Basic Treatment Principles Flashcards
Somatic Dysfunction
Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascialstructures, and related vascular, lymphatic and neural elements.
Viscerosomatic SD
typically has a rubbery tissue texture change
Arthrodial SD
usually a bony end feel at the restrictive barrier
Muscular SD
has a tight, tense end feel
SD associated with strain/counterstraintender points
have more tenderness
Predisposing Factors to SD
Posture
Habitual
Occupational
Active (sports related)
Predisposing Factors to SD
Gravity
Body habitus(obesity, pregnancy)
Weight-bearing
Predisposing Factors to SD
Anatominc Anomalies
Vertebra or facets
Predisposing Factors to SD
Transitional Areas
OA, thoracic inlet, TL junction, LS junction
Predisposing Factors to SD
Muscle Irritability
Emotional stress
Infection
Somatic or visceral reflex
Muscle stress (overuse, overstretch, underpreparation, accumulation of waste products)
Predisposing Factors to SD
Physiologic
locking of a joint
Predisposing Factors to SD
Adaptation to
stressors
Predisposing Factors to SD
trauma
trauma
Predisposing Factors to SD
Compensation for
other structural deficits
Short Leg
Muscle Imbalance
ArthrodialSomatic Dysfunction
It is not “subluxed,” “out of place,” “out of joint,” or “dislocated.”
It won’t complete its normal, full motion.
An external or internal force or factor has caused local segmental irritation sufficient to create focal edema and swelling in a small discrete area.
This causes a tightening of the fascialstructures, myofascialcomponent, and capsular components of a specific joint.
The articulardistortion creates reflex hypertonicityof the muscles crossing that joint, resulting in decreased range of motion.
Motion restoration of the joint results in restoration of normal proprioceptiveinput from the joint and reflex relaxation of muscles surrounding the joint.
2 main theories of SD etiology
Proprioceptive
Nociceptive
It is probably a combination of the two –nociceptiontriggers the SD and proprioceptionmaintains it
Proprioceptive Theory
Alteration in both the intrinsic and extrinsic reflexes
Inappropriate gamma activity (“gamma gain”) creates inappropriate muscle length and tone, resulting in a functionally imbalanced joint
Extrinsic Reflex System
Anterior horn cells of the alpha and gamma efferentsto the muscle receive synaptic impulses from sensory nerves originating in other muscles or organs
Ex: reciprocal inhibition of antagonist muscles and viscero-somatic muscle guarding
Monosynaptic Reflex (Simplified)
Afferent limb from a sensory receptor > spinal cord > efferent limb to a somatic or visceral structure
Ex: patellar tap/knee jerk
Monosynaptic Reflex in Reality
Input to the spinal cord collaterals up and down the cord as well as from the opposite side of the cord > goes through several synapses and interneurons > acts on somatic and sympathetic motoneurons(thoracic/lumbar cord) or somatic and parasympathetic motoneurons(cervical/sacral areas)
How the gamma gain is altered
The gamma gain is one of the determinants of the physiologic motion barrier and the motion barrier of the SD
Resetting the gamma gain may occur via pre-and post-synaptic inhibition at the cord level
This resetting can be affected by cognition. Ex: muscular movement events aren’t as anticipated
Spinal Facilitation
Denslow(1940’s) –found variability in reflex excitability in the paraspinalmuscles of the thoracic spine
These often asymptomatic areas had increased muscle activity as well as pain and tenderness when palpated.
Later studies by Denslowfound that associated visceral organs were affected via altered sympathetic output.
Korr–“facilitated segment”-plays a part in the etiology of SD because that area is hyperirritable and hyper-responsive –muscles in that region will be hypertonic
Somatosomatic
Defensive reflex
Viscerovisceral
Distension of the gut causing increased contraction of the gut muscle
Somatovisceral
Stimulation of abdominal skin inhibits gut activity
Viscerosomatic
Upper back pain with an MI
How does OMT work?
OMT techniques tend to actively stretch the connective tissues in joint capsules, tendons, muscles, and ligaments in the segments of restricted motion.
However, stretching would typically increase the proprioceptiveand nociceptivedrives and worsen the SD.
Therefore, OMT must first decrease or override these drives prior to stretching the tissues.
