Basic Laserology® Outline

BBaassiicc LLaasseerroollooggyy®® OOuuttlliinnee

A. Examination of the cervical spine (Pgs. 16-25)

History • Where is the primary injury (ies) or condition(s) • When did the condition first occur; acute, subacute, chronic • What are the factors that make better or worse (sleeping, driving, motion etc.) • How does the patient describe the injury/condition/symptoms • Frequency and duration of symptoms • Effect on work status or activity of daily living • Occupation • Activities • Previous injuries and/or surgeries • Patient age

Phase 1 Examination of Neck & Upper Extremities 1) Patient performs active range of motion of the cervical spine; flexion/extension, right and left lateral flexion, right and left rotation. • Compare normal vs. abnormal • Evaluate and document exacerbation and location of pain 2) Test intrinsic muscles for symmetry of strength a) Anterior to posterior b) Right to left lateral flexion c) Right to left rotation 3) Check muscle strength of primary stabilizers a) Scalenes (face up arms to the side) b) Sternocleidomastoid (face up arms to the side) c) Neck Extensors (lying face down) d) Neck Extensors with rotation right and left (lying face down) e) Levator scapula (seated)

Treatment of Primary Muscles 1) Laser the cervical spine for 60 seconds with frequencies 9 – neurology, 16 – tissue memory, 42 – lymphatic, 53 – general organ. 2) Adjust with VAIII both posterior and anterior subluxations (Optional) 3) Recheck primary muscles for correction

NOTE:- In all cases the practitioner has an indicator for treatment found on the pretest, specific treatment is applied and the indicator is retested. If the indicator is corrected go on to the next area to test. If the indicator is still active then progress through treatment options, spine, brain, peripheral nerve entrapment, organs and emotions. On subsequent visits evaluate previous weaknesses and correct. Patient only progresses after stability is accomplished.

Phase II Muscle Response Testing (MRT) Muscle response testing is accomplished by the practitioner using a strong indicator muscle and having the patient perform movements of the cervical spine. This is used as an evaluation tool as well as treatment.

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• Flexion/Extension primarily evaluates C1/C2 • Right/Left Lateral flexion primarily evaluates C3 • Right/Left rotation primarily evaluates C4 and Cranial nerve 11

Muscle response testing may be performed using a series of incremented stress; Series #1 a) Performed by using a strong indicator muscle and the patient performing Flexion/Extension (reset) b) Right/Left lateral (reset) c) Right/Left rotation (reset) Series #2 a) Performed by using a strong indicator muscle and the patient squeezing their knees together while performing, Flexion/Extension (reset) b) Rt/Lt lateral flexion (reset) c) Rt/Lt lateral rotation (reset) Series #3 a) Performed by using a strong indicator muscle and the patient squeezing their knees together while performing the cervical ranges of motion against resistance; Flexion/Extension (reset) b) Rt/Lt lateral flexion (reset) c) Rt/Lt lateral rotation (reset) Series #4 a) Performed by using a strong indicator muscle and the patient placing the palm of their hand flat on their forehead while performing the cervical ranges of motion, Flexion/Extension (reset) b) Rt/Lt lateral flexion (reset) c) Rt/Lt lateral rotation (reset)

Phase III Myofascial release using the Erchonia® 3LT® Laser and the Erchonia Percussor

Phase IV (Advanced Seminar Only) Rehabilitation 1) Motion rehab

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B. Shoulder (Pgs.26-39)

Phase I – Examination 1) Shoulder ROM- Have the patient seated and bring the arms up in abduction slow and purposeful. The practitioner is looking for symmetry of motion, proper tracking, compensatory motion, pain and discomfort on the way up and down.

a) Active - abduction, flexion, extension b) Passive - abduction 2) Check muscle strength of myotomes (C5-T1) – These are the big telephone cables. We are evaluating and correcting stability of the trunk. The practitioner will evaluate the the myotomes and treat accordingly. a) C5 mid deltoid b) C6 bicep c) C7 tricep d) C8 finger flexors e) T1 finger abductors 3) Evaluate long lever strength a) Mid deltoid b) Anterior deltoid -forward flexion

Phase II Stabilization 1) Stabilize 2° muscles of the shoulder a) Rotator cuff i) Supraspinatous ii) Infraspinatous iii) Teres Minor iv) Subscapularis b) Posterior Deltoid c) Inverted anterior deltoid d) Pec clavicular e) Pec sternal f) Subclavius g) Latissimus dorsi

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Treatment 1) Using the Erchonia PL5000 place the neurological head (4, 9, 33, 60) on the appropriate spinal region and the programmable head (9, 16, 42, 53) over the muscle of involvement. Treat for 30-60 seconds and re-evaluate.

Phase III Myofascial release using the Erchonia® 3LT®Laser and the Erchonia Percussor

Phase IV (Advanced Seminar Only) Rehabilitation using the Erchonia® 3LT® Laser and the Erchonia Percussor

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C. Peripheral Nerve Entrapments (Pgs. 40-44)

Carpal Tunnel Examination- 1) Supination (palm up) with elbow extension- a) Muscle test the strength of Opponens pollicus digiti & minimi (pinkie to thumb) 2) Pronation (palm down) with elbow extension- isolates entrapments elbow and below a) Muscle test the strength of Opponens pollicus digiti & minimi (pinkie to thumb)

Diagnosis 1) Use the laser diagnostically (10 s) at each possible entrapment site until strength is achieved. a) C/S b) Brachial Plexus c) Coracobrachialis d) Quadra e) Triangular spaces f) Ulnar at the lateral elbow g) Median at the pronator teres h) Retinaculum

Treatment 1) Use the laser therapeutically at the site of entrapment with frequencies 9 – neurology, 16 – tissue memory, 21 – adrenals, 36 – peripheral nerve entrapment (120-180 s) 2) Percuss / Manually release area of entrapment 3) Use the Erchonia® Adjuster to correct any structural subluxations

Lower Extremities - Possible Nerve Entrapment areas 1) Femoral nerve at the Psoas 2) Sciatic nerve at the Piriformis 3) Obturator nerve at the obturator foramen (below the pubic symphisis) 4) Common peroneal nerve at the posterior fibular head 5) Tibial nerve at the tarsal tunnel

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D. Low Back Protocol (Pgs. 45-65) There are many causes of low back pain and these can be divided into the broad categories of traumatic and non-traumatic.

1) Traumatic a) Soft tissue sprain (ligaments)/strain (muscular) b) Fractures c) Subluxations and dislocations d) Herniated discs

2) Non-traumatic a) Arthritis b) Degenerative disc disease c) Side effects from medication (cholesterol lowering drugs)

Phase I Examination 1) Physical examination of the low back should be done on every patient looking for visual inspection of: a) Posture b) Muscle symmetry c) Scars d) Gait 2) Range of Motion a) Patient standing perform ACTIVE Range Of Motion- Flexion, Extension, R/L Lateral Flexion, Right/Left Rotate. b) While the patient lies face up on the table test Range Of Motion of abductors and hamstrings. 3) Orthopedic tests a) Valsalva Maneuver-intrathecal pressure/space occupying lesion b) Fabere Test- Grade severity with ROM of bent leg c) Bilateral Straight leg lift/with cervical compression to determine cervical or low back priority Treatment 4) Reset pubic bone (adjust) a) Pelvic Adduction b) Pelvic Adduction with internal rotation c) Pelvic Adduction with external rotation d) Pelvic Abduction

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e) Pelvic Abduction w/ IR f) Pelvic Abduction w/ER 5) Check muscle strength of 1° stabilizers face up (Myotomes) a) S 1 - Peroneus Longus & brevis b) L 5 - Great Toe Extensors/foot dorsiflexors c) L 4 - Tibialis Anterior d) L 3 - Sartorius e) L 3-5 – Hamstrings f) L 2-4 - Quadriceps g) L 1-3 - Iliopsoas/Rectus Femoris h) L1-L3 - Psoas 6) Check muscle strength of 1° stabilizers face down a) Gluteus Maximus b) Piriformis c) Iliacus

The practitioner will program the PL5000 laser with 9Hz, 16Hz, 42Hz, and 53Hz. Start retesting the primary stabilizers at S1 and correct one at a time. Treatment time is 30-60 seconds over the area of involvement (AOI). Once the correction is made the practitioner stays in neurological order and progresses up.

Both heads can be placed on the spine. (In the case of a sprained ankle the neuro (preset) head can be placed on the spine and the other (programmed) head over the weakened/injured area; ankle.) The neuro (preset) head can be placed on the appropriate brain area and the programmed head stays over the spine Follow laser progression (spine, brain, impingements, organs, emotions)

Phase II Stabilization 1) Stabilization of 2° movers (face up) a) TFL (L4-S1) b) Quadratus Lumborum (T12-L3) c) Glute Medius/Minimus (L4-S1) d) Sacrospinalis group (laser over entire spine) 2) Myofascial Release-Using the Erchonia Laser 3) Myofascial release standing and while marching in place 4) Adjusting while standing and marching in place.

Phase III (Advanced Seminar Only) 1. Set gait - Introduction to the Roller attachment of the Erchonia® Percussor 2. Quadrapedic testing

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3. Violet Laser

Phase IV (Advanced Seminar Only) 1) Rehabilitation

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E. TMJ (Pgs. 66-71)

Phase 1 Examination 1) Active range of Motion a) Have the patient open their mouth; the mouth should open so they could insert three fingers stacked on top of each other. i) Inspection of jaw motion in the swing phase b) Normally the arc of motion is continuous and unbroken with no asymmetrical sideway motion i) Inspection of the jaw in the stance phase c) The jaw should be centered and the teeth close symmetrically in midline 2) Boney Palpation a) The practitioner places their fingers in each of the patients’ ear canal and gently presses anterior while instructing the patient slowly open and close their mouth. The motion should feel smooth bilaterally and any abnormal motion of the mandibular condyle should be noted. 3) Soft Tissue Palpation a) The TMJ is susceptible to trauma involving car accidents and whiplash. In hyperextension injuries the mouth gets whipped open and as a result the joint can subluxate, dislocate, tear the meniscus and/or injure the surrounding muscles. Have the practitioner palpate externally over the; i) Temporalis muscle- pain, tenderness, trigger points ii) Masseter muscle- pain, tenderness, trigger points b) Have the practitioner palpate internally over the; c) External pterygoid muscle- The practitioner will place his finger between the patients’ cheek and back molar pointing posteriorly. Have the patient open and close their mouth slowly.

PhaseII Treatment – Muscle Response Testing 1) Jaw open- primarily the external pterygoid; occasionally anterior belly of digastric 2) Jaw closed- primarily masseter, (posterior) temporalis, and / or internal pterygoid (if the patient clinches tight it may activate a “neurological tooth”) 3) Jaw forward (protrusion) – Internal pterygoid 4) Jaw retraction 5) Deviation to the right 6) Deviation to the left 7) Lightly chew on Rt / Lt side of tongue (proprioception) 8) Check the jaw reflex (laser directly to front of chin) RESET with the PL5000 and both heads set at 4, 9, 33, and 60. Have the patient hold each head over the TMJ for 30 seconds while performing slow, purposeful movements. Retest; move on to the next challenge and fix what you find. End with both heads under the chin and have the patient perform slow, purposeful movements of the weak findings.

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Treatment – Utilize MRT coupled with resistance 1) Check 1-7

Treatment – Utilize MRT coupled with emotions 1) Check 1-7 by performing MRT and having the patient place their hand over their forehead. The jaw is a major emotional filter. When we get stressed we defensively clench our teeth.

Correction- Place the neurological head over one side of the jaw for 15-30 seconds and then place on the other side of the jaw for 15-30 seconds. Place the programmable head over the forehead (with the patients’ hand over their forehead) for 15-30 seconds and then move the programmable head over the heart for 15-30 seconds. Remember: “The heart rules the brain, the brain rules the body”.

Phase III Treatment- Percussion The practitioner will challenge the myofascia and muscle spindles by “pinching” the cheek clockwise and counter clockwise. When an active indicator muscle is determined; place the Erchonia Percussor on the side of the TMJ and torque in the direction of weakness. The practitioner places the listening hand over the opposite and counter torques opposite of the percussor. Stop when the release is felt. Recheck.

Treatment- Adjusting The practitioner will challenge the TMJ in planes of motion (up, down, forward, backward) with an indicator muscle with the mouth closed. Use the Erchonia Adjuster to GENTLY tap the TMJ in the direction of the weakness. Check both sides and repeat with the mouth open. If a correction is determined in the open position it must be corrected in the open position.

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Preface

Erchonia Lasers, Inc. made medical history on January 17, 2002 by being the first low level laser in the USA to be given marketing clearance by the FDA for the treatment of chronic neck and shoulder pain. This alone was considered by most medical companies a huge feat in itself considering that low level lasers have been used in the therapeutic realm for more than 40 years and nobody was able achieve this before. Erchonia has now set the standards and paved the way for other laser companies to follow. Although the technology has become more sophisticated over time, the benefits of low level lasers or cold lasers has not changed much and has been well documented for wound healing, physical therapy, nerve regeneration, and pain management. In fact, there are more than 2000 published articles world wide and not one reports any negative side effects. This is one of the reasons why the Erchonia lasers fall into the laser classification of 3A which is considered a “non-significant risk” factor by the FDA.

This seminar is designed to equip the clinician with the information he/she may need to diagnose and treat difficult conditions using a simple step by step approach. In fact, this easy to use, easy to follow approach, is the same protocol that was used by Erchonia in the clinical trial to determine efficacy of the laser by the FDA. This innovative yet simple approach involves testing the myotomes and the ROM, recording the result, treating with the laser and then rechecking the myotomes and ROM to document improvements.

