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 "Registered Counselor" with Dept. of Health ($35 fee, no requirements, (360) 586-4561).
7. Any existing degrees you might have (BS, etc.), related licenses (ATC, etc.), and relevant memberships (chamber of commerce, etc.)
8. Experience, special training, specialties, special equipment
AMTA Membership Benefits
1. Publications: Hands On, Massage Therapy Journal, AMTA-WA Journal. Of course, you can always visit your massage school library after you graduate and read them there instead, or buy the journal from magazine shops.
2. Ability to participate in AMTA National Sports Massage Team and WSMT (director: 528-6834), and to take the national sports massage exam. The national sports massage exam would provide an additional credential.
3. $1,000,000 (per incident and aggregate) professional and comprehensive general liability insurance,
4. Discounted attendance/participation at National Education Conference and annual conventions,
Business Requirements
1. State Massage License (LMP Status).
2. WA State Business License. Call 1-800-647-7706, and have them send master business license form. Using this form, apply for sole proprietorship status (the best choice for massage therapists in almost all cases). The fee is $15. This will yield a UBI number, which you use when you fill out the Seattle Business License form. You generally don't have to pay a yearly fee or file any forms for this if you're on "non-reporting" status, which many massage therapists will probably be on (see the application for details).
3. Seattle Business License (assuming you practice in Seattle). Call 684-8484. Costs $65/year, starts in January, isn't prorated.
4. EIN (need this only if you have employees)
5. Call 296-0100 to see if you have to pay any county taxes.
General Marketing Advice
1. Principles
  1. "You can't sell something nobody wants"
  2. "You can't sell something unless someone knows about it"
  3. "You must have a way to deliver the product or service"
  4. "Income must at least equal expenses within a reasonable period of time"
2. Generally, the more your advertising is targeted at a specific group, the more effective it will be. It might be better to have several specific campaigns for several different types of clients than to have one general one.
3. Emphasize the benefits to the customer, rather than technical information about your work that they may not understand.
Misc. Advice
1. Check zoning so you are sure you can practice in the place you have in mind. To do this in Seattle, call 684-8850 and speak to a land-use technician. If you wish to practice out of your home, and your home is in a residential area zoned "Single Family", a common requirement is that you follow the Home Occupation Guidelines: basically, run your home-based business by apointment only, do not advertise your address (only your phone number - even in yellow pages!), and have no signs outside your home indicating that a business operates there.
2. If zoning allows it, it is technically legal to live in your office, even if it is located in a business or industrial zone.
3. If you rent space from another practitioner, check with employees and clients of that practitioner to insure his customer draw (and hence your environment) will be stable.
4. Look into sharing a professional space with other practitioners, as unused time in an office is a waste. However, it may be convenient to provide all of the non- consumable supplies yourself so it isn't necessary to pay people off as they leave the shared situation. Be sure this shared situation is OK with the lease you sign. It may be best to have one person's name on the lease, and to have everyone else pay him. It is even better to find a place that you could afford even without sharing, so you aren't financially endangered if people leave and can't easily be replaced. All involved in this must agree NEVER to even ATTEMPT to claim unemployment, or to claim an injury as an on-the-job injury (i.e. do not claim that you have an employer who is responsible for you). You should require that everyone in the shared situation have personal health insurance, on the job health insurance, and professional liability insurance, as well as LMP status. It is possible to register with L&I and then say you don't want coverage, if this would help the situation.
5. It might be more difficult to get MD/DC referrals if you work out of your home.
6. Consider using a laundry service (American Linen 281-1990 or similar provider).
7. Can have hot/cold packs for therapy (Myer 1-800-472-4221 or similar provider), and have some available to sell to clients for home therapy. You can also have relaxation tapes/CD's for sale, and maybe a handout on relaxation.
8. Employees are difficult and expensive to maintain. Think carefully before adding one. There are also very strict rules for whether a worker may be classified as an independent contractor.
9. Remember that you may need to do independent planning for retirement, since you are working for yourself and no employer is providing a pension. An IRA, Keogh, or Simplified Employee Pension may be appropriate.
10. Going into effect July 1, 1994, LMPs will need 16 hours of continuing education every 2 years. These hours must be reported with license renewal. Note that (see WAC 246-830-475) "continuing education" is broadly defined. It may be first aid/CPR training (and perhaps the same course required for renewal), watching educational videotapes (no more than 4 hours), teaching a course for the first time (no more than 8 hours), taking business or management courses (no more than 6 hours), etc.
11. You may wish to look into taking Visa and Mastercard. Check with your bank and with "Credit Card Equipment and Supplies" in the yellow pages. The IMA (see above) may also be offering this service soon.
12. Examine massage school job folders for potential work.
13. A possible phone solution to allow easier client access is to have a pager/voice mail number. Call American Voice Mail at 783-1707 for details; the best approach is probably to have regular voice mail with a pager attached to it, so you won't lose messages if you turn off the pager, and if someone pages you through the voice mail box their phone number is kept as a voice mail message.
Rules Pertaining to Massage (some familiarity with these is needed for the state exam)
1. RCW (Revised Code of Washington)
2. WAC (Washington Administrative Code)
3. AMTA Guidelines
Tax Information
1. Sole proprietors pay self-employment tax instead of social security tax (if necessary).
2. If something is "appropriate and helpful in developing and maintaining your trade or business", you should keep a receipt for it as there is a good chance you can deduct it. This can include business supplies (used exclusively by business), advertising, educational expenses, convention fees, professional fees, etc. Basically, keep receipts for everything until you have a sense of what can be deducted and what can't.
3. If you hire someone to do your taxes a CPA may be more than is needed. Check that your tax professional has done some billing for massage practitioners and has experience representing clients in IRS audits. These services may cost up to $150 per year, depending on complexity, but keep in mind that your personal taxes would be done at the same time (remember that there is little distinction with a sole proprietorship). Also, be sure that this person operates year-round.
4. The IRS may consider your practice as a hobby rather than as an income generating business if you don't:
  1. Sincerely try to make a profit (and keep good records)
  2. Make regular business transactions
  3. Make a profit the last three years out of five.
Client Insurance Billing
1. Medicare pays only if it is billed through a hospital, physical therapist, or physician. You must be an employee of one of these to receive payment.
2. Auto insurance will often cover automotive injury patients for massage.
3. L&I will cover work injury patients for massage.
4. Depending on your comfort level with insurance billing, a professional insurance billing service (such as MPS 775-8007) may be appropriate.
5. Relevant CPT Codes (1994)
  1. 97010 Physical medicine treatment to one area; hot or cold packs
  2. 97039 Unlisted Modality (specify) [note: such as sports, MLD, CTM]
  3. 97112 Neuromuscular Reeducation
  4. 97122 Traction, Manual
  5. 97124 Massage
  6. 97139 Unlisted Procedure (specify)
  7. 97145 Physical Treatment to one area, each additional 15 minutes
  8. 97250 Myofascial release/soft tissue mobilization, one or more regions
  9. 97530 Kinetic activities to increase coordination, strength, or range of motion, one area (any two extremities or trunk), initial 30 minutes each visit.
  10. 97531 Each additional 15 minutes
  11. 97540 Training in activities of daily living (self care skills and/or daily life management skills); initial 30 minutes, each visit
  12. 97541 Each additional 15 minutes
Personal and Business Insurance
1. L&I covers on the job injuries - even carpal tunnel syndrome - but doesn't cover non-work related injuries. So you need personal health insurance. However, if your personal health insurance plan purchased through a private agency (i.e. John Alden, Blue Cross WA/AK, etc.) covers on the job injuries, L&I isn't necessary. One should check the private insurance plan for dental and vision coverage, which is sometimes excluded. Personal health insurance can sometimes be obtained very inexpensively through Washington State (1-800-660-9840).
2. Professional Liability Insurance covers one against any harm you do to someone in the course of practice, excluding sexual abuse. It operates wherever you are.
3. Premises insurance covers one in the event a client slips and falls on your floor.
4. You might also want some sort of insurance for your space against fire/theft/vandalism/earthquake/etc.
5. Note that most homeowner's insurance policies exclude you from all benefits if you run a business from your home. Check the policy. You may need to get a "business endorsement" through the company.

