OSCE: Thoracic and Lumbar Treatments

Question 1

Lumbar ART Sidebending, Lateral Recumbent

Answer 1

1. Stand at the side of the table, in front of and facing the patient.
2. Flex the patient’s knees and hips to approximately 90 degrees.
3. Operator places left hand so that fingers are palpating spinous processes of the lumbar spine.
4. Operator places cephalad hand and forearm under the patient’s ankles and lifts them toward the ceiling until the caudal hand palpates induced sidebending.
5. Hold the stretch 1-2 seconds then return toward neutral.
6. Repeat slowly in a smooth, rhythmic fashion until there is improved motion.
7. Reassess.

Question 2

MET/ART Lumbar Type 2 SD, Seated

Answer 2

1. Instruct the patient to sit on the treatment table with their ipsilateral hand to the PTP clasped behind their neck and holding that elbow with their other hand. Step away from the PTP! Physician places hand on opposite bicep (over two biceps).
2. The physician monitors L2 TPs using pads of thumb & index finger of the right hand and the middle finger pad to monitor the TP of L3.
3. Engage barrier by rotating and sidebending patient until motion is felt under monitoring hand. (Too much if motion is felt at L3)
4. Instruct the patient resist your force &/or “return to the neutral position.” Resist their efforts for 3-5 seconds and tell them to relax.
5. Wait 1-2 seconds and take move them to the next RB.
6. Repeat steps #4 & #5 three to five times.
7. Recheck for 2-4 TART changes.

Question 3

Articulatory Thoracic Sidebending, Prone

Answer 3

1. Stand on the side of diagnosed sidebending dysfunction.
2. Place your caudal hand on the ipsilateral transverse process of the affected segment, fingers pointing cephalad.
3. Place your cephalad hand contralaterally, with the heel of the hand over the opposite transverse process of the affected segment, fingers pointing caudally.
4. Exert sufficient pressure downward toward the table to produce articular motion of the spine.
5. Exert a longitudinal force simultaneously with both hands to carry the affected segment through its restrictive barrier and hold it there 1-2 seconds.
6. Repeat 4 and 5 in a rhythmic fashion until physiologic motion has been restored to the affected segment.
7. Reassessing segmental sidebending at affected segment.

Question 4

ART Lower Thoracic Type 1 (Neutral) SD, Seated

Answer 4

1. Instruct the patient to sit on the treatment table with their ipsilateral hand to the PTP clasped behind their neck and holding that elbow with their other hand. Step away from the PTP!
2. The physician monitors T9 TPs using pads of thumb & index finger of the right hand and the middle finger pad to monitor the TP of T10 until the setup localization to the RB is obtained and then stabilize T10 with your thenar & hypothenar eminences.
3. Place your left hand on the patient’s right bicep by passing it beneath their left arm first and position patient to the sidebending RB & then the rotation RB.
4. Induce motion in an ART fashion through the RB while stabilizing the segment below the SD segment until motion improves.
5. Reassess 2-4 TART findings.

Question 5

MET Lower Thoracic Type 1 (Neutral) SD, Seated

Answer 5

1. Instruct the patient to sit on the treatment table with their ipsilateral hand to the PTP clasped behind their neck and holding that elbow with their other hand. Step away from the PTP!
2. The physician monitors T9 TPs using pads of thumb & index finger of the right hand and the middle finger pad to monitor the TP of T10.
3. Place your left hand on the patient’s right bicep by passing it beneath their left arm first and position patient to the sidebending RB & then the rotation RB.
4. Instruct the patient resist your force &/or “return to the neutral position.” Resist their efforts for 3-5 seconds and tell them to relax.
5. Wait 1-2 seconds and take move them to the next RB.
6. Repeat steps #4 & #5 three to five times.
7. Recheck for 2-4 TART changes.

Question 6

Lumbar Long Restrictor/Rotation MET Type I SD

Answer 6

1. Patient lateral recumbent, PTP down. Physician facing pt.
2. Caudal hand or thigh flexes patient’s knees & hips while cephalad hand monitors the dysfunctional segment. Fine tune hip position until dysfunctional segment is in neutral.
3. Patient’s top leg is lowered off the edge of the table, causing anterior rotation of the pelvis, until the monitoring hand detects motion (at middle finger). Stabilize with thigh to prevent over-rotation.
4. Switch monitoring hands. Use cephalad hand to move the patient’s top shoulder posteriorly until the caudal hand detects motion (at thumb and 1^st finger).