Many studies have shown that different types of cells respond to different frequencies. It is our belief that by incorporating these observations and known interactions into the design mode that Erchonia Laser produces a unique result oriented product. The four frequency PL5 model allows the clinician to take advantage of the time saving as well as the multi-functional aspect of the laser. Each frequency can activate different cell types simultaneously. Therefore the clinician can treat pain, inflammation, lymphatic, and immune system all at the same time. The easy programmable mode ensures accuracy of treatment time and protocol compliance. Armed with a functional portable device and our knowledge of clinical double blind studies is how Erchonia obtained the first FDA approval for low level laser therapy for pain management.

For most of you this will be your first exposure to low level laser therapy (3LT®) and the information can be overwhelming. In order for you to get the most out of the seminar, Erchonia has provided an easy to use “Patient Evaluation Form” to be filled in while you learn the laser protocols from the instructors. We believe this will enhance your learning experience as well as assist you with the documentation needed for insurance billing. We want you to enjoy the seminar and be able to incorporate what you learn today into your practice tomorrow!!!

Sincerely, Steven Shanks President, Erchonia Lasers

Using the Laser Diagnostically

Studies have shown that using a pulsed waveform (Erchonia) versus a continuous has different therapeutic effects on the cells. For instance, to treat a chronic pain syndrome it is usually beneficial to begin with a lower frequency and then alternate with a higher frequency to counter inflammation. (Laser Therapy, Clinical Practice and Scientific Background by J. Turner and L. Hode 2002 p 42, 50, 72, 78, 96, 163, 167, 372). Leos Navratil MD, PhD states in his paper on the “Mechanisms of the Analgesic Effect of

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Therapeutic Lasers In Vivo” (See Appendix #1) when referring to using the low level laser for pain management “that it has been almost unanimously stated in the literature that LLLT is easy to apply, is pain and side effect free, and is well tolerated by patients of all types and ages.

It has also been documented that the laser has an anti- edematous effect. This is based on the dilation of the lymphatic vessels and the reduction in the permeability of blood vessel. (Laser Therapy, Clinical Practice and Scientific Background by J. Turner and L. Hode 2002, p 66, 162, 163,) (Lievens PC 1991, The influence of laser on the lymphatic system. American Society for Laser and Surgery Abstracts 175- 176(See Appendix #2)) From the International Journal of Clinical Pharmacology and Therapeutics, Dr. Wong reports successfully using the low level laser to manage “repetitive stress injury” by applying the laser to the spinous processes of C5-T1 with dramatic amelioration of pain and tingling in the arms, hands, and fingers(See Appendix #3).

After diagnosing the problems and recording the ROM, muscle strength and testing the myotomes, it is now time to apply the laser. Depending on the model you have, you will be able to program either a single or multiple frequencies simultaneously. Assuming we have the Erchonia PL 5 model which is a dual diode, then we are able to program two separate frequencies per diode, four different frequencies in all, simultaneously. This enables the clinician to now treat four different conditions all at the same time, therefore saving valuable time.

Resetting with Laser

The above mention studies provide the foundation for the Applied Neurology protocols for resetting the Neuro-Musculo-Skeletal conditions. Combining our diagnostic clinical evaluations with therapeutic laser parameters we can now program the laser for the treatment phase of the patient evaluation. Program 9 Hz for Pain Management (A1), 16 Hz for Muscle Memory (A2), 42 Hz for Lymphatic Drainage(B1) , and 53 Hz for Organ involvement (B2). The laser can be applied directly on skin to treat a nerve root, or accupoint or 3’-5” directly over the AOI.

1) Begin by lasering C/S, T/S L/S for 30 – 60 seconds in a sweeping motion or by direct contact to the associated spinal level that relates to decrease R.O.M., Muscle Weakness and/or area of Pain.

2) This optional step or lasering for an additional 120 – 300 seconds, which can be performed by a technician and or use of an equipment stand, will strengthen the weak muscle and/or area of pain whether it be the neck, shoulder, elbow, wrist, hand, low back, pelvis, knee, ankle and/or foot.

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3) Retest ROM and Muscle Strength with previous examination format and document results on Patient Evaluation Form.

Starting with the Structural Component you will find that approximately 80% of the time the area will reset at the nerve root, (beyond this follow the process listed below) and at the area of involvement; however for those patients that do not respond, the doctor may now use the laser as a diagnositic tool.

The recommended way to use the laser diagnostically is identify the area of treatment, and place the laser directly to the area affected (check the Laser Protocol book for appropriate frequency settings), then follow the five harmonized steps detailed below.

NOTE: Throughout the seminar and in the course material, these five steps are referenced. Utilizing them, as referenced provides the best results.

Structural (Step 1) Starting with the structural aspect, position the laser at the point where the target myotome departs the spine. Then retest the myotome (See Appropriate section of this booklet) to check if strength has been restored. Lasering the nerve root clears 80% of myotome weaknesses. For the other 20% that remain weak, follow in order steps 2-5.

Brain (Step 2) After applying laser to the never root and assuming that the Myotome weakness has not been remedied and weakness persists, the next step is to stimulate on the same side, of the body of the myotome being diagnosed, at the Cerebellum and the opposite side at the Cortex. Retest to see if strength has begun to be restored.

Entrapments (Step 3) If weakness continues, at this point, begin checking for peripheral nerve entrapments of the extremities. Continue to stimulate each area with the Erchonia laser where an entrapment may be occurring and retest to see if strength has begun to be restored.

Viscera (Step 4) If Myotome strength has not begun to return after working through the above steps, look to visceral components. Begin by applying laser stimulation the organs that share nerve supply with the myotome that is affected. Again retest myotome strength to observe if it has begun to be

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restored. *Note that in most cases Nutritional and Detoxification will be necessary to completely restore myotome strength.

Emotional (Step 5) Finally if the strength of the myotome has not yet begun to return after each of the others step have been ruled out of you diagnosis, begin by applying the laser to the emotional centers over the forehead. Retest as each time before to know if myotome strength is being restored.

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E. Examination of the Cervical Spine

Phase I Exam 1. Check Range of Motion of Cervical Spine

Movement Normal Nerve Root Check Range Flexion 60º C1,C2 See graph 1 Extension 60º C1,C2 See graph 1 Lateral flexion 45º C3 See graph 2 Rotation 80º C4,CNX1 See graph 3

C1, 2 – Flexion & Extension (Graph 1)

Flexion Patient should be able to flex their head forward and touch their chin to their chest

Extension Patient should be able to extend their head back and have their eyes looking directly to the ceiling

C1, 2, – Flexion & Extension of Head

C3– Lateral Flexion(Graph 2)

C3 – Right and left lateral flexion

Right and Left Lateral Flexion Patient should be able to laterally flex their neck 45º without recruiting

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C4 – Rotation (Graph 3)

C4, CN XI – Right and Left Rotation

Right and Left Rotation Patient should be able to approximate their chin to their shoulder

Exam 2. Check Intrinsic Muscle Strength of Cervical Spine (reset)

Patient actively pushes into Doctors hand with increasing pressure during Flexion, Extension, Right & Left Lateral Flexion and Right & Left Rotation.

Doctor records any ROM deficits, strength impairment and/or procedures that elicit pain (grade muscle strength on a scale of 0 to 5, 5 being maximum).

Movement Normal Nerve Root Check Range Flexion 5 C1,C2 See Muscle Chart Extension 5 C1,C2 See Muscle Chart Lateral flexion 5 C3 See Muscle Chart Rotation 5 C4,CN,X1 See Muscle Chart

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Hoppenfeld Muscle Grading Chart Muscle Gradations Description 5- Normal Complete range of motion against gravity with full resistance

4-Good Complete range of motion against gravity with some resistance

3-Fair Complete range of motion against gravity

2-Poor Complete range of motion against gravity eliminated

1-Trace Evidence of slight contractility. No joint motion

0-Zero No evidence of contractility

Neck Flexors Group Action- All scalenes and bilateral SCM’s contract with flexion of the neck when the nose is midline. Test- The patient lies face up with arms extended to the side to prevent compensation. The practitioner will flex the patient’s head off of the table, keeping the nose midline (Watch for deviation!) while supporting the back of the patient’s head as to protect the patient from exacerbation of any sprain/strain injury. The doctor then takes a knife edge contact midline on the forehead. The practitioner will then attempt to push the patients head toward the table.

Start Finish

Exam 3. Check Muscle Strength of primary stabilizers

Anterior Scalene Group (anticus, medius, posticus)

Origin- Anterior tubercles of the transverse processes of the 2nd-7th cervical vertebrae. Insertion- The scalene tubercle on the superior surface of the first rib. Action- Elevates the first rib and is involved in flexion and rotation of the cervical spine. Test- The patient lies face up with arms extended to the side to prevent compensation. An example of testing the RIGHT scalene would be to have the patient rotate the head to the left 10- 15 degrees or the practitioner visually rotates the head until the eye is perpendicular to the table.

Laserology® 18 of 91 33LLTT®® -- LLaasseerroollooggyy®® BBaassiicc Then the practitioner will flex their head off of the table. The doctor would support the back of the patient’s head as to protect the patient from exacerbation of any sprain/strain injury. The

doctor then takes a knife edge contact on the forehead directly over the right eye. The practitioner will then attempt to push the patients head toward the table. Nerve supply (Anticus) – Anterior branches of C5, C6, C7, C8 Nerve supply (Posticus) – Posterior branches C5-C8; lateral muscular branches of C3, C4.

Left Scalene Start Finish

Right Scalene Start Finish

Sternocleidomastoids

Origin-(Sternal Head) Anterior surface of the manubrium of sternum (Clavicular Head) Superior surface of the medial half of the clavicle Insertion- Lateral surface of the mastoid process of the temporal bone and the lateral surface of the superior nuchal line of the occiput Action- Draws the head toward ipsilateral shoulder and rotates the head to the opposite side. When contracting bilateral the SCM will flex the neck forward. Test- The patient lies face up with arms extended to the side to prevent compensation. An example of testing the right SCM would be to have the patient rotate the head to the left and lift their head off of the table. The doctor would support the back of the patient’s head as to protect the patient from exacerbation of any sprain strain injury. The doctor then takes a palm contact on the superior lateral side of the head staying off of the TMJ and ear of the patient. The practitioner will then attempt to push the patients head toward the table. Nerve supply- Cranial nerve XI and Anterior rami of C2, C3

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Left SCM Start Finish

Right SCM Start Finish

Neck Extensors Testing Patient is prone with shoulders/humerus abducted to 90º (elbows flexes for comfort). The Practitioner applies a Knife Edge contact with pressure on the back of the patient’s head into Flexion. Nerve C 1-8

Neutral Start Finish

Neck Extensors Right & Left Patient is prone with shoulders/humerus abducted to 90º (elbows flexes for comfort). The Patient head rotated 30-45°. The Practitioner applies a Knife Edge contact with pressure on the back of the patient’s head into Flexion. Nerve C 1-8

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Left Extensor Start Finish

Right Extensor Start Finish

Levator Scapula

Origin- Transverse process of the upper four cervical vertebrae Insertion- Vertebral border of scapula between superior angle and root of the spine of the scapula Action- Elevates and adducts scapula Test- The patient is seated with the elbow bent at 90 degrees with the palm up and the forearm slightly rotated outward. The patient is instructed to look away and laterally flex the neck. Then the patient is instructed to drop the shoulder being tested as mush as possible limiting the amount of spinal lateral flexion. The practitioner then stabilizes the patient at the shoulder being tested and the other hand is positioned inside the elbow tucked next to the body. The practitioner then applies force in a lateral and slight anterior position.

Nerve supply- Dorsal scapular nerve C3, C4, C5

Right Start Finish

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Left Start Finish

Phase II Series 1. MRT (Muscle Response Testing ) through ROM of C/S Series 1

Seated MRT through C/S ROM (reset w/laser) MRT while patient does active ROM C/S through Flexion, Extension, right and left Lateral Flexion and right and left Rotation.

Start Neutral Position

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Series 2. Physically Stress Patient

Seated Physically Stress Patient (reset w/laser) MRT through C/S ROM while patient physically squeezes knees together.

Start Position: Neutral Position Arm Strong While Squeezing Knees.

Series 3. Strong Arm, Knees Squeezed Against Resistance

Flex Ext Right Flex

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Left Flex Left Rot Right Rot

Series 4. Emotional Stress Patient (reset w/laser) MRT through C/S ROM while patient actively holds hand on forehead. (Emotional Center)

Start position hand on forehead and strong

Phase III MFR (Myofascial Release) Line up Origin and Insertion of Muscle with Laser beam while doing Strain/Counterstrain maneuver. Stop when Muscle is Released/Relaxed.

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Supine Trapezius Laterally Flex Patient’s Head to the Right or Left.

Origin-upper - Occiput bone from the external occipital protuberance and medial one-third of superior nuchal line; the ligamentum nuchae to the spinous process of C7.

Insertion-upper – Lateral one-third of superior surface of the clavicle and acromion process

Origin-middle – Spinous processes of the first five thoracic vertebrae Insertion-middle – Superior border of scapula and medial aspect of acromion Origin-lower – Spinous processes of T 6-12 Insertion-lower – Medial one-third of the spine of the scapula

Supine SCM and Scalenes Rotate Head to 30º-45º and put Patient’s head into Extension

Origin – Sternal head of the muscle attaches to the manubrium; clavicular head attaches to the medial portion of the clavicle.

Insertion – Temporal bone on the lateral side of the mastoid process; Occiput on the lateral half of the superior nuchal line.