Theory of Massage

Classes of physiological effects
1. Mechanical - Definition: Direct effect in the tissue being worked.
2. Reflex
  1. Definition: Indirect effect of the massage. Is the body's response to the direct effect.
  2. Explanations for a reflex effect to occur in an area other than the one being worked
    1. Shared/Common Nerve Trunks (spinal nerve trunks carry axons innervating many different areas)
    2. Autonomic Nervous System (the type of contact, pressure, and rhythm used will stimulated either sympathetic or parasympathetic response)
Physiological Effects of Massage
1. Enhances circulation (this leads to improved nutrition and elimination of metabolic by-products in soft tissue)
2. Enhances joint/muscle function (by breaking adhesions, stretching tissue, and encouraging healthier scar-tissue formation after trauma)
3. Improves energy levels (through improved circulation and sense of well-being)
4. Relieves stiff/sore muscles (through effects 1 and 2 - is especially effective for backaches and tension headaches)
5. Soothes nervous system (reflex effect)
6. Delays muscle atrophy (mechanical/reflex effect)
7. Improves skin texture (through gland stimulation and oil application)
8. Prevents injuries/enhances athletic performance (through effects 1, 2, and 3)
9. Reduces edema (mechanical/reflexive - should not be performed over pitted edema)
10. Enhances organ function (reflexive)
Rules to Determine Safety of Massage
1. If in doubt about treatment, have your client check with his or her health care professional first.
2. Always monitor results during the treatment and ask about delayed reactions at the following treatment time.
3. Take a complete medical history and follow up each indicated area. Use your knowledge, reference materials, and intuition to guide your decision about treatment.
Components of Massage
1. Contact
2. Rhythm
3. Pressure
Physiological Effects of Specific Massage Strokes (note: it is often the INTENT of the practitioner which determines which classification a particular stroke is put into)
1. Effleurage
  1. Definition: Gliding stroke following body contours
  2. Variations: Draining, two-handed, hand-under-hand, warming, forearm, and nerve strokes
  3. Physiological Effects
    1. Moves fluids
    2. Improves local circulation
    3. Creates sense of well-being and relaxes muscles
    4. Produces superficial heat
    5. Deeper effleurage can compress, stretch, and broaden superficial tissues and muscles
    6. Relieves pain
2. Petrissage
  1. Definition: Lifting tissues away from underlying structures
  2. Variations: One-handed/two-handed/bilateral, big-C/little-C, skin rolling, kneading, wringing, fulling
  3. Physiological Effects
    1. Relieves edema
    2. Stretches, broadens, and loosens tissues
    3. Prevents muscle stiffness/soreness
    4. Revitalizes skin
    5. Delays muscle atrophy, enhances muscle tone
    6. In abd, improves digestion and elimination
3. Friction
  1. Definition: Compression of tissues against underlying structures
  2. Variations: Stationary, linear, cross fiber, circular, wringing
  3. Physiological Effects
    1. Break adhesions
    2. Myofascial releasing
    3. Stretch muscle/tendon fibers
    4. Reduce muscle tension
    5. Generate superficial heat
    6. Create local hyperemia
    7. In abd, improves digestion and elimination
    8. Relieves pain
4. Vibration
  1. Definition: Rhythmic shaking of body part
  2. Variations: Stationary, traveling, traction, jostling
  3. Physiological Effects
    1. Relaxes muscles/reduces guarding
    2. Loosens superficial tissues
    3. Soothes
    4. Traction vibration will redistribute synovial fluid
    5. In abd or at sacrum, will stimulate visceral digestion and elimination
    6. Relieves pain
    7. Relieves local sinus congestion
5. Gymnastics
  1. Classifications (from point of view of client)
    1. Passive
    2. Assistive
      1. Visualization or mentally thinking through movement
      2. Active contraction to perform movement, with assistance from practitioner
    3. Active
    4. Resistive
  2. Goals of Gymnastics by Type
    1. Passive
      1. Assess available ROM
      2. Assess structural involvement in trauma (Tx Massage)
      3. Maintain or improve ROM
      4. Decrease muscle guarding/promote relaxation
      5. Neuromuscular re-education
    2. Active
      1. Assess useable ROM
      2. Assess strength (Tx Massage)
      3. Maintain ROM and strength
      4. Assess structural involvement in trauma (Tx Massage)
      5. Neuromuscular re-education and muscle relaxation
      6. Assistive: same as active
    3. Resistive
      1. Assess strength (Tx Massage)
      2. Maintain or improve strength (Tx Massage)
      3. Enhance specific muscle palpation
      4. Assess specific muscle involvement and severity of injury (Tx Massage)
      5. Muscle relaxation (reciprocal inhibition, PNF)
  3. ROM Notes
    1. Normal End Feel
      1. Hard: movement stopped by bone bumping into bone (olecranon)
      2. Firm: movement stopped by tissue (ligament, soft tissue) being stretched to limit
      3. Soft: movement stopped by soft tissue bumping into other soft tissue
    2. Abnormal End Feel
      1. Muscle Spasm/Guarding
      2. Capsular
      3. Bone to Bone
      4. Empty
      5. Springy block (cartilage)
  4. Muscle Grades
    1. Normal: client can resist with full muscle strength
    2. Good: client can resist; perhaps not for long or with full strength
    3. Fair: client can move through ROM unassisted by therapist or gravity
    4. Poor: Client must be assisted in ROM by therapist, support or gravity
    5. Trace: client cannot move the body part, but there is a palpable contraction of the muscle
6. Tapotement
  1. Definition: Rhythmic percussion of tissue
  2. Variations: Cupping, hacking, beating, tapping, spatting, pinching
  3. Physiological Effects
    1. Improve muscle tone
    2. Relieve respiratory/sinus congestion
    3. Stimulate NS for reflexive invigoration (short application) of reproductive/digestive/urinary systems when applied over sacrum
    4. Stimulate NS for reflexive relaxation if applied lightly for a long period of time.
    5. Invigorates body
7. Nerve strove: light effleurage

Disease Related Medical Terminology

Etiology: cause of a disease
Sign: objective (practitioner observed) evidence of a disease
Symptom: subjective (patient reported) evidence of a disease
Diagnosis: identification of a disease
Prognosis: prediction of course and end of a disease, also estimation of chances for recovery from disease

Massage Indications

General
1. Sprain, Chronic
2. Strain, Chronic
3. Contractures
4. Digestive Problems
5. Facial Paralysis (Bell's Palsy)
6. Fatigue
7. Insomnia
8. Long Bed Rest
9. Menstrual Dysfunction
10. Myalgia
11. Myofascial Pain Syndrome
12. Neurasthenia
13. Postural Deviations (Kyphosis, Lordosis, Scoliosis)
14. Spasms
15. Tension Headaches
16. Torticolis
Sub-Acute
1. Adhesions
2. Amputation
3. Arthritis
4. Asthma
5. Burns
6. Dislocations
7. Eczema
8. Fibrositis
9. Fractures
10. Myositis
11. Neuralgia
12. Orthopedic/Neurological Peripheral Neuritis
13. Poliomyelitis
14. Scar Tissue
15. Sciatica
16. Sprains
17. Tendinitis
18. Whiplash

Massage Contraindications

Local
1. Burn, Open
2. Bursitis [common in shoulder or knee]
3. Edema, Pitted [swelling that stays down when you press it]
4. Hematoma [blood clot]
5. Infection, Local
6. Inflammation, Acute
7. Skin Disease
8. Sprain, Acute [trauma to joint]
9. Strain, Acute [trauma to muscle]
10. Synovitis
11. Varicose Veins
12. Wound, Open
General
1. Aneurysm [dilation of a blood vessel, often an artery]
2. Cancer [this is somewhat controversial]
3. Cellulitis
4. Colitis, Ulcerative
5. Diabetes, Advanced
6. Diverticulosis [pouch in wall of organ, esp. colon - may be inflamed]
7. Embolism [obstruction of blood vessel]
8. Encephalitis [inflammation of brain]
9. Erysipelas [inflammation of skin]
10. Fever
11. Heart Condition
12. Hemophilia
13. Hepatitis [inflammation of liver]
14. Hernias [protrusion of part of organ through wall that contains it]
15. Kidney Condition
16. Phlebitis [inflammation of vein]
17. Poliomyelitis, Acute [inflammation of spinal cord]
18. Pregnancy [possible with special training]
19. Sinusitis
20. Surgery, New
21. Thrombus [blood clot obstructing part of the heart]
22. Tuberculosis
23. Undiagnosed Condition (esp. abdominal masses)
Note: -itis is inflammation. The symptoms of inflammation are the same as those of infection: pain, heat, redness, swelling, and disordered function.
Note: a contusion is a bruise

Contraindication Notes

Inflammation
1. Acute: Direct massage contraindicated
2. Sub-acute: General massage indicated
3. Chronic: Direct massage indicated
Pain: do not massage where severe pain is present in joints, bones, or muscles
Arthritis
1. Do not massage currently swollen or inflamed joints.
2. Massage can be beneficial for non-swollen or inflamed joints, especially using slow/gentle ROM exercises and stretching
Orthopedic Disturbances/Post-Surgical Situations
1. Be sure tissue has healed from incisions first
2. Do not position or massage in any way that causes pain
Cardiac Conditions
1. Severe cardiac conditions (i.e. unstable and unmedicated high blood pressure) are a contraindication for massage because heart may not tolerate increased circulation.
2. However, massage in general is good for high blood pressure as well as post heart attack and post-bypass situations
Blood Clots
1. Do not massage anyone with a blood clot. They should be on blood thinners and under medical supervision.
2. Profile of someone prone to clotting
  1. Elderly
  2. History of cardiac problems or cardiovascular disease
  3. Patient treated previously for clotting
3. Clots often occur in lower legs, causing pain and hypersensitivity in calves - obviously, do not use deep massage and draining strokes in such a case.
4. Thrombus = clot, phlebitis = inflamed vein
Varicose Veins
1. Do not use deep pressure or deep draining strokes directly on veins.
2. Spider veins not contraindicated.
Hemophilia (or someone on blood thinners such as Cumaden)
1. Avoid deep pressure, which may cause bruising. Vitamin C can help with bruising.
2. Bruising should not be a result of any type of massage.
Skin Diseases/Rashes/Open Wounds/Burns: Avoid, especially if contagious or integrity of skin is compromised. Sometimes, work can be done through a sheet.
Contagious Disease: Do not massage if either you or a client has one.
Fever: Massage will weaken client in such a condition and make illness worse.
Cysts/tumors
1. Encourage client to see doctor if an abnormality looks suspect.
2. Massage will not benefit tumors/cysts and may cause irritation.
3. Fatty cysts (lipomas) are common under skin, are harmless, and massage will not be benefit them.
Pregnancy
1. Avoid deep abdominal massage
2. Some women develop clots in legs during pregnancy, so avoid deep draining on legs. In general, though, legs need thorough work.
Diabetes
1. Deep massage contraindicated for very advanced diabetes with pitted edema (where tissue stays depressed after you press on it). However, general circulatory strokes are still beneficial in this case.
2. Massage is helpful for diabetes in general.
Cancer: current consensus is that massage is advised for cancer patients. However, do not directly and deeply massage a cancerous tumor. A doctor's OK may be helpful in cancer cases.