Option 1

1. Patient pushes top shoulder forward against physician’s resistance for 3-5s then relaxes.
2. Operator gently moves the patient’s shoulder posteriorly, rotating T/L spine to new restrictive barrier.

Option 2

1. Patient pulls the hip posteriorly & cephalad against physician’s resistance for 3-5s then relaxes.
2. Physician moves the patient’s pelvis anteriorly & caudal, engaging new sidebending & rotation barriers.
3. Repeat 3-5 times or until now new restrictions.
4. Recheck for 2-4 TART changes.

Question 7

ART Upper Thoracic Type 2 SD, Seated

Answer 7

1. Physician either stands behind or sits next to the seated patient.
2. Place the thumb pad on the lateral aspect of the TP of the level with the somatic dysfunction.
3. Use your other hand to control the patient’s head to engage the restrictive barrier of the somatic dysfunction in all planes
   
   1. Usually the flexion/extension motion is engaged first to localize Type 2 dysfunction to the specific segment, followed by rotation and sidebending
4. Apply an articulatory activating force localized to the segment until no restricted motion is perceived.
5. Reevaluate

Question 8

MET Lower Thoracic Type 2 SD, Seated

Answer 8

1. Instruct the patient to sit on the treatment table with their ipsilateral hand to the PTP clasped behind their neck and holding that elbow with their other hand. Step away from the PTP!
2. The physician monitors T7 TPs using pads of thumb & index finger of the right hand and the middle finger pad to monitor the TP of T8.
3. Place your left hand on the patient’s right bicep by passing it over their left arm first.
4. Position patient to the flexion/extension RB, sidebending RB & then the rotation RB.
5. Instruct the patient resist your force &/or “return to the neutral position.” Resist their efforts for 3-5 seconds and tell them to relax.
6. Wait 1-2 seconds and take move them to the next RB.
7. Repeat steps #5 & #6 three to five times.
8. Recheck for 2-4 TART changes.

Question 9

MET Upper Thoracic Type 1 (Neutral) SD, Seated

Answer 9

1. The physician monitors T2 TPs using pads of thumb & index finger of the L. hand and the middle finger pad to monitor the TP of T3.
2. Place the other hand on the patients head explaining that this is the “neutral position.”
3. Induce sidebending to the left by positioning your thigh beneath the right arm. More SB may be induced by leaning the patient toward the leg.
   
   1. If T3 begins to move, too much motion was induced.
4. Induce rotation to the RB by rotating the head to the right. Fine tune sidebending with head motion.
5. Instruct the patient to “return to the neutral position.” Resist the efforts for 3-5 seconds and then have the patient relax.
6. Wait 1-2 seconds, then move to the next RB.
7. Repeat steps #4 & #5 three to five times
8. Recheck for 2-4 TART changes.

Question 10

Lumbar Long Lever/Sidebending MET Type I SD

Answer 10

NUDR

Neutral dysfn. PTP Up. Pt force Down. Lateral Recumbent

1. Monitor at apex of curve with cephalad hand
2. Flex hips & knees until motion is felt
3. Lift patient’s ankles, meeting SB barrier
4. Instruct the patient resist your force &/or “return to the neutral position.” Resist their efforts for 3-5 seconds and tell them to relax.
5. Wait 1-2 seconds and take move them to the next RB.
6. Repeat steps #4 & #5 three to five times.
7. Recheck for 2-4 TART changes.

Question 11

MET/ART Lumbar Type 1 (Neutral) SD, Seated

Answer 11

1. Instruct the patient to sit on the treatment table with their ipsilateral hand to the PTP clasped behind their neck and holding that elbow with their other hand. Step away from the PTP! Physician places hand on opposite bicep (over one bicep).
2. The physician monitors L2 TPs using pads of thumb & index finger of the right hand and the middle finger pad to monitor the TP of L3.
3. Engage barrier by rotating and sidebending patient until motion is felt under monitoring hand. (Too much if motion is felt at L3)
4. Instruct the patient resist your force &/or “return to the neutral position.” Resist their efforts for 3-5 seconds and tell them to relax.
5. Wait 1-2 seconds and take move them to the next RB.
6. Repeat steps #4 & #5 three to five times.
7. Recheck for 2-4 TART changes.