Review Neck

1. Check ROM of Cervical Spine 2. Check Muscle Strength 3. Check Muscle Strength of Intrinsic Neck Stabilizers

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B. Shoulder

Phase I

Exam 1. Check Range of Motion of Shoulder Movement Normal Abduction 180º Adduction 45º Flexion 90º Extension 45º Internal Rotation 55º External Rotation 40º

Exam 2. Check Myotomes C5 through T1(reset) Myotome Muscles C 5 Deltoid C 6 Bicep C 7 Tricep C 8 Finger Flexors T 1 Finger Abductors

Neurological level C5

Bicep Reflex- To find the exact location of the bicep tendon, have the patient flex the elbow and contract the bicep muscle. Place the patients arm so that it rests comfortably across your forearm. The practitioners hand is under the medial side of the elbow to support the arm and the thumb is placed on the bicep tendon in the cubital fossa. Instruct the patient to relax completely and look away when performing the test. With the narrow end of the reflex hammer tap the nail of your thumb. The strength of the reflex needs only be slightly weaker to indicate abnormality. As with all deep tendon reflexes an excessive response may indicate a upper motor neuron lesion (such as a cardiovascular attack or stroke) while a decreased reflex response may be caused by a lower motor neuron lesion such as a peripheral nerve injury.

Sensation Testing- Lateral arm (axillary nerve) The purest patch of the axillary nerve sensation lies over the lateral portion of the deltoid muscle. The area of sensation is approximately from the AC joint to the elbow.

Middle Deltoid Origin- upper surface of the acromion process Insertion- deltoid tuberosity of the humerus Action- abduction of the humerus (the deltoid acts most powerfully in abduction) Nerve Supply- The deltoid muscle is almost a pure C5 (axillary nerve) muscle with some involvement from C6. Test- The patient is seated with the arm extended to the side and the elbow flexed at 90 degrees palm down. The practitioner stabilizes the patient and uses downward pressure on the forearm.

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C5 – Deltoid

Neurological level C6

Brachioradialis Reflex- Place the patients arm so that it rests comfortably across your forearm. The practitioners hand is under the medial side of the elbow to support the arm and the thumb is placed on the brachioradialis tendon at the distal end of the forearm. Instruct the patient to relax completely and look away when performing the test. With the narrow end of the reflex hammer tap the nail of your thumb. The strength of the reflex needs only be slightly weaker to indicate abnormality.

Sensation Testing- Musculocutaneous nerve on the lateral forearm, the thumb, the index finger and the lateral half of the index finger.

Bicep Brachii Origin- Short head is the tip of the coracoid process Long head is the supraglenoid tubercle of the scapula Insertion- Tuberosity of the radius Action- flexes the forearm and is involved with supination against resistance Nerve supply- musculocutaneous nerve of C6 with some involvement of C5 Test- With the patient seated flex the elbow approximately to 75 degrees with the forearm supinated and the palm up. The examiner stabilizes at the elbow and directs pressure against the distal forearm to force the arm into tension.

Wrist Extensor Group (C6 radial nerve) The radial wrist extensors supply most of the power for wrist extension. Extensor Carpi Ulnaris is a secondary wrist extensor and is innervated by C7 radial nerve. If C6 innervation is absent and C7 is present the wrist will deviate to the ulnar side. If C7 innervation is absent and C6 is present the wrist will deviate to the radial side. Functional injury may be obvious when performing the actual muscle test. When testing the individual groups deviate the wrist to the side of the group you are testing.

Extensor Carpi Radialis Longus (right) Origin- lower third of lateral supracondylar ridge of humerus Insertion- Dorsal surface of base of 2nd metacarpal bone

Extensor Carpi Radialis Brevis (right) Origin- From common extensor tendon from lateral epicondyle of humerus, radial collateral ligament of elbow joint Insertion- Dorsal surface of base of 3rd metacarpal bone

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Extensor Carpi Ulnaris Origin- Lateral epicondyle of the humerus, posterior border of the ulna Insertion- Medial side of the base of the 5th metacarpal bone.

Rt Start Weak

Lt Start Weak

Neurological level C7

Tricep Reflex- To test the reflex place the patients arm over the practitioner’s opposite arm so that it rest upon the forearm. The practitioner’s thumb sets in the cubital fossa and the hand supports at the distal end of the bicep of the patient. This offers relaxed control to the patient as well as the practitioner. When there is complete relaxation the practitioner will tap the tricep brachii tendon where it crosses the olecranon fossa and just above the prominent point of the elbow.

Sensation Testing- Sensation is tested on the palmer side of the middle finger extending in a narrow strip where the hand flexes at the wrist. Muscle test- The tests for C7 are the tricep brachii, finger extensors and the wrist flexors.

Tricep Brachii Origin- Long head originates at the infraglenoid tubercle of scapula • Lateral head originates at the posterolateral surface of the humerus • Medial head originates at the lower posterior surface of the humerus Insertion- All three heads come together and attach at the posterior surface of the olecranon Action- Forearm extension and the long head aids in adducting and extending the arm Test- Have the patient seated with the elbow bent at 90 degrees, elbows tucked into the patient’s sides, open hands with the thumbs straight up. The practitioner stands behind the patient and grips the patient’s arm just above the wrist. The patient tries to push down while the practitioner pulls upward.

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Right Start Right Weak

Left Start Left Weak

Neuro head neck program Hand held double (central) Neuro head on spine program head head bicep muscle treatment nerve root

Neurological level C8

Reflex- NONE

Sensation Testing- Sensation testing is done on the ring and little finger of the hand and the distal forearm. The ulnar side of the little finger is the best area to examine C8 for sensation. Muscle Tests- Muscle tests for the C8 nerve are the flexor digitorum superficialis, flexor digitorum profundus, and the lumbricales.

Flexor digitorum superficialis Origin- Medial epicondyle of the humerus, coronoid process of the ulnar head, radial head and the oblique line Insertion- Palmar surface of the middle phalanx of the medial four digits Action- Finger flexion of medial four digits

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Flexor digitorum profundus Origin- Anterior medial surface of ulna Insertion- Distal phalanges of medial four digits Action- Finger flexion of medial four digits

Lumbricales Origin- There are four lumbricales all arising from the tendons of the flexor digitorum profundus. 1. from the radial side of the tendon for the index finger 2. from the radial side of the tendon for the middle finger 3. from adjacent sides of tendons for the middle and ring fingers 4. from adjacent sides of tendons for ring and little fingers Insertion- With the tendons of the extensor digitorum into the bases of the phalanges of the medial four digits Muscle Test- Instruct the patient to flex all joints of the fingers making a fist palms up. Have the patient relax to let the practitioner place their fingers within the curled fist and then forcefully try to open.

C8 – Finger Flexors

Neurological level T1

Reflex- NONE Sensation Testing- T1 supplies sensation to the upper half of the medial forearm and the medial portion of the arm.

Muscle Test- Dorsal Interossei Origin- There are four dorsal interossei, each arises from the two heads of the adjacent sides of the metacarpal bones Insertion- 1. into the radial side of the proximal phalanx of 2nd digit 2. into the radial side of the proximal phalanx of 3rd digit 3. into the ulnar side of the proximal phalanx of 3rd digit 4. into the ulnar side of the proximal phalanx of 4th digit Action- Abduction and Adduction of the fingers

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Test- All the small muscles of the hand are innervated by T1.

ADDUCTION of the fingers are tested by having the patient hold the fingers firmly together in pairs and the practitioner tries to pull apart. The practitioner may also use a piece of paper firmly held between the patient’s fingers and try to slide the paper from the grasp.

ABDUCTION is tested by having the patient fan their fingers apart and the practitioner uses incremented force to push them together. Be aware that anyone can over power the fingers in this position so you are mostly looking for the resistance when medial force is applied.

T1 – Finger Abductors

Exam 3. Long Lever Testing – Muscle Strength of Shoulder

Mid Deltoid (Long Lever test) Origin- upper surface of the acromion process Insertion- deltoid tuberosity of the humerus Action- abduction of the humerus (the deltoid acts most powerfully in abduction) Nerve Supply- The deltoid muscle is almost a pure C5 (axillary nerve) muscle with some involvement from C6. Test- The patient is seated with the arm extended straight out to the side, palm down. The practitioner stabilizes the patient and uses downward pressure on the forearm, just above the wrist.

Long Lever Mid Deltoid Start Finish

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Anterior Deltoid (long lever test)

Origin- anterior, superior lateral third of the clavicle Insertion- deltoid tuberosity of the humerus Action- flexes and internally rotates the humerus; abduction of the humerus Nerve Supply- The deltoid muscle is almost a pure C5 (axillary nerve) muscle with some involvement from C6. Test- The patient is seated with the arm extended straight in front of the patient, palm down and the humerus is 90 degrees to the body. The practitioner stabilizes the patient and places down ward pressure on the back of the forearm just above the wrist.

Long Lever Anterior Deltoid Start Finish

Phase II Exam 1. Check Muscle Strength of Rotator Cuff and Posterior Deltoid(reset w/laser)

Supraspinatus Origin- Medial 2/3 of the supraspinatus fossa located on the superior portion of the scapula just above the spine of the scapula. Insertion- Middle portion of the greater tuberosity Action- Abduction of the humerus Nerve supply- Suprascapular C5, C6 Test- The seated or standing patient will rotate the arm having the thumbs placed downward with the arm straight. In this position the arm is held at approximately the level of the nipple line. The practitioner stabilizes the patient at the shoulder and places the other hand on the superior portion of the wrist forcing the arm in a downward position. Use caution when doing this test due to the fact of the supraspinatus is a relatively small muscle and generally does not work alone unless isolated. If there is a sprain/strain or tears in the muscle this will be painful.

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Start Finish

Infraspinatus Origin- Posterior portion of the shoulder blade from the infraspinatus fossa of the scapula Insertion- On the posterior aspect of the greater tuberosity of the humerus Action- Externally rotates the humerus Nerve supply- Suprascapular nerve C5, C6 Test- The seated patient abducts the shoulder straight out to the side 90 degrees and flexes the elbow joint 90 degrees with external rotation of the humerus. The patient’s arm is in a “stop” position. The practitioner stabilizes the patient at the elbow joint and places their other hand on the back of the patient’s wrist which applies the force pushing forward against the resistance of the patient.

Start Finish

Teres Minor Origin- Upper 2/3 of the posterior border of the scapula Insertion- On the posterior aspect of the greater tuberosity Action- Externally rotates the humerus and is involved in some adduction and extension of the humerus. Test- The seated patient places their elbow at 90 degrees, tucks the elbow into their side and rotates the arm externally. The practitioner stabilizes the patient at the elbow and places the other hand on the dorsal part of the wrist which applies force straight across against resistance from the patient.

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Start Finish

Subscapularis Origin- Anterior portion of the shoulder blade from the subscapular fossa Insertion- Lesser tuberosity of the humerus Action- Internally rotates the humerus and draws the humerus down and forward when the arm is raised Nerve supply- Subscapular nerve C5, C6 Test- The seated patient abducts the shoulder straight out to the side to 90 degrees and bends the elbow to 90 degrees with internal rotation of the humerus. The practitioner stabilizes the patient at the anterior shoulder and the other hand is placed at the palmer side of the wrist which applies the force to externally rotate the shoulder against resistance from the patient. The test can be performed lying down as long as the shoulder and arm position are maintained.

Start Finish

Posterior Deltoid Origin- spine of scapula; inferior lip Insertion- deltoid tuberosity of the humerus Action- extension and external rotation; abduction of the humerus Nerve Supply- The deltoid muscle is almost a pure C5 (axillary nerve) muscle with some involvement from C6. Test- The patient is seated with the arm extended to the side and the elbow flexed at 90 degrees palm down with external rotation of the humerus. The practitioner stabilizes the patient from the front and places the hand applying force on the anterior bicep near the elbow joint using pressure in the line of the forearm posteriorly.

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Start Finish

Inverted Anterior Deltoid (Combination Test of Ant. Delt., Long head of Biceps, and Subclavius) Start Finish

Test – Patient seated or standing, palm up, arm extended with the elbow locked and the humerus 90ºto the chest. Practitioner displaces pressure straight down

Pectoralis Major (clavicular division) Origin- Anterior surface medial (sternal) portion of the clavicle Insertion- Lateral lip of the bicipital groove of the humerus Action- Flexes the shoulder joint, adducts the humerus horizontally and provides some internal rotation Nerve supply- Lateral pectoral nerve C5, C6, C7 Test- The patient lies face up on the table with their arm straight up and rotating the hand internally so the thumb is facing outward. The practitioner stabilizes the patient at the opposite shoulder and places the other hand on the distal portion of the forearm. The force is exerted straight out with the force being placed on the distal forearm against resistance from the patient.

NOTE: The patient must keep the arm being tested completely straight (no bend at the elbow) and both shoulders flat on the table.

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Start Finish

Pectoralis Major (sternal division) Origin- The muscle originates from the lateral sternum to the 7th rib anteriorly and also from the aponeurosis of the external oblique (abdominal muscle). Insertion- Lateral lip of the bicipital groove of the humerus Action- Major anterior shoulder stabilizer; adducts the humerus primarily in the direction of the opposite iliac crest. Muscles always work in the direction of their fibers. Nerve supply- Lateral and medial pectoral nerve C6, C7, C8, T1 Test- The patient lies face up on the table with their arm straight up and rotating the hand internally so the thumb is facing outward. The practitioner stabilizes the patient at the opposite shoulder and places the other hand on the distal portion of the forearm. The force is exerted out and up at a 45 degree angle. The best muscle testing is performed by visualizing a line from the origin and insertion and testing the muscle within this motion.