Massage Endangerment Areas and Structures

Note: lymph nodes are located in many of these areas.

Occipital Area ("Foramen Magnum Area")
1. DEFINING STRUCTURE: Occiput (just under)
2. ENDANGERMENTS
  1. Occipital Artery
  2. Greater Occipital Nerve
  3. Lesser Occipital Nerve
  4. Left and right vertebral arteries (go through cervical transverse processes lateral to erector spinae)
T12
1. DEFINING STRUCTURE: T12 (Lateral to Erector Spinae)
2. ENDANGERMENT: Kidneys
Popliteal Fossa
1. DEFINING STRUCTURES
  1. Biceps Femoris
  2. Semimembranosis
  3. Gastrocnemius
2. ENDANGERMENTS
  1. Popliteal Artery
  2. Popliteal Vein
  3. Tibial Nerve
  4. Common Peroneal Nerve
TMJ
1. DEFINING STRUCTURES
  1. Condylar Process of Mandible
  2. Mandibular Notch of Temporal Bone
2. ENDANGERMENT: Trigeminal Nerve
Anterior Triangle
1. DEFINING STRUCTURES
  1. SCM
  2. Mandible
2. ENDANGERMENTS
  1. Facial Artery
  2. Facial Vein
  3. Facial Nerve
  4. Sublingual/Submandibular/Parotid Glands
  5. Thyroid
  6. External Jugular Vein (over SCM)
Supraclavicular Triangle ("Posterior Triangle")
1. DEFINING STRUCTURES
  1. SCM
  2. Clavicle
  3. Upper Trapezius
2. ENDANGERMENTS
  1. Accessory Nerve
  2. Subclavian Artery
  3. Subclavian Vein
  4. Brachial Plexus
Deltopectoral Triangle
1. DEFINING STRUCTURES
  1. Anterior Deltoid
  2. Pectoralis Major
2. ENDANGERMENTS
  1. Brachial Plexus (C5-T2, goes under clavicle, through axilla)
  2. Axillary Artery
  3. Axillary Vein
Axilla
1. DEFINING STRUCTURES
  1. Pectoralis Major
  2. Latisimus Dorsi
2. ENDANGERMENTS
  1. Axillary Artery
  2. Axillary Vein
  3. Axillary Nerve
Antecubital Fossa
1. DEFINING STRUCTURES
  1. Brachioradialis
  2. Pronator Teres
  3. Bony part of Humeral Condyles
2. ENDANGERMENTS
  1. Brachial Artery
  2. Brachial Vein
  3. Medial Nerve
  4. Basilic Vein
  5. Cephalic Vein
Inguinal Region ("Femoral Triangle")
1. DEFINING STRUCTURES
  1. Inguinal Ligament
  2. Sartorius
  3. Adductor Longus
2. ENDANGERMENTS
  1. Femoral Artery
  2. Femoral Vein
  3. Femoral Nerve
  4. Greater Saphenous Vein
Fibular Head
1. DEFINING STRUCTURE: Head of Fibula
2. ENDANGERMENT: Common Peroneal Nerve
Abdominal Aorta
1. DEFINING STRUCTURE: Abdominal Aorta (near navel, more left than right)
2. ENDANGERMENTS
  1. Abdominal Aorta
  2. Thoracic Duct

Classes of Manual Muscle Manipulations

Isometric Contraction
1. This is contraction of the muscle while the length of the muscle does not change. It can enhance palpation of the prime mover, as that muscle will become tense upon contraction, and can also be used to assess strength. The practitioner may increase pressure while the client is instructed to maintain the current position (commonly a slightly shortened one).
2. Reciprocal Inhibition is an isometric contraction of the antagonist for a given muscle. It will often cause relaxation of the agonist, and thus alleviate a cramp. If it is being used to alleviate a cramp, one will probably not have the luxury of putting the muscle in a shortened position.
Isotonic Contraction (muscle contracts, and length of muscle changes)
1. Concentric: muscle length decreases
2. Eccentric: muscle length increases

Manual Muscle Testing

Note: when several muscles are separated by a slash, the test is a gross muscle test for those muscles - also, client should maintain position of body part against indicated pressure.

Client Prone
1. Levator Scapula/Upper Trapezius
  1. Client slightly moves shoulders to ears
  2. Pressure on shoulders to foot of table
2. Middle Trapezius
  1. Humerus 90 degrees abd, palm forward
  2. Pressure to floor
3. Rhomboids
  1. Humerus 90 degrees abd, palm back
  2. Pressure to floor
4. Lower Trapezius
  1. Humerus 120 degrees abd, palm forward
  2. Pressure to floor
5. Latissimus Dorsi
  1. Slight med rot (palm up). Slight add/ext.
  2. Pressure flex, abd
6. Teres Major
  1. Humerus 90 degrees abd, forearm hanging down
  2. Pressure on humerus to floor
7. Infraspinatus/Teres Minor
  1. Humerus 90 degrees abd, forearm hanging down, slight lateral rotation
  2. Pressure on forearm to foot of table
8. Subscapularis
  1. Humerus 90 degrees abd, forearm hanging down, slight medial rotation
  2. Pressure on forearm to head of table
9. Supraspinatus
  1. Humerus 10 degrees abd
  2. Pressure into add against humerus
10. Deltoid
  1. Humerus 90 degrees abd
  2. Pressure into add against humerus
11. Erector Spinae
  1. Arms at sides. Tester's forearms on client's buttocks, thighs
  2. Have client extend back and hold. Pressure is that of gravity
  3. Note: if client extends too far, glutes become engaged
12. Splenius Capitus/Splenius Cervicus
  1. Neck slightly extended
  2. Pressure into table
13. Quadratus Lumborum
  1. Flex knee, slight femur abd
  2. Pressure on iliac crest to foot of table
14. Gluteus Maximus
  1. Flex knee, slight hip ext
  2. Pressure on thigh downward to table
15. Piriformis
  1. Flexed leg, hip in lat rot (pull leg to center line)
  2. Pressure on ilium to table, on leg away from center line
16. Semimembranosis/Semitendonosis
  1. Flex knee, slight med rot tibia
  2. Pressure on leg to foot of table
17. Biceps Femoris
  1. Flex knee, slight lat rot tibia
  2. Pressure on leg to foot of table
18. Soleus
  1. Flex knee, slight plantarflex
  2. Pressure on sole of foot into dorsiflex
19. Gastrocnemius
  1. Flex knee (less than soleus), slight plantarflex
  2. Pressure against sole of foot into dorsiflex
20. Peroneals
  1. Flex knee, slight plantarflex, slight eversion
  2. Pressure on foot into inversion
Client Side-Lying
1. Gluteus Medius
  1. Hip abduction
  2. Pressure against leg downward to table
2. Tensor Fascia Latae
  1. Hip abduction, slight hip flexion
  2. Pressure against leg downward to table
Client Supine
1. Tibialis Anterior
  1. Slight foot inversion
  2. Pressure on foot into eversion
2. Sartorius
  1. Flex hip, knee
  2. Pressure simultaneously into hip ext, knee ext, med rot of hip
3. Adductors
  1. Flex knee, foot on table
  2. Pressure just proximal to knee to nearest side of table
4. Rectus Abdominus
  1. Flex knees
  2. Have client hold "crunch" - pressure is that of gravity
  3. Note: if client goes too high hip flexors activate
5. Obliques
  1. Have client reach left shoulder to right hip
  2. Pressure against shoulder back to table
  3. Note: this uses left external obliques, right internal obliques
6. Pectoralis Major
  1. Flex, add, med rot humerus (arm over chest)
  2. Pressure humerus into abd
7. Pectoralis Minor
  1. Arm to side. Have client push shoulder up.
  2. Pressure against shoulder downward into table.
8. Serratus Anterior
  1. Fist in air, shoulder off table
  2. Pressure on fist downward to table
9. SCM/Scalenes
  1. Flex neck
  2. Pressure against head back to table
  3. Note: if chin juts out too far, client is using SCM more than scalenes
10. Coracobrachialis
  1. Flex humerus and arm. Rotate so hand points to head.
  2. Pressure humerus into ext, abd (in opp dir of arm)
11. Biceps Brachii/Brachialis
  1. Flexed elbow, thumb points to nearest edge of table
  2. Pressure against forearm to foot of table
12. Brachioradialis
  1. Flex elbow, thumb points to head of table
  2. Pressure against forearm to foot of table
13. Triceps Brachii
  1. Flex shoulder, forearm points horiz across chest
  2. Pressure on forearm into flex (stabilize at humerus)
14. Flexor Carpii Radialis/Ulnaris
  1. Flex arm, then flex wrist
  2. Pressure wrist into ext
15. Extensor Carpii Longus/Brevis/Ulnaris
  1. Flex arm, then ext wrist
  2. Pressure wrist into flex
16. Pronators
  1. Flex arm, partial pronation
  2. Pressure into supination
17. Supinators
  1. Flex arm, partial supination
  2. Pressure into pronation
Client sitting on edge of table
1. Quadriceps
  1. Slight leg extension
  2. Pressure on leg into flexion
2. Illiopsoas
  1. Flex hip
  2. Pressure on thigh downward to table

Muscular System General Treatment

Trigger points
1. Use constant pressure (10 seconds) on point, within pain tolerance of client.
2. May have to come back to point 3 times or so.
3. Follow treatment by moving muscle through range of motion (full)
4. Have client do ROM+stretch several days after
5. Drinking more water can help prevent TP's
6. Feels like tense point. Will either refer pain or cause jump response if it's a trigger point - otherwise it's a tender point
7. Go in slowly
8. When treating TP
  1. ask client if point is tender upon palpation (usually is for trigger/tender point)
  2. Ask if there are any referred sensations when examining point
  3. Ask if there is a release or reduction in discomfort during/after pressure
Using proprioceptors on cramp
1. Press on GTA at musculotendinous junction
2. Reciprocal inhibition: engage antagonist against resistance (isometric)
After an isometric contraction, muscle relaxes and lengthens, causing increased ROM. This is more for freeing extremes of ROM than for normal HT.
Do stretches slowly to allow muscle spindles time to adapt.

