Advanced Clinical Therapy-Basic
Techniques-Dermatomal Palpation-Lumbar
Copyright © Ted Nissen March 2004
SPEAKER: Ted Nissen Date
E-Mail: questions@anatomyfacts.com
Web Site: http://www.anatomyfact.com
Phone: (562) 439-3803
Office:
Advanced Physiocare
440 Redondo Ave. # 201
Long Beach Calif. 90814
LECTURE NOTES
Ø
Ted Nissen has a successful
private practice and has been in business as a massage therapist for over 30
years.
1.) Clinical assessment allows you to determine which areas of
the body may need treatment.
2.) Dermatomal palpation involves getting feedback from client to
determine which dermatomes are most sensitive.
3.) You will learn how to perform a clinical assessment using
Dermatomal palpation to determine treatment areas.
4.) Then you will learn how to treat the nerve areas with thumb
stripping and Ischemic Compression.
5.) Finally, you will learn to reassess your treatment to
determine if your treatment was successful.
v Viewing Notes and Illustrations Online
You
can view all of these notes and illustrations online by going to the anatomy
facts web site (See Web Site address Above).
Under the projects menu see Free School Onsite Demos and then Clinical Methods
Demo.
v Overview-why this approach?
Muscle
tension, pain and dysfunction is caused by irritation of the afferent sensory
nerve fibers which supply the tendon and ligament cells near where they attach
to the bone. This root cause will be much more prevalent than the usual
explanations or Diagnosis by soft tissue professionals (Medical Doctors,
Physical Therapists, Chiropractors, Sports Doctors and others) for the pain
phenomena post exercise or activity soreness (Sprain/Strain, DOM, Trigger
Points, Subluxation ect). The tendon and ligament cells near where they attach
to the bone receive greater stress than the other cells of the tendon or
ligament because of their proximity to the bone, which is being pulled by
opposing muscles. If you cut a strip of paper ¼ to 1/3 of an inch thick and
affix one end to a stable surface while pulling on the other end the following
result should occur. Assuming the paper strip is equally strong in all its
parts, the strip of paper will break more frequently on either end of the paper
strip. In the case of ligament cells, both ends of their attachments are
vulnerable to the stresses of movement and receive greater metabolic demand. In
the case of tendon cells only the cells near the bone seem prone to irritation
probably because the tendon cells which interdigitate with the muscle cells
have a better blood supply than the cells near the bone. The blood and lymph
supply to these tendon and ligament cells is probably fixed based on the usual
activity of the person. When a patient becomes more active (Over activity),
initiates a new movement (Novel Activity), or repeats a movement more times
than usual (Repetitive Activity) the tendon and ligament cells need more
oxygen, glucose, and protein to survive. Since the body cannot meet the cells
metabolic demand they either die or the demand on the cells must be reduced.
That is the person must become less active. How would anyone know to become
less active unless they received a distress call from the overworked tendon and
ligament cells? The Sympathetic Nerves (Afferent Fibers) become over
stimulated. The efferent fibers of the sympathetic nervous system constrict the
muscles around the arterial walls (vasoconstriction) and the blood flow to the
cells is reduced (ischemia). This is what is known as a Reflex Arc. Incoming
sensory stimulation (Afferent Fibers) from the viscera triggers a response from
the spinal cord, which in turn sends its response to the viscera (Efferent
Fibers). This is very similar to overloading electrical circuits, which trigger
a fuse to shut down the power. This reduces the flow of the metabolic waste out
of the area and increases the concentration of these wastes resulting in
irritation of the afferent sensory nerve fibers resulting in Nociceptive
(Uncomfortable, Noxious) The patient is thereby informed to reduce the activity
level. If the person does not reduce their activity level, the cells in these
areas may die in sufficient numbers and produce a higher concentration of
enzymatic chemicals. These enzymes initiate the production of inflammatory
chemicals from the cell walls of the local vessels (blood and Lymph?). These
inflammatory chemicals (Kinin System, Prostaglandins and Leukotrienes ect)
decrease the size of the cells, which comprise the walls of these vessels.
These or other chemicals may also initiate the relaxation of muscles
surrounding the vessels resulting in vasodilation. Fluid from the blood and
lymph system flows out of the vessels in greater volume because the opening in
the vessel walls has increased (vasodilation) and the vessels have become more
porous. This fluid flows to the areas with less interstitial fluid (osmosis)
around the tendon and ligament cells and helps decrease the concentration of
metabolic waste. This may temporally reduce the excitation of the afferent
nerve fibers. This reduced excitation will be short lived. Afferent Sensory
Nerve fibers are excited by the increased concentration of inflammatory
chemicals. This nerve irritation may result in Nociceptive (Uncomfortable,
Noxious) Sensory Phenomena. The patient is thereby informed to reduce the
activity level. Because vessel walls become more porous, large lymphatic cells
(macrophages) are able to travel in and out of the area of injury to retrieve
and carry away dead ligament and tendon cells. Inflammatory chemicals may have
the additional benefit of encouraging the growth blood vessels, which will
increase the blood supply and allow for greater future activity (Exercise
Adaptation). If the person continues their activity level, the problems will be
exacerbated. Cells in these areas will continue to die. Cell Death will result
in higher concentration of enzymatic chemicals and resultant increase in
inflammatory chemicals. Afferent Sensory Nerve fibers are excited by the
increased concentration of inflammatory chemicals. This nerve irritation may
result in Nociceptive (Uncomfortable, Noxious) Sensory Phenomena. The patient
is thereby informed to reduce the activity level. Dermatomal palpation helps you find the source of the pain
spending less time in areas that won’t give the client complete relief. A
simple technique called thumb stripping increases blood flow to the area that
needs it. Thumb stripping will be more effective and require less effort than
either generalized swedish, deep tissue, or even rolfing because the source of
the pain is treated not just the symptom area. Over time these imbalances may
contribute to osteoarthritis and degenerative disc disease. You will help your
clients end the cycle of pain, muscle imbalance, functional limitation, and
stress to the skeletal system.
