Massage School Notes

Anatomical Sections and Regions

Sections
1. Frontal (or coronal) - divides body into anterior and posterior sections
2. Saggital (midsaggital if in centerline) - divides body into right and left sections
3. Transverse (or horizontal) - divides body into superior and inferior sections
Regions (note: right and left are CLIENT'S right and left)
1. Superior: Right hypochondriac, epigastric, left hypochondriac
2. Middle: Right lumbar, Umbilical, left lumbar
3. Inferior: Right iliac, hypogastric, left iliac

Cells

Note: cells acquire their unique characteristics during "differentiation"

Components
1. Cell Membrane - surrounds cell - lipid bilayer - doesn't allow passage of water soluble molecules
2. Cytoplasm - fluid surrounding nucleus
3. Nucleus - innermost part
Organelles
1. Endoplasmic Reticulum - Communication network (if ribosomes are attached it's called rough ER)
2. Ribosomes - Synthesize proteins initially
3. Golgi Apparatus - Package proteins made by ribosomes
4. Lysosomes - Digest foreign material
5. Mitochondria - Form ATP from materials lysosomes produced
6. Cilia/Flagella - Propel fluid over surface and/or allow cell to move
Movements Through Cell Membranes
1. ATP Not Required
  1. Diffusion - scattering from higher concentration to lower concentration
  2. Facilitated Diffusion - movement from higher concentration to lower concentration via cells that carry substance through cell membrane
  3. Osmosis - diffusion of water molecules
  4. Filtration - movement from area of higher hydrostatic pressure to area of lower hydrostatic pressure (blood pressure causes filtration through capillary walls)
2. ATP Required
  1. Active Transport - movement from lower concentration to higher concentration - molecule escorts substance through membrane
  2. Endocytosis - cell membrane engulfs substance - phagocytosis for solid material and pinocytosis for liquid material

Tissues

Epithelial Tissue
1. Covers body surfaces/lines cavities (including blood vessels), and forms glands
2. Is avascular
3. Reproduces quickly
4. Types of Epithelial Tissue
  1. Simple squamous - lines blood vessels, lungs
  2. Simple cuboidal - ovaries, kidney tubules, ducts of glands
  3. Simple columnar - uterus, stomach
  4. Pseudostratified columnar epithelium - has cilia - passages of respiratory system, reproductive tubes
  5. Stratified squamous - skin, throat, vagina, anus, mouth
  6. Transitional - undergoes changes in response to increased tension - urinary bladder and passages
  7. Glandular - secretes (exocrine if secretes onto surface, endocrine if secretes into tissue or blood)
Connective Tissue
1. Most abundant tissue
2. Functions of Connective Tissue
  1. Binds, support, protects
  2. Produces/stores adipose (fat)
  3. Produces blood cells
  4. Provides protection against infection
3. Contains Cells (ground substance is gel-like material between connective tissue cells)
  1. Fibroblasts - produce connective tissue fibers
    1. Collagen Fibers (strong, flexible - forms tendons/ligaments)
    2. Elastin Fibers (elastic/stretchable)
    3. Reticular Fibers (support cells, hold organs together - found in solid organs like liver)
  2. Macrophages - phagocytize
  3. Mast cells - produce histamine (histamine brings about inflammatory process: increasing permeability of tissues, which results in more water and blood cells/macrophages in the area)
4. Types of Connective Tissue
  1. Loose: binds, fills in spaces between organs - adipose tissue is an example
  2. Dense/Fibrous: fibers packed together tightly (like tendons, ligaments)
  3. Cartilage: supports, protects
    1. Hyaline: articular cartilage
    2. Fibrocartilage: shock absorption (like intervertebral disks)
    3. Elastic Cartilage - ears/larynx
  4. Bone: most rigid CT
  5. Blood: plasma and cells (red/white platelets)
5. CT Healing Process
  1. Mitosis of Fibroblasts - to build more tissue
  2. Macrophages - to destroy foreign cells
  3. Inflammation - to immobilize area
Muscle Tissue - see Muscular System section for detail
1. Functions of Muscle Tissue
  1. Contracts to produce movement
  2. Produces heat as by-product of contraction
  3. Maintains posture
2. Types of Muscle Tissue
  1. Skeletal - "voluntary"
  2. Smooth - "involuntary"
  3. Cardiac - "involuntary"
Nervous Tissue - see Nervous System section for detail
1. Functions of Nervous Tissue
  1. Sensory
  2. Integrative
  3. Motor
2. Types of Nervous Tissue
  1. Neurons - generate and conduct nervous impulses
  2. Neuroglial - binds, supports, nourishes, protects neurons

Membranes

tissues that line a surface and secrete something

Cutaneous - skin - secretes sweat, oil (sebum)
Mucous - lines cavities open to exterior (like digestive tract)
Serous - lines cavities closed to external environment (like thoracic cavity)
Synovial - lines joints

Organ Locations

Liver: Right upper quadrant, directly under diaphragm, protected by ribs 8-12, crosses mid saggital line but remains under costal arch
Spleen: Left upper quadrant directly under diaphragm, posterior to stomach, between ribs 9-11
Gall Bladder: Directly behind liver, level 9-10 rib
Stomach: Left upper quadrant but crosses midsaggital line, inferior and anterior to spleen, between ribs 6-10
Kidneys: Retroperitoneal, bilateral thoracolumbar region, upper half under ribs 11-12, approx above iliac crest
Pancreas: Retroperitoneal, posterior to stomach, lies horizontal across middle of abdominal cavity (above umbilicle)
Colon: Ascending: Right ASIS to bottom of ribcage; Transverse: from right to left bottom of ribcage sagging down to just above umbilicle; Descending: between left bottom of ribcage and left ASIS
Small intestine: unattached; central AP cavity, anterior to ascending and descending colon, inferior to stomach
Appendix: Inside right inner iliac fossa, 1-2" superior to pubis
Bladder: posterior to pubis symphasis

List of Body Systems

Integumentary
Skeletal
Muscular
Nervous
Endocrine
Circulatory (includes lymphatics)
Respiratory
Digestive
Urinary
Reproductive

Integumentary System

Protects, regulates temperature, slows water loss, houses sensory apparatus, synthesizes chemicals, excretes some waste
Layers
1. Epidermis - stratified squamous epithelium - outermost layers keratinized
2. Dermis - variety of tissues
3. Subcutaneous Layer - loose connective tissue/adipose tissue
Erector pili muscles cause hairs to stand on end in response to cold or fright
Glands
1. Sebaceous - oil glands - keep skin waterproof
2. Sweat
  1. Apocrine - in armpits and groin - don't function until puberty
  2. Eccrine - everywhere

Skeletal System

Axial skeleton is Hyoid, Sternum/Ribs, all Vertebrae, and Skull. Peripheral skeleton is everything else.
Functions of skeletal system
1. Support
2. Movement (acts as levers)
3. Protection
4. Blood Production
5. Mineral Storage
  1. Calcium - helps muscle contraction
  2. Phosphorus - a component of ATP
Bone Cells
1. Osteocytes - mature osteoblasts - don't do much
2. Osteoblasts - lay down bone calcium matrix
3. Osteoclasts - break down bone calcium matrix
Bone Structures
1. Osteon - A group of bone cells and the blood vessel surround
2. Matrix - calcium and collagen
3. Parts of typical long bone
  1. Red Marrow: in ends (epiphysis) - produces blood cells
  2. Yellow Marrow: in central part of bone (diaphysis) - stores fat, but was red marrow in organism's youth. This is in medullary cavity, and is surrounded by compact bone.
  3. Articular Hyaline Cartilage: lines articulating surfaces of bones at joints
  4. Periosteum: connective tissue surrounding bone
Vertebral Landmarks
1. Iliac crest at L4/L5
2. Sacral dimples at S2 and PSIS
3. First significant vertebral protuberance at C7
4. Last rib at T12
5. Root of scapula at T2/T3
6. Inferior angle of scapula at T6

Bones of the Body

Note: there are 206 bones in the human body

Single Bones
1. Cranium
  1. Frontal
  2. Occipital
  3. Sphenoid
  4. Ethmoid
2. Facial
  1. Mandible
  2. Vomer
3. Misc
  1. Hyoid
  2. Sternum
Multiple Bones
1. Vertebrae
  1. Cervical (7)
  2. Thoracic (12)
  3. Lumbar (5)
  4. Sacrum (1)
  5. Coccyx (1)
2. Ribs
  1. True (7/side)
  2. False (3/side)
  3. Floating (2/side)
3. Hands
  1. Metacarpal (5/hand)
  2. Phalanx (14/hand)
4. Feet
  1. Metatarsal (5/foot)
  2. Phalanx (14/foot)
Paired Bones
1. Cranial
  1. Parietal
  2. Temporal
2. Facial
  1. Maxilla
  2. Zygomatic
  3. Lacrimal
  4. Nasal
  5. Turbinate
  6. Palatine
3. Auditory Ossicles
  1. Malleus
  2. Incus
  3. Stapes
4. Arms and Shoulders
  1. Clavicle
  2. Scapula
  3. Humerus
  4. Radius
  5. Ulna
5. Wrists
  1. Scaphoid
  2. Lunate
  3. Triangular
  4. Pisiform
  5. Trapezium
  6. Trapezoid
  7. Capitate
  8. Hamate
6. Legs and Hips
  1. Coxal Bone (W/ Ilium/Ischium/Pubis)
  2. Femur
  3. Tibia
  4. Fibula
  5. Patella
7. Ankles
  1. Talus
  2. Calcaneous
  3. Navicular
  4. Cuboid
  5. Cuneiform, medial
  6. Cuneiform, intermediate
  7. Cuneiform, lateral

Skeletal System Diseases

Infectious (Commonly treated with antibiotics)
1. Osteomyelitis: Inflammation of medullary red marrow
  1. Carried by microorganisms such as staphylococci
  2. Surgery can clear out dead bone tissue
2. Tuberculosis of Bone
  1. Affects ends of long bones or vertebrae
  2. Can destroy cartilage
Vitamin/Mineral Deficiencies
1. Rickets
  1. Primarily infancy/childhood
  2. Bones don't ossify (harden)
  3. Caused by Vitamin D deficiency, which prevents absorption of calcium into bone
  4. Sunlight and Vitamin D fortified milk help
2. Osteomalacia (Rickets in adults)
Secondary Bone Diseases
1. Osteitis Fibrosa Cystica: Cysts form in bone (inflammation), causing loss of calcium. Caused by hyperparathyroidism.
2. Osteoporosis: Loss of bone due to increased calcium reabsorption. If due to disease, is disuse atrophy.
3. Paget's Disease: Overproduction of bone in skull, vertebrae, and pelvis
Bone Fractures
1. Compound Fracture: skin is pierced
2. Comminuted Fracture: bone splintered or crushed
3. Greenstick Fracture: bone broken on one side, bent on other
Dislocations and Sprains
1. Dislocation: bone forcibly displaced from joint
2. Sprains: damage to ligament
Neoplasia (tumor)
1. Benign: may have no symptoms or appear as merely swollen
2. Malignant: commonly affects ends of long bones. Often treated with chemotherapy.

Joints

Contents of Synovial Joint
1. Ligaments
2. Joint Cavity
3. Synovial Membrane
4. Joint Capsule
5. Articular Cartilage
Types of Joints
1. Ball/Socket (rot, flex/ext, abd/add)
2. Hinge (flex/ext)
3. Saddle (flex/ext and abd/add - metacarpal/carpal of thumb)
4. Condyloid (flex/ext and abd/add - radiocarpal, metacarpal/phalange, metatarsal/phalange)
5. Pivot (rot)
6. Gliding (sliding)
Classes of Joints
1. Synarthroses - immobile
2. Amphiarthroses - slightly mobile (fibrocartilage)
3. Diarthroses - freely mobile (synovial)

Joint Diseases

Arthritis
1. Rheumatoid: Inflammation of synovial membranes. Membrane fills joint cavity. Bones fuse.
2. Osteoarthritis: Accompanies aging. Results from wear of joints. May affect only one joint.
Bursitis: Inflammation of bursea (especially at shoulder). Very painful. Caused by injury or repeated irritation. Treatment includes resting joint and moist heat. Steroids sometimes injected to reduce inflammation.
Gout: Affects joints of feet, often big toe. Caused by uric acid crystals in joints.
Herniation of Intervertebral Disk (Slipped Disk): Inner core of disk bulging outward. Can cause nerve impingement. Need exercises that improve posture and muscle use. Can also use bed rest on firm mattress/board, muscle relaxants, and careful application of heat. Note that if the disk's annulus fibrosus breaks, allowing the nucleus pulposus to spill out, the condition is called a rupture.

