pain when exhaling
aka exhalation restriction or anterior rib
key = bottom rib
exhalation rib dysfunction
rib is stuck in exhalation or stuck down
exhalation motion is more free, inhalation motion is more restricted
doesn't want to go into inhalation thus pt complains of pain when inhaling
aka inhalation restriction or posterior rib
key = top rib
how to evaluate ribs
motion testing - put hands on ribs, have pt breathe in/out
check landmarks
check for any tenderpoints
remember to check the other side, compare inhalation and exhalation
palpation of first rib
Posterior, superior surface (deep to the trapezius)
Anterior, superior surface (depression superior to & behind the clavicle)
Anterior articulation (Just below the clavicle at the sternal border)
Check symmetry and motion at all three places
evaluate ribs 2-12
generally follow thoracic spine - fix thoracic problem
inspirator muscles
Diaphragm
Attaches to the lower 6 or seven ribs
Pulls these ribs inferiorly and flattens abdominal contents
SCM
By the relation to the clavical & 1st rib, lifts the cage superiorly
Scalenes
Lift the cage superiorly
Pectoralis Major
Lifts Ribs 2-6
Pectoral
expirator muscles
Quadratus lumborum
Pulls the 12th and 11th ribs inferiorly
Latissimus dorsi
With arm at side aids in expiration
Serratus Posterior Inferior
Originates on the SPs of T10-L2, Inserts on ribs 9-12
Iliocostalis
Longisimus
Interal intercostalis
Rectus abdominu
BITE mneumonic
for rib dysfunctions
Bottom Inhalation
Top Exhalation
muscle energy for ribs
Rib 1: Ant. & Mid. Scalenes
Rib 2: Post. Scalene
Ribs 3-5: Pec minor
Ribs 6-9: Serratus Anterior
Ribs 10-12: Lat. Dorsi
scoliosis
abnormal lateral curvature of the spine
kyphosis
abnormal flexion of thoracic spine
Two forms:
1) structural
2) postural
flat back
reduced kyphotic curve aka exaggerated military posture
maybe due to extension SD due to pain during flexion
costochondritis
inflammation of costochondral junction
aggravated by coughing, sneezing, deep inhalation
not an SD??
most commonly fractured bone in kids?
Clavicle
do we treat lumbar HVLA from below or above?
we treat from below, lock out the vertebrae above the dysfunctional one
ex: to treat L3, you stabilize L3 and the spine above it,
????
short lever HVLA
force vector directly placed on anatomical landmark as focal point
ex. Kirksville crunch
long lever HVLA
force vector directed from a distance to the level of dysfunction
ex. lumbar HVLA
Lumbar HVLA mechanics (rotation) explained ****
L3 N Sl Rr
stabilize L3 and above
the thrust brings L4 and below (lower vertebra) into alignment with L3 (even though it is still rotated/messed up)
aligning the vertebra into the same plane as messed up L3 will bring all of them back to normal/neutral
Lumbar HVLA Sidebending correction: L3 N SLRR
lay pt down so dysfunction's concavity is up (if sidebent left pt lays on right side so left side is up) - we are trying to flatten the curve
Will set up to stabilize L3 and above and Thrust L4 and down caudally
This will essentially sidebend L4 to the ri
Lumbar HVLA rotation correction: L3 N SLRR
lay pt down so posterior TP is down (SP is rotated to side that is up) - if rotated right lay pt on left side so right side is up
stabilize L3, force L4 to rotate into the barrier??
since rotation is coupled with sidebending, if you fix rotation you also
Lumbar HVLA summary
if you are treating side bending, keep the side bent side UP
if you are treating rotation, keep the rotated side DOWN
This is for both type I and type II dysfunctions
primary spinal curves
Thoracic and sacral (concave anterior; convex posterior)
think fetus and womb
secondary spinal curves
Cervical and lumbar (concave posterior; convex anterior)
spinal curve developmental order
Thoracic --> cervical --> lumbar
ferguson's angle
Lumbosacral angle
Angle between line through sacral base and line parallel to ground
30-40 degrees, increases with pregnancy, obesity, weak abs, etc
lumbar spine ROM
Flexion: 160 degrees
Extension: 100 degrees
Rotation: 5 degrees
Side bending: 40 degrees
lumbar spine primary movement
Flexion
Lumbarization
S1 becomes L6
sacralization
L5 becomes part of the sacrum aka the batwing deformity
partial fusion can occur
spondylolisthesis
Defect in the pars interarticularis that may be accompanied by Forward slip of one vertebra
dysplastic (congenital) - dysplastic sacral facet joints allow forward translation of one vertebra (L5), can result in pars fracture
isthmic - Characterized by str
wolfe's law
bone formation occurs along lines of stress
structure and function are interrelated
embryo - NP and AF/ vertebra
NP - endoderm (notochord remnant)
AF/ vertebra - mesoderm
diseased/old vs normal spinal disc
diseased/old disc is less squishy and more compressible
decreased disc thickness causes increased weight load on facet joints
body position that puts greatest load on spinal disc
sitting with poor posture (slumping forward)
herniated disc X + 1 rule
herniated disc affects lower nerve root
L4/L5 herniation affects L5
cervical spine??
most common cause of lower back pain
iliolumbar ligaments (attach at L4/L5 TP)
increase stability at lumbosacral junction
commonly strained in traumatic injuries
anterior longitudinal ligament limits what motion
extension
posterior longitudinal ligament limits what motion
flexion
what ligaments are the AF attached to?
anterior and posterior longitudinal
the dirty half dozen
Patient with "failed back syndrome"
1) Non neutral (type 2) SD
2) Pubic shear
3) extended sacrum
4) superior innominate shear
5) Anatomic short leg with pelvic tilt
6) psoas syndrome and supporting muscle dysfxn