v Theoretical Model-Why Do We Hurt? Illustration
This
illustration can be viewed by going to the anatomy facts web site (See Web Site
address Above). Under the projects menu see Theoretical Perspective Why Do We
Hurt?
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Side Bar-Otzi the snow man- 5200 year
old man perfectly preserved in ice. Scientists were surprised to find 59
markings that were clearly tattoos on Ötzi's skin. They were even more
surprised that the back and leg tattoos were on or near typical acupuncture
points for treating back and leg pain. X-rays showed evidence of osteoarthritis
in Ötzi that might have responded to acupuncture. But there's a problem with
this theory: Acupuncture is believed to have originated in China 2,000 to 3,000
years ago. Because of Ötzi, some scientists now think that acupuncture (or at
least an acupuncture type of medical system) was practiced 5,200 years ago a
long, long way from China. It now looks probable that acupuncture or something
like it arose simultaneously in different cultures, indicating that prehistoric
populations may have had a deep, possibly intuitive knowledge of the body.
Could these markings point to a much simpler system of massage. It certainly
seems equally plausible since thumb stripping massage is done in the exact same
areas. Acupuncture meridians Bladder lines 1 (1.5 cun 2 fingers) & 2 (3 cun
4 fingers) seem to be outside the two parallel markings in what appears to be
the lumbar L4-5 area. Illus. # 1 Before we begin learning how to identify and
treat referred pain, it’s important to
understand the underlying anatomy and physiology. Embryology. Our
muscles, bones & skin form when we’re still in the womb. The dermatome is
the name for a specialized set of cells in the developing fetus which forms the
connective tissues, including the dermis or skin. Illus. # 4
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The
skin over the entire body is supplied segmentally by spinal nerves. The skin
segment supplied by the dorsal root of a spinal nerve is also called a
dermatome. Neurology. Illus. # 2 Illus. # 3 Spinal nerves are the paths of communication between the brain, spinal
cord tracts and the periphery. Each pair of spinal nerves is connected to a
segment of the cord by two points of attachment called roots. The posterior
dorsal (sensory) root contains sensory nerve fibers only and conducts nerve
impulses from the periphery to the spinal cord. Each dorsal root also has a
swelling the posterior or dorsal (sensory) root ganglion which contains the
cell bodies of the sensory neurons from the periphery. The other point of
attachment of the spinal nerve to the cord is the anterior or ventral (motor)
root. It contains motor neuron axons only and conducts impulses from the spinal
cord to the periphery. These two roots motor and sensory form one nerve which
then exits the spine via the intervertebral foramen. The dorsal ramus (RA-mus)
innervates the deep muscles and skin of the dorsal surface of the back. The
ventral ramus of a spinal nerve innervates the muscles and structures of the
extremities and the lateral and ventral trunk. In addition to dorsal and
ventral rami, spinal nerves also give off a meningeal branch. Shortly after a
spinal nerve leaves its intervertebral foramen, it divides into several
branches. These branches are known as rami (RA-mi). This branch reenters the
spinal canal through the intervertebral foramen and supplies the vertebrae,
vertebral ligaments, blood vessels of the spinal cord, and the meninges. Neurons and Supporting Cells. The nervous system is composed of neurons, which
produce and conduct electrochemical impulses, and supporting cells, which
assist the functions of neurons. Neurons are classified functionally and
structurally; the various types of supporting cells perform specialized
functions. The nervous system is divided into the central nervous system (CNS),
which includes the brain and spinal cord, and the peripheral nervous system
(PNS), which includes the cranial nerves arising from the brain and the spinal
nerves arising from the spinal cord. The nervous system is composed of only two
principal types of cells-neurons and supporting cells. Neurons are the basic
structural and functional units of the nervous system. They are specialized to
respond to physical and chemical stimuli, conduct electrochemical impulses, and
release chemical regulators. Through these activities, neurons enable the
perception of sensory stimuli, learning, memory, and the control of muscles and
glands. Most neurons cannot divide by mitosis, although many can regenerate a
severed portion or sprout small new branches under certain conditions.