Muscular System

Connective Tissue Coverings
1. Fascia: surrounds entire muscle, intertwines with tendon or aponeuroses (sheetlike tendon)
2. Epimysium: surrounds entire muscle, deep to fascia
3. Perimysium: divides muscle into compartments, each of which contains a fascicle (a bundle of muscle fibers)
4. Endomysium: surrounds individual muscle fibers
Muscle fibers (single cell of muscles)
1. Sarcolemma: cell membrane, deep to endomysium
2. Consists of myofibrils, floating in sarcoplasm
3. Contains many nuclei, mitochondria
4. Myofibrils consist of functional units called sarcomeres
5. Myofibrils have two kinds of filaments: actin and myosin. Actin surrounds myosin. Actin joins at Z lines.
6. Connected at neuromuscular junction to a motor neuron, which innervates several muscle fibers called a motor unit. All contract at once, and all the way (all or nothing). Contraction requires calcium ions, creatine phosphate, and ATP. Motor unit has threshold stimulus to contract. This is lower when the muscle is warn.
7. Sarcoplasmic retinaculum stores calcium. Is all around muscle fiber
Muscular Metabolism
1. Aerobic metabolism is more efficient, doesn't produce lactic acid
2. Lactic acid buildup can cause muscle fatigue, which leads to microtears. Microtears can cause muscle soreness after exertion.
Muscle tone: resting contraction level
Proprioceptors
1. Golgi tendon apparatus
  1. At musculotendinous junction
  2. Sense muscle/tendon force, send info to CNS, which will inhibit contraction if forces too high.
2. Muscle spindles
  1. Located between muscle cells
  2. Sense length of muscle or change in length (will stimulate contraction)
  3. Assist in maintaining muscle tone

Muscular System Diseases

Note: this section does not include diseases caused by poor muscular tissue innervation

Muscular Dystrophy
1. Hereditary
2. Muscle fibers die, and dead fibers are replaced by fat and connective tissue. Usually appears by second or third year of life.
3. Only treatments are PT and orthopedics
Myasthenia Gravis
1. Transmission of impulse at myoneural junction fails.
2. Principal symptom is fatigue in all voluntary muscles.
3. Drugs that decrease normal destruction of acetylcholine help, as does removal of thymus.
4. Greatest danger is respiratory failure.
Tumors of Muscle: usually highly malignant and difficult to deal with. Usually advanced when it is diagnosed.

Muscular System Pathologies

Strain: tear in muscle or tendon
Sprain: tear in ligament
Cramp: involuntary muscle contraction (short term/acute). Extra potassium (like in bananas) can help avoid night cramps.
Spasm: involuntary contraction (long duration/intermittent)
Twitch: one short contraction
Myositis Ossificans: calcium replaces other tissue after repeated injury
Fibromyalgia (fibromyositis): muscle stiffness (w/ decreased ROM) and pain. Characterized by poor sleep.

Diagnostic Tests for Muscular/Skeletal Dysfunction

Physical Examination: Improper gait, decreased joint mobility, and/or deformities/masses
Laboratory Tests: X-Rays, MRI
Serum Tests: Calcium, phosphorus, alkaline phosphatase.

Major Muscle Origins, Insertions, and Actions

Upper Extremity
1. Trapezius
  1. Upper
    1. O: Occipital ridge -> T12
    2. I: Lat 1/3 of clavicle & acromion
    3. A: ELEV, upward rot
  2. Middle
    1. O: Occipital ridge -> T12
    2. I: Full spine of scapula
    3. A: RETR
  3. Lower
    1. O: Occipital ridge -> T12
    2. I: Root of spine of scapula
    3. A: DEPR, upward rot
2. Latissimus Dorsi
  1. O: T6 -> sacrum & post iliac crest, slips last 3 ribs & inf angle of scapula
  2. I: Bicipital groove (med lip)
  3. A: EXT, MED ROT, ADD
3. Teres Major
  1. O: Inf angle of scapula
  2. I: Bicipital groove (med lip)
  3. A: EXT, MED ROT, ADD
4. Levator Scapulae
  1. O: C1 -> C4 (trans processes)
  2. I: Sup angle to root of spine of scapula
  3. A: ELEV, downward rot
5. Rhomboids
  1. O: C7 -> T5
  2. I: Vertebral border of scapula, root to inf angle
  3. A: RETR, downward rot
6. Deltoid (note: Supraspinatus initiates abduction)
  1. Anterior
    1. O: Lat 1/3 of clavicle
    2. I: Deltoid tubercle
    3. A: ABD, flex, horiz add, med rot
  2. Middle
    1. O: Acromion
    2. I: Deltoid tubercle
    3. A: ABD
  3. Posterior
    1. O: Spine of scapula
    2. I: Deltoid tubercle
    3. A: ABD, ext, horiz abd, lat rot
7. Coracobrachialis
  1. O: Coracoid process
  2. I: Mid-med shaft of humerus
  3. A: FLEX, ADD
8. Supraspinatus (note: is one of "rotator cuff" muscles [Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis] which guard integrity of glenohumeral joint)
  1. O: Supraspinous fossa
  2. I: Sup greater tubercle
  3. A: ABD
9. Infraspinatus
  1. O: Infraspinous fossa
  2. I: Post greater tubercle
  3. A: LAT ROT
10. Teres Minor
  1. O: Axillary border of scapula
  2. I: Post greater tubercle
  3. A: LAT ROT
11. Subscapularis
  1. O: Subscapular fossa
  2. I: Lesser tubercle
  3. A: MED ROT
12. Pectoralis Major
  1. O: Med 1/2 of clavicle, ribs 1-6, and costocartilages
  2. I: Bicipital groove (lat lip)
  3. A: FLEX, ADD, horiz add, med rot, ext from a flexed position
13. Pectoralis Minor
  1. O: Ribs 3-5
  2. I: Coracoid process
  3. A: PROTR, depr, downward rot
14. Serratus Anterior
  1. O: Lat ribs 1-8
  2. I: Vertebral border of scapula
  3. A: PROTR, upward rot
15. Biceps Brachii
  1. O: Long Head: Supraglenoid tubercle Short Head: Coracoid process
  2. I: Radial tuberosity
  3. A: Long Head: FLEX, SUPIN Short Head: FLEX, SUPIN, shoulder flex
16. Brachialis
  1. O: Mid-ant shaft of humerus
  2. I: Coranoid process & ulnar tuberosity
  3. A: FLEX
17. Triceps Brachii
  1. O: Long Head: Infraglenoid tubercle Lat Head: Prox post humerus Med Head: Mid post humerus
  2. I: Olecranon process
  3. A: EXT (long head also performs shoulder ext)
18. Anconeus
  1. O: Lat humeral epicondyle
  2. I: Olecranon process
  3. A: EXT
19. Brachioradialis
  1. O: Lat suprocondylar ridge of humerus
  2. I: Radial styloid process
  3. A: FLEX in a neutral position
20. Extensor Carpi Radialis Longus
  1. O: Lat supracondylar ridge of humerus
  2. I: Base of 2nd metacarpal (dorsal)
  3. A: EXT, radial dev
21. Extensor Carpi Radialis Brevis
  1. O: Lat humeral epicondyle
  2. I: Base of 3rd metacarpal (dorsal)
  3. A: EXT
22. Extensor Carpi Ulnaris
  1. O: Lat humeral epicondyle
  2. I: Base of 5th metacarpal (dorsal)
  3. A: EXT, ulnar dev
23. Extensor Digitorum Communis
  1. O: Lat humeral epicondyle
  2. I: Phalanges 2-5 (dorsal)
  3. A: EXT OF FINGERS
24. Supinator
  1. O: Post lat humeral epicondyle & post ulna
  2. I: Prox ant radius
  3. A: SUPIN
25. Abductor Pollicis Longus
  1. O: Post radius, ulna, & interosseous membrane
  2. I: 1st metacarpal (dorsal)
  3. A: ABD OF THUMB
26. Extensor Pollicis Brevis
  1. O: Post radius & interosseous membrane
  2. I: Prox thumb (dorsal)
  3. A: EXT OF THUMB
27. Extensor Pollicis Longus
  1. O: Post ulna
  2. I: Dist thumb (dorsal)
  3. A: EXT OF THUMB
28. Pronator Teres
  1. O: Med humeral epicondyle
  2. I: Mid lat radial shaft
  3. A: PRON, flex
29. Pronator Quadradus
  1. O: Dist 1/4 of ulna
  2. I: Dist 1/4 of radius
  3. A: PRON
30. Flexor Carpi Ulnaris
  1. O: Med humeral epicondyle
  2. I: 5th metacarpal, pisiform, & hamate
  3. A: FLEX, ulnar dev
31. Palmaris Longus
  1. O: Med humeral epicondyle
  2. I: Palmar aponeurosis
  3. A: FLEX
32. Flexor Carpi Radialis
  1. O: Med humeral epicondyle
  2. I: Base of 2nd & 3rd metacarpals (palmar)
  3. A: FLEX, radial dev
33. Flexor Digitorum Superficialis
  1. O: Med humeral epicondyle, coranoid, & radial tuberosity
  2. I: Middle phalanges 2-5 (palmar)
  3. A: FLEX OF PIP JOINTS
34. Flexor Digitorum Profundus
  1. O: Ant ulna & interosseous membrane
  2. I: Dist phalanges 2-5 (palmar)
  3. A: FLEX OF DIP JOINTS
35. Flexor Pollicis Longus
  1. O: Mid-ant radius & interosseous membrane
  2. I: Dist thumb (palmar)
  3. A: FLEX OF THUMB
Lower Extremity
1. Gluteus Maximus
  1. O: Sacrum & post iliac fossa
  2. I: Gluteal tuberosity & lateral tibial condyle (Gerdy's tubercle) via ITB
  3. A: EXT, lat rot
2. Gluteus Medius
  1. O: Post iliac crest
  2. I: Greater trochanter
  3. A: ABD, med rot
3. Gluteus Minimus
  1. O: Post iliac fossa
  2. I: Ant greater trochanter
  3. A: ABD, med rot
4. Tensor Fasciae Latae
  1. O: Ant ilium
  2. I: Lat tibial condyle via ITB
  3. A: FLEX, ABD, med rot
5. Piriformis
  1. O: Ant sacrum
  2. I: Greater trochanter
  3. A: LAT ROT
6. Iliopsoas
  1. O: T12 -> L5 & inner iliac fossa
  2. I: Lesser trochanter
  3. A: TRUNK FLEX, HIP FLEX, lat rot
7. Sartorius
  1. O: ASIS
  2. I: MAPS (Medial Anterior Proximal Shaft of the tibia: Gracilis and Semitendinosus also insert here)
  3. A: FLEX, LAT ROT, KNEE FLEX, hip abd
8. Rectus Femoris (note: quadriceps group is Rectus Femoris, Vastus Medialis/Lateralis/Intermedius)
  1. O: AIIS & acetabulum
  2. I: Patella & tibial tuberosity via patellar tendon
  3. A: EXT, hip flex
9. Vastus Medialis
  1. O: Med linea aspera
  2. I: Patella & tibial tuberosity via patellar tendon
  3. A: EXT
10. Vastus Lateralis
  1. O: Lat linea aspera
  2. I: Patella & tibial tuberosity via patellar tendon
  3. A: EXT
11. Vastus Intermedius
  1. O: Ant femoral shaft
  2. I: Patella & tibial tuberosity via patellar tendon
  3. A: EXT
12. Pectineus
  1. O: Ant pubis
  2. I: Between lesser trochanter & linea aspera
  3. A: ADD, flex
13. Adductor Longus
  1. O: Ant Pubis
  2. I: Mid linea aspera
  3. A: ADD, flex
14. Adductor Brevis
  1. O: Ant Pubis
  2. I: Proximal linea aspera
  3. A: ADD, flex
15. Adductor Magnus
  1. O: Pubic & ischial ramii, ischial tuberosity
  2. I: Full linea aspera to adductor tubercle
  3. A: ADD
16. Gracilis
  1. O: Ant pubis
  2. I: MAPS
  3. A: ADD, knee flex
17. Biceps Femoris (note: hamstrings are Biceps Femoris, Semitendinosus, and Semimembranosis)
  1. O: Ischial tuberosity, mid linea aspera
  2. I: Fibular head
  3. A: FLEX, hip ext
18. Semimembranosus
  1. O: Ischial tuberosity
  2. I: Post med tibial condyle
  3. A: FLEX, hip ext
19. Semitendinosus
  1. O: Ischial tuberosity
  2. I: MAPS
  3. A: FLEX, hip ext
20. Gastrocnemius
  1. O: Post femoral condyles
  2. I: Calcaneus via achilles tendon
  3. A: PLANTARFLEX, knee flex
21. Soleus
  1. O: Post tibia & fibula
  2. I: Calcaneus via achilles tendon
  3. A: PLANTARFLEX
22. Tibialis Posterior
  1. O: Post tibia, fibula, & interosseous membrane
  2. I: Navicular, cuneiforms, metatarsals 2-5 (plantar)
  3. A: INV, assists plantarflex
23. Flexor Digitorum Longus
  1. O: Post tibia
  2. I: Phalanges 2-5 (plantar)
  3. A: FLEX OF TOES, plantarflex
24. Flexor Hallucis Longus
  1. O: Post fibula
  2. I: Hallux (plantar)
  3. A: FLEX OF GREAT TOE, plantarflex
25. Tibialis Anterior
  1. O: Lat ant tibia
  2. I: 1st metatarsal, 1st cunieform (dorsal)
  3. A: DORSIFLEX, INV
26. Extensor Hallucis Longus
  1. O: Ant fibula
  2. I: Hallux (dorsal)
  3. A: EXT GREAT TOE, dorsiflex
27. Extensor Digitorum Longus
  1. O: Ant tibia, fibular head
  2. I: Phalanges 2-5 (dorsal)
  3. A: EXT OF TOES, dorsiflex
28. Peroneus Brevis
  1. O: Mid fibula
  2. I: Base of 5th metatarsal
  3. A: EVERSION, plantarflex
29. Peroneus Longus
  1. O: Prox fibula
  2. I: 1st metatarsal, 1st cuneiform (plantar)
  3. A: EVERSION, plantarflex
Head, Neck, and Trunk Muscles
1. Sterncleidomastoid
  1. O: Manubrium & med clavicular head
  2. I: Mastoid process
  3. A: NECK FLEX, LAT FLEX, ROT TO OPP SIDE
2. Scalenes (note: brachial plexus passes betwwen scalenes anterior and scalenes medius)
  1. O: C3 -> C7 transv processes
  2. I: Anterior & medius: 1st rib Posterior: 2nd rib
  3. A: NECK FLEX, LAT FLEX, RESPIRATION
3. Rectus Abdominis
  1. O: Pubis
  2. I: Sternum & ant ribs 5-7
  3. A: TRUNK FLEX
4. External Obliques
  1. O: Iliac crest, inguinal ligament, & pubis
  2. I: Ant lat ribs 5-12 (interdigitates with serratus anterior)
  3. A: TRUNK FLEX, ROT TO OPP SIDE, LAT FLEX
5. Internal Obliques
  1. O: Inguinal ligament & pubis
  2. I: Ant ribs 8-12 & linea alba
  3. A: TRUNK FLEX, ROT TO SAME SIDE, LAT FLEX
6. Quadratus Lumborum
  1. O: Post iliac crest
  2. I: Post 12th rib & L1-L4
  3. A: HIP HIKING, LAT TRUNK FLEX
7. Splenius Capitis
  1. O: Lower ligamentum nuchae -> T3 (transv processes)
  2. I: Mastoid process
  3. A: NECK EXT, LAT FLEX, rot to same side
8. Splenius Cervicus
  1. O: T3 -> T6 (spinous processes)
  2. I: C1 -> C3 (transv processes)
  3. A: NECK EXT, LAT FLEX, rot to same side
9. Iliocostalis (note: erector spinae group consists of Iliocostalis, Longissimus, and Spinalis)
  1. O: Ilium and ribs
  2. I: All cervical transv processes
  3. A: SPINE EXT, TRUNK LAT FLEX,
10. Longissimus
  1. O: Thoracolumbar aponeurosis, all transv processes and ribs
  2. I: Mastoid process
  3. A: SPINE EXT, TRUNK LAT FLEX
11. Spinalis
  1. O: Thoracolumbar anoneurosis, all spinous processes
  2. I: Occiput
  3. A: SPINT EXT, TRUNK LAT FLEX