The method used to change these drives is unique to each OMT technique.
High Velocity Low Amplitude (HVLA)
“An osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique.”
Direct technique
Barrier Mechanics
Evaluate quantity and quality of motion
Quantity: amount of motion from a neutral point
Remember anatomic, physiologic, and restrictive barriers
Quality: palpatorysense of joint motion
End feel: quality of motion at its final barrier
HVLA best suited to SD with restricted motion with a hard end feel
HVLA Steps
The physician precisely positions the patient’s restricted joint to the restrictive barriers of the somatic dysfunction by “stacking” in each plane of the SD.
A short (low amplitude), quick (high velocity) force is applied to the joint to move it through the restrictive barrier –no backing off or winding up.
The joint resets itself and appropriate physiological motion is restored.
HVLA Mechanisms
Abnormal muscle activity maintains joint restriction
When the joint restriction is treated, there is an immediate change in the muscles and the quality and quantity of motion which suggests an immediate change in neural activity
Sudden stretch or change of position of the joint alters the afferent output of the mechanoreceptors in the joint capsule, resulting in release of muscle hypertonicity
But What is the Pop?
Theories:
Release of gas into the synovial fluid breaks the surface tension of the synovial fluid
Snapping or releasing of ligamentousadhesions in the joint
Bone is pulled out of place and snaps back into a neutral position
Ballooning of the joint capsule
The main thing is that you don’t need the snap, crackle, or pop for a successful treatment!
HVLA Indications and Dosage
SD with distinct, firm barrier mechanics*
Useful when not much time is available
The sicker the patient, the less the dose
Generally, treating the same segment with HVLA more than once a week is discouraged due to the possibility of causing joint hypermobility
If the same SD keeps recurring, investigate!
HVLA Contraindications –Absolute*
Rheumatoid arthritis
Down syndrome
Achondroplasticdwarfism
Chiarimalformation
Fracture / dislocation / spinal or joint instability
Ankylosis/ Spondylosiswith fusion
Surgical fusion
Klippel-Feilsyndrome
Vertebrobasilarinsufficiency
Inflammatory joint disease
Joint infection
Bony malignancy
Patient refusal
HVLA Contraindications -Relative
Acute herniated nucleus pulposus
Acute radiculopathy
Acute whiplash / severe muscle spasm / strain/sprain
Osteopenia/ Osteoporosis
Spondylolisthesis
Metabolic bone disease
Hypermobilitysyndromes
Muscle Energy Technique (MET)
A form of osteopathic manipulative diagnosis and treatment in which the patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, and against a distinctly executed physician counterforce.
Direct technique
Muscle contraction is a principle mechanism for promoting lymphatic and venous circulation, thereby making muscle energy technique important in the treatment of edema/congestion.
MET Steps
Accurate diagnosis
Position to the point of initial barrier resistance (feather edge)
Physician establishes appropriate counterforce
Patient introduces appropriate muscle energy effort
Direction
Duration
Amount of force
Patient must completely and voluntarily relax
Pause 2-3 seconds for neuromuscular adaptation (post-relaxation phase)
Reposition to the new restrictive barrier
Repeat until no further change is obtained
Reassess for appropriate change
Isometric
no length change –most common
Isotonic
length change –good for hypotonic, reflexively inhibited muscles
Concentric
shortening –“the patient wins”
Eccentric
lengthening –“the doc wins”
IsolyticEccentric
a quick movement –used to treat fibrotic or chronically shortened myofascialtissues
Isokinetic
concentric or eccentric where the length change occurs at a constant velocity
MET Mechanisms By Type of Activating Force*
Post-Isometric Relaxation
Joint Mobilization Using Muscle Force
Respiratory Assistance
OculocephalogyricReflex
Reciprocal Inhibition
Crossed Extensor Reflex
Post-Isometric Relaxation
Immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotaticreflex opposition. All the physician needs to do is resist the contraction, and then take up the soft tissue slack during the refractory period.
Joint Mobilization Using Muscle Force
Similar to HVLA: distortion of articularrelationships and motion loss results in a reflex hypertonicityof the musculature crossing the dysfunctional joint. This increase in muscle tone tends to compress the joint surfaces and results in thinning of the intervening layer of synovial fluid and adherence of joint surfaces. Restoration of motion to the articulation results in a gapping, or reseating of the distorted joint with reflex relaxation of the previously hypertonic musculature.