Supporting cells aid the functions of neurons and are about five times more
abundant than neurons. In the CNS, supporting cells are collectively called
neuroglia, or simply glial cells (glia = glue). Unlike neurons, glial cells retain limited mitotic abilities
(brain tumors that occur in adults are usually composed of glial cells rather
than neurons). Neurons. Although neurons vary considerably in size and shape,
they generally have three principal regions: (1) a cell body, (2) dendrites,
and (3) an axon (Illus. # 2 ). Dendrites and axons can be
referred to generically as processes, or extensions from the cell body. The
cell body, or perikaryon (peri= around; karyon = nucleus), is the enlarged
portion of the neuron that contains the nucleus. 1t is the "nutritional
center" of the neuron where macromolecules are produced. The cell body
also contains densely staining areas of rough endoplasmic reticulum known as.
Nissl bodies that are not found in the dendrites or axon.
The
cell bodies within the CNS are frequently clustered into groups called nuclei
(not to be confused with the nucleus of a cell). Cell bodies in the PNS usually
occur in clusters called ganglia (Illus. # 2 ). Dendrites (dendron = tree
branch) are thin, branched processes that extend from the cytoplasm of the cell
body. Dendrites provide a receptive area that transmits electrical impulses to
the cell body. The axon is a longer process that conducts impulses away from
the cell body. Axons vary in length from only a millimeter long to up to a
meter or more (for those that extend from the CNS to the foot). The origin of
the 'axon near the cell body is an expanded region called the axon hillock; it
is here that nerve impulses originate. Side branches called axon collaterals
may extend from the axon. Proteins and other molecules are transported through
the axon at faster rates than could be achieved by simple diffusion. This rapid
movement is produced by two different mechanisms: axoplasmic flow and axonal
transport (table 7.2). Axoplasmic flow, the slower of the two, results from
rhythmic waves of contraction that push the cytoplasm from the axon hillock to
the nerve endings. Axonal transport, which employs rnicrotubules and is more
rapid and more selective, may occur in a reverse (retrograde) direction as well
as in a forward (orthograde) direction. Indeed, retrograde transport may be
responsible for the movement of herpes virus, rabies virus, and tetanus toxin
from the nerve terminals into cell bodies. As the anterior root of the spinal
cord emerges from the anterior and lateral gray columns, it traverses the
surrounding membranes of pia, arachnoid and dura. The posterior root, which is
attached to the posterolateral portion of the spinal cord, originates from two
bundles of fibers in the spinal ganglion. Both anterior and posterior roots
pierce the dura separately as they make their exit through their respective
intervertebral foramina. As a rule, the posterior root is thicker and larger
than the anterior root. They are enclosed in a common dural sheath just beyond
the spinal ganglion, where they become the spinal nerve and are surrounded by
epineurium. The spinal ganglia, which lie at the outer portion of the
intervertebral foramina, are oval-shaped and vary in size corresponding to
their. nerve. roots. The Spinal nerves lie horizontally in the cervical region
but below these segments the spinal nerves assume an increasingly oblique and
downward direction as they approach the lumbar region where they are almost
vertical, forming the cauda equina. At the lower thoracic level there is a
difference of two vertebral segments between the origin of the spinal nerve and
the level of exit. From each sympathetic trunk ganglion, which lies on the
posterolateral surface of the vertebral body, a branch (gray ramus communicans)
joins the adjacent spinal nerve. Efferent, preganglionic sympathetic fibers
(white ramus communicans), which originate in the lateral column~, pass along
with the anterior root to the corresponding sympathetic ganglion or along its
trunk to sympathetic plexuses. Shortly
after emerging from the intervertebral foramen each spinal nerve gives off a
meningeal branch which turns back through the same foramen to supply the spinal
cord membranes, blood vessels, intervertebral ligaments and joint surfaces. The
spinal nerve then divides into two branches, each with fibers from both roots:
I. Anterior division supplies the anterior and lateral portions of the trunk
and limbs.
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In the thoracic region it spans the
space between the pleura and intercostal membrane, runs below the lower rib
margin and supplies the intercostal muscles and adjacent skin. In the cervical
and lumbar regions the anterior divisions form plexuses. 2. Posterior division
is directed backward shortly beyond the formation of the spinal nerve. Its
medial branch Supplies the multifides, longissimus, semispinalis and trapezius,
then proceeds along the spinous process, and supplies the skin. Its lateral
branch traverses the longissimus and supplies the intercostal muscle and
adjacent skin. In the lumbar region the medial branches of the posterior
division hug the articular processes of the vertebrae and end in the
multifides, and the lateral branches supply the group of. sacrospinalis
muscles, adjacent fascia and skill. Posterior aspect of the cervical
segment of the dura mater ( right half) Illus. 3 Specific remarks: To
demonstrate the deep structures contained within the vertebral column) the
following steps are carried out: All muscles from the back of neck are removed
the vertebra/laminae) together with the spinous processes) are removed. the
content of the epidural space (connective tissue and venous plexus) is removed
from the posterior aspect of the dura mater The intervertebral foramina are enlarged posteriorly several
vertebrarterial foramina are opened posteriorly. Following such a dissection
the extensions of the dura mater to the spinal ganglia, distribution of spinal
nerves into the rami, grouping of the ventral rami, and the relationship of the
vertebral artery to the transverse processes and the spinal nerves become
'apparent
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Dermal Segmentation Illus.