SOAP Notes

General Information
1. Relate emotional symptoms to physical conditions so as to justify whole body treatment to insurance companies
2. Explain treatment of areas distant from injury in terms of injury, so insurance company will pay
3. Document improvement so treatment won't be considered palliative and insurance company will pay
4. See Hands Heal text for jargon and abbreviations
5. On subjective section, only client pain complaints should go on figures
6. If you notate something on figure, it doesn't have to be written out
7. Can "sunset" complaints with phrase: "Let me know if X acts up again"
8. Can ask about new injuries with phrase "Do you have any physical concerns today"
Pain Descriptions
1. Qualify (dull/sharp/etc.)
2. Quantify (L,M,S)
3. Freq (cons, freq, inter, seld)
4. Duration
5. What increases/decreases pain
Limitation Descriptions
1. Qualify (L,M,S)
2. Duration
SOAP Format
1. Subjective
  1. Primary Complaint
  2. Location
  3. When
  4. How
  5. Description
2. Objective
  1. Postural Assessment
  2. Palpation (knots, etc.)
  3. ROM (passive/active)
  4. Strength (mm test: L,M,S)
  5. Special Tests
3. Assessment: post massage changes (subjective or objective) - "Do you feel any differently then before the massage?"
4. Plan: for this massage
  1. Goals
  2. What to do to accomplish goals
  3. Homework
  4. Progress of an ongoing treatment
  5. Next treatment plan

Treatment Massage Procedure

Assess Needs (Evaluate)
1. Interview and History
2. Observe and Palpate (includes posture/gait)
3. ROM Tests
  1. General Advice
    1. Do unaffected side first for reference
    2. Document ROM on star charts
      1. Extremes of chart are extremes of normal motion in that direction
      2. Feel free to cross things off or annotate the chart
    3. Tell client to tell you when they experience pain
  2. Procedure (do in order)
    1. AROM
      1. Watch for compensating movements that were not present on unaffected side
      2. If this is pain free, there is no discernible problem with that joint and you may quit
    2. PROM
      1. Client should consciously relax muscle
      2. Generally "lift" limb before rotating
      3. Pain indicates inert tissue problems
        
        If in all directions, indicates joint
        
        If in certain directions, indicates ligaments
      4. Lack of pain indicates contractile tissue problems
    3. RROM (isometric, in neutral position, stabilize properly - note that pain here is true pain, not a stretch sensation)
      1. Strong/Painless: No Problem
      2. Strong/Painful: Minor Lesion - ask client to pinpoint pain
      3. Weak/Painful: Severe Lesion - ask client to pinpoint pain
      4. Weak/Painless: Rupture of muscle or impairment of nerves
4. Strength Tests (see RROM)
5. Special Tests (see "Special Tests" section)
Set Goals
1. The more specific and "assessable" the better
2. Some should be short term, some should long term
Plan Treatment (also determine frequency of assessments and treatments)
1. Hydrotherapy
2. Massage/Gymnastics
3. ADL's
Treat Client
Post-Massage Assessment

Information Desired from Treatment Evaluation

Structures involved in pathology (where to Tx)
Stage of healing (Tx goals and plan)
Severity of injury (whether to refer)

Stages of Severity

Acute Onset
1. Mild
  1. Mild swelling and loss of function
  2. Sharp pain with short duration
2. Moderate
  1. Moderate swelling and loss of function
  2. Sharp pain with long duration
3. Severe
  1. Severe swelling and loss of function
  2. Sharp pain initially with long duration ache
Chronic Onset
1. Mild: Pain after activity
2. Moderate: Pain during activity
3. Severe: Pain at all times

Treatment Guidelines

Acute (until 2 days after injury)
1. Physiology
  1. Hemorrhage & chemical activation lead to inflammation and swelling
  2. Increased membrane permeability leads to secondary edema formation
  3. Pain/spasm/pain cycle
  4. Hematoma formation
2. Signs/Symptoms
  1. S-Swelling
  2. H-Heat
  3. A-A Loss of Function
  4. R-Red color in tissue
  5. P-Pain (sharp/stabbing)
3. Goals
  1. Stabilize
    1. Hemorrhage and swelling
    2. Pain/spasm/pain cycle
    3. Secondary edema
  2. Protect hematoma organization
4. Treatment Plan
  1. Hydro: RICE (rest, ice, compression, elevation)
  2. Massage: indirect, contralateral, or antagonist
  3. Exercise: ROM passive through assistive (active if possible) - must be pain free! No stretching or resistives.
Subacute (from end of acute until about 7-14 days after injury)
1. Physiology (Healing begins)
  1. Decreased number of leukocytes
  2. Increased number of fibroblasts
  3. Granulation tissue formed
2. Signs/Symptoms
  1. Decrease in swelling, heat, and pain (changes to ache)
  2. Increase in AROM and strength
  3. Color changes to purple/yellow
3. Goals (Improve and enhance following)
  1. Circulation to decrease swelling
  2. Decrease of pain
  3. Increase of ROM and strength
  4. Proper fiber alignment
4. Treatment Plan
  1. Hydro: ice, contrast (i.e. ice knee, heat hip), cryokinetics
  2. Massage: direct, beginning in periphery of swelling with eff, petr, light Cyriax friction.
  3. Exercise: progressive ROM active through resistive (isometric), passive and active stretches.
Maturation/Mobility (from end of maturation/mobility on)
1. Physiology (Collagen Remodeling): Collagen synthesized by dissolving the granulation and exudate
2. Signs/Symptoms
  1. Swelling only after activity
  2. Normal temperature
  3. 80% normal AROM but still painful at end ranges - resistives painful
3. Goals
  1. Reduce adhesion and spasm
  2. Return full pain free ROM
  3. Create strong but pliable scar
  4. Begin strengthening
4. Treatment Plan
  1. Hydro: Heat before activity or massage, ice after. Cryokinetics.
  2. Massage: Deep and direct work like Cyriax friction and myofascial release
  3. Exercise: Full AROM with isometric strengthening, passive to active stretches
Maturation/Strength (from end of subacute on)
1. Physiology (Collagen Remodeling): Collagen completely replaces granulation and is strengthened by demands made on tissue
2. Signs/Symptoms
  1. Swelling only after activity
  2. Normal temperature
  3. Pain free 80% normal AROM and can resist without pain
3. Goals: All of those in Maturation/Mobility, plus return to full muscle strength
4. Treatment Plan
  1. Hydro: same as in maturation/mobility
  2. Massage: same as in maturation/strength
  3. Exercise: Progressive active ROM and isotonic resistives, all stretches are appropriate.

Notes on Treatment Guidelines

Four signs of tissue damage
1. Swelling (extra fluid due to hemorrhage and secondary edema)
2. Heat (caused by increased blood flow and chemical activation)
3. A Loss of Function (damage to nerves or pressure on nerves, also chemicals)
4. Redness (caused by blood flow and vasodilatation)
5. Pain (damage to nerves or pressure on nerves, also chemicals)
Tissue will take longer to repair if additional activity causes damage, and if secondary edema/injury wasn't controlled.
Reasons to maintain as much movement as possible during healing phase
1. to prevent or limit development of adhesions
2. to decrease atrophy and stiffness in surrounding tissues
3. to maintain and increase blood flow to improve nutrient/waste exchange
4. to create a mobile scar
Pain/spasm/pain is caused by damage to nerve or pressure on nerves due to hematoma. Muscles spasm to protect the area, in turn causing more pressure and more pain. A viscous cycle begins. Ice, pressure (massage), heat can all be used to break to cycle.
If client has a month-an-a-half old contusion that still yields severe pain with movement or inability to use muscle, refer this patient to a medical doctor.

Treatment Miscellaneous Principles

Basically, if you want someone to stretch and pain is what is limiting the motion, use ice first. If you want someone to stretch and tightness is what is limiting the motion, use heat first.
The general pattern for optimal functioning of a muscle is: break adhesions (XFF or similar, increased water intake) to allow free movement, obtain full range of motion (neuromuscular reeducation/passive stretching, possibly preceded by ice or heat), and finally strengthening (client's responsibility).
Often, a muscle spasm is the result of another injury (such as a ligament sprain) and is not the cause of the pain.
Basically, then, there are only two things we do to injuries: ice site in acute phase to reduce cell death, and friction/stretch/ROM in late subacute/maturation phase (which prevents restrictions on full motion).
Treat causes, not merely symptoms.