Index of Major Muscles by Actions

Note: muscle name is in caps if the action is the major action of that muscle; facial and transversospinalis muscles are not included.

Scapula
1. Depression
  1. LOWER TRAPEZIUS
  2. Pectoralis Minor
2. Elevation
  1. UPPER TRAPEZIUS
  2. LEVATOR SCAPULA
3. Protraction
  1. PECTORALIS MINOR
  2. SERRATUS ANTERIOR
4. Retraction
  1. MIDDLE TRAPEZIUS
  2. RHOMBOID
5. Downward Rotation
  1. Levator Scapula
  2. Rhomboids
  3. Pectoralis Minor
6. Upward Rotation
  1. Upper Trapezius
  2. Lower Trapezius
  3. Serratus Anterior
Humerus
1. Extension
  1. LATISSIMUS DORSI
  2. TERES MAJOR
  3. Posterior Deltoid
  4. Triceps Brachii (long head)
  5. Pectoralis Major (only from flexed position)
2. Flexion
  1. PECTORALIS MAJOR
  2. CORACOBRACHIALIS
  3. Anterior Deltoid
  4. Biceps Brachii (short head)
3. Abduction
  1. SUPRASPINATUS
  2. DELTOID (Anterior, Middle, and Posterior)
4. Adduction
  1. PECTORALIS MAJOR
  2. CORACOBRACHIALIS
  3. LATISSIMUS DORSI
  4. TERES MAJOR
5. Lateral Rotation
  1. INFRASPINATUS
  2. TERES MINOR
  3. Posterior Deltoid
6. Medial Rotation
  1. SUBSCAPULARIS
  2. TERES MAJOR
  3. LATISSIMUS DORSI
  4. Anterior Deltoid
  5. Pectoralis Major
7. Horizontal Abduction
  1. Posterior Deltoid
8. Horizontal Adduction
  1. Anterior Deltoid
  2. Pectoralis Major
Elbow
1. Extension
  1. TRICEPS BRACHII
  2. ANCONEOUS
2. Flexion
  1. BICEPS BRACHII (in a supine position)
  2. BRACHIALIS (in any position)
  3. BRACHIORADIALIS (in a neutral position)
  4. Pronator Teres
3. Pronation
  1. PRONATOR TERES
  2. PRONATOR QUADRATUS
4. Supination
  1. BICEPS BRACHII
  2. SUPINATOR
Wrist
1. Extension
  1. EXTENSOR CARPI RADIALIS LONGUS
  2. EXTENSOR CARPI RADIALIS BREVIS
  3. EXTENSOR CARPI ULNARIS
2. Flexion
  1. FLEXOR CARIP RADIALIS
  2. FLEXOR CARPI ULNARIS
  3. PALMARIS LONGUS
3. Abduction (radial deviation)
  1. Flexor Carpi Radialis
  2. Extensor Carpi Radialis Longus
4. Adduction (ulnar deviation)
  1. Extensor Carpi Ulnaris
  2. Flexor Carpi Ulnaris
Fingers
1. Extension
  1. EXTENSOR DIGITORUM COMMUNIS
2. Flexion
  1. FLEXOR DIGITORUM SUPERFICIALIS (PIP joints)
  2. FLEXOR DIGITORUM PROFUNDUS (DIP joints)
Thumb
1. Extension
  1. EXTENSOR POLLICIS LONGUS
  2. EXTENSOR POLLICIS BREVIS
2. Flexion
  1. FLEXOR POLLICIS LONGUS
3. Abduction
  1. ABDUCTOR POLLICIS LONGUS
Hip
1. Extension
  1. GLUTEUS MAXIMUS
  2. Biceps Femoris
  3. Semimembranosis
  4. Semitendinosis
2. Flexion
  1. ILIOPSOAS
  2. TENSOR FASCIAE LATAE
  3. SARTORIUS
  4. Rectus Femoris
  5. Pectineus
  6. Adductor Longus
  7. Adductor Brevis
3. Abduction
  1. GLUTEUS MEDIUS
  2. GLUDEUS MINIMUS
  3. TENSOR FASCIAE LATAE
  4. Sartorius
4. Adduction
  1. PECTINEUS
  2. ADDUCTOR LONGUS
  3. ADDUCTOR BREVIS
  4. ADDUCTOR MAGNUS
  5. GRACILIS
5. Medial (Internal) Rotation
  1. Gluteus Medius
  2. Gluteus Minimus
  3. Tensor Fasciae Latae
6. Lateral (External) Rotation
  1. PIRIFORMIS (and other Deep Lateral Hip Rotators)
  2. SARTORIUS
  3. Gluteus Maximus
  4. Iliopsoas
Knee
1. Extension
  1. RECTUS FEMORIS
  2. VASTUS MEDIALIS
  3. VASTUS LATERALIS
  4. VASTUS INTERMEDIUS
2. Flexion
  1. BICEPS FEMORIS
  2. SEMIMEMBRANOSIS
  3. SEMITENDINOSIS
  4. SARTORIUS
  5. Gastrocnemius
  6. Gracilis
Foot
1. Dorsiflexion
  1. TIBIALIS ANTERIOR
  2. Extensor Hallucis Longus
  3. Extensor Digitorum Longus
2. Plantarflexion
  1. GASTROCNEMIUS
  2. SOLEUS
  3. Tibialis Posterior (weakly)
  4. Flexor Digitorum Longus
  5. Flexor Hallucis Longus
  6. Peroneus Longus
  7. Peroneus Brevis
3. Eversion
  1. PERONEUS LONGUS
  2. PERONEUS BREVIS
4. Inversion
  1. TIBIALIS POSTERIOR
  2. TIBIALIS ANTERIOR
Toes
1. Extension
  1. EXTENSOR DIGITORUM LONGUS
2. Flexion
  1. FLEXOR DIGITORUM LONGUS
Great Toe
1. Extension
  1. EXTENSOR HALLUCIS LONGUS
2. Flexion
  1. FLEXOR HALLUCIS LONGUS
Trunk
1. Flexion
  1. ILIOPSOAS
  2. RECTUS ABDOMINUS
  3. EXTERNAL OBLIQUES
  4. INTERNAL OBLIQUES
2. Lateral Flexion
  1. ERECTOR SPINAE
  2. QUADRATUS LUMBORUM
  3. EXTERNAL OBLIQUES
  4. INTERNAL OBLIQUES
3. Spine Extension
  1. ERECTOR SPINAE
4. Rotation to Opposite Side
  1. EXTERNAL OBLIQUES
5. Rotation to Same Side
  1. INTERNAL OBLIQUES
"Hip Hiking": QUADRATUS LUMBORUM
Neck
1. Extension
  1. SPLENIUS CAPITUS
  2. SPLENIUS CERVICUS
2. Flexion
  1. STERNOCLEIDOMASTOID
  2. SCALENES
3. Lateral Flexion
  1. STERNOCLEIDOMASTOID
  2. SCALENES
  3. SPLENIUS CAPITUS
  4. SPLENIUS CERVICUS
4. Rotation to Opposite Side
  1. STERNOCLEIDOMASTOID
5. Rotation to Same Side
  1. Splenius Capitus
  2. Splenius Cervicus
"Respiration": SCALENES, DIAPHRAGM

Miscellaneous Muscles

Deep Lateral Hip Rotators (excluding Piriformis)
1. Gemellus Superior
  1. O: Ischium
  2. I: Greater trochanter
  3. A: LAT ROT
2. Gemellus Inferior
  1. O: Ischium
  2. I: Greater trochanter
  3. A: LAT ROT
3. Obturator Externus
  1. O: Obdurator foramen
  2. I: Greater trochanter
  3. A: LAT ROT
4. Obturator Internus
  1. O: Obturator foramen
  2. I: Greater trochanter
  3. A: LAT ROT
5. Quadratus Femoris
  1. O: Ischium
  2. I: Greater trochanter
  3. A: LAT ROT
Transversospinalis (deep muscles span 1 or 2 vertebrae and superficial muscles have longer spans; muscles are listed below in order of superficial to deep)
1. Semispinalis
  1. O: Cervical and thoracic transv processes
  2. I: Cervical and thoracis spinous processes and occiput
  3. A: BILAT EXT OF SPINE, UNILAT ROT TO OPPOSITE SIDE
2. Multifidus
  1. O: All transv processes
  2. I: All spinous processes
  3. A: BILAT EXT OF SPINE, UNILAT ROT TO OPPOSITE SIDE
3. Rotatores
  1. O: All transv processes
  2. I: All spinous processes
  3. A: BILAT EXT OF SPINE, UNILAT ROT TO OPPOSITE SIDE
4. Interspinales
  1. O: Spinous processes
  2. I: Spinous processes
  3. A: EXT OF SPINE
5. Intertransversarii
  1. O: Transv processes
  2. I: Transv processes
  3. A: LAT FLEX OF SPINE
Facial Muscles
1. Frontalis
  1. O: Frontal bone
  2. I: Frontal bone
  3. A: LIFTS EYEBROWS, WRINKLES FOREHEAD
2. Masseter
  1. O: Zygomatic arch
  2. I: Mandible
  3. A: CLOSES, RETRACTS, PROTRACTS JAW
3. Buccinator
  1. O: Mandible & Maxilla
  2. I: Lips
  3. A: WHISTLING, KISSING
4. Temporalis
  1. O: Temporal bone
  2. I: Mandible
  3. A: CLOSES JAW
Diaphragm
1. O: Domed muscle separating ventral cavities, costocartilages 6-12, and body of L1-3
2. I: Xiphoid process
3. A: MAJOR MUSCLE OF RESPIRATION