# 4 Sensations from the outside world are carried to the consciousness
by the spinal and some cranial nerves to the brain. They travel over the
posterior roots; their further detailed course is for the moment " not of
interest. All the cell bodies are situated in ganglia outside of the central
nervous system proper; they have a peripheral branch going to the "sense
organ and a central branch going to the spinal cord or the brain. We include
here the fibers carrying hot and cold, pain and touch. Vibration sense and
position sense are probably complicated sensations involving several of the
primitive sensations, including the proprioceptive sensations, which in the
spinal cord go also into the ganglia, but in the head region end in the
mesencephalic nucleus of the trigeminal nerve. In the head, sensations are
mediated by the trigeminus, and in a small region behind the external auditory
meatus by the facial and the vagus nerves. In the body, the various spinal
nerves take over. These are by and large arranged metamerically, that is to
say, one segment lies behind the other in an orderly sequence. But these
sequences are interrupted in the arm and the leg regions where several segments
have been carried out to the periphery of the limb and are, therefore, no more
represented near the axis of the body. Hence, on the ventral side of the body,
C5 borders on TI, and LI OnS2. Two other important points should be realized:
The segmentations given in almost all diagrams are based on pain, but the
borders for the reception of pain are not the same as those for the reception
of, say, touch, which generally involves a somewhat narrower sphere. The second
point is that the different nerves overlap to some extent, so that frequently
no more than a hypesthesia develops after one root has been cut. If one is
familiar with the cutaneous distribution of various nerve roots, it is possible
to localize the site and level of any pathologic disturbance. A chart outlining
the exact sensory dermal segments serves as a good reference. It is valuable to
remember some surface landmarks which will serve as a general guide to
localization : illus.#4 Illus.#4b The clavicular region is supplied by cervical
5 sensory root. The deltoid region is supplied by cervical 5 and 6 sensory
roots. The nipple area is supplied by thoracic 4 sensory root. The umbilicus is
supplied by thoracic 10 sensory root. The groin region is supplied by thoracic
I2 sensory root. The lateral aspect of the arm is supplied by cervical 5,6 and
7 sensory roots. The inner aspect of the arm is supplied by cervical 8 and
thoracic I sensory roots. The inner and anterior surfaces of the thigh are
supplied from above down by lumbar I, 2, 3 and 4 sensory roots. The outer and
posterior surfaces of the thigh are supplied by lumbar 5 and sacral I and 2
sensory roots. The perineum is supplied by sacral 2, 3, 4 and 5 sensory roots.
The hand is supplied from the radial to the ulnar borders by cervical 6, 7 and
8 sensory . roots. Cervical 6 supplies the thumb, cervical 7 the middle of the
hand. Including the index and middle fingers, and cervical 8 the ulnar border,
including the ring and little fingers. The foot is supplied from its lateral to
its medial surface by sacral I, lumbar 5 and lumbar 4 sensory roots. NOTE: Some
discrepancies exist in the definition of the dermal segments as published by different
authors. The chart produced here is based essentially on the work of Dr. J. Jay
Keegan, University of Nebraska College of Medicine. Keegan, J. J.: J.
Neurosurg. 4:1'5,1947 Keegan, J. J.: J. Bone Jt. Surg. 26:238, 1944 Eaton, L.
M.: Surg. Clin. N. Amer. 26,8"" 1946.
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Circulatory. Arteries. Illus.
# 5 The spinal cord derives its blood supply from the vertebral artery
and from a series of spinal rami which enter the intervertebral foramina at successive
levels. The posterior spinal artery is a branch of the vertebral artery which
begins near the lateral margin of the medulla oblongata and descends on the
dorsolateral surface of the spinal cord posterior to the spinal roots. In its
downward course to the cauda equina the posterior spinal artery receives a
succession of small arterial branches. They enter the spinal canal through the
intervertebral foramina. These vessels and their branches anastomose freely
around the posterior roots and with the corresponding vessels on the opposite
side, dipping also into the substance of the spinal cord, and in the midline
form the posterior central artery. The anterior spinal artery is formed by the
union of two branches from the terminal portion of the vertebral artery at the
level of the foramen magnum. The artery descends as a single trunk on the
anterior aspect of the spinal cord to the conus medullaris. It then continues
along the cauda equina and ends as a fine arteriole accompanying the filum
terminale. At successive levels it, too, is reinforced by spinal branches
entering through the intervertebral foramina. Along its course small twigs from
this artery enter the sub- stance of the spinal cord and in the anterior median
fissure these form the anterior central artery. The spinal branches arise at
various levels from the sacral, iliolumbar, intercostal, inferior thyroid and
vertebral arteries which enter the spinal canal through the intervertebral
foramina. Each spinal"branch divides into two rami: (I) a peripheral ramus
which after entering the spinal canal divides into an ascending and descending
branch and then anastomose with the one above and below to form two lateral
chains on the posterior surfaces of the vertebral bodies near the junction of
the pedicles, and (2) a central ramus which supplies the spinal cord and its
membranes by dividing into anterior and posterior arteries which anastomose
with the anterior and posterior arteries of the spinal cord.
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Veins Illus.