Start Finish

Subclavius Origin- 1st rib at the costal cartilage near the sternum Insertion- Anterior, inferior portion of the middle clavicle between the conoid ligament and the costoclavicular ligament Action- Although small this muscle is a major stabilizer of the clavicle during shoulder abduction. The Subclavius draws the clavicle inferiorly and anteriorly Nerve supply- C5, C6 Test- Have the patient seated and abduct the arm completely until the elbow is nearly touching the side of the head. This arm will be tested with the thumb pointed toward the patient and also the thumb will be internally rotated and turned outward. The patient’s elbow must be locked out in the starting position. The practitioner stabilizes the opposite shoulder and places their other hand on the distal internal portion of the forearm and applies the force straight out in the frontal plane of the body. The area of this muscle will be very sore if there is numerous weaknesses associated in the shoulder area or the muscle weak itself. Treat over the subclavius muscle with the laser.

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Start 1 Start 2

Finish 1 Finish 2

Latissimus dorsi Origin- A broad fan like muscle that originates from the lower six thoracic spinous processes, the five lumbar spinous processes, the lower four ribs, and the crest of the ilium, and even the tip of the inferior angle of the scapula Insertion- It runs underneath the armpit and attaches on the anterior humerus at the intertubercular groove of the humerus Action- extension, adduction, and internal rotation of the humerus Nerve supply- Thoracodorsal nerve C6, C7, C8 Test- The patient standing will place the arm in full extension keeping the elbow tucked into their side and internally rotating the arm. The practitioner stabilizes the shoulder on the same side as testing and the other hand is placed on the distal forearm between the hip and the wrist. The practitioner places pressure outward and slightly forward in the line of the muscle fibers.

Start Finish

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Phase III MFR (Myofascial Release) Shoulder Girdle

Pectoralis Origin –Medial one-third to one-half of the clavicle Origin – Anterior surface of the sternum and cartilages of ribs 1-6 and aponeurosis of the external oblique. Insertion –Lateral lip of the bicipital groove of the humerus

Latissimus Dorsi Origin – Spinous process of T6-12, L1-5, and the upper sacral vertebrae; the thoracolumbar fascia of ribs 9-12; the posterior one third of the medial iliac crest; and occasionally on inferior inferior angle of the scapula. Insertion – The muscle forms a tendon that passes through the axillary region to attach on the intertubercular groove of the humerus.

Rhomboids

Origin-major – Spinous processes of second through fifth thoracic vertebrae. Origin-minor – Ligamentum nuchae, spinous processes of seventh cervical and first thoracic vertrebrae. Insertion-major – By fibrous attachment to medial border of scapula between spine and inferior angle of scapula.

Laserology® 38 of 91 33LLTT®® -- LLaasseerroollooggyy®® BBaassiicc Insertion-minor – Medial bolder at root of spine of scapula.

Teres Minor

Origin – Middle to lower one third of the axillary border of scapula Insertion – Lowest facet of the greater tubercle of the humerus

Review Shoulder

1. Check R.O.M. of Shoulder 2. Check Myotomes 3. Check Muscle Strength of Rotator Cuff and Posterior

MFR with Percussor

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C. Peripherial Nerve Entrapment

Treatment of Carpal Tunnel and Upper Extremity Exam 1: Check muscle strength of opponens digiti minimi PT Approximates the finger pad of the thumb to the finger path of the little finger with palm up. Doctor tries to abduct fingers checking for muscle weakness. If muscle is weak possible nerve entrapment from c/s down.

• Use laser diagnostically starting at number one c/s for 10 seconds using FZ 9, 16, 21, 36 • Recheck for muscle strength, if strong, laser an additional 120 seconds and MFR area of entrapment • Continue down until you find the nerve compartment that restores muscle strength.

• Recheck with patients palm down (pronation). • If weak nerve entrapment is from elbow down

*Maybe more than one area of nerve entrapment Double Crush Syndrome

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Upper Extremity: Areas of possible nerve entrapments

a. Cervical Spine

b. Brachial Plexus / Scalenes

c. Musculocutaneous Nerve: *AOE: Travels through Coracobrachialis Muscle -Supplies Coracobrachialis, Biceps and Brachials

d. Axillary Nerve: *AOE: Quadrilateral Space Between Teres Minor, Teres Major, Long Head Triceps ad the Humerous -Supplies Deltoid and Teres Minor

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e. Radial Nerve: AOE: Triangular space between Teres Minor, Long Head Triceps and the Humerous also between the Superficial and Deep Layers of the Supinator Muscle -Supplies Triceps, Brachialis, Brachioradialis, Extensor Carpals, Anconeus, Supinator, Abductor Pollic’s and extensor of Hand

f. Ulnar Nerve: *AOE: Elbow between the Olecranon and the Medial Epicondyle -Supplies Flexor Carpi Ulnaris, Flexor Digiti Profundus III and IV, Palmaris Brevis, Abd, Opp. And F1 Digiti minimi, Palmar Interossei, Lumbricales III & IV, Fl. Pollicis Brevis, Adductor Pollicis

g. Median Nerve: *AOE: Between the two heads of the Pronator Teres and under the Flexor Retinaculum -Supplies Pronator Teres, Flex Carpi radialis, Palmaris Longus, Flex Digiti, Pronator, Quadratus, Abd Pollicis, Lumbricales I & II Flex Digiti, Pronator, Quadratus, Abd Pollicis, Lumbricales I & II

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h. Flexor Retinaculum

Lower Extremity Nerve Entrapments 1. Femoral Nerve: *AOE: Travels through the Psoas muscle -Supplies the Iliacus, Sartorius and Quadriceps

2. Sciatic Nerve: *AOE: Lies beneath the Piriformis Muscle -Supplies Biceps Femoris, Semitendinosus, and Semimembranosus

3. Obturator Nerve: *AOE: Travels through the anterior part of the External Oblique Muscle -Supplies the Obturator Externus and Adductors

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4. Common Peroneal Nerve: *AOE: Passes between the Biceps Femoris and the lateral head of the Gastrocnemius to the posterior Fibula -Supplies Peronei Muscles, Ankle Dorsiflexors and Everters

5. Tibial Nerve Tarsal Tunnel

*AOE= Area of Entrappment, Fz 36 for Peripheral Nerve

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D. Low Back Protocol

Phase I Exam 1. Physical Txamination of the low back should be done on every patient looking for visual inspection of: a. Posture b. Muscle symmetry c. Scars d. Gait Exam 2. Check Range of Motion Lumbar Spine, Straight Leg Raise and Leg Abduction Bilaterally a. Patient standing perform ACTIVE Range of Motion- Flexion, Extension, R/L Lateral Flexion, Right/Left Rotate b. While the patient lies face up on the table test Range of Motion of abductors and hamstrings. Exam 3. Orthopedic Tests a.VALSALVA MANEUVER is performed by asking the patient to bear down as if they were trying to have a bowel movement. This increases the intrathecal pressure. If bearing down causes pain in the back or radiating pain down the legs it caused by an injury to the disc and a possible herniation.

b.PATRICK OR FABERE TEST is a test that can be used to detect pathology in the hip as well as in the sacroiliac joint. Have the patient lie supine on the table and place the foot of his involved side on his opposite knee. The hip joint is now flexed, abducted, and externally rotated. In this position if there is inguinal pain it is a general indication that there is an injury in the hip joint or the surrounding muscles. To stress the sacroiliac joint, extend the range of motion by placing one hand on the flexed knee joint and the other hand on the anterior superior iliac spine of the opposite side. Press down on each of these points as if you were opening the binding of a book. The end point puts the legs in a figure four position. If the patient complains of increased pain in the inguinal area it is common that there is an injury in the sacroiliac joint. If there is pain in the back it may represent a disc injury.

• Grade 0 = Leg is flat with no pain, indicating no disc or hip problem. • Grade 5 = Leg is straight up with intense pain and unable to perform at all. This indicates a significant injury and that surgery may be necessary, however, a full exam and treatment with the laser is recommended. • Grade 1-4 = These functional levels indicate that conservative treatment is recommended and the patient should respond independent of symptomatology and pain levels.

Grade 0 Grade 1 Grade 2

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Grade 3 Grade 4 Grade 5

Exam 4. Check Muscle Strength of Hip Adductors, Hip Abductors, and Adjust Pubic Bone

Adductor Group- Pectineus, Adductor brevis, Adductor Longus, Adductor Magnus Pectineus Origin- Superior surface of the pubic bone between the iliopectineal line and pubic tubercle Insertion- Lesser trochanter (pectineal line) to the linea aspera Action- adduction of the hip, flexion, and internal rotation of the thigh Nerve supply- femoral and obturator nerve L2, L3, L4

Adductor Brevis Origin- inferior ramus of the pubis Insertion- lesser trochanter to the linea aspera Action- adduction of the hip, some hip flexion Nerve supply- obturator L2, L3, L4

Adductor Longus Origin- between the pubic crest and pubic symphysis Insertion- middle one third of the linea aspera Action- adduction of the hip, some hip flexion Nerve supply- obturator L2, L3, L4

Adductor Magnus Origin- Posterior fibers originate at the ischial tuberosity and ramus of the ischium. Anterior fibers originate at the ramus of ischium Insertion- greater trochanter, along the linea aspera and to the adductor tubercle of the medial condyle of the femur Action- Posterior adduct the thigh and hip extension. Anterior adduct the thigh and hip flexion Nerve supply- obturator and sciatic L2, L3, L4, L5, S1

Test- The patient can be lying face up and is instructed to firmly hold legs together while the practitioner tries to force apart. This can be done by having the patient perform this with toes straight up, toes rotated inward and toes rotated outward. Inward the test isolates the superior groups more and outward isolates the lower adductor groups.

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Test A Test B Test c

Reset Pubis Bone Testing – The Patient bends knees and places feet flat on the table, while the doctor places hands outside of the knees. Doctor places hands on lateral knees in abductions, while the patient forces the legs in adduction. Test three times, in one second pulse

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Gluteus Medius Origin- Outer surface of the ilium from the iliac crest and posterior gluteal line to the anterior gluteal line. Insertion- Lateral surface of the greater trochanter Action- Abducts and rotates the thigh internally. It is a major lateral pelvic stabilizer. Test- The patient lies face up and the patient spreads legs apart while the practitioner tries to push the legs together. The test can be performed with the toes extended straight up, toes rotated inward and toes rotated outward. Nerve supply- Superior gluteal nerve L4, L5, and S1

Test D Test E Test F

Reset Pubis Bone Testing – The doctor places hands inside medial knee and abducts knees, while patient actively adducts legs Test three times, in one second pulse Doctor places hands on lateral knees in adduction, while the patient forces the legs in abductions If weak in N, Int. R, Ext R, inís t in same position.

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Manual Adjusting of Pubic Bone

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Exam 5. Check Myotomes L1 through S1 (reset) Myotomes Muscles S1 Peroneus L. & B. L5 Toe Extensors L4 Tibialis Anterior L3 Sartorius L4,5 S1-3 Hamstrings L2-4 Quadriceps L1-3 Iliopsoas L1-3 Psoas

S1 – Peroneus L. & B. Neurological level S1

Tendon Reflex- Achilles tendon is a large tendon originating from the calf muscles and inserting into the calcaneus. You may have the patient sitting in a relaxed position and the practitioner will lightly traction the foot upward to place tension on the tendon and then strike with a reflex hammer. This is a deep tendon reflex which is also a lower motor neuron reflex. Sensation- The S1 dermatome covers the lateral side of the foot over the area of the digiti minimi

Muscle Test- Peroneus Longus Origin- Head of the fibula and the proximal two-thirds (lateral surface) of the fibula Insertion- Lateral side if the cuneiform form bone and base of the first metatarsal Action- Plantar flexion and eversion; gives lateral stability to the foot Nerve supply- peroneal L4, L5, and S1

Peroneus Brevis Origin- Lower two-thirds of the fibula Insertion- Styloid process of the base of the 5th metatarsal Action- Plantar flexion and eversion; gives lateral stability to the foot Nerve supply- peroneal L4, L5, and S1

Test- (Peroneus longus and brevis) the patient lies supine, keeping their leg straight, plantar flexes and everts the foot. The practitioner places the stabilizing hand on the medial calf and forces fully tries to invert the foot with the other.

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Start Finish

S1 – Peroneus L. & B.

L5 – Toe Extensors Neurological level L5

Tendon Reflex- The tibialis posterior muscle provides an L5 reflex but is difficult to get a clear response; therefore, many sources may claim there is no reflex.

Sensation Testing- The L5 dermatome covers the lateral leg and the dorsum of the foot; the crest of the tibia separates L4 from L5.

Muscle Test Extensor Hallucis longus (deep peroneal nerve) Origin- Middle half of the anterior fibula and the interosseous membrane between the tibia and fibula. Insertion- Dorsal surface of the distal phalanx of the great toe Action- Have the patient walk on their heals extending the great toe Test- Have the patient sit on the edge of a table while dorsiflexing the great toe. The practitioner will stabilize the foot near the calcaneus and place their thumb of the other hand on the nail bed of the extended great toe with the fingers stabilizing the ball of the foot and pulling the toe down.

NOTE if the practitioners thumb crosses the interphalangeal joint they are testing the extensor hallucis brevis as well.

Extensor Digitorum Longus (deep peroneal nerve) Origin- Upper three-fourths of the anterior surface of the fibula and interosseous membrane Insertion- Dorsal surface of the middle and distal phalanges of lateral four toes Action- Have the patient walk on their heals extending the toes Test- Have the patient seated on the edge of the table while dorsiflexing the toes. The practitioner will stabilize the foot near the calcaneus and with their other hand push the extended toes downward.