Nervous System Overall Structure

CNS
1. Spinal Cord: Extends from Foramen Magnum to L2. Nerves pass through Vertebral Foramen.
2. Brain
  1. Cerebrum - All areas also handle association
    1. Lobes
      1. Frontal Lobe - Motor
      2. Parietal Lobe - Touch/Movement
      3. Temporal Lobe - Hearing
      4. Occipital Lobe - Vision
    2. Corpus Collusum bridges left, right hemispheres
    3. Cerebral Cortex - cell bodies surrounding cerebrum
  2. Cerebellum - behind brainstem - handles balance, coordination, smooth movement
  3. Diencephalon - on top of brainstem
    1. Thalamus
      1. Relays info to appropriate lobe of cerebrum
      2. Able to interpret at very vague/non-localized level pain, touch, pressure, etc.
    2. Hypothalamus
      1. Thirst
      2. Feeding/Satiety
      3. Temperature
      4. Circadean Rhythm
      5. Psychosomatic Effects (Mind over body)
      6. Integrates nervous/endocrine system
      7. Receives info from ANS
      8. Rage/aggression
  4. Brainstem
    1. Midbrain
      1. Relays info up/down tracts
      2. "Tracking Reflex" - turn to see moving object
    2. Pons
      1. Relays info up and down tracts
      2. Respiratory function
    3. Medulla Oblongata
      1. Ascending/descending tracts cross here
      2. Relays info up/down tracts
      3. Vital reflex center
        
        Medullary Rhythmicity Center for Respiration
        
        Cardiac Center (heart rate + force)
        
        Vasomotor Center (Blood Pressure)
      4. Non-vital reflexes: sneezing, coughing
      5. Reticular Activity - Triggers different levels of consciousness
PNS
1. Afferent (sensory)
2. Efferent (motor)
  1. Somatic (skeletal muscle)
    1. "Voluntary"
    2. Excitatory (take away acetylcholine [ACH] to stop)
    3. One motor neuron in path from spinal cord to effector
  2. ANS (smooth muscle/cardiac muscle/glands - "Involuntary" - at least 2 motor neurons in path from spinal cord to effector)
    1. Sympathetic
      1. Emanate mostly from T1-L2
      2. From SC, there is a preganglionic cell body in SC, a postganglionic cell body in paravertebral ganglion near SC
      3. One sympathetic neuron goes to adrenals (releases NE like substance)
      4. Can use NE instead of ACH - NE breaks down more slowly
      5. Increases heart rate, decreases digestion
    2. Parasympathetic
      1. Emanate mostly from cranial and sacral areas
      2. Vagus nerve carries 80% of parasympathetic neurons
      3. There is one cell body in SC, another in terminal ganglia, near effector. Proximal axon is prefiber, distal axon (on second neuron) is postfiber.
      4. Decreases heart rate, increases digestion

Nerves/Plexuses of Body

Nerves
1. Cranial Pairs (12)
  1. Mnemonic for remembering sensory, motor, or both: "Some Say Marilyn Monroe, But My Brother Says Brigit Bardot - My My". Note that all spinal nerves are mixed.
  2. Nerves 1-2 are in higher brain, 3-4 are in Midbrain, 5-8 are in Pons, 8-12 Medulla
  3. Important Cranial Nerves: 1 Olfactory-S, 2 Optic-S, 5* Trigeminal (mastication/facial/scalp), 7* Facial (taste, facial expressions), 8 Auditory-S, 10* Vagus (Goes under SCM, supplies all thoracic/abd structure), 11* Accessory (speech, SCM, traps), 12 Hypoglossus
  4. Cranial Nerves 3,7,9,10 have parasympathetic neurons
2. Cervical Pairs (8)
3. Thoracic Pairs (12)
4. Lumbar Pairs (5)
5. Sacral Pairs (5)
6. Coccyxageal Pair (1)
Plexuses (A plexus is a place where the spinal nerves emanating from vertebral segments recombine to form new nerves - note that neurons remain distinct)
1. Cervical Plexus - neurons from C1-C4
  1. Phrenic Nerve - to diaphragm
  2. Segmental Nerve - to lev scap, scalenes
2. Brachial Plexus neurons from C5-T1/T2
  1. Axillary (through armpit)
  2. Median (through carpal tunnel, controlling 1st 3 digits of hand)
3. Thoracic Region (no plexus) - neurons from T2-T12
4. Lumbar Plexus - neurons from T12-L3
  1. Femoral Nerve (innervates quads)
5. Sacral Plexus - neurons from L3-S5
  1. Sciatic (under Piriformis, through sciatic notch - separates into common tibial, common peroneal - feeds glutes, hams, leg, foot)

Nervous System Specialized Structures and Effects

Meninges - Wrap brain and spinal cord - Denticulate ligaments provide extra protection
1. Spinal Cord - Innermost Layer
2. Pia Mater - Vascular
3. Subarachnoid Space - Contains CS Fluid
4. Arachnoid Mater - Avascular
5. Dura Mater - Vascular
6. Epidural Space - Blood/lymph vessels - Outermost Layer
Horns of spinal cord - Note that the "H" makes contact dorsaly with the spinal cord
1. Posterior Grey Horns: Axons of sensory neurons entering PNS - Dorsal root ganglion contains the cell bodies, and axons travel through dorsal root
2. Anterior Grey Horns: Cell bodies of somatic neurons leaving PNS
3. Lateral Grey Horns: Cell bodies of autonomic neurons leaving PNS
4. Ventral Root: Lets out axons from lateral and anterior horns
Specialized CNS Structures
1. Basal Ganglia - in cerebrum - release dopamine, which allows larger subconscious movements
2. Broca's Brain: part of Frontal Lobe that handles speech
3. Limbic System - Stores survival related emotions - in brain
Cerebro-spinal fluid
1. Made in brain ventricles
2. Choroid plexuses (special capillaries) filter things out of blood to form CSF - note that all capillaries in brain are selectively permeable to form the blood-brain barrier
3. Made of water, electrolytes, little proteins, glucose, macrophages
4. Acts as shock absorber in subarachnoid space, carries electrolytes for nervous transmission, facilitates waste removal
Nervous System Supporting Cells
1. Glial Cells
  1. Astrocyte - Nourishment, Support - In both PNS and CNS
  2. Oligodendrocyte - Produce myelin in CNS
  3. Microglia - Phagocytosis in CNS
  4. Ependyma - Line ventricles, have cilia, in CNS
2. Schwann Cells
  1. Produce myelin in PNS
  2. Found around axon sheaths
  3. Cell membrane is called Neurilemma
  4. Myelinated axons in PNS can regenerate if cut if Schwann cell isn't cut
Neurons
1. Neuron coverings
  1. Endoneurium: one neuron
  2. Perineurium: several neurons
  3. Epineurium: whole nerve
2. Nissl Bodies
  1. Synthesize proteins to form neurotransmitters
  2. Found in neuron cell bodies
  3. Technically, are clumps of rough ER
3. Myelination
  1. Grey Matter - Nervous tissue that is unmyelinated (such as all cell bodies)
  2. White Matter - Nervous tissue that is myelinated.
    1. Myelinated axons carry information faster.
    2. Periodic gaps along myelinated nerve are called Nodes of Ranvier.
    3. Myelination produces sultatory (instead of continuous) transmission.
4. Misc Info
  1. Almost all neurons in PNS are unipolar
  2. Input fibers to a neuron are termed dendrites, output fibers are termed axons. Each neuron has only one axon. All impulses conducted on a fiber are the same strength.
  3. Some neurons are self-excitable: this mostly happens in frontal lobe of cerebrum
Nervous Impulse Transmission
1. Stimulus above threshold (action potential) increases axon membrane permeability. Previously, existed at resting potential.
2. Na+ (sodium) ions enter axon at this point
3. This changes electric potential, which opens next "gate", continuing the process
4. Na/K Pump. Uses a lot of ATP - binds proteins to electrolytes to move them back across cell membrane. Note: K is potassium.
5. Calcium closes gates
6. Note that many sub-threshold stimuli may be sufficient to open gate: summation
7. At synapse, signal increases membrane permeability to calcium. Calcium enters, binds with vesicles and carries them down to end of axon. Then neurotransmitters are released into synaptic cleft to bind at receptor cites.
Neuron Terminology
1. Somatic neurons go to/from muscle/fascia/skin
2. Visceral neurons go to/from viscera
3. A ganglion is a collection of neuron cell bodies in PNS, in CNS this would be called nuclei
4. A nerve is a bundle of axons in PNS, in CNS this would be called an ascending or descending tract.
Gate Control Theory
1. Pressure, heat, and cold impulses travel on their nerve fibers to the CNS faster than pain impulses
2. These impulses reach the CNS before the pain impulses and close the gate to pain.
3. Additional pain relief may be provided by release of endorphins.
Sensation
1. Classifications of Sensory Receptors
  1. Exteroreceptors - receptors on outside of body
  2. Visceroceptors - receptors on internal organs
  3. Proprioceptors - receptors of body position
2. Sensory Receptors
  1. Chemoreceptors - sense chemical changes - like taste buds - externo
  2. Mechanoreceptors - senses shape changes - proprioceptors, etc
  3. Photoreceptors - extero
  4. Thermoreceptors - extero/viscer
  5. Pain Receptors - extero/viscer
3. Tactile Sensations (all mechanoceptors)
  1. Touch
  2. Pressure
  3. Vibration
4. Pain
  1. Special Pain Sensors are called Nociceptors
  2. Pain can be somatic or visceral. It can also be referred.
5. An awareness of change in the environment is a sensation. If it becomes conscious it's a perception
Specialized Effects
1. Stretch Reflex
  1. Monosynaptic
  2. Ipsilateral
  3. Somatic spinal reflex
  4. Monosegmental
  5. Uses muscle spindles to get relaxation
2. Reflex: fast, unconscious response to some change in the environment. The reflex effect is the result that takes place as a result of a change in the environment, while a reflex arc is the physical path the impulse travels (often simple)

Nervous System Disorders

Note: C means contagious in acute stage.

ALS: progressive destruction of motor neurons in ventral horns of spinal cord
Bell's Palsy: irritation of facial nerve
Carpal Tunnel Syndrome: Compression of median nerve as it passes between transverse carpal ligament and flexor retinaculum. Caused by repeated use of wrist (repetitive), pregnancy, or trauma. Causes pain, numbness, tingling, loss of function to digits 1-3.
Cerebral Palsy: a nonprogressive paralysis resulting from developmental defects in brain or trauma at birth
Epilepsy: brain impulses disturbed, can be caused by trauma
Huntington's Disease: inherited abnormality of neurotransmitters, leads to dementia
Meningitis-C: bacteria-caused inflammation of membranes of spinal cord
MS: myelin sheaths in CNS break down, impairs muscles
Parkinson's Disease: brain degeneration, appearing late in life, of cells in basal ganglia
Polio-C: virus-caused infection of CNS motor neurons, muscles lose stim and become paralyzed
Sciatica/Piriformis: Compression of sciatic nerve where it passes through the sciatic notch and under piriformis. Often caused by pregnancy or trauma. Causes pain, numbness, tingling, decreased function in glutes, hams, knee, foot.
Shingles-C: inflammation of nerve cells, caused by chicken pox virus, follows nerve path
Spina Bifida: congenital defect where there isn't a union between laminae of vertebrae
Thoracic Outlet Syndrome/"Pitcher's Syndrome": compression of subclavian arteries/veins and/or brachial plexus. Caused by sleeping posture, or actions involving shoulder. Causes pain, tingling, decreased function numbness of 4th/5th fingers, starting at elbow. Can cause coldness to arm. Structures of compression can be clavicle against rib, Scalenes Anterior against Scalenes Medius, or Pec Minor against ribs.