# 6 Outside and inside the vertebral canal, running along the entire
length, is a series of venous plexuses which freely join with each other and
end in intervertebral veins. Two groups of venous plexuses are found on the
outside of the vertebral canal: (I) the anterior group lies in front of the
vertebral bodies. This group receives some venous tributaries from vertebral
bodies and communicates with the basivertebral and intervertebral veins, and
(2) the posterior group which forms a network of venous plexuses spreading over
the spinous processes, laminae, facets and adjacent deep musculature. In the
cervical region these veins communicate with the deep cervical, occipital and
cerebral veins. Illus. # 6 The venous plexuses on the inside of the vertebral
canal lie between the dura and inner vertebral surfaces. These veins receive
tributaries from the adjacent bony structures and the spinal cord. Although
they form a close network, running vertically within the spinal canal, they may
be subdivided into ( I) a pair of anterior internal venous plexuses which lie
on either side of the posterior longitudinal ligament and into which
basivertebral veins empty, and (2) a single posterior internal venous plexus
which lies anterior to, and on either side of, the vertebral arches and
ligamentum flavum, and anastomose with the posterior external veins. These
plexuses form almost a series of venous rings at the level of each vertebra,
found most strikingly at the foramen magnum. Tunneling the bony structure of each
vertebral body is the basivertebral vein which has a small valve-like opening
as it joins the anterior internal venous plexus. The intervertebral veins leave
the spinal cord through the intervertebral foramina in company with the spinal
nerves.~They also have a valve-like mechanism as they join the intercostal,
lumbar and sacral veins. The veins of the spinal cord are minute and delicate.
They emerge from the anterior median fissure as the anterior central vein, and
from the posterior sulcus as the posterior central vein. There are also two
lateral longitudinal veins on either side of the spinal cord, and they all
empty into the intervertebral veins. How- ever, those near the foramen magnum
empty into the inferior petrosal sinus or cerebellar veins.
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Bones. Sacrum. Illus.
# 7 In the adult, the sacrum articulates with the fifth lumbar
vertebra, the coccyx and the two hip bones. It is large, triangular and
wedge-shaped and forms the posterior wall of the pelvis. Its base is oval-shaped and articulates with
the inferior aspect of the body of the fifth lumbar vertebra, forming the
prominent sacral vertebral angle. To either side of the sacrum are triangular
areas called the alae. Just below and to either side of the base is a ridge
forming the sacral portion of the pelvic brim. The lower portion of the sacrum,
the apex, articulates with the coccyx. The pelvic surface of the sacrum is
concave in both dimensions, vertically and horizontally. At its middle it is
grooved with four transverse ridges which mark the points of fusion of the
original five vertebrae. Four anterior sacral foraminae on either side of the
ridges permit passage of the anterior division of the sacral nerve and the
lateral sacral arteries. A cross-sagittal section of the sacrum demonstrates
the sacral canal which en- closes the lower portion of the dura and contents,
the roots of the cauda equina, the filum terminale externum, fat, areolar
tissue, blood vessels and fine nerve filaments.
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Lumbar vertebrae. Illus.
# 8 Illus. # 9
The lumbar vertebrae, five in number, are large and massive because of their
weight-bearing function. Are chiefly characterized by having no foramen in
their transverse processes and no articular facets on their vertebral bodies.
The lumbar curve is convex anteriorly with interposing fibrocartilaginous discs
for mobility. The spinal foramen in the lumbar region is triangular in shape
though smaller than in the cervical region. The body of each lumbar vertebra is
narrower from before backward and wider from side to side. It is slightly
taller anteriorly than posteriorly, and shows more concavity above than below.
The pedicles arise from either side of the upper portion of the vertebral body.
They are short, strong and proceed directly backward with grooves above and
below forming the superior and inferior vertebral notches. These join to form
foraminae for the exit of the spinal nerves. Springing from the pedicles ,are
the short, broad and powerful laminae which meet in the midline to form the
spinous process. This process is thick and .broad and directed backward in an
almost horizontal direction. At the base of the laminae are the articular
facets. The superior articular facet is concave and directed medially and
backward whereas the inferior articular facet is directed forward and
laterally. The transverse processes which arise from the pedicles are
comparatively slender and are situated in front of the articular 27 processes.
On the posterior superior aspect of the articular facets are slight elevations
called mammillary processes. A similar elevation on the posterior aspect of the
transverse process Is called the accessory process. The intervertebral disc, a
fibrocartilaginous structure, acts as a cushion between the adjacent vertebral
bodies. It varies in size and shape and conforms to the corresponding vertebral
body. These discs are thickest in the lumbar region, increasing in size as they
approach the sacrum. The fibrocartilaginous tissue is concentrically arranged
with a thick and tough outer layer called the annulus fibrosus and a soft
gelatinous pulpy substance called the nucleus pulposus"the remains of the
notochord. The intervertebral discs are particularly poor in blood supply.
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Muscles. Illus.
# 10 Muscles which are Innervated by the anterior or dorsal rami of the
lumbar spinal nerves may contribute to postural problems if the nerves that
supply them are irritated. Although there are many muscles in the lower back
which can affect the structure and press on sensitive tissue a few stand out
for review. These muscles are susceptible to lumbar nerve dysfunction and may
be either too weak or contracted as a result. The iliocostalis lumborum,
quadratus lumborum, longissimus thoracis, spinalis thoracis, &
multifidus, can in unilateral action
laterally flex the spine or bilaterally extend the spine if contracted. All of
these muscles can tug on the ribs and further exacerbate the dorsal rami of the
thoracic nerves. The rotatores brevis/longus, multifidus can in unilateral
action rotate the spine to the opposite side or bilaterally extend the spine if
contracted. The above muscles which extend the spine can be responsible for
increasing lordosis. Most of the buttocks muscles and leg muscles are
innervated by the lower lumbar vertebrae and the contraction of the larger
buttocks muscles results in hip extension which would tend to flatten the
lordotic curve. When postural problems are noted check the dermatomes to assess
whether spinal nerve involvement may contribute.