Question 12

Lumbar Long Lever/Sidebending MET Type II, Extended SD

Answer 12

SUUE

Modified Sims. PTP Up. Pt force Up. Extension dysfunction

1. Place patient in a lateral recumbent position with torso rotated to the table.
2. Monitor dysfunction with cephalad hand.
3. Flex hips & knees, engaging flexion barrier.
4. Drop patient’s legs off table, engaging SB barrier. (may stabilize with knee to localize and for patient comfort.)
5. Instruct patient to raise ankles up against operator’s counter-resistance for 3-5 seconds and then relax.
6. Wait 1-2 seconds and take move them to the next RB.
7. Repeat steps #5 & #6 three to five times.
8. Recheck for 2-4 TART changes.

Question 13

MET Upper Thoracic Type 2 SD, Seated

Answer 13

1. The physician monitors T3 TPs using pads of thumb & index finger of one hand and the middle finger pad to monitor the TP of T4.
2. Place the other hand on the patient’s head explaining that this is the “neutral position,” and then induce flexion via forward bending from above down to T3.
   
   1. If T4 begins to move, then too much flexion was induced.
3. Once localized to T3, induce sidebending to the restrictive barrier (RB) and then rotation to the RB.
4. Instruct the patient to “return to the neutral position.” Resist the efforts for 3-5 seconds and then have patient relax.
5. Wait 1-2 seconds, then move to the next RB.
6. Repeat steps #4 & #5 three to five times
7. Recheck for 2-4 TART changes.

Question 14

Lumbar Long Restrictor/Rotation MET Type II, Extended SD

Answer 14

1. Patient lateral recumbent, PTP down. Physician facing the patient.
2. Caudal hand or thigh flexes patient’s knees & hips while cephalad hand monitors the segment. Flex top hip until dysfunctional segment motion is felt to flex. (1^st finger and thumb)
3. Place patient’s top foot behind the bottom knee in popliteal fossa.
4. Switch monitoring hands. Use cephalad hand to move patient’s top shoulder posteriorly until the caudal hand detects motion. (Engages the rotation left barrier)

Option 1

1. Patient pushes top shoulder forward against doc’s resistance for 3-5s then relaxes.
2. Operator gently moves the patient’s shoulder posteriorly, rotating T/L spine to new restrictive barrier.

Option 2

1. Patient pulls the hip posteriorly & cephalad against doc’s resistance for 3-5s then relaxes.
2. Physician moves the patient’s pelvis anteriorly, engaging new sidebending & rotation barriers.
3. Repeat 3-5 times or until no new restrictions
4. Recheck for 2-4 TART changes.

Question 15

Lumbar Long Lever/Sidebending MET Type II, Flexed SD

Answer 15

FDDR

Flexed dysfn. PTP Down. Pt force Down. Lateral Recumbent

1. Patient in lateral recumbent position. Physician in front of patient. PTP side down.
2. Monitor at dysfunction with caudal hand.
3. Grasp patient’s arm and pull anterior/superior, engaging rotation & SB barriers. (also extends)
4. Switch monitoring hands.
5. Straighten bottom leg, engaging extension barrier.
6. Engage SB barrier by lifting top ankle.
7. Instruct the patient to push towards floor with the ankle against resistance. Resist the efforts for 3-5 seconds and tell the patient to relax.
8. Wait 1-2 seconds and take move them to the next RB.
9. Repeat steps #7 & #8 three to five times.
10. Recheck for 2-4 TART changes.

Question 16

Lumbar Long Restrictor/Rotation MET Type II, Flexed SD

Answer 16

1. Patient lateral recumbent, PTP down. Physician facing the patient.
2. Caudal hand or thigh flexes patient’s knees & hips while cephalad hand monitors the segment. Flex hip until motion is felt at the inferior segment. (at middle finger)
3. Place patient’s top foot behind the bottom knee in popliteal fossa.
4. Switch monitoring hands. Use cephalad hand to move patient’s top shoulder posteriorly until the caudal hand (first finger and thumb) detects motion. Extend the torso to feel motion at finger and thumb.

Option 1

1. Patient pushes top shoulder forward against doc’s resistance for 3-5s then relaxes.
2. Operator gently moves the patient’s shoulder posteriorly, rotating T/L spine to new restrictive barrier.

Option 2

1. Patient pulls the hip posteriorly & cephalad against doc’s resistance for 3-5s then relaxes.
2. Physician moves the patient’s pelvis anteriorly, engaging new sidebending & rotation barriers.

Repeat 3-5 times or until no new restrictions

Recheck for 2-4 TART changes.