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Analysis and Correction of Locomotor Dysfunction as It Applies to Autonomic

Nervous System Dysregulation

Lab

Lino Cedros ATC, MT, CAMTC

Neal O’Neal PT

Test leg for loss of femur internal rotation – Mechanical or Chapman’s

Obturator internus

Piriformis

Quadratus Laborum

Illiopsoas

Test groin glands for pelvic congestion

GG-The lowest 2/5ths of the Sartorius muscle and its tendinous attachment on the

tibia and just above the inner condyle of the femur.

Chapmans drainage - Rectum and Hemorrhoids

R-Lesser trochanter of the femur downward.

H-Just medial and above the tuber ischii.

Indicates congestion of the glands draining the rectal walls and tissues – in the rectum just below the sigmoid flexure

Deep rotatory movement

Reach from back for femoral points

Drainage area-At angles of 7th and 8 rids on left side is a very sensitive reflex about 3 inches from the spine.

Indicates a variant of rectum and colon close to the sigmoid flexure.

Deep pressure between 5-6 sacral nerves for tight anal sphincter.

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Test heel sign

Test Hypogastic plexus

Midline

Sided

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Test foot shake

Test great toe movement on first cuneiform

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Test muscles of the foot related to fluid drive

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Test talus for glide- Fred Mitchell Jr test.

Test fibula for glide

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Test posterior lateral knee

Check pubes/correct

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Muscles to treat for venous pump

Soleus / Medial head of the gastrocnemius

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Vastus lateralis.

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Flexor Hallicus longus

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Iliopsoas

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Superior Thoracic inlet

With deep breathing check for asymmetry of end range

Find presence of rotation, Drive the bus

Check manubrium/sternum

Diaphragm

Side glide with tension to see if there is a difference hands on abdomen pointing

toward Zyphoid

Deep breath / look for motion restriction.

Breathing: in men and children, is abdominal respiration.

But in women the breathing is thoracic respiration.

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Pelvic floor

With deep inhalation look for marked tension on the side of dysfunction

Coordinating the diaphragm to the pelvic floor

Patient supine/Knees flexed

Operators hand on pelvic floor

Inhale less/exhale more

Have the patient take a deep breath/ as they inhale increase the pressure

With the next deep breathe /hold the pressure and release with exhalation

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Abdominal Tension

Just below the attachment of the inguinal (Poupart’s) ligament along the upper edge of the body and ramus of the pubic bone to a point near the symphysis.

Dr Ada – anterior medial and inferior to ASIS bilaterally

Contraction of the inguinal ring Orchitis- Epididymitis

Deep firm rotatory movement

Leucorrhea

Most often used for pelvic drainage by Chapman but not Owens

Inner condyle of the femur and upwards from 3-6 inches on the posterior aspect.

Thigh and groin glands, ovaries are also involved

Rotatory movement

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P.T.A.S.

(Pelvic-Thyroid-Adrenal-Syndrome)

Broad ligament

On the outer aspect of the femur to 2” above knee

Posterior

Between PSIS and L-5

The Broad Ligament

 This is a fold of peritoneum with mesothelium on its anterior and posterior surfaces.  It extends from the sides of the uterus to the lateral walls and floor of the pelvis.

 The broad ligament holds the uterus in its normal position.

 The 2 layers of the broad ligament are continuous with each other at a free edge.  This is directed anteriorly and superiorly to surround the uterine tube.

 Laterally, the broad ligament is prolonged superiorly over the ovarian vessels as the suspensory ligament of the ovary.

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 The ovarian ligament lies posterosuperiorly and the round ligament of the uterus lies anteroinferiorly within the broad ligament.

 The broad ligament contains extraperitoneal tissue (connective tissue and smooth muscle) called parametrium.  It gives attachment to the ovary through the mesovarium.

 The mesosalpinx is a mesentery supporting the uterine tube.

The Broad Ligament

Venous Drainage of the Uterus

 The uterine veins enter the broad ligaments with the uterine arteries.

 They form a uterine venous plexus on each side of the cervix and its tributaries drain into the internal iliac vein.  The uterine venous plexus is connected with the superior rectal vein, forming a portal-systemic anastomosis.

Lymphatic Drainage of the Uterus

 The lymph vessels of the uterus follow three main routes:

1. Most lymph vessels from the fundus pass with the ovarian vessels to the aortic lymph nodes, but some lymph vessels pass to the external iliac lymph nodes or run along the round ligament of the uterus to the superficial inguinal lymph nodes. 2. Lymph vessels from the body pass through the broad ligament to the external iliac lymph nodes. 3. Lymph vessels from the cervix pass to the internal iliac and sacral lymph nodes.