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Individual muscles. Interspinales illus.
# 11. Origin and insertion:pairs of small muscles joining the spinous
processes of adjacent vertebrae, one on each side of the interspinous ligament.
Continuous in the cervical region extending from the axis to the 2nd thoracic
vertebra and in the lumbar region from the first lumbar vertebra to the sacrum.
Action: extension of the spine. Nerve supply: dorsal rami of the spinal nerves.
Synergists: multifidus rotatores, intertransversarii groups. Intertransversarii illus.
# 11. ORIGIN AND INSERTION: pairs of small muscles, anterior and
posterior, on each side of the spine joining the transverse processes of
adjacent vertebrae. They extend from the atlas to the first thoracic vertebra
and from the 10th thoracic vertebra to the last lumbar vertebra. ACTION: acting
unilaterally, lateral flexion of the spine. NERVE SUPPLY: ventral and dorsal
rami of the spinal nerves. SYNERGISTS: interspinales, rotatores, multifidus
groups. Rotatores longus: illus. # 11. (A
series of pairs of small muscles extending from the sacrum to the axis).
ORIGIN: transverse processes of the vertebrae. INSERTION: bases of the spinous
processes (lamina) of the 2nd vertebra above. ACTION: acting unilaterally,
rotation of the spine to the opposite side. Acting bilaterally, extension of
the spine. NERVE SUPPLY: dorsal rami of the spinal nerves. SYNERGISTS:
intertransversarii, interspinales, multifidus and rotatores brevis. ROTATORES
BREVIS illus. # 11. (A series of pairs of small
muscles extending from the sacrum to the axis.). ORIGIN: transverse processes
of the vertebrae. INSERTION: bases of the spinous processes (lamina) of the 1st
vertebra above. ACTION: acting unilaterally, rotation of the spine to the
opposite side. Acting bilaterally, extension of the spine. NERVE SUPPLY: dorsal
rami of the spinal nerves. SYNERGISTS: intertransversarii, interspinales,
multifidus and rotatores longus.
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SERRATUS posterior inferior. Illus.
# 12 ORIGIN: spinous processes of 11th and 12th thoracic and 1st, 2nd
and 3rd lumbar vertebrae, and the thoracolumbar fascia. INSERTION: inferior borders
of lower 4 ribs just beyond their angles. ACTION: counteracts the pull of the
diaphragm by drawing the ribs posterior and inferior, aids in respiration.
NERVE SUPPLY: ventral rami of T9 -12. SYNERGISTS: internal intercostals. Latissimus
Dorsi. Illus. # 12 Origin:Broad aponeurosis that
originates on the spinous processes of lower 6 thoracic and all lumbar
vertebrae; Posterior crest of ilium, posterior surface of sacrum, lower 3 or 4
ribs, and an attachment to the inferior angle of the scapula. Above the
Latissimus Dorsi tendon fuses with that of the teres major, as they attach to
the medial edge of the intertubercular grove of the humerus. INSERTION:Flat
tendon that twists upon itself to insert into the intertubercular sulcus of the
humerus, just anterior to and parallel with tendon of pectoralis major
Action:Extends, retracts and medially rotates the humerus at the shoulder.
Through its action on the humerus it depresses, retracts and rotates the
scapula downwards. Assists in forced expiration. Nerve supply:Thoracodorsal
from brachial plexus, C6, 7, 8. SYNERGISTS:Rhomboids, pectoralis major, teres
major. lLIOCOSTALIS LUMBORUM. Illus. # 12 ORIGIN:
anterior surface of a broad and thick tendon which originates from the sacrum,
spinous processes of the lumbar and 11th and 12th thoracic vertebrae, and from
the medial lip of the iliac crest. INSERTION: inferior borders of the angles of
the lower 6 or 7 ribs. ACTION: acting bilaterally, extension of the spine,
acting unilaterally, laterally flexes the spine. NERVE SUPPLY: dorsal rami of
the spinal nerves. SYNERGISTS: longissimus thoracis, quadratus lumborum. MULTIFIDUS. Illus.
# 12 (A series of pairs of
small muscles extending the full length of the spine just superficial to the
rotatores and each spanning 2 or 3 intervertebral spaces before inserting.}.
ORIGIN: posterior surface of the sacrum, the dorsal end of the iliac crest, the
mamillary and transverse processes of the lumbar and. The thoracic vertebrae
and the articular processes of the 4th -7th cervical vertebrae. INSERTION:
spinous processes of all the vertebrae except the alias. ACTION: acting
unilaterally, lateral flexion and rotation to the opposite side. Acting
bilaterally, extension of the spine. NERVE SUPPLY: dorsal rami of the spinal
nerves. SYNERGISTS: rotatores, interspinales, intertransversarii groups.
v Illustrations
12
v
Anatomy
& Physiology Review
External abdominal oblique. Illus.