Endocrine System

Endocrine glands secrete chemical hormones into body fluids (local hormones skip the blood) which connect with target cells carrying specific receptors. Endocrine effects can be more widespread and longer-lasting than nervous system effects. Endocrine is contrasted with exocrine: exocrine glands secrete through ducts to internal or external body surfaces.
Hormone Level Controls
1. Hormones are subject to negative feedback: levels that are too high can signal a decrease in production.
2. Some hormones (e.g. adrenaline) are released upon nervous system signal. Note that the release of hormones in the pituitary ("master" gland) is controlled by the hypothalamus.
3. Tropic hormones target other endocrine tissues.
Endocrine Glands (Gland: a group of cells that secrete a product)
1. Pineal
2. Pituitary
  1. Located under hypothalamus
  2. Releases: Human Growth Hormone (increased bone and NS growth), ADH (reabsorb water), misc. tropic hormones, FSH/LH (ovaries/testes), etc.
3. Thyroid
  1. Located in neck
  2. Releases: Calcitonin (calcium in blood to bone), T3/T4 (increase heat)
4. Parathyroid
5. Adrenals
  1. Located on Kidneys
  2. Releases: E/NE (adrenaline/noradrenaline), cortisol (decrease inflammation, healing, WBC, immune system)
6. Thymus
  1. Located behind manubrium
  2. Releases thymosin (which makes WBC's into T Cells)
7. Pancreas
  1. Located behind stomach
  2. Releases: insulin (increases glucose uptake into cells), glucagon (decreases glucose uptake into cells)
8. Ovaries/testes

Circulatory System

Blood
1. Functions of Blood
  1. Transports nutrients (glucose and O2) and wastes
  2. Protects hemostasis (White Blood Cells mitigate immune response)
  3. Regulates temperature
2. Blood Components
  1. Plasma (55% of blood volume - composed of water, nutrients, hormones, wastes)
  2. Formed Elements (cells - formed in red bone marrow [also called myeloid tissue])
    1. Red Blood Cells (erythrocytes - no nucleus - oxygen/carbon dioxide transport function - live about 3 months - 45% of blood volume)
      1. Produce and carry 100,000s of hemoglobins (an X shaped protein with an iron at each point that can hold oxygen at the iron points) so oxygen can be transferred to tissues
      2. Are phagocytized by liver and spleen when they get old - iron is recycled
    2. White Blood Cells (leukocytes - have nucleus - disease control function - small percentage of blood volume)
      1. Granular Leukocytes
        
        Neutrophils (small, get to invasion site first and phagocytize indiscriminately)
        
        Basophils (secrete histamine)
        
        Eosinophils (secrete antihistamine)
      2. Agranular Leukocytes (these are also made in lymphoids)
        
        Lymphocytes (become differentiated into T-Cells and B-Cells)
        
        Monocytes (are large macrophages - work like neutrophils but produce Interluken 1 code for lymphocytes)
        
        Platelets (Thrombocytes - no nucleus)
        
        Break into many pieces, which are attracted to an injured area. They then get stickier and bigger until they form a platelet plug at the break in the blood vessel wall.
        
        Ingest fat (atherosclerosis)
3. Hemostasis (stoppage of bleeding)
  1. Vascular spasm partially seals blood vessel break
  2. Platelet plug forms
  3. Coagulation factors (there are 13, the final one being fibrin threads over break) cause blood to clot
4. Blood Groups
  1. Antigens A,B can exist in red blood cell membranes. Their presence is used to classify blood into A,B,AB. If you have neither A nor B your blood type is O. If you have Rh factor (with any A/B/O combination) the designation "positive" is added to your blood type.
  2. You generally have antibodies against the antigens you DIDN'T have at birth. If you subsequently receive blood with an antigen that you have an antibody against, or blood with antibodies for an antigen you have, the red blood cells carrying that antigen are destroyed in an attempt to destroy the antigen.
Heart
1. The heart is part of the cardiovascular system along with the blood vessels. The cardiovascular system is necessary to distribute blood (see section on "blood").
2. Surrounding structures (outermost to innermost)
  1. Mediastinum (area heart is located in - bordered by lungs, backbone, and sternum)
  2. Heart Coverings (pericardium)
    1. Fibrous pericardium (fibrous bag)
    2. Visceral pericardium (turns back on itself at base of heart to become parietal pericardium, which forms inner lining of fibrous pericardium - there is a pericardial cavity with serous fluid between the visceral and parietal layers)
  3. Wall of Heart
    1. Epicardium (same as visceral pericardium)
    2. Myocardium (thick, contains muscle tissue that forces blood out of heart - supplied with blood, lymph, and nerves)
    3. Endocardium (contains some Purkinje fibers - inner lining is continuous with inner linings of blood vessels attached to heart)
3. Path of Blood
  1. Superior/inferior vena cava (low oxygen, from rest of body)
  2. Right atrium
  3. Tricuspid valve
  4. Right ventricle
  5. Pulmonary semilunar valve
  6. Pulmonary trunk
  7. Right/left pulmonary arteries
  8. Lungs (becomes oxygenated)
  9. Right/left pulmonary veins
  10. Left atrium
  11. Bicuspid (mitral) valve
  12. Left ventricle
  13. Aortic semilunar valve
  14. Aorta (high oxygen, to rest of body)
4. Heart Functioning
  1. Path of self-excitability system (ANS innervation also affects these nodes)
    1. SA Node (fires to both atria, controls heart rate)
    2. AV Node
    3. AV Bundle
    4. Purkinje fibers (fires both ventricles)
  2. Heart has own blood supply - the coronary arteries
  3. Valves are one directional
5. Pathologies
  1. Angina pectoris: lack of blood to heart
  2. Ischemia: lack of oxygen (in this case to heart)
  3. Myocardial Infarction: heart attack (as a result of ischemia)
Blood Vessels (arteries carry blood away from heart, veins carry blood to heart)
1. Layers of blood vessels (outermost to innermost - blood cavity is called lumen)
  1. Tunica Externa (CT, Collagen, Elastin)
  2. Tunica Media (Smooth Muscle, Sympathetic Innervation - contracts or relaxes to produce vasoconstriction or vasodilation)
  3. Tunica Interna/Endothelium (simple squamous epithelium)
2. Order of blood vessels (heart back to heart)
  1. Aorta (LARGE artery, drains from heart)
  2. Arteries (thick wall with all three layers)
  3. Arterioles (like artery, but thinner in all three layers)
  4. Capillaries (just innermost layer)
  5. Venules (like arteriole, but less muscle and elastic tissue)
  6. Veins (like artery, but with less muscle - has one-way valves)
  7. Superior/Inferior Vena Cava (LARGE vein, drains into heart)
3. Arterial System (ascending/descending aorta join before they enter the heart)
  1. Arteries emerging from ascending arch of aorta (note that before splitting into these two coronary arteries emerge which feed heart)
    1. Brachiocephalic artery (becomes right common carotid and subclavian)
    2. Left common carotid artery (feeds left side of head)
    3. Left subclavian artery (feeds let arm)
  2. Arteries emerging from descending aorta (descending aorta becomes thoracic aorta becomes abdominal aorta and then splits into right and left iliac arteries
4. Venous System
  1. Veins Drained by Superior Vena Cava: (Symmetrical) subclavian, external jugular, and internal jugular join to form brachiocephalic. Right and left brachiocephalic join to form superior vena cava.
  2. Veins Drained by Inferior Vena Cava: (Symmetrical) Left, right common iliac, various visceral veins farther up.
5. Blood vessels exhibit anastomosis (blood finding alternate route, or finding new route - lymphatic system doesn't do this as much)
6. Blood Pressure (force exerted by blood against inner walls of aorta)
  1. Systolic is highest pressure exerted against vessel. Diastolic is pressure exerted against vessel during ventricular relaxation.
  2. BP is highest in arteries
  3. Factors increasing blood pressure
    1. Cardiac output (CO = volume of blood ejected by left ventricle per minute = stroke volume X heart rate)
    2. Blood volume
    3. Peripheral resistance (friction between blood and vessel inner walls - vasomotor center of medulla oblongata can cause vasoconstriction to increase blood pressure)
    4. Viscosity (large numbers of formed cells can increase viscosity)
  4. Little pressure remains by venule ends of capillaries. Blood flow depends on skeletal muscle contraction and breathing movements (just like lymphatic system).
7. Easily endangered vessels
  1. Subclavian artery (in supraclavicular triangle)
  2. Superficial femoral vein (in femoral triangle)
  3. External jugular vein (over SCM in supraclavicular triangle)

Lymphatic System

Any fluid not picked up by venous return goes into lymphatic vessels or capillaries (note that more fluid leaves blood capillaries than returns to them). These are one way vessels that carry previously interstitial fluids and wastes to be emptied into the blood stream at the internal jugular/subclavian junction. The lymphatic system also supports disease control and immunity efforts of lymphocytes, and transports fats from GI tract back to the bloodstream. All body parts have elements of the lymphatic system except for the CNS.
Components of lymphatic system
1. Lymph: clear, water laden fluid with little proteins and lots of lymphocytes/monocytes along with different pathogens. Any fluid that enters a lymphatic pathway is called lymph.
2. Lymphatic Pathways (or "lymphatics")
  1. Lymphatic Capillaries: Found in almost all tissues. Microscopic, closed ended. More porous than other capillaries. Formed by single layer of squamous epithelium. Empty into vessels.
  2. Lymphatic Vessels: empty into trunks
    1. Lymphatic vessels look like veins. They have lots of valves, but generally have less smooth muscle than blood vessels. They often run near veins. They contain many nodes.
  3. Trunks: empty into ducts
    1. R/L Lumbar trunks (drains legs)
    2. Intestinal trunk (drains abdomen)
    3. R/L Bronchomediastinal (drains thorax)
    4. R/L Subclavian Trunks (drains arms)
    5. R/L Jugular (drains head/neck)
  4. Ducts
    1. Right Lymphatic Duct: Drains R Bronchomediastinal, R Subclavian, and R Jugular trunks. Then it empties into the venous system at R subclavian and R internal jugular venous junction.
    2. Thoracic duct: Drains all other trunks (all lymph other than that from right upper body) and empties into L subclavian and L internal jugular venous junction.
3. Organs and other tissues: spleen, thymus, nodes, and myeloid tissue
Lymph nodes
1. Nodes have many afferent lymph vessels, and one or two efferent vessels.
2. Depression where efferent vessel emanates is called hilum. It accepts blood arteriole, emits blood venule, and accepts innervation.
3. Contains medullary cords (CT holding rows of lymphocytes, and monocytes)
4. Contains spaces (lymph sinuses) which hold nodules. Nodules produce and contain lymphocytes and monocytes. They produce more T-Lymphocytes upon reception of thymosin hormone from thymus. Nodules can also exist outside of a node.
5. There are three areas of superficial node clusters: inguinal, axillary, and cervical. There are also three areas of deep nodes: thoracic, intestinal, and lower pelvic.
Spleen (largest lymphatic organ)
1. In upper left quadrant, under diaphragm behind stomach, is 5-7".
2. Looks like a large lymph node, but there is blood in the sinuses instead of lymph.
3. Has two types of tissue
  1. White pulp: nodules containing lymphocytes and monocytes
  2. Red pulp
    1. Works with liver to break down old blood cells
    2. Has fixed macrophages
    3. Acts as a blood reservoir - squeezes blood out upon sympathetic innervation
Factors in lymph fluid movement
1. Skeletal muscle contraction
2. Respiration
3. Valves

Immunity

Terms to Know
1. Pathogen: any disease causing organism (like a virus, bacterium, etc.)
2. Antigen: any protein that stimulates your body to produce antibodies against it.
3. Antibody: protein made by a B-Cell in your own body to fight a particular antigen.
4. Resistance: body's ability to fight off different antigens/pathogens. Susceptibility is the inability to resist.
Non-specific Resistance (resistance mechanisms you are born with)
1. Species resistance (i.e. ants do not acquire measles)
2. Mechanical Features/Structures (skin, cilia, hairs, ear wax, oil, sweat, mucous, urination)
3. Chemicals (gastric juice, enzymes [such as the lysozomes in tears], etc)
4. Interferon (interferes with proliferation of viruses)
5. Inflammation Process
  1. Increased blood vessel dilation and permeability (upon tissue damage, mast cells release histamine)
  2. Phagocytosis by white blood cells (neutrophils and monocytes)
  3. Fibrin formation (clotting)
6. Fever (slows down reproductive capabilities of pathogens)
Specific Resistance (Immunity - resistance mechanisms you acquire)
1. Lymphocytes (note: the undifferentiated immunity cells str produced in red bone marrow [myeloid tissue] or lymph nodes - lymphocytes are differentiated in the thymus to be one of the following)
  1. T-Cells ("T-Lymphocytes")
    1. Comprise about 75% of all circulating lymphoctyes
    2. Found often in spleen and lymph nodes
    3. Differentiated in thymus or in a lymph nodule upon receipt of thymosin from thymus
    4. Form cell-mediated immunity
  2. B-Cells ("B-Lymphocytes")
    1. Comprise about 25% of all circulating lymphocytes
    2. Found often in spleen and lymph nodes
    3. Differentiated in liver and other places
    4. Form antibody-mediated immunity
2. Immune Process
  1. Antigen invades body (i.e. survives non-specific resistance mechanisms)
  2. Monocyte phagocytizes antigen
  3. This monocyte then produces Interluken 1
  4. T-Cell receives Interluken 1, becomes Helper-T
  5. This Helper-T clones itself. Each clone is familiar with initial antigen.
  6. This Helper-T clones Killer-T (Cytotoxic-T). These Killer-T's produce specific lymphotoxins - chemicals that directly wipe out initial antigen. (note: lymphotoxins are more attracted to initial it if it is coated with interferon)
  7. Interluken 2 affects B-Cell, making it into a Plasma-Cell. This cell just makes antibodies against initial antigen.
  8. Plasma-Cell antibodies lock into antigen, neutralizing it for subsequent destruction.
  9. Once antigens are significantly weakened, Suppresser-T's are made to scale down the immune response.
  10. Memory-T's are made by Helper-T's. Memory-T's can live a long time and will remember antigen, thus saving time should the antigen reappear.