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inís inís

L5 – Toe Extensors

L4 – Tibialis Anterior Neurological level L4

Patellar Tendon Reflex- The patellar tendon reflex is a deep tendon reflex predominantly from L4 but some input from L2 and L3. To test the patellar tendon reflex have the patient sit on the edge of the examination table with the legs dangling. The infrapatellar tendon is stretched in this position and primed for being tested. Palpate the bottom of the boney patella and feel where the bone depresses into soft tissue and palpate the edges of the tendon and the tibial tuberosity. With a reflex hammer apply a sharp specific tap to the knee. If the reflex is difficult to obtain have the patient clasp their hands together and attempt to pull them apart while you tap the reflex point. This is a deep tendon reflex which is also a lower motor neuron reflex.

Sensation Testing- The L4 dermatome covers the medial side of the leg and extends to the medial side of the foot.

Muscle Test Tibialis Anterior Origin- Lateral condyle of the tibia, upper two thirds of the anterolateral surface of tibia, interosseus membrane Insertion- Medial and plantar surfaces of the medial cuneiform bone, base of the 1st metatarsal bone. Action- Dorsiflexion and inversion of the foot Test- The patient is supine, keeping the entire leg straight, dorsiflexes and inverts the foot (example; the right foot would point the toes and move the ankle toward the left shoulder). The practitioner applies force against the medial dorsal surface of the foot.

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L4 – Tibialis Anterior

L3 – Sartorius Sartorius Origin- anterior superior iliac spine (ASIS) Insertion- Upper part of the medial surface of the tibia, near the anterior border Action- Promotes support of the ilium from posterior misalignment, flexes knee and hip, gives medial support to the knee Test- The patient lies face up and placing the right ankle over the left knee and having the right knee fall to the table. This resembles a figure four position in the lower extremity. The practitioner supports the knee of the right leg and tractions forcefully from the right ankle sliding the bent leg down the left leg.

Nerve supply- femoral nerve L2, L3

Start Finish

L2, 3, 4 – Sartorius

L3-5 – Hamstrings Semitendinosis (Medial Hamstring) Origin- ischial tuberosity with the tendon of biceps Femoris Insertion- proximal portion of medial surface of the tibia and deep fascia of the leg Nerve Supply- tibial branch of the sciatic nerve L5, S1, S2

Semimembranosus (Medial Hamstring) Origin- upper and lateral aspect of the ischial tuberosity Insertion- posteromedial surface of the medial condyle of the tibia Nerve Supply- tibial branch of the sciatic nerve L5, S1, S2

Laserology® 54 of 91 33LLTT®® -- LLaasseerroollooggyy®® BBaassiicc Action of the medial hamstrings flexes and internally rotates the knee; extends, adducts, and internally rotates the thigh

Test- With the patient face down the lower leg is bent approximately 60 degrees with pressure being applied just proximal to the ankle; the pressure is applied to push the leg straight and slightly lateral to isolate the medial hamstring

Biceps Femoris (lateral hamstring)

Origin- Long head- ischial tuberosity and sacrotuberous ligament Short head lateral lip of the linea aspera and lateral supracondyle of the femur Insertion- lateral side of the head of the fibula and the lateral condyle of the tibia Nerve supply- Long head tibial branch of the sciatic nerve S1, S2 Short head peroneal branch of the sciatic nerve L5, S1, and S2 Test- With the patient face down the lower leg is bent approximately 60 degrees with pressure being applied just proximal to the ankle; the pressure is applied to push the leg straight and slightly medial to isolate the lateral hamstring

Hamstring as a group

Test- With the patient face down the lower leg is bent approximately 60 degrees with pressure being applied just proximal to the ankle; the pressure is applied to push the leg straight down with no deviation in pressure to test the group.

Anterior aspect of the lumbar spine is best performed with the patient lying on there back with their knees bent. The umbilicus lies at the level of L3/L4 disc space. This is also the area that the aorta divides into the common iliac arteries. • The sacral promontory lies at L5/S1 and can be palpated with some difficulty with the patients legs bent. Increase pressure gradually while the patient relaxes the abdominal muscles (linea alba) and the practitioner can palpate the sacral promontory. • The pubic bone is commonly involved in pelvic instability and will be sore upon palpation. If the practitioner looks at leg length the short leg will have the pelvis on that side rotate posterior and possibly causing the pubic bone to subluxate superiorly. On the long leg side the opposite would be true. The pubic bone is a major area of anatomical stability and the site of many muscle attachments. Subluxation of pubic bone can affect every muscle test performed for the low back and pelvis. Muscles evaluated for the low back patient can be performed on their back, face up.

L4, 5, S1, 2, 3 – Hamstrings

L3-5 – Hamstrings

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Test by having patient flex hip and knee to 90º Doctor places hand on patient’s ankle and stabilizes knee Instruct patient to resist Doctor attempts to straighten patients knee

L2-4 – Quadriceps Group The quadriceps group is made up of the Vastus Intermedius, Vastus Medialis, Vastus Lateralis and Rectus Femoris. The rectus femoris will be discussed separately due to the convenience of an isolated muscle test. The prior three will be tested as a group.

Test (as a group) – With the patient lying face up have the patient bend the knee and the hip 90 degrees. The practitioner will stabilize this position to ensure no rotation by placing the stabilization hand proximal to the knee and the testing hand proximal to the ankle. The practitioner then places force straight down to approximate the heel to the buttock.

Vastus Intermedialis Origin- Proximal 2/3 of the antero-lateral surface of the femur in conjunction with the lateral supracondylar line and the lower half of the linea aspera. Insertion- tibial tubercle and the upper border of the patella via the ligamentum patellae Action- Leg extension

Vastus Medialis Origin- The lower half of the intertrochanteric line, medial supracondylar line, and the linea aspera. Insertion- Medial border of the patella with the ligamentum patellae extending to the tibial tubercle Action- Leg extension and stabilizes the medial patella.

Vastus Lateralis Origin- Greater trochanter, gluteal tuberosity, linea aspera, intertrochanteric line, and hip joint capsule Insertion- Lateral border of the patella with the ligamentum patella connecting to the tibial tubercle Action- Leg extension

Nerve Supply of the quadriceps group is L2, L3, and L4

Start

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L2, 3, 4 – Quadriceps

L2 – Quadriceps Test by having patient flex hip and knee to 90º Doctor places hand on patient’s ankle and stabilizes knee Instruct patient to resist Doctor attempts to approximate the patient’s ankle and buttocks

L1 – Iliopsoas (Rectus Femoris) The iliopsoas is made up of the iliacus and the psoas muscle and come together at the inguinal ligament to form the iliopsoas muscle. The Rectus Femoris is part of the quadriceps group and is the only muscle of this group the crosses the anterior hip joint. Origin- Straight head- anterior inferior iliac spine Reflected head- groove of the acetabulum Insertion- tibial tubercle and the upper border of the patella via the ligamentum patellae Action- extends the leg and flexes the thigh Test- Have the patient flex the knee and hip to 90 degrees. The practitioner places their hand just proximal to the knee and exerts a force to place the leg in extension making sure there is no rotation of the foot, knee, or thigh. The psoas is very active while doing this test and needs to be evaluated separately to make a comparison to the rectus Femoris. Nerve Supply- femoral nerve L2, L3, L4 / with the involvement of the (ilio)psoas there is L1 involvement

Start

T12, L1, 2, 3 – Iliopsoas

L1 – Iliopsoas Test by having patient flex hip and knee to 90º Doctor places hand on patient’s knee Instruct patient to resist Doctor increases caudal pressure gradually on knee

L1-L3 Psoas Origin- originates from the transverse processes of T12-L5 and the associated vertebral discs Insertion- the lesser trochanter of the femur with the iliacus Action- This is the main hip flexor. It also gives minimal action in external rotation and adduction of the thigh.

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Test- With the patient laying on their back lift the leg up and out at approximately 45 degrees with external rotation of the foot. The practitioner places force on the lower leg at an appropriate area of leverage and stabilizes the pelvis on the opposite side being tested. Place the force down in out in the direction of the extended leg. Nerve supply- lumbar plexusT12, L1, L2, L3, (L4)

Start Finish

Exam 6. Check Muscle Strength 1° Stabilizers Face Down Gluteus Maximus Origin- Posterior gluteal line of the ilium, tendon of the sacrospinalis, dorsal surface of the sacrum and coccyx and sacrotuberus ligament Insertion- Gluteal tuberosity of the femur and the iliotibial tract of the tensor fascia lata Action- Extends the hip and assists in externally rotating the thigh Test- With the patient prone flex the knee to 90 degrees and have the patient lift the leg in the air as high as they can without any rotation. The practitioner places their hand on the back of the hamstring muscle near the knee and increases pressure straight down. Nerve supply- Inferior Gluteal Nerve L5/S1/S2

Start Finish

Piriformis Origin- Anterior surface of the sacral foramen and the capsule of the sacroiliac articulation Insertion- Superior birder of the greater trochanter of the femur Action- rotates the thigh externally and abducts the thigh when the leg is flexed Test- Sitting the patients knee is flexed to a 90 degree position; the practitioner positions themselves lateral on the side of the leg being tested positioning one hand stabilizing the knee and the other hand on the inside of the ankle. With the hand on the inside of the ankle pull out. This muscle can be tested prone and supine as well with the same force being applied to the leg. The piriformis muscle is a major muscle involved in with sciatica, sacral stability and low back pain. Nerve supply- sacral plexus S1/S2

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Start Finish

Iliacus Origin- The iliacus is located on the internal aspect of the hip bone on the upper two thirds of the iliac fossa, internal border of the iliac crest; anterior sacroiliac, lumbosacral and Iliolumbar ligaments Insertion- the lesser trochanter of the femur with the psoas Action- with the psoas (Iliopsoas) is the primary hip flexor Test- The test is the same as the test for the psoas except that the leg is taken up and out much further. This may be difficult to test on those with a low back condition. An alternate test for the iliacus is similar to the piriformis test if the patient is lying on their back and bends the knee at 90 degrees. The practitioner will stabilize the knee and placing the other hand just above the ankle Nerve Supply- Femoral nerve L1, L2, L3

Start Finish

Phase II

Stabilization Exam 1. Stabilization of 2° Movers (face up)

Tensor Fascia Lata Testing

Testing – Hip joint is flexed and abducted about 20º with moderate medial rotation(pronation), and the knee maintained in maximal extension. One of the practitioner’s hands stabilizes the contralateral distal leg, and the other holds under the distal end of the leg with the resisted force toward adduction and extension.

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Start Finish

Quadratus Lumborum Origin- Iliolumbar ligament, posterior part of the iliac crest Insertion- Inferior border of the last rib and the transverse processes of L1-L4 Action- laterally flexes the lumbar spine and helps with inspiration of the diaphragm and depressing the last rib Test- Patient is supine and is instructed to hold onto the sides of the table keeping the upper body stationary while laterally flexing the straightened legs.

Start Left Finish Left

Start Right Finish Right

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Nerve supply- Superior gluteal nerve L4, L5, and S1

Test d Test e Test f

Sacrospinalis group (aka Paraspinal Muscles)- composed of three layers of muscles of which only the superficial layer composed of the spinalis, longissimus, and the iliocostalis. These as a group are referred to as the sacrospinalis group. Origin- deep muscles arising from the sacrum, iliac crest, spinous processes, transverse processes and ribs Insertion- ribs, spinous processes, transverse processes and the occiput Test- There is a considerable amount overlap between muscle function. Having the patient face down, arms to their sides, the practitioner must stabilize the pelvis while the patient lifts their left shoulder as far off the table extending their head up and to the left. The practitioner while stabilizing the pelvis will try to force the shoulder back to the table. Repeat on the opposite side.

Right Start Right Finish

Exam 2. Myofascial Release-Using the Erchonia Laser • Have patient hold breath and stretch • Have patient exhale and stretch • PNF Stretching

Hamstrings Origin- Medial-hamstrings: tuberosity of the ishium. Origin- Lateral hamstrings: the long head attaches to the sacrotuberous ligament and tuberosity of the ischium; the short head attaches on the lateral lip of lineas aspera, proximal two- thirds of the supracondyle line, and lateral intermuscular septum. Insertion- Semitendinosus: proximal medial tibia and deep fascia of the lateral leg membranosus: medial condyle of the tibia, and deep fascia of the lateral leg

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Gastronemius

Origin-Medial proximal and posterior part of medial condyle and adjacent part of femur, capsule of knee joint. Origin-Lateral Lateral condyle and posterior surface of femur, capsule of knee joint. Insertion- Middle part of posterior surface of calcaneus.

Exam 3. Myofascial release standing and while marching in place Standing Front Back

Marching in place

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Exam 4. Adjusting while standing and marching in place.

Standing Front Standing Back

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Phase III

Introduction to Roller Attachment

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Review Low Back and Pelvis 1. Check range of motion, lumbar spine, straight leg raise and leg abduction bilaterally 2. Check myotomes L1 –S1 3. Check muscle strength 4. Myofascial release

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E. TMJ Phase 1 Examination-

b) Jaw Active ROM c) Palpation - crepitus = popping / clicking d) Three finger test

Phase 2 Stabilization & Muscle Response Testing (MRT)

1.) MRT through TMJ ROM

1. Jaw Open 2. Bite / Clench 3. Protrude

4. Retract 5.. Deviation Right 7. Deviation Left

7. Chew on R/L side of tongue (proprioception)

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Treatment - FZ 4, 9, 33, 60

1.) Laser Left TMJ for Thirty (30) seconds with slow purposeful movements.