# 13 ORIGIN: external surfaces and inferior borders of the 5th -12th
ribs. By tendinous slips that interdigitate with those of serratus anterior and
Latissimus Dorsi. INSERTION: Linea alba by means of the broad abdominal
aponeurosis from ribs to crest of pubis, inguinal ligament and the anterior
half of the iliac crest along the outer lip. ACTION: acting unilaterally, rotates
the trunk to the opposite side, and flexes it laterally on the side of muscle
contraction. If rotation is only activity, the opposite internal oblique is
synergist. Acting bilaterally, flexes the trunk anteriorly, supports and
compresses the abdominal viscera, giving anterior support to the spinal column.
Gives anterior stabilization to pelvis, decreasing lordosis. Assists in forced
expiration. NERVE SUPPLY: branches of the 7th -12th intercostal nerves.
SYNERGISTS: Rectus abdominis, internal oblique and external oblique abdominals
of opposite side. Psoas on lumbar spine in total trunk flexion. Longissimus
THORACIS. Illus. # 13 ORIGIN: the common broad thick
tendon with the iliocostalis lumborum, fibers from the transverse and accessory
processes of the lumbar vertebrae and thoracolumbar fascia. INSERTION: the tips
of transverse process of all thoracic vertebrae and the lower 9 or 10 ribs
between the tubercles and angles. ACTION: acting unilaterally, laterally flexes
the vertebral column. Acting bilaterally, extension of vertebral column; Draws
ribs down. NERVE SUPPL V: dorsal rami of the spinal nerves. SYNERGISTS:
iliocostalis lumborum, iliocostalis thoracis, quadratus lumborum. INTERNAL
ABDOMINAL OBLIQUE (Lateral Division) Illus. # 13 ORIGIN:
Middle 1/3 of the iliac crest on the middle line and thoraco lumbar fascia.
INSERTION: Inferior borders of the 1Oth, 11th and 12th ribs. ACTION: Acting
unilaterally, approximates thorax and pelvis laterally. Contributes to rotation
of the trunk on the fixed pelvis toward the side of contraction. Acting
bilaterally, flexes the trunk on the pelvis. NERVE SUPPLY: Ventral rami of T7
-12, and iliohypogastric and ilioinquinal nerves, L 1. SYNERGISTS: Internal
oblique (anterior division, contralateral external oblique, rectus
abdominis. SPINALIS
thoracis. Illus. # 13 ORIGIN: the spinous processes of
the 1st and 2nd lumbar vertebrae, the thoracic vertebrae 11 and 12. INSERTION:
the spinous processes of the upper thoracic vertebrae varying from 4 -8.
ACTION: acting unilaterally, lateral flexion of the spine. Acting bilaterally,
extension of the spine. NERVE SUPPLY: dorsal rami of the spinal nerves.
SYNERGISTS: semispinalis thoracis, longissimus thoracis, iliocostalis thoracis,
iliocostalis lumborum, longissimus thoracis, quadratus lumborum.
v Illustrations
13
v
Anatomy
& Physiology Review
Internal abdominal oblique(Anterior
division). Illus. # 14 ORIGIN: lateral :1/3 of the
inguinal ligament and the anterior 1/3 of the middle (or intermediate) line of
the iliac crest. INSERTION: crest of the pubis and the linea alba by its
aponeurosis. ACTION: acting unilaterally, rotates the trunk to the same side,
and laterally flexes the trunk toward the side of muscle contraction. Acting
bilaterally, flexes the vertebral column, approximating the anterior thorax and
pelvis. Supports and compresses the abdominal viscera. Assists in forced
expiration. NERVE SUPPLY: ventral rami of T7 -12, and iliohypogastric and
ilioinquinal nerves, L 1. SYNERGISTS: opposite external oblique, rectus
abdominis. RECTUS ABDOMINIS (4 divisions as 1). Illus.
# 14 ORIGIN: the pubic crest and the symphysis pubis. INSERTION: the
costal cartilages of the 5th, 6th and 7th ribs and the side of the xiphoid
process. ACTION: flexion and lateral flexion of the trunk. In standing
position, supports organs anteriorly, gives anterior support to lumbar spine.
With aid of gluteus maximus and hamstrings keeps pelvis from going into
anterior tilt, decreasing lumbar lordosis. NERVE SUPPLY: ventral rami of TS
-12. The various levels of the rectus abdominis, superior, inferior as well as
those between inscriptions receive nerve supply from different levels.
Therefore act independently as they influence each other . SYNERGISTS: internal
and external oblique abdominals, pyramidalis. TRANSVERSUS abdominis. Illus.
# 14 ORIGIN: lateral 1/3 of the inguinal ligament, anterior ?!3 of
inner lip. Of the iliac crest, thoracolumbar fascia and from the inner edges of
the lower 6 costal cartilages. INSERTION: the linea alba by its aponeurosis.