Respiratory System

Functions
1. Gas exchange (supply oxygen, excrete carbon dioxide)
2. Filter particles from air
3. Produce vocal sounds
4. pH regulation
5. Water elimination
Organs of Respiration (note: organs outside thorax are part of "upper respiratory tract")
1. Nose
2. Nasal Cavity (nasal conchae support mucous membrane, cilia beat particles to pharynx)
3. Sinuses (air filled spaces, opening into nasal cavity, lined with mucous)
4. Pharynx (behind oral cavity, below nasal cavity, splits to become larynx and esophagus)
5. Larynx (between pharynx and trachea, houses vocal cords, below epiglottis [which lowers to prevent food from entering larynx when swallowing])
6. Trachea (below larynx, splits into right and left primary bronchi, cilia beat upward to pharynx, cartilage c-rings keep it from collapsing)
7. Bronchial Tree (primary bronchi -> secondary bronchi -> tertiary bronchi -> bronchioles -> alveolar ducts -> alveoli, greater percentage of muscle in walls as approaches alveoli, can be dilated by sympathetic innervation)
8. Lungs (right and left lungs separated by heart and mediastinum and enclosed by diaphragm and thoracic cage, surrounded by visceral/parietal pleura [which contains serous fluid in pleural cavity between them], contains air passages/alveoli/connective tissues/blood vessels/lymphatic vessels/nerves, right lung has three lobes while left has two lobes)
Sequence of Respiration (gas exchange)
1. Pulmonary Ventilation (inhalation and exhalation of air to lungs - following is mechanism of ventilation)
  1. Inhalation
    1. Diaphragm contracts (upon stimulation by phrenic nerve) and lowers, drawing in air
    2. External Intercostals, SCM, and Pectoralis Minor may also lift ribs to increase volume
  2. Exhalation
    1. Diaphragm/intercostals relax
    2. Abdominals may contract
    3. Elastic recoil of lungs assists
2. External Respiration (transferring gasses between lungs and blood - 97% of gasses carried on hemoglobin - following comprise respiratory membrane)
  1. Alveolus
  2. Alveolar Basement Membrane
  3. Capillary Basement Membrane
  4. Capillary
3. Internal Respiration (transferring gasses between blood capillaries and ECF/cells)
4. Cellular Respiration (oxygen and glucose are made into ATP/carbon dioxide/water)
Breathing Rate: Conscious control of breathing rate may be accomplished from apneustic/pneumotaxic areas of Pons, but basic rate is set by MRC in Medulla.
Disorders
1. Asthma: Spasm of smooth muscle of bronchioles.
2. Bronchitis: Inflammation of mucous membranes bronchial tubes, generally for three weeks or more.
3. Emphysema: Destruction of walls of alveoli, making it hard to exhale.
4. Pleurisy: Inflammation of pleura.
5. Pneumonia: Bacterial/viral/irritant caused inflammation of lungs.
6. Tuberculosis: Contagious disease affecting primarily respiratory system. Breathing becomes painful.

Digestive System

Functions
1. Ingestion of food and liquids
2. Digestion
  1. Mechanical (chewing, stomach churning)
  2. Secretion (enzymes break foods down)
  3. Absorption of nutrients
  4. Motility (moving unused products)
  5. Elimination
Alimentary Canal (continuous 29 foot tube from mouth to anus)
1. Canal Wall Structure (innermost to outermost - lumen is space they enclose)
  1. Mucosa (mucous membrane)
  2. Submucosa (loose connective tissue: contains blood vessels, lymphatic vessels, and nerves)
  3. Muscularis (smooth muscle: contains circular and longitudinal fibers)
  4. Serosa (secrete serous fluid, so canal can slide around)
2. Movements of canal
  1. Mixing (rhythmic contractions, especially in stomach)
  2. Propelling (peristalsis)
3. Elements of canal
  1. Mouth
    1. Reduces size of food (with assistance of teeth)
    2. Mixes food with saliva to form bolus
    3. Contains oral cavity between tongue and palate
  2. Pharynx/Esophagus
  3. Stomach
    1. Is a dilation of canal
    2. Bordered by lesser esophageal sphincter at top (keeps food from coming back up - an anatomical sphincter), and pyloric sphincter at bottom (true sphincter - releases chyme into small intestine bit by bit)
    3. Contains gastric juice: produced by chief cells (precursor of pepsin to digest protein), parietal cells (hydrochloric acid to facilitate digestion, and intrinsic factor to aid absorption of B12 in small intestine), and mucous cells (mucous to protect stomach lining). Gastric juice production is stimulated upon parasympathetic innervation.
    4. Stomach absorbs very little - mainly drugs and small quantities of water, alcohol, salts, and glucose.
    5. Fatty foods remain in stomach longest - up to 6 hours.
    6. Rugae (folds) provide more potential area.
    7. Stomach is the last place mechanical digestion is performed
  4. Small Intestine
    1. Continues enzyme breakdown sequence
    2. Performs most of the nutrient absorption
    3. Structural parts (order from stomach to large intestine)
      1. Duodenum
      2. Jejunum
      3. Ileum (ends in sphincter called ileocecal valve)
  5. Large Intestine
    1. Structural parts (in clockwise order to anus)
      1. Cecum (appendix projects downward from it - appendix contains lymphatic tissue in the same manner tonsils do)
      2. Colon
        
        Ascending (followed by hepatic flexure)
        
        Transverse (followed by splenic flexure)
        
        Descending (followed by sigmoid flexure)
      3. Rectum
      4. Anal Canal/Anus (guarded by internal anal sphincter and external anal sphincter [only external sphincter is under conscious control])
      5. No digestive function - secretes only mucous
      6. Reabsorbs water/electrolytes and forms feces
      7. Motility is peristalsis via mass movements
Accessory Digestive Organs
1. Salivary glands
  1. Moisten/bind food
  2. Saliva contains amylase for beginning digestion of carbohydrates
  3. Saliva released upon parasympathetic innervation
  4. Major salivary glands
    1. Parotid
    2. Submandibular
    3. Sublingual
2. Pancreas
  1. Secretes pancreatic juice through pancreatic duct to duodenum (duct inserts at same place as bile duct from liver/gallbladder)
  2. Pancreatic juice contains enzymes to break down fats, carbohydrates, and protein
  3. Also releases Bicarbonate ions to neutralize HCl
3. Liver
  1. Plays key role in metabolism by helping regulate normal levels of blood glucose by hormone control
  2. Synthesizes and converts nutrients
  3. Stores glycogen and other substances
  4. Secretes bile through bile duct (overflow stored in gallbladder) into duodenum. Bile emulsifies fats (breaks them into smaller clumps).
Nutrients
1. Lipids
  1. Converted to fatty acids or to long chains for long term storage by liver
  2. Used in cell membranes, nerve sheaths, fat soluble hormones, and yellow marrow
2. Carbohydrates
  1. Converted to glucose
  2. Used first for energy - excess stored in liver as glycogen
  3. If you ingest too much, you excrete it as urine
  4. Cellulose doesn't digest
3. Proteins
  1. Converted to amino acids
  2. Form structural molecules
  3. Used for energy when all else is exhausted
  4. "Essential Amino Acids" can't be synthesized by body, and must be ingested
4. Vitamins (water soluble and fat soluble)
5. Minerals
6. Water
Terminology
1. Metabolism: both catabolism and anabolism
  1. Catabolism: breaking down molecules into smaller elements (releases energy)
  2. Anabolism: building up molecules from smaller elements (requires energy)
2. Mastication: chewing
3. Deglutition: swallowing
4. Micturition: urinating
Disorders
1. Hemorrhoids (Dilated, irritable anal veins - caused in response to high pressure in anal canal)
2. Diverticulitis (Inflamed outpouching in intestinal wall)
3. Peptic Ulcer (Sore in mucosa of stomach, generally caused by HCl)
4. Colon Disorders
  1. Spastic colon (alternates diarrhea with constipation - also called irritable bowel syndrome)
  2. Diarrhea (rapid transit)
  3. Constipation (delayed transit)

Urinary System

Functions (these may all be considered functions of kidneys)
1. Eliminate wastes (esp. urea/uric acid from protein metabolism)
2. Filter blood (regulates chemical concentration - can filter all but blood's formed elements and large proteins)
3. pH regulation
4. Blood pressure regulation
5. Triggers creation of more red blood cells
6. Activates vitamin D
Organs
1. Paired kidneys
2. Ureters (transport urine to bladder - wall is composed of mucous, muscular, and fibrous layers)
3. Bladder (holds urine for later elimination - detrusor muscle forces urine out - internal and external [voluntary] urethral sphincters guard against unwanted micturition)
4. Urethra (transports urine from bladder to external environment)
Kidney Structure
1. Medial hilum (depression) accepts ureter into renal pelvis. Renal pelvis is divided into two or three tubes called major calyces, which subdivide into minor calyces. Small projections called renal papillae project into minor calyx. Hilum also accepts renal artery and vein.
2. Bulk of kidney is composed of inner renal medulla and outer renal cortex. Renal medulla has renal columns and renal pyramids.
3. Entire kidney is surrounded by renal capsule.
4. Interlobular arteries pass between renal pyramids.
5. Kidney contains many nephrons, which are functional unit of kidney: the point of filtration between blood and urine.
Nephron Structure
1. Renal Corpuscle
  1. Glomerulus (tangled ball of capillaries) between afferent and efferent arteriole in renal cortex.
  2. Diameter of capillaries is larger before the glomerulus than after, thus creating high pressure in the glomerulus. Capillaries are also much more permeable than normal at this point.
2. Renal Tubule
  1. Bowman's capsule (expansion of closed end of renal tubule) surrounds glomerulus.
  2. Portion of renal tubule near Bowman's capsule is called proximal convoluted tubule. Dips down into medulla as descending limb, curls back up at loop of Henle, and continues up as ascending limb. Forms distal convoluted tubule when back in cortex. Distal convoluted tubule contacts afferent and efferent arterioles at juxtaglomerular apparatus (which measures blood pressure).
  3. Arterial/venal flow continues in vessels which curl around entire length of tubule (peritubular capillary system)
  4. Many distal convoluted tubules merge in renal cortex to form collecting duct. This passes through medulla, joining with other collecting ducts, and empties into a minor calyx through a papilla.
Urine Formation (removes unwanted water, electrolytes, and wastes such as urea/uric acid)
1. Glomerular Filtration: Water and other substances are filtered out of blood into tubule at Bowman's capsule as glomerular filtrate.
2. Tubular Reabsorption: Some substances (glucose, water, etc.) are transported back from tubule into blood vessel. If you are taking in more glucose than this system can handle, you will excrete some.
3. Tubular Secretion: Some substances (drugs, hydrogen to regulate pH, etc.) are transported from blood vessel into tubule distal to the renal corpuscle.
Disorders
1. Nephritis: Inflammation of kidneys
2. Cystitis: Inflammation of urinary bladder
3. Urinary Tract Infections: Infection of urinary tract
4. Kidney Stones
  1. Form in collecting ducts and renal pelvis
  2. Eventually pass into ureter, causing pain.
  3. Currently treated by extracorporeal shock-wave lithotripsy.

Order of Massage Strokes

Effleurage
Petrissage
Friction
Vibration
Gymnastics
Tapotement
Nerve Strokes

Intake Questions

Surgeries
Hospitalizations
Illnesses
Injuries
Medications
Health Care Practitioner
Circulatory
Pregnancy
Kidneys
Contacts
Why are you here?