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UTERUS

TREATMENT OF THE UTERUS

SUPINE:

For the treatment of the uterus in the supine position, start with the patient resting comfortable on the table.

1. Knees bent to 45º or with a pillow beneath the knees.

2. Practitioner sitting or standing beside the table facing patient’s feet.

3. Starting with the hands on the abdomen supra-pubically, allow the fingers to sink into the tissue just above the symphasis to that the bladder can be felt.

4. Glide the fingers superiorly until they can be directed behind the urinary bladder and into the tissue between the bladder and the uterus. With a rolling motion of the fingers, lift the uterus toward the head and hold the tissue until a relaxation is felt.

5. Repeat the procedure until the tissue in the area felt relaxed and does not resist your hands beyond normal tension.

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ALTERNATE SUPINE TREATMENT

1. For this technique, you will need an adjustable table or some form of pillows or other supporting device.

2. The end of the table is raised to approximately 45º so that an angle is formed with the rest of the table.

3. The patient is placed so that their knees are over the end of the table and their head and back lying on the flat portion of the table.

4. This position will allow the patient’s uterus to “float “ away from the bladder to a slight extent thereby increasing your ability to relax the tissues in the area.

5. The treatment procedures are as outlined above.

NOTES:

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Uterus/Prostate

Anterior medial aspect of the obturator foramen

Posterior

Between PSIS and spine of L-5

Innervation of the Uterus

 The nerves of the uterus arise from the inferior hypogastric plexus, largely from the anterior and intermediate part known as the uterovaginal plexus.  This lies in the broad ligament on each side of the cervix.

 Parasympathetic fibres are from the pelvic splanchnic nerves (S2-4), and sympathetic fibres are from the above plexus.

 The nerves to the cervix form a plexus in which are located small paracervical ganglia.  One of these are large and is called the uterine cervical ganglion.

 The autonomic fibres of the uterovaginal plexus are mainly vasomotor.

 Most the afferent fibres ascend through the inferior hypogastric plexus and enter the spinal cord via T10-12 and L1 spinal nerves

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The Prostate

 This is the largest accessory gland of the male reproductive system.  The prostate (prostate gland) is partly glandular and partly fibromuscular.

 It is about the size of a walnut and surrounds the prostatic urethra.

 It is enveloped in a thin, dense fibrous capsule (true capsule), which is enclosed within a loose sheath derived from the pelvic fascia called the prostatic sheath (false capsule).  It is continuous inferiorly with the superior fascia of the urogenital diaphragm.

 Posteriorly, the prostatic sheath is part of the rectovesical septum.

 This separates the bladder, seminal vesicles, and prostate from the rectum.

 The prostatic venous plexus lies between the fibrous capsule and the prostatic sheath.

 The prostate has a base, apex, and 4 surfaces (posterior, anterior, and 2 inferolateral surfaces

Arterial Supply of the Prostate

 The arteries are derived mainly from the inferior vesical and middle rectal arteries.  They are branches of the internal iliac artery.

Venous Drainage of the Prostate

 These for the prostatic venous plexus around the sides and base of the prostate.  This plexus is located between the capsule of the prostate and its fascial sheath.  It drains into the internal iliac veins.

 It also communicates with the vesical venous plexus and the vertebral venous plexus.

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Lymphatic Drainage of the Prostate

 The lymph vessels terminate chiefly in the internal iliac and sacral lymph nodes.  Some vessels from its posterior surface pass with the lymph vessels of the bladder to the external iliac lymph nodes.

Innervation of the Prostate

 Parasympathetic fibres arise from the pelvic splanchnic nerves (S2, S3, and S4).  The sympathetic fibres are from the inferior hypogastric plexuses.

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Ovaries Or Testies

The round ligaments from the Upper border of pubic bone

in grove lateral

Symphasis Pubes

Posterior

Inner ½ - 9th thoracic vertebral gutter

Outer ½ 10th thoracic vertebral gutter

Arterial Supply of the Ovaries

 The ovarian arteries arise from the abdominal aorta around the level of L2 vertebra.  They descend along the posterior abdominal wall.  On reaching the pelvic brim, the ovarian arteries cross over the external iliac vessels and enter the suspensory ligaments.

 At the level of the ovary, the ovarian artery sends branches through the mesovarium to the ovary and continues medially in the broad ligament to supply the uterine tube.

 It anastomoses with the uterine artery.