ACTION: constricts abdominal contents; Assists in forced expiration. NERVE
SUPPLY: branches of the 7th -12th intercostal and the iliohypogastric and
ilioinquinal nerves, L 1. QUADRATUS
LUMBORUM Illus. # 14 ORIGIN: Iliolumbar ligament,
posterior part of the iliac crest. INSERTION: Inferior border of the 12th rib
and transverse processes of the upper 4 lumbar vertebrae. ACTION: Lateral
flexion of lumbar vertebral column; helps action of the diaphragm in
inspiration. NERVE SUPPLY: Lumbar plexus, T12, L1, 2, 3. SYNERGISTS: Internal
and external abdominal obliques, iliocostalis lumborum, longissimus thoracis
and psoas major.
v Illustrations
14
v
Vocabulary
& Skills Training
Vocabulary Thumb
stripping=using your thumbs in a continuous movement with pressure
towards the heart. The intent is to create ischemia and then hyperemia.
Ischemic Compression=Using you
thumbs, fingers, and or elbows to press on an area of treatment. Ischemia=insufficient
blood supply to a tissue or organ. Hyperemia= increased
quantity of blood in a body part shown by redness of skin. Central
nervous system (CNS)=brain and spinal cord. Peripheral
nervous system (PNS)=nerves, ganglia, and nerve plexuses (outside of the
CNS). Motor neuron (efferent neuron)=neuron that
transmits impulses from the CNS to an effector organ, for example, a muscle. Nerve=cable like
collection of many axons, may be “mixed” (contain both sensory and motor
fibers). Ganglion=grouping of neuron cell bodies located outside the
CNS. Nucleus=grouping of neuron cell bodies within the CNS. Deep
Lateral Rotators, Iliac Crest, and Vertebral Palpation Illus.
# 15 Palpate Deep Lateral Rotators at their origin and insertion.
Palpate the iliac crest on both sides, its massive crescent shape can be seen in
the illustrations. Palpate the sacroiliac joint on both sides. Palpate the L3
facet joint on both sides. Palpate L5 vertebrae which is located just below a
line drawn across the iliac crests. Palpate L4 which is just above the crest
line. Palpate L1 which is just below where the 12th rib attaches. The rest of
the spinal vertebrae may be approximated with the above landmarks. Dermatomal
Palpation Supine Using the dermatomal chart palpate L5 which is on the
side of the upper leg and over the anterior tibiallis, and top and bottom of
the foot on the lower leg. Palpate L4 which is on the front of the upper leg
and on the medial side of the tibia and the medial side of the foot on the
lower leg. L3 palpation is done on the front of the upper leg medial side to
just below the knee. Palpate L1 & L2 in the groin area. Dermatomal
Palpation Prone Palpate L5 along the iliac crest and over the
trochanter onto the lateral leg. Palpate S1 on the medial buttocks between the
trochanter and sacrum, the lateral aspect of the upper leg, the lateral
gastrocnemius and lateral foot. Palpate S2 along the sacrum and onto the medial
aspect of the upper/lower leg, and onto the inner heal and part of the hip.
S3-5 form the outermost, and inner circles with S5 and the center. Palpation
assessment & Thumb Stripping Palpate the dermatomes and ask the
client which ones are most Sensitive. Test the hamstring muscle (3 ways) and
determine if it is weak. Ask the client which areas hurt along the vertebra, SI
joint, and or L3 facet identified above. With the client prone use your inside
thumb along the areas that hurt and complete thumb stripping and or Ischemic
Compression several times. Reassess the dermatomes and ask the client which
areas hurt if any. Retest the hamstrings.
Repeat the process as necessary.
v Illustrations
15
v Summary
Clinical assessment allows you to
determine which nerves may be irritated but does not diagnose conditions such
as disc degeneration. Dermatomal palpation involves using your fingers and
getting feedback from client to determine which dermatomes are most sensitive.
Patient discomfort post novel, repetitive and or over activity is caused by
irritation of the afferent sensory nerve fibers which supply the tendon and
ligament cells near where they attach to the bone. The blood and lymph supply
to these tendon and ligament cells is probably fixed based on the usual
activity of the person. Since the body cannot meet the cells metabolic demand
they either die or the demand on the cells must be reduced. Tendon and or ligament
cell stress triggers over activity in the Sympathetic (Afferent) Nerves and
results in vasoconstriction by the Sympathetic (Efferent) Nerves. This is very
similar to overloading electrical circuits, which trigger a fuse to shut down
the power. This reduces the flow of the metabolic waste out of the area and
increases the concentration of these wastes resulting in irritation of the
afferent sensory nerve fibers resulting in Nociceptive (Uncomfortable,
Noxious). If activity levels remain constant, cell death will trigger the
production of inflammatory chemicals which will further irritate sensory nerves
and increase referred discomfort. Chronicity may ensue if activity levels are
not reduced and or blood flow reestablished to the affected area. Muscles that
lie within the dermatome become tight, and pull on the their bony attachments namely the hip, spine and rib
cage. Thumb stripping and Ischemic Compression may create hyperemia which helps
disperse those noxious substances.
Hyperemia is an increased quantity
of blood in a body part shown by redness of skin. Our muscles, bones & skin
form when we’re still in the womb. Additional Training Additional training in
this series will include Clinical Assessment in Thoracic & Lumbar areas,
Neurolymphatic reflexes and evaluation & treatment of joint pain.
Additional training materials will be posted on the Web at http://www.anatomyfact.com
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