Neurologic Pain

Note: In general, if client reports shooting pains [usually down the entire length of a limb] during friction treatment, the problem could be an impinged nerve. Note also that pain/numbness/weakness/tingling are often felt in relation to situations where a disc is pressing on a nerve.

True: Impingement of nerves against/within vertebral bodies. Generally caused by herniated/ruptured disc. Exhibits one or more of the following signs/symptoms
1. Burning sensation
2. Decreased myotome/dermatome
3. Decreased autonomic organ function
4. Decreased deep tendon reflex
5. Positive special test (such as Valsalva)
Peripheral: Impingement other than true neurologic

Lumbar Evaluation

Key Questions (note: this information is in addition to the normal relevant information found in an evaluation)
1. Is trauma soft tissue or structural?
  1. Onset: Gradual onsets aren't usually structural
  2. Type of Pain at Onset
    1. Soft Tissue: Twinge followed by warm rush
    2. Structural: Felt pop/snap and sharp stabbing pain.
  3. Type of Pain Now
    1. Soft Tissue: Stiff and achy, but it warms up
    2. Structural: Constant ache, sharp stabbing pain upon movement
2. Are client's neurological signs true neurological or peripheral nerve signs?
3. Should I refer this client?
Special Tests
1. SLR
2. Millgram's
3. Valsalva
4. Gaenslen's
5. Patrick/Fabere's
See Back/Spine Decision Tree for Treatment Assistance (Appendix A)

Pelvic Exercises

Client Exercises Each Morning
1. On your back, feet flat (knees bent), arms out at side. Knees go to one side, straighten legs and do again. Alternate sides. For variety, try turning the head to the opposite direction that the knees are going.
2. Resistance stretch: on your back with legs flat on floor. Pull one knee towards chest until tightness. Push knee in opposite direction while holding it with the hands. Breathe, exhale, and pull knee closer to chest to tightness. Repeat 3-4 times, both sides.
3. On your back, arms out at side, feet flat. "Hip hike" to isolate low back muscles.
4. Lying on side, thighs at 90 degrees to trunk. Alternate extending the knee that lies on top.
Pelvic Stabilization (Done for pelvic anterior tilt, or for situations where one leg appears on supine client to be longer than the other)
1. First do various stretches of leg and thigh muscles
2. Put client's foot on your shoulder, with your outside hand thumb on client's ASIS, inside hand supporting buttocks.
3. Come forward until thing perpendicular to table
4. Ask client to press foot against your shoulder while you count to ten.
5. Have client inhale, then as he/she exhales press foot forward and rotate up with hands.
6. Do once for each leg, then alternate legs until leg lengths the same.

Postural Evaluation

General Information
1. Ideal Posture: where there is minimum stress applied at each joint
2. Postural/gait assessment can be done even as the client walks into the treatment room. It may be helpful to have the client bring a swimming suit to the first treatment.
3. If client is standing and you press down on their shoulders, they will buckle at place of weakness.
4. If client closes eyes and walks forward, they will often veer in the direction of the "shortened" leg.
5. Generally, work on concave side 4x more than you do on convex side of postural deviation. The "short" side will need releasing, the "long" side will need strengthening.
Plumb line visualization
1. Anterior
  1. Landmark/what you should see
    1. HEAD: level, facing straight ahead
    2. SHOULDERS/CLAVICLE: level
    3. HANDS/ARMS: distance from side, thumbs point forward
    4. WAIST/TRUNK: straight forward, no difference in angle at waist
    5. PELVIS: ASIS/iliac crest level
    6. KNEES/PATELLA: level, patella straight in groove, alignment with tibial tuberosity
    7. FEET/ARCHES: toes forward, equal arches
  2. Faulty Posture
    1. HEAD: Rotated/Lateral flexion
    2. SHOULDERS/CLAVICLE: Not level
    3. HANDS/ARMS: Decrease or increase, dorsum or palm forward
    4. WAIST/TRUNK: Rotation, lateral shift
    5. PELVIS: Not level
    6. KNEES/PATELLA: Knock knees/bow-legs, shifted patella
    7. FEET/ARCHES: Internal/external Rotation, collapsed arch
  3. What Above Faulty Posture Might Mean
    1. HEAD: Tight suboccipitals, SCM, Scalenes, Transversospinalis
    2. SHOULDERS/CLAVICLE: Tight Trapezius, Levator
    3. HANDS/ARMS: Tight QL and abdominals, pecs and rotator cuff muscles
    4. WAIST/TRUNK: Tight QL, External obliques, erector spinae, iliopsoas
    5. PELVIS: ASIS/iliac crest level
    6. KNEES/PATELLA: Quad imbalance, structural anomaly
    7. FEET/ARCHES: Tibial torsion?
2. Side View (do left AND right)
  1. Location of Plumb Line: From ear, through glenohumeral joint, bodies of cervical and lumbar vertebrae, and just anterior to lateral malleolus
  2. Landmark/what you should see
    1. EAR: directly above shoulder
    2. SHOULDER: in line with ear
    3. SPINAL CURVES: lordotic neck and lumbar, kyphotic cervical curves
    4. PELVIC ANGLE: Level ASIS to PSIS
    5. KNEES: Over feet, relaxed
    6. FEET: Weight evenly distributed front to back
  3. Faulty Posture
    1. EAR: Anterior to shoulder
    2. SHOULDER: Protraction/retraction
    3. SPINAL CURVES: Increase/decrease of those curves
    4. PELVIC ANGLE: Anterior tilt = ASIS lower, posterior tilt = ASIS higher
    5. KNEES: Hyperextended or flexed
    6. FEET: Weight forward/backward
  4. What Above Faulty Posture Might Mean
    1. EAR: Tight SCM's, Scalenes
    2. SHOULDER: Tight pectoralis muscles and subscapularis
    3. SPINAL CURVES: See notes at end
    4. PELVIC ANGLE: Tight iliopsoas, QL, Hams, Quads, Erector Spinae
    5. KNEES: Often related to lordosis and pelvic tilt
    6. FEET: Too many things to mention
3. Posterior
  1. Landmark/what you should see
    1. HEAD: Level and straight
    2. SHOULDERS: Level, even contour of traps
    3. SCAPULA: Level and flat against body
    4. SPINE: Straight
    5. WAIST/TRUNK: Equal side angles
    6. ARMS: Equal distance from trunk
    7. PELVIC THROUGH LEGS AND FEET: Level at PSIS, gluteal fold, knees, and straight Achilles
  2. Faulty Posture
    1. HEAD: Sidebend or rotation
    2. SHOULDERS: One shoulder higher, uneven contour of trapezius
    3. SCAPULA: One higher or rotated, winged
    4. SPINE: Scoliosis
    5. WAIST/TRUNK: Unequal side angles, rotation, lateral shift
    6. ARMS: Unequal distance
    7. PELVIC THROUGH LEGS AND FEET: Unequal
  3. What Above Faulty Posture Might Mean
    1. HEAD: Same as from anterior view
    2. SHOULDERS: Same as anterior view
    3. SCAPULA: What muscles effect scapular rotation. Examine role of serratus anterior.
    4. SPINE: Determine functional/structural, short tight/long tight, whether there is a leg length discrepancy.
    5. WAIST/TRUNK: Same as anterior view
    6. ARMS: Same as anterior view
    7. PELVIC THROUGH LEGS AND FEET: Various
Postural Pathology Terms
1. Lordosis: The anterior or concave curvature normally present in the cervical and lumbar spine. What we must evaluate is whether that curvature is excessive (hyperlordosis) or decreased (hypolordosis).
2. Sway Back: The normal lordosis may be present, but the trunk is shifted posteriorly.
3. Kyphosis: The posterior or concave curvature normally found in the thoracic spine and sacrum. Lumbar hyperlordosis is often accompanied by hyperkyphosis in the thoracic spine and protracted head and shoulders. In this case, the LMP must carefully check for spasm and trigger points in the muscles of anterior neck, medial rotators of shoulder, scapular protractors, hip flexors, and erector spinae.
4. Scoliosis: A lateral curvature and rotation of the spine. In this case there is no bone deformity.
  1. Functional: A reversible lateral curve with the following possible causes
    1. True or apparent leg length discrepancy
    2. Muscle spasm
    3. Asymmetric posture (i.e. curve disappears with trunk flexion)
  2. Structural: An irreversible curvature with bone deformity/fixed rotation of vertebrae
    1. The ribcage is prominent on the convex side
    2. Lateral curve remains apparent with trunk flexion.
5. Pelvic Tilt: Refers to the relationship between ASIS and PSIS (level or tilted). Ideally, the angle should be 0-10 degrees in men, and 5-15 degrees in women.

