Somatic Dysfunction Impaired or altered function of related components of the somatic system including the skeletal, arthrodial, myofascial structures and their related vascular, lymphatic and neural elements.
Inhibition Associated with somatic dysfunctions, no matter which components are impaired Implies consideration of all components in treatment planning
Inhibition Causes local and distant weakness, depending on location and specific components involved Peripheral dysfunctions, except neurogenic ones, associated with local weakness
Inhibition Spinal dysfunctions usually cause distant weakness in distributions similar to spinal motor nerves leaving at that level
Weakness Inhibition-> Weakness-> Imbalance-> Compensatory strategies-> Further dysfunctions
Weakness For want of a nail the shoe was lost. For want of a shoe the horse was lost. For want of a horse the rider was lost. For want of a rider the battle was lost. For want of a battle the kingdom was lost.
MMT Attributes Accuracy Reliable Reproducible Painless ( usually ) Relatively quick to do
MMT Requirements Technique: Reproduce angles/stabilize joints Positioning: comfortable for both Basic muscle anatomy Basic muscle innervation: to interpret data
MMT Positioning Facilitates reproducibility Limits tester needed effort/fatigue Improve patient comfort/effort and thus, accuracy
MMT Performance Keep patient comfortable (positioning) Apply force or Resist force Test joint distally at/near adjacent joint Stabilize joint being tested
Start with small or moderate force until resistance felt; Ramp up quickly to (near) maximal force application for about ½ second, at most
Stop effort as soon as either: Pain interference identified; Normal strength appreciated; Weakness appreciated
High Striker
Weakness Pattern (often) Makes the Diagnosis and thus Helps to Direct Treatment Options Available
Neck C5 dysfunction Presentation: Neck and/or shoulder pain Test: Shoulder external rotation Test: Shoulder flexion Most common associated finding: ipsilateral rib 2 dysfunction
Shoulder Local issues may be secondary to distant dysfunctions, usually cervical, upper thoracic and upper rib Tightness especially in shoulder flexion and internal rotation
Shoulder Isolated weakness: Anterior deltoid-> anterior capsular restriction Subscapularis-> lateral capsular restriction Post. Deltoid-> posterior capsular restriction
Elbow Posterior interosseous nerve-> test EPL Anterior interosseous nerve-> test FPL Joint dysfunction-> test triceps Ulnar nerve at elbow-> test FCU/FDP(IV/V)/FDI
Wrist Dysfunction-> isolated pronator quadratus weakness
Hand Weakness All: rib 1 upslip (superior) APB and Opp Poll only: CTS APB only: Thumb CMC joint dysfunction FPL only: Anterior Interosseous neuropathy EPL only: Posterior Interosseous neuropathy FDP IV/V only: rib 1 posterior Ulnar hand (e.g. FDI, ADQ): Ulnar neuropathy at wrist (Guyon s canal)
Patient places the hand parallel to the floor and points the thumb to the ceiling. Examiner tries to flex / adduct the 1 st MCP joint.
Tests C8-T1 Pinky to Thumb Opposition Patient s elbow is kept against their side Pull separately on distal thumb and distal small finger C8/T1 nerves with median AND ulnar nerve components
Tests C8-T1 Pinky to Thumb Opposition Patient s elbow is kept against their side Pull separately on distal thumb and distal small finger C8/T1 nerves with median AND ulnar nerve components
Tip of Examiner s thumb stabilizes the dorsum of patient s flexed 1 st Interphalangeal Joint. Examiner tries to straighten the distal IPJ.
Patient extends the thumb while Examiner stabilizes the 2 nd /3 rd MCP joints. Examiner tries to flex the 1 st MCP joint.
Tests C7 Wrist Extension Splint wrist with palm to prevent wrist motion
Tests C6 Wrist Flexion Patient supinates around the long axis from elbow through the wrist
Tests C5 Shoulder External Rotation (Also can be abnormal with Rotator Cuff Problems) Left hand stabilizes elbow. Right hand stabilizes distal end of the forearm.
Tests: Abduct shoulder to 90, bring arm forward C6, Rotator Cuff, about 30 & fully Scapular Stabilizers; rotate internally, with thumb pointing to floor Shoulder Horizontal Abduction (empty (also weak can with position) T1-T4 somatic dysfunction)
Apply downward pressure on distal arm at the elbow, NOT the forearm.
cc
Instruct patient to pull elbow back as far as possible. Try to pull the elbow forward. Test C5 (and Scapular Stabilizers) Shoulder Extension
Tests C6 (and rotator cuff, Shoulder weak also with innominate abducted rotation) to Abducted Shoulder 90, Internal elbow Rotation flexed to a right angle, forearm parallel to floor
Try to lift hand with pressure under distal forearm at the wrist, while stabilizing the elbow.
Tests C1-C4 Pt puts Neck his Flexion chin to the chest. Examiner tries to rotate the head backwards on an axis through the ears, applying pressure to the forehead.
Patient puts chin to the chest. Examiner tries to rotate the head backwards - on an axis through the ears, applying force to the forehead.
PAUL SHAPIRO, M.D. paul.shapiro@stjoeshealth.org 734-712-0050 Associates in PM&R APMandR.com