2.) Laser Right TMJ for Thirty (30) seconds with slow purposeful movements.

3.) Laser suprahyoid muscles for thirty (30) seconds with slow purposeful movements.

4.) Laser anterior mandible for thirty (30) seconds with slow, purposeful movements.

5.) Percuss TMJ / Occiput.

6.) Dural Release a. Dr. contacts with laser the most restricted spinal area (Laser contact is a pivot point)

b. Patient puts head into extension, externally rotates shoulders and retracts mandible

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Phase III

Percussion of the TMJ

Adjusting TMJ Mouth Closed

Adjusting TMJ Mouth Opened

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Advanced TMJ Treatment-

1) Evaluate with MRT coupled with physical stress 2) Evaluate with MRT coupled with emotional stress 3) Combine steps one and two

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Patient Name:______SS#______

DOB: ______/______/______SEX: M / F Heigth:______Weight:______

Section 1 Neck Exam Date: ______/______/______Exam 1: Check ROM and Muscle strength of Cervical Spine Exam 2. Check Intrinsic Muscle Strength of Cervical Spine Movement Normal ROM Normal M/S Initial Comp Laser Initial Comp Laser ROM ROM ROM M/S M/S M/S Flexion 60º 5 Extension 60º 5

Lateral flexion 45º 5

Rotation 80º 5 Exam 3: Check Ms Strength Exam 4:MRT(Muscle Response Testing) thruROM of C/S Movement Normal Initial Comp Laser Movement Normal Initial Comp Laser M/S M/S M/S M/S M/S M/S M/S M/S Levator 5 MRT through 5 Scapulae C/S ROM Neck Flexors 5 Physically 5 Stress SCM 5 Emotional 5 Stress Scalenrs 5 Combine Steps 5 1, 2 & 3 Neck Extensors 5 Exam 5:(MFR) MyoFacial Release: Supine 1 Movement Trapezius Origin-Upper Insertion- Origin- Insertion- Origin-Lower Insertion- Upper Middle Middle Lower Initial ROM

Comp ROM

Laser ROM

5:(MFR) MyoFacial Release: Supine 2 and Supine 3 Movement SCM & Origin Insertion Levator Origin Insertion Scalenes Scapulae Initial ROM Comp ROM *Post Laser ROM Section 2 Shoulder Exam 1: Check ROM Shoulder Exam 2. Check Myotomes C5 thru T1(reset) Movement Normal Initial Comp Laser Movement Normal Initial Comp Laser ROM ROM ROM ROM M/S M/S M/S M/S Abduction 180º Deltoid 5 Adduction 45º Bicep 5 Flexion 90º Tricep 5 Extension 45º Finger Flexors 5

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Exam 3: Check Muscle Strength of Rotator Cuff and Posterior Deltoid Exam 4: MFR (Myofascial Release) Shoulder Girdle Movement Posterior Infra Subscapularis Teres Supra Pectoralis Latissimus Rhomboid Teres Deltoid spinatus Minor Spinatus Dors Minor Normal M/S 5 5 5 5 5 5 5 5 5 Initial M/S

Comp M/S Laser M/S

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Basic Cranial Nerve Testing Neurological Test Laser Stimulation 4, 9, 33, 60 CNI-Olfactory Inhalation of known substances while eyes shut; i.e. coffee and The sense of smell cinnamon The cribriform plate CNII-Optic Eye Chart Occipital Lobe The sense of vision CNIII-Occulomotor Visual accommodation-ask patient Frontal Lobes to focus on finger 5 inches in front The ability of Focus of face; then focus at a distant object, and then back to your finger CNIII, IV,VI-Occulomotor, Test eyes in all directions Frontal Lobes Up, down, left, right, up and right, Trochlear, and Abducts up and left, down and right, down Movement of the eyes and left CN V-Trigeminal 1. Swipe bilaterally the forehead, Foramen Rotundum and cheeks, and chin for the 1. Sensation to the face sensation of the face Ovale 2. Motor to muscles of 2. Jaw jerk reflex for muscles of Superior Orbital Fissure mastication tap on the chin mastication while mouth is slightly open

CN VII-Facial Having patient squint, smile, and Stylomastoid Foramen raise their eyebrows Innervates all facial muscles CN VIII-Vestibulocochlear 1. Snap fingers over right and the Auditory Meatus left ear 1. The sense of hearing 2. Position head in flexion, 2. The sense of balance extension, right and left lateral flexion

CN IX,X- Ask the patient to swallow, Jugular Foramen Glossopharyngeal, Vagus tickle roof of mouth and say Ahh! Innervates the palate, tongue, throat, and most organs in the body CN XI-Spinal Accessory Ask patient to flex head forward Upper cervical area and back, then rotate head to the Innervates the SCM and right and left, and shrug shoulders Trapezius CN XII-Hypoglossal Ask patient to protrude tongue, Hypoglossal Foramen straight out, then out to the right Tongue protrusion and left and ramus of the jaw

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Cranial Nerve I (Olfactory Nerve) This test is rarely tested in traditional practice; however, smell is one of the most powerful senses related to memories and therefore very important to check for the holistic practitioner. Aromatherapy is an entire healing art itself and is based upon this pathway.

PERFORMING OF THE TEST Simple: Coffee is the traditional scent of choice. Have the patient close their eyes and hold the object used for testing at a comfortable distance. Test the nostrils separately and then together.

Formal: For those who have lost their sense of smell and or taste utilizing the technique of Muscle Response Testing and the Erchonia Laser will identify and correct functional weaknesses. Perform as above; however, challenging the patient to as many scents is beneficial. Upon each positive test the practitioner will then laser over the bridge of the nose of the patient for 60 seconds utilizing the frequencies of 4, 9, 33, and 60.

WHAT IT MEANS CLINICALLY • The patient is able to identify smells appropriately; NORMAL • Positive responses to scents utilizing Muscle Response Testing; FUNCTIONAL WEAKNESS • The patient is unable to identify smells; ANOSMIA (unilateral loss of smell is unilateral anosmia)

NOTE: Damage or irritation to the uncus may produce phantom smells. Ammonia can be recognized by the nasal epithelium and does not require an intact olfactory nerve.

Cranial Nerve II (Optic Nerve) The optic nerve is primarily evaluated by the practitioner using an ophthalmoscope for the evaluation of the; • Optic disc • Blood vessels • Retinal background

This is outside of the neurological scope of this class.

The optic nerve is formed by the axons of retinal ganglion cells and is considered an extension of the brain for two main reasons. First, it is surrounded by myelin from the oligodendrocytes and second, it is an embryological derivative of the diverticulum of the forebrain. Due to these reasons, patches of demyelination along the course of the optic nerve are seen in multiple sclerosis. Visual information from the temporal and nasal halves of the corresponding retina, as well as impulses concerned with pupillary light and accommodation reflexes are carried by the optic nerve. Fibers of the optic nerve leave the retina medial to the fovea centralis and converge

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on the optic disc, piercing the choroid layer, sclera, and entering the orbit. In the orbit, it is crossed by the ophthalmic artery. Then, it leaves the orbit and gains access to the cranial cavity through the optic canal. Posterior to the optic canal, the nasal fibers decussate to form the optic chiasma. In the cranial cavity, the internal carotid artery lies laterally to the optic nerve, and ventral to the anterior cerebral artery.

Visual acuity may be assessed by using the Snellen eye chart, positioned approximately 20 feet from the patient. Each eye is tested separately and the first number in the standard ratio 20/20 denotes the actual distance of the patient from the chart, while the second number represents the distance at which a person with normal vision can read the chart. Visual acuity of each eye, which reflects the macular function, should be tested independently with and without glasses.

Swinging light test is performed to detect the differences between both eyes in response to afferent stimuli. In this test the patient is asked to look at a distant object while the examiner rapidly swings a light beam from one eye to the other. When directing the light into the blind eye, neither eye will show constriction. However, upon moving the light back to the intact eye, the blind eye shows apparent pupillary dilatation due to the lack of afferents to the retina and optic nerve.

Cranial Nerve III (Oculomotor), Cranial Nerve IV (Trochlear) and Cranial Nerve VI (Abducens) The eyes have a profound effect on the body as a whole. Physically the eyes have a significant effect on balance and awareness of space. Emotionally the eyes are related to the limbic system by embryological development. The limbic system and the visual system are made from neuroectoderm and therefore explain how the eyes are “The window to the soul”.

Eye movements can be divided into four types; • Convergence- the eye movements that maintain fixation as an object is brought close to the face. The site of control is located in the midbrain. • Pursuit eye movements- This is a slow eye movement used to maintain fixation on a moving object such as a person walking across the room. The site of control is located in the occipital lobe. • Vestibular-positional eye movements- This eye movement is utilized when the head is in motion and it is necessary to maintain fixation. The site of control is located in the cerebellar vestibular nuclei. This is especially useful when using Muscle Response Testing. Have the patient seated (to start) and focus on a very specific point. Then instruct the patient to maintain focus on the specific point while turning their head to the left and the right while testing a previously strong muscle. Allow the patient to practice a few times prior to using the muscle test. • Saccadic eye movements- This eye movement is described as rapid movement from one point of fixation to another. Open skilled athletic events such as a quarterback locating a receiver during a football game. The site of control is located in the frontal lobe.

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Cranial Nerve III (Oculomotor) controls the four mentioned muscles. The oculomotor nerve divides into the superior ramus and the inferior ramus which innervate specific muscles.

• Inferior Rectus (Inferior Ramus) • Medial Rectus (Inferior Ramus) • Superior Rectus (Superior Ramus) • Inferior Oblique (Inferior Ramus)

Oculomotor palsy is characterized by ipsilateral:

• Ptosis is the drooping of the upper eyelid due to paralysis of the levator palpebrae superior. (This deficit may be distinguished from the ptosis observed in Horner’s syndrome due to the ptosis (in Horner’s Syndrome) is less pronounced and occurs as a result of paralysis of the superior tarsal muscle. • Mydriasis (dilatation of the pupil) is due to paralysis of the constrictor pupillae muscle and the unopposed action of the dilator pupillae muscle. • Diplopia (double vision) is seen in all directions except in lateral gaze and the distance between true and false images is maximal in the direction of the gaze. The false image will always be peripheral to the true image. • Lateral strabismus (lateral deviation) and downward deviation of the eye is due to activation of unopposed lateral rectus and the superior oblique muscles.

• Enophthalmos (inward displacement of the eye) • Loss of pupillary and accommodation reflexes. The integrity of the oculomotor nerve can be checked by observing the light reflex and eye movement.

To test the light reflex, the patient is asked to focus on a specific target at a distance, while the examiner shines a bright light into one eye of the patient. The examiner then observes the pupils in both eyes (direct and consensual light reflexes). In normal individuals both pupils will constrict in response to the light applied to one eye. In lesions of the oculomotor nerve, the affected eye remains unreactive regardless of which eye is stimulated. Both the optic and oculomotor nerves mediate the accommodation reflex. NOTE: When shining the light in the patient’s eye that in many cases the pupil may DILATE instead of the proper response constriction. This is due to a hyper-sympathetic response to over reactive adrenal glands to the mild stress of light. This needs to be treated nutritionally in relation to the adrenal gland response.

The functional integrity of Cranial Nerve III is easily tested by the practitioner having the patient follow the “H” configuration.

Cranial Nerve IV (Trochlear) controls: • Superior Oblique

Trochlear nerve palsy is characterized by impairment of downward gaze of the adducted eye. The eye on the affected side remains elevated and assumes a higher position in the adducted

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position and the elevation decreases with abduction. Elevation of the eye on the affected side assumes maximal position when the neck is bent toward the affected side, maintaining normal position upon bending of the neck toward the intact side (Bielschowsky's head-tilt test). The patient may adopt a characteristic posture, tilting the head toward the opposite side so that the face will be directed toward the affected side (Bielschowsky sign). (Pictures pg 232 of Neuro of clinical neurology)

Cranial Nerve VI (Abducens) • Lateral Rectus

The abducens nerve is more prone to injury than any other cranial nerve due to its long intracranial course and sharp bend over the petrous temporal bone. This nerve may be damaged due to trauma to the cavernous sinus thrombosis, fracture of the superior orbital fissure, and aneurysm of the internal carotid artery. Proximity of the abducens nerve to the internal carotid artery may account for the initial signs of abducens nerve palsy in individuals with an aneurysm of the internal carotid artery. Abducens nerve palsy is characterized by a medial strabismus (convergent squint), in which the patient is unable to direct both eyes toward the same object. This occurs due to paralysis of the lateral rectus muscle.

Many of the medical pathologies are not necessary in order to detect dysfunction to these cranial nerves. While evaluating the above diagnostic criteria the practitioner will utilize Muscle Response Testing to detect a functional weakness. This same technique can be used if the patient does have the pathological condition. The practitioner will program the PL5000 with 4, 9, 33, and 60 and laser over the appropriate area described above for 60-120 seconds and recheck.

Cranial Nerve V (Trigeminal) The trigeminal nerve is the largest of all the cranial nerves. The trigeminal nerve gives off the ophthalmic, maxillary and mandibular divisions.

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The ophthalmic nerve (V1) reaches the orbit through the superior orbital fissure. It supplies the frontal and ethmoidal sinuses, eyeball, the nasal cavity, upper eyelid, the skin of the forehead region and scalp as far as the lambdoid suture and the dura of the anterior cranial fossa. This division has frontal, nasociliary, and lacrimal branches. The frontal nerve provides sensory fibers to the forehead, upper eyelid, and scalp via its supratrochlear and supraorbital branches. The lacrimal nerve also transmits postsynaptic parasympathetic fibers to the lacrimal gland. The nasociliary branch of the ophthalmic nerve gives rise to sensory fibers to the lateral nose and the eyeball. It also carries presynaptic parasympathetic fibers that eventually run the constrictor pupillae muscle.