Hydrotherapy

General Information
1. Water Temperatures (Fahrenheit)
  1. Very Cold: <=55
  2. Cold: 56-69
  3. Cool: 70-80
  4. Tepid: 81-92
  5. Warm: 93-99 (also called "neutral")
  6. Hot: 100-105
  7. Very Hot: 105-110
    1. Scalding at 120
    2. Tissue damage starts at 110
    3. During pregnancy, core temperature should never go above 102 (thus, avoid hot baths, sauna, steam)
2. Energy Transfer
  1. Conduction: water against skin
  2. Convection: air acts as insulator
3. General Contraindications
  1. If Unfavorable Reactions Are Observed: Headache, uncontrollable shivering, dizziness, insomnia (after repeated treatments, heart palpitations, skin sensitivity (often manifested by ticklishness), hives, hyperventilation, faintness, nausea, any other stress-related sign
  2. Sensitivity to water
  3. Malignant cancer (get MD approval first)
  4. Client hemorrhages easily
  5. Client has decreased ability to sense pain (such as with leprosy)
  6. Weakness
  7. Skin lesions (or any condition that could be irritated by hydrotherapy)
Therapies
1. Cold
  1. Physiological Effects
    1. Short Cold (9-16 minutes)
      1. Decreased skin temperature
      2. Raised threshold levels for muscles
        
        Decreases risk of cramp
        
        Relieves spasm and tension
      3. Pain relief (reduces sensory neuron impulses to spinal cord)
      4. Local vasoconstriction
        
        Decreases capillary permeability
        
        Reduces swelling
      5. Decreases tissue post-injury destruction
        
        Vasoconstriction slows macrophages
        
        Decreased metabolism allows tissue to survive hypoxia of trauma
    2. Long Cold (after "short cold", lasting about 6 minutes after application removed - shouldn't ice more than 20 minutes)
      1. Vasodilation (hands, feet, face only)
      2. Tissue may be damaged (chemical release from blood/local cells)
      3. Respiration gradually decreases
  2. When to use
    1. Acute stage (especially with "sharp pain")
    2. Hemorrhage
    3. Inflammation
    4. Pain relief (better at this than heat)
  3. Application
    1. For events, fold a cloth in quarters, wet, put in plastic bag, freeze.
  4. Special Contraindications
    1. Shivering
    2. Advanced cardiovascular disease
    3. Severe hypertension
2. Heat
  1. Physiological Effects
    1. Local vasodilation
      1. Over a large scale, such as with a warm bath, this can cause a decrease in blood pressure.
      2. This also causes increased blood and lymph circulation in the skin, especially for 5-10 minute applications.
    2. Metabolic rate increase (locally).
      1. Speeds healing (increases leukocyte levels)
      2. Raises body temperature
      3. Increases respiration rate
    3. Muscle spasm is reduced (but muscle threshold levels are lowered, increasing possibility of cramps)
    4. Pain is reduced.
    5. Collagen becomes more pliable (as well as all connective tissue)
    6. Local perspiration (elimination) is increased.
  2. When to use
    1. Chronic onset conditions (especially with "aching" pain)
    2. Mature healing stages
    3. Anytime more collagen pliability is desired (such as before cross fiber friction). However, never use heat in an acute phase.
    4. Spasm relief (better at this than cold)
  3. Application
    1. For events, fold a cloth in quarters, wet, put in plastic bag, microwave.
  4. Special Contraindications
    1. Pregnancy
    2. Active Tuberculosis
    3. Anemia
    4. Diabetes Mellitus (consult treating Physician)
    5. Heart disease
    6. Hypertension
    7. Peripheral vascular disease (especially atherosclerosis/arteriosclerosis
    8. Don't allow body temperature to go above 104 F. An oral thermometer may be used to monitor.
    9. Don't let pulse exceed 140 beats per minute
    10. For full body heat applications, allow 30 minutes of well-covered rest afterwards.
3. Contrast
  1. Consists of alternating heat and cold in one place
  2. Can form vascular pump
  3. Facilitates edema removal
  4. Use in subacute stage, or when uncertain
4. Zone
  1. Heat locally, cold distally
  2. Can pump blood away from cold

Cross Fiber Friction

Goal: Reduce adhesions which lead to decreased mobility and pain; realign collagen
Placement of Tissue
1. For sheathed tendons (tenosynovitis, etc.), place on stretch
2. For lesions in muscle, place in relaxed and shortened position
Area of Treatment
1. Done directly on lesion
2. Serves no purpose on an area of REFERRED pain
3. Resisted motion can help determine exact spot of injury. The client can also locate the area of pain, as it is usually tender to the touch.
4. Can be done on ligaments, tendons, and muscles
Treatment Technique
1. No lubricants are used.
2. Done in one direction only (transverse to tissue fibers), moving with skin, pressure to depth of lesion.
3. Pressure can be built up over session: stay at "6" on 1-10 pain scale, and check in to be sure this is where one is.
4. Done for 10-20 minutes only.
5. Pain involved in this treatment (as should be the case with any adhesion-breaking treatment) should decrease in subsequent sessions, as the adhesions which cause the primary discomfort are being broken.
Contraindicated for: rheumatoid arthritis, infective arthritis, calcification of soft tissue, over nerves, and during acute/early subacute stages. Also, if injury is too deep, perhaps PROM and stretches would be more appropriate to break adhesions.
Procedure
1. Heat
2. XFF
3. Massage
4. Stretch/Full ROM
5. Ice

Special Tests

Note: In all cases where a test produces sensation you should have client describe location and type. Unless otherwise noted, a positive result is reproducing the pain of interest.

Neck
1. Compression/Distraction (for spine). Easiest when patient sitting. If distraction relieves pain, might indicated compressed nerve root. Compression should reveal source of pain.
2. Kernig's: supine patient puts hands behind head and lifts head to chest. Can be used to locate interthecal problems on the spine, or nerve root problems.
Upper Extremities
1. Carpal Tunnel Syndrome
  1. Tinel's
    1. Repeatedly tap over volar carpal ligament on median nerve at palmar side with wrist in SLIGHT extension.
    2. Positive produces tingling or shocking sensation in hand.
  2. Phalen's
    1. Client maximally flexes wrists (inverted prayer position) and holds one min.
    2. Repeat for extension
    3. Positive reproduce tingling sensation (paresthesia) in hand, often in first three digits.
2. Thoracic Outlet Syndrome
  1. Adson's
    1. Identifies thoracic outlet syndrome via Scalene and Cervical Rib Syndrome.
    2. Take radial pulse at wrist on affected side. Have client take/hold a deep breath and rotate head to that side, while therapist abducts and extends arm.
    3. Positive is a weakening of pulse or reproduction of pain
  2. Military
    1. Identifies thoracic outlet syndrome via Costoclavicular Syndrome
    2. Therapist stands behind client. Client should simultaneously hold a deep breath and pull shoulders back and down. Client needs to keep head in normal position.
    3. Positive is reproduction of pain.
  3. Pec Minor
    1. Identifies thoracic outlet syndrome via Hyperabduction/Pectoralis Minor Syndrome
    2. Therapist stands beside the client with one hand on the radial pulse and the other over the acromioclavicular region. The client holds their arm in an abducted position as the therapist externally rotates the humerus, and gives it traction to create scapular elevation.
    3. Positive is a weakening of pulse or reproduction of pain
  4. Roos
    1. Identifies thoracic outlet syndrome via compression of the subclavian artery, but provides no information as to where it is being impinged.
    2. Client holds arms at 90 degrees abduction, palms forward, wrists flexed. Ask them to repeatedly and rapidly open/close hands for one minute.
    3. A positive is when one hand slows or pain is reproduced.
Lower Extremities
1. Straight Leg Raise (practitioner lifts one leg of supine patient, and stabilizes)
  1. If produces pain (especially shooting, burning, from 30-60 degrees), back off and dorsiflex foot (La Seagues Test). If this reproduces pain, ask client to locate source of pain. If is along sciatic nerve, problem may be sciatica.
  2. If SLR positive (buttock pain), you can externally rotate leg at point of pain to see if symptoms diminish. If symptoms diminish, this is further evidence that piriformis is impinging on sciatic nerve.
  3. Well leg raise. If this is positive, SLR pain could be could be true neurological pain (especially herniated disc)
  4. If SLR pain is at > 60 degrees, is probably a stretch sensation. If pain is at less than 30 degrees and is present mainly in posterior thigh, may be muscle pain rather than neurological.
2. Gaenslen's: Supine patient, patient draws both legs to chest, then shifts so one buttock is over edge of table. Allow unsupported leg to drop while other stays flexed. Complains of SI pain indicate pathology in that area.
3. Milgram's Test: Supine client raises straight legs 2" from table and holds. If patient can hold 30 seconds without pain, interthecal problems may be ruled out.
4. Patrick/Fabere's: Patient lies supine and places foot of involved side on opposite knee. Inguinal pain indicates pathology in hip joint or surrounding muscles. At end of motion, place one hand on flexed knee joint and other on opposite ASIS, then press. Increased pain indicates pathology of sacroiliac joint.
General
1. Valsalva (pain when excreting solid wastes or bearing down with the same muscles used to do so) - indicates interthecal problem if pain in back or pain radiating down legs. Can identify difficulties in entire length of spine, such as herniated discs in cervical region.