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Venous Drainage of the Ovaries

 The ovarian veins leave the hilum of the ovary and form a vine-like network of vessels, called the pampiniform plexus (L. pampinus, tendril + forma, form), in the broad ligament near the ovary and uterine tube.  This plexus of veins communicates with the uterine plexus of veins.

 Each ovarian vein arises from the pampiniform plexus and leaves the pelvis minor with the ovarian artery.

 The right ovarian vein ascends to the IVC, whereas the left ovarian vein drains into the left renal vein.

Lymphatic Drainage of the Ovaries

 The lymph vessels follow the ovarian blood vessels and join those from the uterine tubes and the fundus of the uterus as they ascend to the aortic lymph nodes in the lumbar region.

Innervation of the Ovaries

 The nerves of the ovary descend along the ovarian vessels from the ovarian plexus.  It is formed from the aortic, renal, and superior and inferior hypogastric plexuses.  These nerves supply the ovaries, broad ligaments, and uterine tubes.

 The parasympathetic fibres in the ovarian plexus are derived from the vagus nerves.

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Thyroid

2nd- 3rd intercostal space close to sternum

Posterior

T-2 vertebral gutter

Venous Drainage

There is a venous plexus on the anterior surface of the gland which is drained by three pairs of veins.

The superior and middle thyroid veins drain the superior and lateral aspects of the thyroid, respectively, and converge to drain into the internal jugular veins.

The inferior thyroid veins drain the inferior poles of the gland and go to the brachiocephalic veins. These inferior thyroid veins lie on the anterior surface of the trachea inferior to the isthmus, and thus are a potential source of bleeding during tracheotomy.

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Lymphatic Drainage

The lymphatics that run in the interlobular connective tissue around arteries of the thyroid communicate with a capsular network of lymphatics. These vessels drain the the prelaryngeal, pretracheal, and paratracheal lymph nodes.

Laterally, the lymphatics are located along the superior thyroid veins and pass to inferior deep cervical lymph nodes. Some lymph vessels may also drain to brachiocephalic lymph nodes or directly to the thoracic duct. Nervous Innervation

Nerve supply of the thyroid gland is derived from the superior, middle, and inferior cervical sympathetic ganglia reaching the gland via the cardiac and laryngeal branches of the vagus nerve which run along the arteries. These nerves are postganglionic fibers and are vasomotor, affecting the gland indirectly through their action on blood vessels.

The thyroid gland produces two hormones of significance: thyroxine (T4) and triiodothyronine (T3), in a ratio of 9:1, respectively.2 T4 is converted to T3 in the blood and peripheral tissues. T3 is thought to be the active form, and T4 may be predominantly a storage form, as T3 persists for only a short time. It is believed the true intracellular hormone is principally T3, rather than T4.2 Thyroid hormones control metabolism and virtually all other processes in the body. Without thyroid hormones, the body cannot form RNA, which is needed for the process of transcription necessary to produce proteins and enzymes.2 Consequently, without thyroid hormones, the body cannot produce proteins to repair damaged tissues, or enzymes, which catalyze virtually all reactions within the body. The release of thyroid hormones by the thyroid gland is initiated when thyroid stimulating hormone (TSH) is secreted by the anterior pituitary gland. Thyroid releasing hormone (TRH), secreted by the hypothalamus, initiates the release of TSH. Most of the thyroid hormones in the blood are bound to thyroid-binding globulin. The free portion of the thyroid hormone is the true determinant of the thyroid status of the patient.1

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Adrenals

1” lateral and 2 ½ “ above umbilicus

Posterior

11th intertransverse space vertebral gutter

but unilateral with single involvement

Arterial Supply of the Suprarenal Glands

 These glands has a profuse supply from 3 sources:

1. The aorta (one or more middle suprarenal arteries); 2. The inferior phrenic artery (6-8 superior suprarenal arteries); 3. The renal artery (one or more inferior suprarenal arteries).

Venous Drainage of the Suprarenal Glands

 These glands are drained mainly be a single, large suprarenal vein.  The right one drains into the IVC.  The left one joins the left renal vein.

 There are also many small veins that accompany the suprarenal arteries.

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Lymphatic Drainage of the Suprarenal Glands

 The lymph vessels arise from a plexus deep to the capsule and from one in the medulla.  Many lymph vessels leave the suprarenal glands and most of them end in the superior lumbar (lateral aortic) lymph nodes.

Innervation of the Suprarenal Glands

 These glands have a rich innervation from the adjacent coeliac plexus and the greater thoracic splanchnic nerves.

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