The ophthalmic nerve mediates both corneal and lacrimal reflexes. The corneal reflex is a somatic reflex which is elicited by a light touch of the cornea with a wisp of cotton, as the patient looks to the opposite side. As a result, contraction of the orbicularis oculi muscles and subsequently blinking in both eyes is produced.

The maxillary nerve (V2) provides sensory fibers to the following areas: • Skin overlying the maxilla, upper lip, lower eyelid and side of the nose

• Molar and premolar maxillary teeth and maxillary sinuses

• Meningeal branches to the dura of the middle cranial fossa.

• Mucosa of the palate via the greater and lesser palatine branches.

• Nasal branches to the nasal cavity and nasopharynx.

• Temporal region

• The nasal branches form the afferent limb of the nasal (sneeze) reflex, which is performed by contraction of the muscles of the soft palate, pharynx and larynx, diaphragm and intercostal muscles in response to irritation of the nasal mucosa.

The mandibular nerve (V3) has sensory and a motor component. The mandibular branch is sensory to the mandibular teeth, floor of the mouth, anterior two-thirds of the tongue skin of the jaw and chin. The motor division innervates the muscles of mastication. The anterior trunk of the mandibular nerve gives rise to nerves that supply the temporalis, lateral and medial pterygoid, masseter, tensor tympani, and tensor palatini muscles. The buccal nerve is the only sensory branch of the anterior trunk which supplies the skin and mucosa of the cheek.

EXAMINATION AND TREATMENT All of the tests will be performed with Muscle Response Testing. When a test is positive the practitioner will treat over the tested area with the standard head set at the brain frequencies (also set on the preset head) of 4 Hz, 9 Hz, 33 Hz and 60 Hz. The laser will be placed on a bilateral area such as the left and right TMJ or over the area being tested and/or the brain stem, cerebellum or cortex as which ever negates the neurological indicator for 60-120 seconds. Since the jaw joint is somewhat covered by Cranial Nerve V the practitioner may include the TMJ protocol in clinical practice.

Motor Testing • Have the patient clinch their teeth

• Have the patient open their mouth against resistance

WHAT IT MEANS- Muscle wasting of the Masseter and Temporalis is rare even with pathology such as MS. Test will indicate neurological dysfunction with structural misalignments.

Sensory Testing

Laserology® 77 of 91 33LLTT®® -- LLaasseerroollooggyy®® BBaassiicc • Test each of the sensory divisions for light touch and pin prick comparing one side to the other (V1 forehead, V2 cheek, V3 lower jaw)

• The practitioner can challenge sensory testing using vibration, temperature (hot and cold) and electro-magnetics utilizing north and south side of magnets.

WHAT IT MEANS -- If the test is positive only using MRT then it is a dysfunctional finding; if positive without using MRT pathological assessment is possible.

Positive finding of light touch only indicates; • Ipsilateral loss indicates contralateral parietal lobe involvement

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Trigeminal Neuralgia The most common disorder to involve trigeminal sensory function is trigeminal neuralgia or tic douloureux (Fothergill’s neuralgia). Trigeminal neuralgia causes excruciating facial pain usually involving the 2nd and 3rd divisions, unilaterally, (rarely the first) of CN V. Patients describe a trigger zone that is involved in nerve distribution provoking the lancinating pain. It may be brought on by chewing, talking, brushing teeth, shaving, exposure to temperature changes and wind. Trigeminal Neuralgia generally affects those 50+ years old. A complete history of facial trauma, emotional stress, and structural evaluation commonly uncovers underlying factors causing the condition. Resolution may be rapid or at times in extended and slow to recover. Injury to the trigeminal nerve or its branches may occur as a result of a tumor of the pontocerebellar angle, otitis media, herpes zoster/infection, cavernous sinus thrombosis, fractures involving the middle cranial fossa, or metastatic carcinomas. In particular, the ophthalmic nerve may be damaged as it courses within the superior orbital fissure in conjunction with the oculomotor, trochlear, and abducens nerves. It may also be injured in orbital apex syndrome together with the optic, oculomotor, trochlear, and abducens nerves. A fracture confined to the ramus of the mandible may put the mandibular nerve out of function. Traditional medicine considers sensory compression commonly caused by the anterior inferior cerebellar artery and anterior superior cerebellar artery. Destruction of the trigeminal nerve produces combined sensory and motor, as well as reflex disorders. These dysfunctions include unilateral anesthesia in the area of distribution of the trigeminal nerve, loss of corneal reflex on both sides when the affected eye is stimulated, and also atrophy of the muscles of mastication, tensor tympani, and tensor palatine muscles. Additional deficits include loss of sensation from the facial region, oral and nasal cavities, and the anterior two thirds of the tongue. Sensations from the temporomandibular joint, paranasal sinuses, and anterior part of the external acoustic meatus may also be lost. The jaw-jerk, oculocardiac (a reflex that mediates slowing of heart rate upon compression of the eyeball), sneezing, and lacrimation reflexes are impaired. Impairment of the post-synaptic parasympathetic innervation to the head region may also be noticed. Projected pain to the area of distribution of branches of the trigeminal nerve is common. For example, pain from carious tooth and ulcer of the tongue may produce pain that is felt in the ear and temporal region that corresponds to the area of distribution of the auriculotemporal nerve. Multiple sclerosis may produce trigeminal neuralgia and transient facial anesthesia in young adults. It is uncommon that a patient present with bilateral involvement of the condition but is more susceptible to be seen in Multiple Sclerosis patients. It is usually caused by a demyelinating lesion involving the trigeminal nerve root entry into the pons.

NOTE: In all cases of Trigeminal Neuralgia the Erchonia Laser may provide major benefits. The laser decreases inflammation, promotes neurological functional restoration, allows frequency variables to underlying causes, and is non-invasive to this hypersensitive condition.

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Reflex Testing • Jaw jerk reflex- Ask the patient to relax the mouth and hang open slightly. Place your thumb on the chin and strike appropriately with a reflex hammer. • Corneal Reflex- Ask the patient to look up and away from the practitioner and bring a piece of cotton wool twisted to a point to touch the cornea (the colored part of the eye) from the side. Common mistakes are touching the white part of the eye instead of the cornea and bringing the wool in to quickly and creating a blinking stimulus. • Lacrimal reflex- is mediated by the ophthalmic nerve (afferent limb), which conveys the signals to the (superior salivatory nucleus in the reticular formation of the) pons. Postsynaptic parasympathetic fibers to the lacrimal gland via the zygomaticotemporal branch of the maxillary and the lacrimal branches of the ophthalmic nerve. NOTE: There is no challenge for this reflex; however, if a person has an improper working tear gland it may be useful in leading the practitioner to evaluate Cranial Nerve V.

WHAT IT MEANS- Failure to elicit the jaw jerk reflex may indicate a pontine lesion involving the trigeminal nerve and a hyper-active reflex may involve damage of the corticobulbar tract.

The corneal reflex is due to afferent nerves from the ophthalmic branch of Cranial Nerve V and the efferent nerves from Cranial Nerve VII. Following corneal stimulation contraction of the orbicularis oculi muscles and subsequently blinking in both eyes is produced. • Failure of either side of the face to contract = VI involvement • Failure of only one side of the face to contract = CN VII

Cranial Nerve VII (Facial Nerve) Cranial nerve VII has nerve innervation associated with the face, ear, taste and tear. • Face- muscles of facial expression • Ear- stapedius muscle • Taste- the anterior 2/3 of the tongue • Tear- parasympathetic supply to the lacrimal glands

EXAMINATION AND TREATMENT All of the tests will be performed with Muscle Response Testing. When a test is positive the practitioner will treat over the tested area with the standard head set at the brain frequencies (also set on the preset head) of 4 Hz, 9 Hz, 33 Hz and 60 Hz. The laser will be placed over the area being tested and/or the brain stem, cerebellum or cortex as which ever negates the neurological indicator for 60-120 seconds.

Motor Testing

The facial nerve innervates muscles of facial expression. Have the patient go through a series of expressions while using MRT. Have the patient squint, frown, lift eye brows, puff out their cheeks, pucker their lips, wrinkle their nose etc.

The stapedius muscle increases hearing threshold. This is muscle contacts to LOUD stimuli.

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Cranial nerve VII provides innervation to the mylohyoid, stylohyoid and posterior belly of the digastric (elevation of the hyoid bone). The practitioner may challenge the hyoid bone in specific directions.

Reflex Testing

Corneal Reflex- (As with cranial nerve V) Ask the patient to look up and away from the practitioner and bring a piece of cotton wool twisted to a point to touch the cornea (the colored part of the eye) from the side. Common mistakes are touching the white part of the eye instead of the cornea and bringing the wool in to quickly and creating a blinking stimulus. The corneal reflex is due to afferent nerves from the ophthalmic branch of Cranial Nerve V and the efferent nerves from Cranial Nerve VII. Following corneal stimulation contraction of the orbicularis oculi muscles and subsequently blinking in both eyes is produced. • Failure of either side of the face to contract = VI involvement • Failure of only one side of the face to contract = CN VII

Glabellar Reflex- exhibits contraction of the orbicularis oculi muscle which is elicited by repetitive finger taps on the forehead and supraorbital margin in a downward direction to the glabella.

Sensory Testing

Cranial nerve VII has sensory innervation to the anterior two thirds of the tongue for taste. This may not be convenient to challenge in the standard office setting, however, if the patient has numerous findings associated with cranial nerve VII it would be advantageous to test with a variety of stimuli and then use MRT.

Bell’s Palsy

Cranial Nerve VIII (Vestibulocochlear Nerve) There are two components called the auditory (cochlear) and vestibular. The auditory apparatus consists of the external, middle, and inner ear.

The external ear (aka the auricle) is innervated by the motor portion of the facial nerve and receives sensory innervation from the lesser occipital, facial, auriculotemporal, greater auricular and vagus nerve.

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The middle ear consists of cavities within the temporal bone containing the ossicles known as the malleus, incus, and stapes. This portion of the ear transmits mechanical energy in the form of vibrational sound waves from the external environment to the inner ear.

The inner ear contains the receptors for the auditory and vestibular system which consists of an outer boney labyrinth and an inner membranous labyrinth. The boney labyrinth consists of the cochlea, vestibule, and semicircular canals. The membranous labyrinth forms the utricle and the saccule. The utricle responds to linear deceleration and acceleration and gravitational pull while the saccule is thought to be stimulated by vibration.

Auditory portion of the vestibulocochlear nerve is responsible for the hearing portion of the nerve. If nerve deafness is present it appears on the side of the lesion. This type of deafness may be accompanied by tinnitus and is distinguished from conduction deafness by Rinne and Weber tests. The standard way of testing the auditory portion of cranial nerve VIII is:

Test one ear at a time. Have the patient cover one ear with their hand and the practitioner will rub their fingers together or hold a ticking watch near the ear and gradually move the stimulus away from the ear being tested. Note the distance that the patient can no longer hear. Have the patient cover the opposite ear and reproduce the test. If there is a reduction in hearing in one of the ears then perform Rinne’s test and Weber’s test.

Rinne’s Test is performed by having the practitioner hold a 516 Hz tuning fork on the mastoid process (bone conduction) and when the patient can no longer hear it then the tuning fork is placed in front of the ear (air conduction). Because air conduction lasts longer than bone conduction, the sound is heard through the air louder and longer than the bone portion of the test (positive Rinne test). In conduction deafness the sound is perceived louder and longer through the bone than through the air (negative Rinne test). In neuronal deafness both air and bone are compromised, however, air conduction remains longer and louder than bone conduction.

Weber’s Test is performed by holding a 516 Hz tuning fork on the vertex of the head and asking the patient which ear is louder; the good ear or the impaired ear? The sound will lateralize to the impaired side.

To test the function of the acoustic portion of Cranial Nerve VIII using a series of medical tuning forks challenging the ear to specific tones while the practitioner performs Muscle Response Testing. When a positive is identified periodically ring the fork over the involved ear while using the Erchonia PL5000 into the involved ear canal at the frequency of 4, 9, 33, and 60 for 60-120 seconds. Repeat the process with individual and combinations of tuning forks.

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The Vestibular portion of Cranial Nerve VIII has a cochlear and vestibular component.

The cochlea consists of a boney shell, a central axis (modiolus) and a spiral lamina that protrudes into the auditory canal. The basilar membrane which contains the inner and outer hair cells and rods converts the mechanical energy created by sound waves to electro-chemical potential. High frequency activates the neuroepithelial hair cells in the basal turn of the cochlea. Low frequency activates the neuroepithelial hair cells in the apical turn of the cochlea.

The vestibular receptors are contained within the inner ear in the semicircular canals and the vestibule. These receptors convey input to the cerebellum and brain stem. Disruption or injury to these nerve pathways may lead to vertigo, ataxia, and nystagmus.

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Cranial Nerve IX (Glossopharyngeal Nerve)

EXAMINATION AND TREATMENT All of the tests will be performed with Muscle Response Testing when possible. When a test is positive the practitioner will treat over the tested area with the standard laser head set at the brain frequencies (also set on the preset head) of 4 Hz, 9 Hz, 33 Hz and 60 Hz. The laser will be placed over the area being tested, such as the throat when swallowing, and the brain stem, cerebellum or cortex as which ever negates the neurological indicator for 60-120 seconds.