Common General ADL's

Drinking more water
1. This will prevent adhesions and decrease spasm
2. If you have to urinate immediately after drinking, you aren't drinking enough. Also, if you pinch the skin at the back of the hand and the fold stays up, this may also be an indication that client isn't drinking enough water.
Stretching
1. Pectoralis minor is often most in need of stretching - this can be done through a door frame.
2. Emphasize that stretching shouldn't hurt or be ballistic.
3. Demonstrate stretches, or recommend a good book on stretching. Referring to a gentle yoga class might be advisable.
Exercise
1. Advise not to overdo it
2. Advise to be careful to use the full range of motion for muscles.
Ice
1. If a client comes in for relaxation massage but has an acute injury, set 20 min. ice as an ADL
2. Have ice packs available
Pain Journal
1. When they have pain, what preceded it, what works to alleviate it
2. Explain to clients that healing is a participatory process

Often Confused Terms

Hemorrhage: bleeding from a blood vessel, caused by a break in that blood vessel. One can hemorrhage internally or externally.
Hematoma: Mass of blood, tissue debris, and edema confined to a certain area. Result of hemorrhage and/or injury. Note that this mass is generally outside the blood vessels.
Inflammation: The attempt of the body to remove the hematoma (chemical activation by histamine through destroyed mast cells cause vasodilation (and hence decreased circulation) at site of injury and increased blood vessel permeability - this allows phagocytosis by white cells that leave the blood vessels). However, the decreased blood flow and lack of good circulation (exacerbated by damaged vessels) can cause more cells to die from lack of oxygen. The debris from these dead cells and the original ones can cause secondary edema through water "pulled" from blood vessels by osmosis, "attracted" by extra interstitial protein (the primary edema was just fluid lost from hemorrhage and fluid released from ruptured cells). Secondary edema may build until 48 hours after injury (end in increase of this and marks end of acute phase of injury.) Ice will cause cells to "hibernate", requiring less oxygen and perhaps living through period of oxygen scarcity. Once the hematoma and swelling are gone, it is easier for the body to repair the structures in the area.
Thrombus: A clot obstructing a blood vessel.
Contusion: ANY injury in which the skin is not broken. Contusion is the technical term for a bruise.
1. Usually seen as discolored, painful, swollen area.
2. For treatment, use rest, ice, compression, and elevation (RICE).
3. For 48 hours past injury (into subacute), use heat and gentle massage.
4. Generally, one won't see an arterial hematoma (except at wrist).
Fibrosis: scarring within one tissue
Lesion: any part of a muscle that won't contract
Myositis: inflammation of muscle tissues.
Fibrositis: inflammation of fibrous CT components of muscles, joints, tendons, ligaments, and other "white" connective tissues.
Dermatome: region of skin innervated for sensation by certain nerve root. Discovering the number and identity of dermatomes involved indicates which nerve roots may be damaged.
Extension past center line is hyperextension. Flexion above center line is hyperflexion.

Treatment Massage in Practice

It is important to maintain good records, as these may assist in the future for claims, etc. One must keep old records a minimum of seven years, although they may be microfilmed for convenience.
Try to prioritize client's problems - only so much can be done comfortably in one session.
Try to see treatment clients several times per week. Explain goals and need for treatment. Show them documentation of improvement when it occurs. Phrases such as "Most MD's would prescribe 6 sessions in a case like this" are helpful.
Don't charge for initial intake time - this will leave them more cooperative. When you see a new client (aside from asking how they heard about you) find out as soon as possible whether relaxation or treatment of some injury is their highest priority.
Note that primary health care providers will not generally refer clients for relaxation massage, and we cannot bill insurance companies for relaxation massage.
When clients come in with a definite complaint, either deal with that first or reassure them that you will get to it after doing other things that must precede it.
One can also take before/after pictures. You need client's release if you want to keep them in your file.

General Treatment References

Therapeutic Exercise: Foundations and Techniques, 2nd ed.; Kisner & Colby.
Management of Common Musculoskeletal Disorders, 2nd ed.; Hertling & Kessler.
Textbook of Orthopedic Medicine; Cyriax.

Neck Injuries

Neck/Shoulder
1. If pain gets worse when client moves head in certain directions, injury is probably a neck injury. Pain from neck injury may also arise from holding head in certain positions for long periods.
2. If pain gets worse when client moves arm, injury is probably in shoulder.
Neck ligament problems often refer pain, which can provide added complications during diagnosis.
Whiplash
1. An imprecise term for injuries where head is violently snapped back, then forward (such as in a car accident).
2. When head goes back and then forward, damage/contracture is often present in SCM or scalenes. Such clients often have a forward head posture.
3. It is important to learn the position of the client's head at impact and the type of impact in order to form an initial hypothesis about the cause of pain.

Spasm

Muscles under tension often exhibit poor circulation. This can cause inflammation (myositis) and localized pain. The pain causes additional spasm, and if this cycle continues for long enough fibromyalgia results.
Adhesions can cause spasms.
Should a spasm be maintained for a long period of time, connective tissue can adapt to the new position (contracture). This is characterized by decreased ROM, and can be treated with friction and circulation-improving strokes.
Treatment
1. Generally, remove the cause of the spasm to permanently remove the spasm.
2. For mild contracture (tightness), gentle stretching and broad fiber spreading is sufficient.
3. For adhesion-caused contracture, break adhesions with cross fiber friction (if from old injury) or passive/active exercise (if from injury that is still healing).
4. Ice is excellent at relieving spasm. Once muscle is less contracted and painful, you may stretch. Anything that can cause a greater stretch while avoiding damage and pain sensations is useful. A good example is of this is preceding stretch with reciprocal inhibition.

Tendinitis

Definition: inflammation of tendon
Chronic tendon inflammation can result in calcified tendinitis (calcium deposits in tendon)
Note that the attachment points for the tendon (the bone or musculotendinous junction) are usually weaker than the tendon, and the tendon will pull away from these rather than break in the middle
Avoid overworking with friction or remedials
Signs/Symptoms
1. General pain/crepitus along tendons with AROM.
2. Resisted movement painful
3. Local tenderness over tendons
4. Passive stretch is painful
5. Mild swelling/increased temperature
6. Pain/stiffening with rest that decreases after activity.
Treatment (also good for bursitis)
1. Acute
  1. Hydro: Ice
  2. Massage: PROM
  3. Stretch: None
2. Subacute
  1. Hydro: Ice before treatment, heat after
  2. Massage: Effleurage, Petrissage, Friction around periphery
  3. Stretch: Pain free gymnastics
3. Maturation
  1. Hydro: Heat
  2. Massage: Deep/direct friction or XFF
  3. Stretch: Pain free gymnastics, working towards RROM

Tenosynovitis

Definition: inflammation of tendon sheaths
Note that sheathed tendons are in the minority of tendons. They are usually found in the wrist and ankle where the tendons pass close to bone.
Signs/Symptoms: same as for Tendinitis.
Treatment: same as for tendinitis, but put the tendon on a stretch during treatment (esp. for XFF)

Bursitis

Definition: acute or chronic inflammation of a bursa.
Calcium deposits and adhesions with adjacent tendon/ligament (usually bursa is underneath ONE tendon or ligament) can occur with chronic bursitis
Signs/symptoms
1. Palpation produces a sharp localized pain (not necessarily true for chronic bursitis)
2. Painful AROM in all movements, but one motion creates sharp pain and may be weak.
3. Visible or palpable swelling with redness (if superficial bursa)
4. Exercise or excessive movement/pressure increases pain.
Treatment: see Tendinitis, but note following
1. Do not heat acutely inflamed bursa. Do not work too deeply over acutely inflamed bursa.
2. Note that one can't treat the bursa per-se, only the spasm/restrictions that are secondary to it.
3. Massage in the area is contraindicated if there are calcium deposits in bursa.

Myositis Ossificans

Definition: abnormal ossification occurring within the muscle tissue (not ossification attached to bone, as that would be a bone spur).
Etiology
1. Can be caused by repeated reinjury.
2. This injury can be CAUSED by using massage or heat into hematoma during acute phase of healing
3. One should use only painfree motion during gymnastics to avoid this situation, and especially avoid painful gymnastics if it is already present.
Signs/symptoms
1. Palpable hard lump in muscle belly
2. Limited and painful ROM for muscle
Treatment: One should work under the advice or prescription of a doctor in a case such as this. In such a case, it may be prescribed for you to massage from periphery into the middle of hematoma (late subacute on).

Headaches

Factors Contributing Headaches (of any type)
1. Anxiety/stress
2. Poor posture
3. Cervical spine trauma
4. Overeating, or drinking
5. Stuffy environment
6. Eyestrain
7. Depression
8. Overbite/TMJ dysfunction
9. Fatigue
10. Noise
11. Heavy work
Types of Headaches
1. Tension
  1. Cause: increased activity/spasm of cervical, upper back, and cranial muscles. This muscular tension causes vasoconstriction of the supra-orbital, temporal, and occipital arteries.
  2. Signs/Symptoms
    1. Pain beginning unilaterally in the neck or occipital region of the head
    2. Bilateral pain beginning in frontal and/or frontotemporal area
    3. Pain described as dull ache or squeezing in head which progresses around or over the head
    4. Occasional signs: nausea, bruxism, myofascial pain dysfunction syndromes
  3. Exacerbated by: stress and anticipation
  4. Relieved by: rest, analgesics
  5. Treatment
    1. Heat
    2. Deep massage as tolerated
      1. Vibration over cervical spine joints
      2. Myofascial releases shoulder and cervical regions
      3. Occipital traction and specific muscle stretches
    3. ADL's
      1. Relaxation exercises
      2. Decreased use of stimulants
      3. Stretching
        