Hour-Long Swedish Massage Sequence

Note: this sequence has relaxation as its primary goal. Strokes in brackets are optional. Remember to: go FULL lengths of muscles, progress light to deep, keep in contact, and keep even rhythm.

Client Prone, bolster under ankles
1. Back
  1. Effleurage (Superstroke - light, to apply oil)
  2. Effleurage (linear up back)
  3. Petrissage
  4. Friction (CT Erectors, CT Sacrum, [elbow erectors], LF Suprascap)
  5. Effleurage (Superstroke)
  6. Vibration (full back jostling)
  7. [Gymnastics - Hip Mobilization]
  8. Tapotement (Traps, Interscap, Sacrum)
  9. Effleurage (Pulling/Fanning)
  10. Effleurage (Superstroke)
  11. Nerve Strokes
2. Back of Leg (note: include front of leg as much as possible on return strokes)
  1. Effleurage
  2. Petrissage
  3. Friction
  4. Effleurage (Wringing)
  5. Effleurage (Draining)
  6. Vibration
  7. "Foot"
  8. [Gymnastics (Plantar/Dorsiflexion, Quad Stretch, Hip Rotation)]
  9. Effleurage
  10. Tapotement
  11. Nerve Strokes
Client Supine, Bolster Under Knees
1. Front of Leg (keep draped) [or optionally undrape, then Eff, Petr, Frict, Vibr, Eff, Tap, NS]
  1. Petrissage (quads: grab/lift/squeeze)
  2. Friction (Compression)
  3. Vibration (jostling: esp. quads)
  4. Tapotement (quads)
  5. Nerve Strokes
2. Arms
  1. Effleurage (Start Medial to Pec)
  2. Petrissage (Start on Inside Hip)
  3. Effleurage (forearm)
  4. Petrissage (forearm)
  5. Effleurage (draining, lower arm)
  6. "Hand"
  7. Effleurage
  8. Tapotement
  9. Nerve Strokes
3. Chest/Neck (all done from head of table)
  1. Effleurage (Chest/Shoulders/Neck, Fingers inferior to clavicle, last eff friction strength)
  2. Petrissage (Neck bilateral)
  3. Petrissage (Occiput to C7, One handed)
  4. Friction (C7 to Occiput, Bilateral "Bobbing")
  5. Effleurage ("Knuckles")
  6. Effleurage (Same as first stroke)
4. Face (from head of table, sitting)
  1. Friction (Scalp)
  2. Friction (Ears)
  3. Friction (Face)
  4. Cup Face/Pressure Third Eye
  5. Nerve Strokes (Up face/hair)
  6. Goodbye

Gymnastics Hints

Bermuda Shorts Draping: drape normally, then bring both parts of sheet down to just above knee. Roll bottom over top at side of thigh. Hold this with thumb (fingers go under thigh). This hand rotates to oppose the movement of the thigh. Forearm supports foot. You only have your inside hand on the foot for the flexors.
Take out bolster for all FOL gymnastics.
For people who do computer work, remember gymnastics of fingers (as unit) and wrist.
Encourage client to "let limb feel heavy" if they are guarding.
Encourage client to imagine moving limb through the ROM you are moving it through.
Encourage client to breathe in before stretch, breathe out as you stretch.
You can hold stretches for one minute or more.
For the normal FOL routine, you are doing gymnastics just as BOL: dorsi/plantarflexion, knee to chest (don't compress hip or knee joint), and rotation of hip in two directions. Can start with Achilles stretch. Don't do rotation/knee to chest if client has low back problems.

Back of Leg and Back Variations

Back of Leg
1. Warming Effleurage: Flat, relaxed hands - fast and alternating
2. Fulling Petrissage: Start at top just below glutes. Lift up and squeeze out when you get to top. Keep all of fingers in contact.
Back
1. Twisting Friction: Facing side of table, do one side at a time. Heel of hand on erectors (between central and transverse processes of spine). Hand on hand, thumb points in direction you are moving. Interlock fingers. Lumbar to top and back down, then do opposite side
2. Ironing Effleurage: Hands point together. Start one on glutes, one on opposite scapula. Pass toward each other. Do once near spine and once further out. Switch sides.
3. Insomnia Friction (replaces pulling/fanning): Fingertip friction on erectors (all fingers) with small, subtle movements. Then fan directly out. Go up/down spine then do other side.
4. Scapula Work: Support shoulder like for shoulder girdle rotation. Put client's hand in small of back. Do friction around/slightly under scapula.
5. Coccyx Vibration: Heel of hand on gluteal cleft. Hand over hand vibration. Hands point towards head. Focus on head and moving it.

Advanced Massage Techniques

Forearm Effleurage: down erectors, palm down, crosses over spine, but contact is with proximal forearm. Use entire forearm when drawing up.
Sub-scapularis Friction: arm in small of back, trace under medial border of scapula. You can also do this just by lifting shoulder.
Elbow Friction: down erectors, keep chin over thumb. Afterwards, smooth out with Forearm Effleurage.
Scapular Effleurage/Friction: from opposite side of table. Out over sides of scap, draw up and grab. Good transition stroke (one side of table to another).
Gluteal Wringing: one hand glut. med, other hand on rotators. Good precursor to pelvic mobilization. 45 degree drape.
Pelvic Mobilization: 0 degree drape, and tuck in. One hand on sacrum, other on ASIS. Pull up, push down straight up with no sliding. Movie sacral hand up spine to ribs, then back down to sacrum. Stay on same side of spine as other hand. If you don't feel quadratus lumborum release, do QL pull.
Pelvic Gymnastics: see Pelvic Mobilization, but start with superior hand on ribs, don't push down, and don't move. Hold instead of bobbing.
QL Pull: with both hands (middle finger deepest) pull QL towards spine. Lock and lean. Then fan out.
Skin Rolling: walk fingers, thumb follows and skin rolls move with them. Can do this with or across muscle grain.
Integrating Back and BOL: Can undrape one leg and back (sheet in clump at sacrum, tucked into opposite leg), and then do lots of Lomi-Lomi style full-length-of-body full arm effleurage.

Side Lying Position

Without Body Cushions: pillows on side of lumbar region. Remove head rest cushion and put it on table (build up if necessary) for side of head. Pillow between upper arm and table. Pillow between lower leg and table. Tuck draping under upper arm (have client hold) and at waist of back.
Side lying position is good for pregnant people

Front of Leg + Back of Leg Supine

Do normal draping and leg placement with no bolster
1. Effleurage: to apply oil. Distal to proximal, including BOL on return stroke
Lift leg from thigh (no need to change draping, but check it and tuck if necessary) and sit on foot
1. Petrissage: bilateral of thigh to ankle
2. Effleurage: compression (anterior hand) up calf, compression (posterior hand) up thigh
Abduct hip (keep knee flexed)
1. Petrissage: rectus femoris
2. Effleurage: palmar on rectus, ulnar forearm on adductors
3. Friction: fingers around patella, fist up ITB
4. Wringing: calf, compress tissue to bone (keep thumbs against hand), up to top of thigh
5. Friction: rectus femoris - anchor tissue, lean back, then slide up. Use fingers, leaving small space for septum of muscle.
6. Effleurage: rectus femoris
Return leg to table
1. Vibration: lift/jostle quads, then jostle to foot
2. Effleurage: foot
3. Friction: CTF anterior tib.
4. Wringing: foot
5. Friction: LF intermetatarsals (til reach bone), trace back up
6. Friction: toes, rolling in and milking out
7. Friction: finger friction around malleoli (2 dirs)
8. Effleurage: V-drain to head of table
9. Vibration: over trochanter, hand over hand, stationary
10. Vibration: jostle down to foot.
11. Vibration: align leg, then do traction of whole leg (support above malleoli outside hand, inside hand above foot)
Position as for anterior leg gymnastics, but no need for bermuda draping (check tuck, though)
1. Gymnastics: knee to chest
Leg back to table, aligned
1. Tapotement: vertical hacking down quads, pincemont medial calf, spatting sole of foot
2. Nerve strokes: entire leg
Optional: Friction: like first non-oil applying effleurage, but use more pressure and fist on hamstrings

Notes on Positioning: Take out bolster. Leave 8-10" hem at top. Have client lift legs and point feet towards each other, then tuck draping under feet. Then do U draping for stomach. It helps if you left material in the abdominal area. Work from client's right side. For the gymnastics, put client's knees down [hold sheet at waist as you are doing so].

Wringing over abdomen.
Face head of table and outline the ribcage with thumbs from sternum down to table (upon client's exhalation) and continue by tracing iliac crest using flat fingers from table to center of abdomen. Do this three times, about as fast as client breathes.
From right of client, petrissage full abdomen. Start at opposite side from you and work toward you, then back to center.
Friction: Three concentric circles over the small intestines using flat fingertips (start at umbilicus, work each circle a little larger in a clockwise direction).
Friction: Flat fingertips tracing large intestines (ascending, transverse, and descending) plus stationary vibration over sigmoid flexure (three times).
Vibration - stationary - over spleen, liver, and gallbladder area, on client's exhalation. This amounts to twice on client's right side, once on left.
Vibration of abdominal wall on client's exhalation (reach under client's back and jostle abdominal wall, table to center of abdomen. Do this three times. Start underneath ribcage, anterior.
Gymnastics: stretch obliques by stabilizing hip and lifting ribcage in two or three positions. Repeat other side. Lift straight up.
Wringing over abdomen.
Goodbye.

Sports Massage Basics

General Advice
1. Done fast, through clothing, vigorous music, no lubricants, rarely longer than 30 min.
2. When in doubt, vibrate
3. Increase compression pressure from light to deep
4. Deep/precise work shouldn't be part of pre-event work, and should be used with caution for post event
5. Have ice packs and first aid equipment for emergencies - be prepared to call for triage (especially if more than one muscle cramps at once)
6. Encourage adequate hydration
7. In case of cramp
  1. Remain calm and confident
  2. Direct compression over cramp, followed by attempt at either reciprocal inhibition or Golgi tendon stimulation
  3. After cramp subsides a little, gently stretch and repeat above step until it's gone.
  4. When cramp is gone, ice muscle and have it stay that way for the next couple of hours. Have disposable ice containers to give athletes.
8. Pre-event massage must follow warm-up, be 15-20 minutes
9. Post-event massage should be done between 1 and 2 hours after the event. Should be slower to prevent cramps, and avoid tense-relax stretching for the same reason.
Areas to emphasize by sport
1. Running
  1. Full legs, buttocks, low back, interscapular
  2. If running more than 3 times a week, 1 massage per week
2. Swimming
  1. Upper back and neck, full arms, shoulders, chest, and abdomen
  2. If swimming more than 3 times a week, 1 massage per week
3. Bicycling
  1. Full legs (esp. thighs), low back, neck, shoulders, and chest.
  2. Legs should be massaged after each work-out, and 1 full massage per week
4. Court Sports
  1. Entire upper body with emphasis on arms and shoulders, legs in general
  2. General leg massage after each hard work-out, upper body 1 per week
5. Skiing
  1. Full legs and back, arms, shoulders and neck if cross country
  2. Full body massage after each weekend of skiing for amateurs - competitive skiers should have legs and back done 2 per week.
6. Hiking/Back Packing
  1. Back and shoulders, legs and feet, abdomen
  2. End of each day
7. Weight Lifting
  1. "Body Builder" stress points shoulders and chest, esp. pectoralis. "Power lifter" has most strain low back, thighs, upper trap/neck
  2. Emph upper or lower body depending on which has been worked that day. Ideally, would treat for 30 min before each workout, 30 min after each workout.
8. Baseball/Softball
  1. Shoulders and arms
  2. Amateurs need one massage after each long weekend of playing
9. Basketball
  1. Full legs, back
  2. Each game should be followed by a full leg massage including low back. Shoulders, neck, and arms as needed.
Pre-event massage
1. Prone
  1. Full hip and leg jostling
  2. Glutes and hamstring compressions and petrissage (with knee bent to 90 degrees)
  3. Frog leg iliotibial band compression and circular friction
  4. Palmar friction and muscle jostling of hamstrings and glutes
  5. Gastroc compressions and petrissage
  6. Palmar friction and muscle jostling of gastroc
  7. Ankle rotation plus Achilles stretch
  8. Contract-relax stretch of quads
  9. Anterior compartment compressions and circular friction
  10. Foot compressions
  11. Tapotement
2. Supine
  1. Full limb jostling
  2. Quadricep Compressions (3 sets)
  3. Petrissage of quads with light friction of patellar tendon
  4. Myofascial stretch of quads
  5. Foot molding
  6. Hip mobilization followed by groin compressions
  7. Groin, hamstring, lats stretch
  8. Jostling and tapotement
Post-event Massage for Runners/Joggers
1. Prone
  1. Full hip and leg jostling
  2. Glutes and hamstring compressions and petrissage (bend the knee to 90 degrees)
  3. Hip rotations and gentle quad stretch
  4. Frog leg ilotibial band compression and circular friction
  5. Gentle jostling of hamstrings and glutes
  6. Gastroc compressions and petrissage
  7. Muscle jostling of gastroc
  8. Hold and release tender points if muscle guarding is sufficiently reduced (common points in gluteals, hamstrings, mid-gastroc and Achilles insertion)
2. Supine
  1. Full limb jostling
  2. Quadricep compressions
  3. Petrissage and twisting friction of quads
  4. Myofascial stretch of quads
  5. Quick compression of anterior compartment then foot molding
  6. Hold and release tender points if muscle guarding is sufficiently reduced (common points in origin of rectus femoris, across the musculotendinous junction of quads, and the origin of anterior tibialis and peroneus brevis)
  7. Hip Mobilization followed by groin compressions
  8. Groin, hamstring, lats stretch
  9. Petrissage [optionally include effleurage with oil] both front and back of legs
Supine Upper Body
1. Compressions of pec
2. Compression stretch pec
3. Petrissage up traps/delts
4. Compressions brachium -> petrissage
5. Compression forearm -> petr. forearm
6. Interior Fingers -> hand work
7. "Chuck Berry"
8. Hand over head -> triceps compression
9. Arm over head -> stretch
10. Lift arm to ceiling -> down to table