The Glossopharyngeal nerve is involved with the following functions;

Autonomic Nervous System Parasympathetic involvement to the parotid gland

Motor Swallowing from the stylopharyngeus muscle

Sensory Posterior 1/3 of the tongue associated with taste

Retro-auricular area associated with pain, temperature, touch and general sensations

Pain, temperature, and sensations from the tongue, oropharynx, and palatine tonsils.

Reflex Baroreceptors and chemoreceptors involved with the carotid sinus reflex. The carotid sinus reflex is mediated by the afferent receptors of the glossopharyngeal nerve and the efferent limb of the vagus nerve. An increase in blood pressure will stimulate the carotid sinus and activate the neural mechanism that adjusts blood pressure to normal.

Baroreceptors and chemoreceptors involved with the carotid body reflex. The carotid body reflex is mediated by the afferent receptors of the glossopharyngeal nerve and the efferent limb of the vagus nerve. An increase in carbon dioxide in the blood will stimulate the carotid body and activate the neural mechanism that adjusts oxygen levels in the blood.

Oculocardiac Reflex – The oculocardiac reflex is a triad of bradycardia, nausea, and syncope. The ocular causes are numerous. Orbital causes also exist. The ophthalmic division of the trigeminal nerve is the afferent limb. The impulses pass through the reticular formation to the vagus nerve’s visceral motor nuclei. The efferent limb message is carried by the vagus nerve to the heart and stomach. The practitioner performs the reflex by using Muscle Response Testing and by gently placing light pressure on the closed eyes of the patient while the head is in moderate extension. A weakening of a previously strong muscle indicates appositive finding. Treatment with the PL5000 laser over the brainstem, heart and or stomach are the primary areas.

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Cranial Nerve X (Vagus Nerve)

The Vagus nerve is involved with the following functions;

Autonomic Nervous System The vagus nerve provides secretomotor sensations to the glandular tissue of the esophageal, bronchial, small intestine and right 2/3 of the large intestine.

Motor Swallowing and phonation (from the soft palate, pharyngeal and laryngeal muscles)

Motor to the intestinal wall

Sensory Taste

Cutaneous sensations associated with the outer ear

Chemoreceptors and pressure changes from the larynx, pharynx, bronchi, aortic arch, most of the digestive tract, the right 2/3 of the large intestine.

Cranial Nerve XI (Spinal Accessory Nerve)

Cranial Nerve XI has a cranial part which is derived from the ambiguous nucleus and a spinal portion that originates from the upper five spinal segments. The cranial portion joins Cranial Nerve X (Vagus) and innervates the muscles of the pharynx and larynx. The spinal portion forms the “Accessory” nerve which enters through the foramen magnum and exits the skull through the jugular foramen innervating the trapezius muscle and the sternocleidomastoid muscle.

Test the trapezius muscle by having the patient shrug their shoulders against resistance. (A more specific test for the upper trapezius muscle is to test the left upper trapezius having the patient seated, elevating the left shoulder, rotating the cervical spine slightly to the right (20 degrees) and gently looking up. The practitioner places one hand on the shoulder and the other on the head increasing force to try to separate the origin from insertion. The same is done for the opposite side.)

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Test the sternocleidomastoid muscles have the patient lying face up with arms extended to the side to prevent compensation. An example of testing the right SCM would be to have the patient rotate the head to the left and lift their head off of the table. The doctor would support the back of the patient’s head as to protect the patient from exacerbation of any sprain strain injury. The doctor then takes a palm contact on the superior lateral side of the head staying off of the TMJ and ear of the patient. The practitioner will then attempt to push the patients head toward the table.

Muscle response testing is used to identify function. Have the patient perform the shoulder shrug and rotate the head left and right while testing a strong muscle.

Treatment is performed by using the Erchonia PL5000 with the preset head (4 Hz, 9 Hz, 33 Hz, and 60 Hz) over the brainstem and the programmable head set at 9 Hz, 16Hz, 42 Hz, and 53 Hz over the muscle.

Cranial Nerve XII (Hypoglossal Nerve)

The hypoglossal nerve controls all intrinsic and extrinsic muscles of the tongue except the palatoglossus muscle which is innervated by the pharyngeal plexus. These muscles change the shape of the tongue and maintain movement.

A unilateral lesion of cranial nerve XII will produce ipsilateral atrophy of the lingual muscles and deviation of the tongue to the injured side during protrusion. Upon retraction of the tongue the injured side elevates.

Treatment consists of the practitioner utilizing Muscle Response Testing and challenging the tongue with specific actions such as; sticking out the tongue (protraction), retraction, tongue out to each side and curling of the tongue. Each time there is a positive test place the Erchonia PL5000 laser on the brainstem and under the fleshy part of the chin and program 4 Hz, 9 Hz, 33 Hz, and 60 Hz for 60-120 seconds.

Laserology® 86 of 91 33LLTT®® -- LLaasseerroollooggyy®® BBaassiicc Section 3 Low Back and Pelvis Exam 1. Check Range of Motion Lumbar Spine, Straight Leg Raise and Leg Abduction Bilaterally Exam 2. Check Myotomes L1 through S1 (reset) Myotome L1-3 L2-4 L3 L4,5 S1-3 L4 L5 S1 Muscle Iliopsoas Quadriceps Sartorius Hamstrings Tibialis Toe Extensors Peroneus L. Anterior & B. ROMNormal 90º 90º 90º 90º ROM Initial ROM Comp ROM Laser M/S Normal 5 5 5 5 5 5 5 M/S Initial M/S Comp M/S Laser Exam 3: Check Ms. Strength Movement Hip HipAbductors Tensor Psoas Iliacus Gluteus Piriformus Adductors Fascia Lata Maximus M/S 5 5 5 5 5 5 5 Normal M/S Initial M/S Comp M/S Laser Exam 4:MFR (Myofascial Release) Hamstrings Gastronemius Pectineus Adductor Adductor Adductor Psoas Piriformis Magnus Brevis Longus

Exam 5: Gait Anaylsis Gait Function Heel Foot Flat Toe Off Foot Foot Left Leg Cross Right Perform w/ opposite Strike Inversion Eversion Leg in Front&inBack Arm and Leg Check Reset w/ Laser

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Parasympathetic and Sympathetic Facilitation Utilizing the Erchonia Laser

The autonomic nervous system is made up of the sympathetic and parasympathetic systems and is under constant activity to provide the appropriate physiological adaptation throughout every system in the body. The majority of patients who walk into your office are stressed out creating sympathetic dominance and/or sympathetic exhaustion. It is impossible to have proper sympathetic and parasympathetic “tone” in the body if any disease process is present. It is beneficial to enhance the parasympathetic nervous system, especially in those that are extremely health compromised. Parasympathetic innervation drives the homeostatic systems such as digestion, immune enhancement and delivery of respiratory gases.

Neurologically the parasympathetic system is made up of cranial nerves III, VII, IX, and X; sacral parasympathetic nerves include S2-S4 and occasionally S1. Almost 75% of all parasympathetic nerve fibers are in cranial nerve X (the vagus nerve) which passes through the entire thoracic and abdominal region of the body.

Stimulate and test the Parasympathetic Nervous System by firing the appropriate neurology to CN III, CN VII, CN IX, and CN V (S2 – S4 is involved as well). Use MUSCLE RESPONSE TESTING when performing. Parasympathetic frequencies are to produce parasympathetic facilitation. This is also done by using the above entrance points and driving the neurological pathways that are under parasympathetic control. The brain balance frequencies may be used (over the specific area of the brain) as well.

1º 9 Hz 2º 20 Hz 3º 5000 Hz 4º 10,000 Hz

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Phase I - Examination

Light Reflex- This can be done to prioritize the dysfunctional eye as well as to facilitate the parasympathetic / sympathetic response.

Motor- Cover an eye; have the patient move the uncovered eye straight up, medial, and down and out; and determine which motion is involved.

Phase II - Treatment Treat the area of the brain or brainstem that negates the weakness while the patient repeatedly performs slow, purposeful eye motions that showed involvement; 4Hz, 9 Hz, 33 Hz and 60 Hz. The doctor may choose to treat with alpha, beta, delta, or theta waves depending on the specific area of the brain involved. The doctor may also need to use the parasympathetic frequencies or the sympathetic inhibition frequencies.

Facial Nerve - CN VII

Phase I - Examination

Glabellar Reflex- exhibits contraction of the orbicularis oculi muscle which is elicited by repetitive finger taps on the forehead and supraorbital margin in a downward direction to the glabella.

Motor Testing– the facial nerve innervates muscles of facial expression. Have the patient go through a series of expressions while using MRT. Have the patient squint, frown, lift eye brows, puff out their cheeks, pucker their lips, wrinkle their nose etc.

Hyoid bone anatomically associated with to the mylohyoid, stylohyoid and posterior belly of the digastric.

Sensory Testing - Cranial nerve VII has sensory innervation to the anterior two thirds of the tongue for taste. This may not be convenient to challenge in the standard office setting, however, if the patient has numerous findings associated with cranial nerve VII it would be advantageous to test with a variety of stimuli and then use MRT.

Phase II Treatment - Treat the area of the brain or brainstem that negates the weakness using 4 Hz, 9 Hz, 33 Hz and 60 Hz. The doctor may choose to treat with alpha, beta, delta, or theta waves depending on the specific area of the brain involved. The doctor may also need to use the parasympathetic frequencies or the sympathetic inhibition frequencies.

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Glossopharyngeal / Vagus Nerve – CN IX / X

Phase I - Examination

CN IX & CN X – Have the patient say “Ah”, swallow and tickle the top of their mouth with their tongue.

Ocular Cardiac Reflex – The doctor gently places pressure over the closed eyes of the patient creating a decrease in heart rate (parasympathetic response). Further modifications can be made such as instructing the patient to extend their head back may further stimulate a parasympathetic response.

Carotid Sinus Reflex- Apply appropriate pressure to the carotid sinus. Baroreceptors and chemoreceptors involved with the carotid sinus reflex. An increase in blood pressure will stimulate the carotid sinus and activate the neural mechanism that adjusts blood pressure to normal

Carotid Body Reflex- Apply appropriate pressure to the carotid body (have the patient hold their breath will increase the CO2 response). Baroreceptors and chemoreceptors are involved with the carotid body reflex. An increase in carbon dioxide in the blood will stimulate the carotid body and activate the neural mechanism that adjusts oxygen levels in the blood.

NOTE: Parotid glands are under parasympathetic supply and cannot be challenged directly.

S2 – S4 - These splanchnic nerves are inhibitory to the urethral sphincters and vasodilatory to the erectile tissue of the external genitalia. You may have the patient relax their urethra while performing MRT (only if their bladder is empty). Stimulation of external genitalia is not recommended.

Phase II - Treatment Perform MRT and treat the area of the brain or brainstem that negates the weakness using 4 Hz, 9 Hz, 33 Hz and 60 Hz. The doctor may choose to treat with alpha, beta, delta, or theta waves depending on the specific area of the brain involved. The doctor may also need to use the parasympathetic frequencies or the sympathetic inhibition frequencies.

Stimulate and test Sympathetic by firing the appropriate neurology to T1 – L2 and the organ entrance points Use MUSCLE RESPONSE TESTING when performing (Red / Violet Laser only). Sympathetic Inhibition frequencies are to produce calming. The practitioner can scan the visceral points and place the programmable head (#1) over the organ and the preprogrammed head (#2) over the nerve root to the organ. Laser for 30 seconds while the patients places a hand over their forehead. 1º 2.5 Hz 2º 7.83 Hz 3º 764 Hz 4º 10,000 Hz

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NERVE ROOT ENTRANCE POINTS; The practitioner will perform MRT while utilizing the red and violet laser over each spinal level (nerve root) individually of T1 – L2. The frequencies used will be 2.5, 7.83, 764, and 10000. The practitioner starts with a strong muscle and then places the red/violet laser over the T1 spinal nerve and retests the strong indicator muscle. If there is a weakness to the indicator muscle this identifies a sympathetic / parasympathetic imbalance. The practitioner will maintain the laser over the involved area for 15 seconds and retest the indicator muscle. A strengthening of a previously weak muscle identifies a correction toward resetting the sympathetic / parasympathetic balance at that particular nerve root. The practitioner will then move down one nerve root at a time making the correction as determined by Muscle Response Testing.

ORGAN ENTRANCE POINTS; The practitioner will perform MRT while utilizing the red and violet laser over each anatomical area of organs. Such as over the liver, gallbladder, right and left lung etc. using the frequencies of 2.5, 7.83, 764, and 10000. The practitioner starts with a strong muscle and then places the red/violet laser over the liver and retests the strong indicator muscle. If there is a weakness to the indicator muscle this identifies a sympathetic / parasympathetic imbalance. The practitioner will maintain the laser over the involved area for 15 seconds and retest the indicator muscle. A strengthening of a previously weak muscle identifies a correction toward resetting the sympathetic / parasympathetic balance at that particular organ. The practitioner will then progress through the organs of the body one at a time making the correction as determined by Muscle Response Testing.

Organ map to be tested; • Liver • Gallbladder • Rt. / Lt. Lung • Heart • Spleen • Pancreas • Stomach • Small Intestine • Large Intestine (ascending, transverse, descending colon) • Bladder • Prostate/ Uterus • Testes / Ovaries • Rt. / Lt. Kidney Adrenals • Thymus • Thyroid

NOTE: The doctor may choose to treat with alpha, beta, delta, or theta waves depending on the specific area of the brain involved. The doctor may also need to use the parasympathetic frequencies.

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