        SCM
        
        Scalenes
        
        Pectorals
    4. Biofeedback (refer)
    5. Client's understanding of role of stress on condition
2. Vascular
  1. Cause: extreme vasodilation/swelling of the cranial blood vessels, which results in strains in their walls. This vasodilation is usually preceded by some vasoconstricting event that makes the rebound vasodilation more severe.
  2. Migraines
    1. Contributing Factors
      1. Genetics (Migraines tend to run in the family)
      2. Certain foods (especially cheese, wine, chocolate) tend to trigger HA
      3. Possible relationships to menstruation, stress, and psychological illness
      4. Fatigue, glare, or flickering lights
    2. Physiology
      1. Nervous system responds to trigger, such as stress, by creating a spasm in the arteries in the base of the brain. The spasm and serotonin reduce blood flow to the brain. Blood oxygen levels are then decreased, which cause the various symptoms.
      2. Arteries in and around brain tissue then dilate in an effort to improve circulation and meet the brain's energy and oxygen needs. The rapid vasodilation triggers the release of pain producing chemicals called prostaglandins which increase sensitivity of the nociceptors to pain. This combination of chemicals and dilation of arteries result in the throbbing headache.
    3. Signs/Symptoms
      1. Vision loss, seeing dots or zig-zag lines, tinnitus, mood shift, mental confusion, or fatigue (these precede headache)
      2. Pain frequently unilateral in forehead, temple, ear, jaw, or around eye
      3. Pain behind eye, light sensitivity
      4. Diarrhea, vomiting, nausea
      5. Intense throbbing pain in head
    4. Treatment
      1. Encourage client to keep diary of events surrounding attacks
      2. Massage only when client is not having an attack
      3. Check the tension in cervical muscles and suboccipital muscles
      4. Refer to biofeedback, relaxation therapy, meditation, or yoga
      5. Client may get temporary relief by wrapping a cold towel around head
      6. Regular aerobic exercise can reduce frequency and severity.
  3. Cluster Headaches
    1. Repeated occurrence in groups or clusters. Pain begins around one eye and reaches extraordinary intensities. Lasts a few hours, subsides, and returns (sometimes for several days). After one attack, it may be a year or more before the next one.
    2. Contributing factors: alcohol/nicotine, stress, age/gender (most common in men between ages 20-40)
  4. Physiology/Treatment: same as for migraines

Fibromyositis

Definition: A non-specific condition with signs/symptoms of pain, tenderness, stiffness of joints, muscles, capsules, and adjacent structures. Any fibromuscular tissue may be involved.
1. Lumbago: Low back
2. Torticollis: Neck
3. Pleurodynia: Shoulders, neck
4. Aches/Charleyhorses: Thighs
Etiology: Specific disturbances in sleep may produce or exacerbate the pain. the disturbance in slow wave sleep is usually induced or intensified by trauma, exposure to dampness or cold, systemic (usually rheumatic) disease, sometimes viral or bacterial infection. The condition is exacerbated by environmental or emotional stress, and is therefore considered by many as a psychophysiologic disorder. Females are most commonly affected.
Signs/symptoms
1. Large number of tender points largely unknown to the patient and non-anatomic, especially over upper scapular region.
2. No objective findings other than pain, tenderness, stiffness, exhaustion aggravated by fatigue or chill; eased by heat and massage. Typically, the client has great difficulty sleeping.
3. May be sensitive to weather, cold, bright lights, loud noises demanding of themselves, or trying to others.
4. Ill-defined or variable areas of numbness
Structures Involved
1. "Fibrositic" sites within the affected region; connective tissue
2. Does not seem to involve muscles (except for myositis).
Goals
1. Improve sleep
2. Relieve pain, tenderness, tightness in affected areas
3. Prevent loss of strength or ROM of joints in affected areas.
Precautions
1. Don't work too deeply in the affected area until you and the client know how tissue is going to react
2. GRADUALLY increase intensity of work.
Treatment
1. Hydro: Usually heat
2. Massage: All strokes. Relaxation exercises may be beneficial.
3. Referral to other HCP's, such as biofeedback, hypnotists, etc.
4. Generally, you want too look for ways in which they can reduce the emotional and physical stress in their lives.

Torticollis

Definition: Unilateral spasm or contracture of the cervical muscles
Etiology: Idiopathic
Structures Involved: Chronic or acute spasms of sternocleidomastiod or related muscles.
Signs/Symptoms
1. Head and neck are being held in a flexed and rotated position by the spasm
2. Pain is usually unilateral and may extend fully across the chest and upper back.
Treatment
1. Hydro: Heat before massage
2. Massage: Position supine lying or sitting with the head supported in the direction of the rotation. Use general effleurage and petrissage to prepare for more specific work; use trigger point, reciprocal inhibition, and Golgi tendon stimulation to reduce the spasm.

Thoracic Outlet

Pathology: compression of neurovascular bundle in cervical thoracic dorsal outlet. Usually, C8 or T1 nerve trunks of brachial plexus [corresponding to ulnar branch] and/or subclavian artery are compressed in this condition. In rare cases, the subclavian vein and/or brachial artery are compressed. Compression may occur in the following three areas:
1. Scalene and cervical rib syndrome: brachial plexus and subclavian artery may be compressed between the anterior and middle scalenes. A congenital accessory rib (an elongation of C7) can make this more likely, as can abnormalities in the scalenes.
2. Costoclavicular syndrome: subclavian artery and lateral cord of brachial plexus can be compressed as they pass between the clavicle and first rib.
3. Hyperabduction/Pectoralis Minor Syndrome: Compression of subclavian artery and lateral cord of brachial plexus can occur under the coracoid process between the rib cage and the tendon of the pectoralis minor.
Possible Etiologies
1. Protracted scapula/head
2. Heavy lifting
3. Holding/lifting arms overhead
4. Clavicular fracture
5. Fatigue, tension, or depression
Signs/Symptoms
1. Aching pain in shoulder
2. Heavy sensation in arm
3. "Pins and Needles" (paresthesia) from shoulder to elbow, may proceed to digits 4-5.
4. Arm pain that wakes them up in the night
5. Protracted head quite common
6. Hypertonic anterior and posterior cervical region
Special Tests
1. Adson's
2. Military
3. Pec Minor
4. Roos
Treatment (regardless of type of compression)
1. Postural re-education (esp. shoulder retract, head up)
2. Massage techniques (use heat or compression first, follow with general Swedish massage)
  1. Regional myofascial release
    1. Anterior shoulder
    2. Anterior neck
    3. Posterior neck
  2. Scalene knuckling: Kneel at the side of the table with the client supine. Make a loose fist with one hand and apply downward (towards the table) pressure to the SCM while slowly rotating the head away with the other hand.
  3. Linear friction of scalenes: Palpate mastoid process and use it as a landmark for the cervical transverse processes. Therapist pressure is more inferior than medial. When a tight point is located, have the client breath deeply, and reach the same side arm toward their feet on the exhale.
  4. Pectoral Lift: From the side of the table, hold the arm in slight abduction and place a loose fist of the hand in the axilla. Lift the lateral border of the pectoralis major as you slowly abduct and flex the shoulder. An alternate method would be to stand at the head of the table with the inside hand in the axilla, and outside hand holding the shoulder in flexion. Lift both hands at same time to stretch the pectoralis muscles.
  5. Subclavius Stretch: Stand behind the client as they sit. The client places one hand over the sternum, while the therapist reaches over their shoulder to grasp the flexed elbow with both hands. Client breathes deep, and therapist passively elevates the scapula on the exhale and holds for three more deep breaths.
3. Relieve spasms/tension
  1. Stretch scalenes/pec minor
  2. Strengthen upper trap/levator scapula
4. Improve mobility at Sternoclavicular joint, particularly with costoclavicular syndrome

Carpal Tunnel Syndrome

Pathology: compression of medial nerve as it passes through carpal channel on palmar side of hand/wrist. Compression occurs between transverse carpal ligament, flexor tendons, and carpals.
Possible Etiologies
1. Work involving stress to thenar region
2. Forceful wrist flexion/extensions
3. Gripping
Signs/Symptoms
1. Paresthesias in digits 1-3, usually palmar
2. May have loss of strength
3. May have problems with fine movements
4. Pain often wakes them up at night, worse in morning
5. Note: sometimes subscapular TP's can masquerade as CTS - check for subscapular TP's
Special Tests
1. Tinel's
2. Phalen's
Treatment
1. Immobilize (splint) wrist for 2-3 weeks (especially at night) - this should be prescribed by physician.
2. Anti-inflammatories (Advil/Cortisone) may help relieve pain.
3. Friction, MR, TP work on hand, forearm, supracondylar ridges of humerus.
4. Goals/Methods
  1. Reduce spasm/tension in finger, thumb, wrist flexors (esp. TP)
  2. Improve flexibility of transverse carpal ligament (flexor retinaculum) with XFF, friction with mobilizations. Note that these tendons have sheaths, so one should put them on stretch for XFF.
  3. Release myofascial restrictions of full upper extremity and cervical region with twisting, regional myofascial release with mobilizations
  4. Stretch/broaden wrist, finger, and thumb muscles.
Prevention
1. Make gripping areas of tools larger, grasp with all fingers and thumb when possible
2. Check that wrists and arms are comfortable when working
3. Wear padded gloves when using vibrating tools
4. Stretch shoulders, elbows, wrists, and fingers before, during, and after work
5. Use rhythmic controlled motions
6. Alter sleeping position to avoid flexed wrists (perhaps splint in neutral position for sleeping)

Carpal Tunnel Syndrome/Thoracic Outlet References

Management of Common Musculoskeletal Disorders: 2nd ed.; Hertling and Kessler; 1990; Lippincott.
Evaluation, Treatment, and Prevention of Musculoskeletal Disorders; Saunders, Duane H.; 1985; Educational Opportunities.
Therapeutic Exercise: Foundations and Techniques: 2nd Ed.; Kisner and Colby; 1990; F.A. Davis.

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