Lomi-Lomi Basics

General principles
1. Use body weight instead of force
2. Use as much of arm as possible
3. Do everything three times (unless noted otherwise)
4. Do Back, then Front
5. Do Left, then Right
6. Cultivate grace: if it looks beautiful, it probably feels beautiful
Back
1. "Superstroke" like motion: three circles around heart, three around ribs, one around glutes (come back with forearms along sides), three brushes out over shoulders, one going down arms and up glutes as before.
2. Form T with both hands at sacrum, travel up over spine (vertebrae between index and middle finger), vibrating as you go.
3. Quick "flush" up side (up, shoulder to neck). On third go out to arm, wriggle wrist, and break popsicle.
4. Hand to face cradle
  1. Elbow to armpit
  2. Elbow to ribs
  3. Elbow to glutes. On third pivot to head of table
  4. Glutes to ribs
  5. Glutes to armpit. On third sandwich arm and stretch.
5. Arm to table, and repeat for other side, starting with "flush"
Back of Leg
1. Undrape leg, go to opposite side of table
2. Place foot off side of table. Compress Glutes: place, lean, and drop with heel of hand in three places (sacrum, middle, external)
3. Fist compression into thigh/calf, working down and up. Fists at angles
4. Pull up inside of leg, go around, pull up outside of leg
5. Wrap around trochanter three times
6. Split hands, effleurage with one to shoulder, the other down to foot. Put two hands on sacrum and cover foot.
7. Go to same side of table
8. Effleurage full leg with open palm and forearms
9. Pick up foot, drain calf (up tibia, down gastroc, and visa versa)
10. With knee bent, flex foot and drain Achilles
11. Effleurage foot to knee
12. Effleurage foot to glute (one hand up hams, one up ITB), after third compress ischial tuberosity with one hand and area above trochanter with the other
13. Effleurage from foot up to top of fingers, back down arm, pivot when going up at ribs, pivot at knee when going down.
14. Forearm effleurage plantar surface of foot (hand up, leg up - hand down, leg down)
15. Foot compression/rock
Front of body
1. Starting at ankle, full arm effleurage leg all the way up. Inside arm around iliac crest (over, then under).
2. Support leg with your knee/thigh
  1. Warm foot
  2. Fingers around malleoli, alternating, with foot moving back and forth
3. Palm drains up anterior tibialis while other hand presses hard on quads
4. Thumb (wrist straight) along tibia, fingers (flat) looped on other side of tibia. Fan open at knee.
5. Petrissage the knee with both hands - one on each side (to just below patella)
6. Pick up leg by skin just below knee and wiggle
7. Bend knee (client's heel to client's buttocks) and sit on foot
  1. Fingers grab quads. Lean in and out rhythmically as you glide down leg.
  2. Effleurage medial and lateral thigh with palms of hands moving at same time up and down. Should rock leg.
8. Pick up leg and stretch (frog leg). Lean on knee.
9. Stretch leg, straight, to side of table. Push at heel, support at knee.
10. Rotate hip, letting heel touch table each time, hand under heel. When knee inside just let leg slide drop. Immediately vibrate quad to foot.
11. Seat hip: hand on foot, push straight up to acetabulum
Arm
1. Forearm drains, thumbs together, one set on each side
2. Thumb friction of palm
3. Arm over face, go around head of humerus.
4. Bend your knees, lift arm at elbow, hook arm at elbow, stretch over client's head
5. Undrape leg, while leaving arm's side undraped too
6. Starting at ankle, full arm effleurage leg all the way up. Inside arm around iliac crest (over, then under).
7. Repeat above step, but just lower leg
8. Repeat above step, but full leg
9. One stroke up all the way and stretch arm
Stomach
1. Hands on upper sternum, slide down to stomach and open to sides
2. Flat thumbs around ribcage to iliac crest
3. Petrissage stomach
4. Reach to back, pull from spine to navel
5. Thumbs in navel, pull in 4 cardinal directions
6. "Energy Massage" - palm circles above body, becoming wider as palms ascend
Neck/Face
1. Hands on upper sternum (crossed)
2. Finger friction out in 3 intercostals. Outline inferior clavicle, pivot over shoulders, come up neck.
3. Linear hand friction - upper sternum to ear - turn neck a little to get each side
4. Knuckles ("duck bill") from acromion process to ear
5. Thumb behind ear to brachial plexus, press, out over shoulder
6. Lift head with one hand, do "hourglass" friction with the other (fingers, thumb on opposite sides of cervical vertebrae, start at C4 or so, expand up to occiput, contract to start position again, expand down to rhomboids, repeat)
7. Fingers hold head up at occiput. Slide fingers in slowly and let head slide down to table.
8. Side neck stretch
9. Cheeks
10. Chin
11. Eyebrows
12. Scalp friction, in groups of three
13. "Star" hand to client's face (hold hand up in air first)

Precautions Against Contagious Disease

Handwashing: Wash hands thoroughly before and after each massage with any household or microbicidal soap and hot water.
Equipment: Clean before and after each massage with a solution of two tablespoons of household bleach per one gallon of water. A spray-on alcohol solution would probably also be sufficient.
Linens: Use clean linens for each massage. Wash them in hot water, and dry in highest heat setting. If blood or other infected fluids are present, add one-quarter cup of household bleach to the wash cycle.
Gloves: Latex gloves should be used when client's skin has seeping, open, or overly sensitive manifestation. They should also be used when client has a transmissible condition. Gloves should also be used when practitioner's skin is broken. Open sores should never be massaged even with gloves, as this would increase damage. Use water- based lubricants with latex gloves (i.e. lotions).

First Aid/CPR

Certification: CPR Certification is good for one or two years (AHA), first aid certification is good for three years (ARC). After this, check with fire department for "Medic II" retraining.
CPR
1. Within 2 hours, 60% of people who start showing heart attack symptoms die
2. Heart Attack: portion of heart doesn't get enough blood (and hence oxygen). Can be caused by athro/arteriosclerosis.
3. Angina: less blood gets to heart, but no total blockage. Nitro can cause vasodilation and ease this problem.
4. Within 10 minutes of a heart attack, irreparable damage is done to cells
5. Only one person performs CPR, until he switches with another person
6. Symptoms of heart attack
  1. Chest discomfort ("tightness", "weight on chest") - pain can radiate to shoulder, arm, or jaw
  2. Shortness of breath
  3. Loss of color (blueness around lips/fingertips)
  4. Nausea
  5. Sweating
  6. "Looks bad"
  7. History of heart attack
  8. Sense of "impending doom"
  9. Sudden collapse
7. CPR Procedure (ABC - airway, breathing, circulation)
  1. Tap/shout (find out if they're conscious)
  2. Tell one specific person to call 911 to come for "unconscious person" and come right back
  3. Position victim supine, flat on floor
  4. Head tilt/chin lift (hand on forehead, grasp chin).
  5. Look/listen/feel for breathing (wait 7 sec). If no air, continue...
  6. Pinch nose, blow in two deep breaths
  7. Check pulse for 7 sec (in groove by Adam's Apple), if no pulse, continue...
  8. Repeat these steps 4 times, then check pulse again
    1. Do 15 compressions (Press on sternum [not xiphoid] with two-handed press, elbows straight, shoulders over work. One second between compressions, go down 2")
    2. Head tilt, chin lift as above. 2 breaths.
8. For adult CPR, 15 compressions, then 2 breaths. Rescue breathing is one breath every 5 seconds.
9. For a child or infant, 5 compressions, then 1 breath. Rescue breathing is one breath every 3 seconds.
10. Above routine is good for any situation, including drowning
11. Child/Infant CPR
  1. Child: Compressions - one hand on head, one hand for compression (1" down). Compressions should be faster.
  2. Infant: Compressions as above, but use three fingers - 1st on nipple line, rest go down, then lift first finger. Compressions should be quite fast. Pinch toe to see if it is conscious. Don't crack head back all the way. Use brachial pulse. Use only a puff of a breath.
Choking
1. "Choking" implies total obstruction. If a person can speak at all, it isn't choking.
2. Heimlich Maneuver Procedure (NEVER use back blows, unless victim is age 0-1)
  1. Note: if victim is unconscious, check for food obstruction
  2. Side of fist on belly button - first thrust should be the hardest (if victim is pregnant, use CPR landmark)
  3. For infant choking, turn upside down facing down - then 5 back blows - then roll over for chest thrusts (quite fast)
First Aid
1. Open wounds: Applying cold helps control pain and bleeding
2. Burn
  1. Cool with cold water (note: don't put on water or anything else if skin is broken)
  2. Dry, clean dressings (note: don't wrap burns tight)
  3. Call ambulance, especially if victim has trouble breathing
3. Injury to joint
  1. Rest
  2. Ice
  3. Elevation (immobilize if significant)
4. Fainting - after fainting, put victim on back and elevate feet
5. Diabetic Crisis (typified by physically lethargic, and possibly verbally abusive victim): administer sugar, request assistance
6. Signs of Shock
  1. Restlessness
  2. Pale skin
  3. Rapid breathing/pulse
7. Wound
  1. Cover
  2. Press firmly
  3. Elevate above head
  4. Bandage
  5. Squeeze artery if necessary
8. Swelling: ice will decrease swelling
9. Heat stroke (typified by dry/hot skin) - put victim in cold water. Administer water.
10. Don't give liquids to a groggy or unconscious person
11. Monitor "ABC"'s in all injuries and illnesses

Business Information

Note: this information is current as of February, 1995. It applies to WA State Only. (360) 236-4867 is the new number for massage licensing at DOH. Licenses must be renewed every year before your birthday, whether or not you receive a reminder (otherwise there's a $40 late fee). To renew, send $40 to Washington Department of Health / health Professions Quality Assurance Division / PO Box 1099 / Olympia WA, 98507-1099; checks should be made out to Dept. of Health, and you should put your LMP licence number on your check and indicate it is for a Massage License.

Potential Credentials for Self-Promotion
1. Graduation from accredited school, with over 500 hours of training.
  1. School curriculum (i.e. kinesiology, anatomy, etc.)
  2. Electives
  3. AIDS Education
  4. First Aid/CPR Certification
2. LMP licensing (practical exam fee $50, written exam fee $65, initial license $55, yearly license renewal $65).
3. Reciprocity with Oregon (this may require additional forms and fees)
4. Passing NCE (National Certification Exam). This will ease being able to practice in many different states. Fee to take this test is $150.
5. AMTA membership ($30 application fee, $235 per year active membership, $20 WA Chapter fee), or membership in a similar professional massage organization. This will provide the added credential and safety of being fully insured. Please note that there are less expensive alternatives to AMTA membership and insurance. One can receive $1,000,000 insurance through the IMA (1-800-933-7113) which covers special events, general/office liability, professional liability, and product liability with no deductible for only $99 per year (half that for the first year if you sign up in your last month as a student). Another option is the NAMT (1-800-776-NAMT) which offers full insurance (as above, but including prior acts and with different coverage amounts) for $159 per year. Look in Massage magazine for applications.
6. Becoming a "R

TABLE OF CONTENTS

Massage School Notes