Respiratory Assistance
The muscular forces involved in these techniques are generated by the simple act of breathing. This may involve the direct use of the respiratory muscles themselves, or motion transmitted to the spine, pelvis, and extremities in response to ventilation motions. The physician usually applies a fulcrum against which the respiratory forces can work.
Oculocephalogyric Reflex
Functional muscle groups are contracted in response to voluntary eye motion on the part of the patient. These eye movements reflexively affect the cervical and truncalmusculature as the body attempts to follow the lead provided by eye motion. It can be used to produce very gentle post-isometric relaxation or reciprocal inhibition.
Reciprocal Inhibition
When a gentle contraction is initiated in the agonist muscle, there is a reflex relaxation of that muscle’s antagonistic group.
Crossed Extensor Reflex
This form of muscle energy technique uses the learned cross pattern locomotion reflexes engrammedinto the central nervous system. When the flexor muscle in one extremity is contracted voluntarily, the flexor muscle in the contralateralextremity relaxes and the extensor contracts.
MET Indications
SD
MET Contraindications
Absolute*
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
Oculocephalogyricreflex technique in someone with recent eye surgery or trauma
MET Contraindications
Relative
Infection, hematoma, or tear in involved muscle
Fracture or dislocation of involved joint
Rheumatologic conditions causing instability of the cervical spine
Undiagnosed joint swelling of involved joint
Positioning that compromises vasculature
Patient with low vitality who could be further compromised (acute post myocardial infarction for example)
MyofascialRelease Technique (MFR)
A system of diagnosis and treatment, first described by Andrew Taylor Still and his early students, which engages continual palpatoryfeedback to achieve release of myofascialtissues.
Direct MFR
a myofascialtissue restrictive barrier is engaged for the myofascialtissues and the tissue is loaded with a constant force until tissue release occurs.
Indirect MFR
the dysfunctional tissues are guided along the path of least resistance until free movement is achieved.
MFR Mechanisms
Fascia is capable of changes in length (plasticity and elasticity), with associated changes of energy content (hysteresis).
MFR provides peripheral neuroreflexivealterations in muscle tone and neural facilitation, in part, by its influence on mechanoreceptors.
The application of MFR allows for connective tissue plastic changes (creep) which are associated with release of energy. This may include heat, electromagnetic, and piezoelectric changes.
External forces applied to fascia facilitate restoration of normal structure and function.
Tensegrityprinciples coupled with fascialbioelectric (piezoelectric) properties influence the anatomical and physiological responses of tissues to applied manipulative forces.
MFR Steps -Indirect
Movement of a patient by the physician into the position of ease for all planes, following any tissue release or fascialunwinding until completed. May also utilize:
1. Regional compression, distraction, or torsion
2. Tissue inhibition or traction
3. Respiratory cooperation in the phase which encourages tissue relaxation
4. Eye, tongue, jaw, head or limb movements
MFR Steps -Direct
Movement of a patient by the physician into the restriction for all planes, applying steady force until tissue release or fascialunwinding is completed. May also utilize:
1. Respiratory cooperation in the phase which encourages tissue tension
2. Tissue inhibition
3. Oscillation
4. Eye, tongue, jaw, head or limb movements
MFR Indications
Somatic dysfunctions involving myofascialor other connective tissues
MFR Contraindications
Absolute*
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
MFR Contraindications
Relative
Fractures
open wounds,
acute thermal injury
soft tissue or bony infections
deep venous thrombosis (threat of embolism)
disseminated or focal neoplasm
recent post-operative states over the site of proposed treatment (wound dehiscence)
aortic aneurysm
Osteopathy in the Cranial Field (OCF)
A system of diagnosis and treatment by an osteopathic physician using the primary respiratory mechanism and balanced membranous tension.
Also known as Cranial Osteopathy, Cranial Manipulation
Can be direct or indirect
OCF Mechanisms
The primary respiratory mechanism refers to the presumed inherent (primordial) driving mechanism of internal respiration as opposed to the cycle of diaphragmatic respiration (inhalation and exhalation). It further refers to the innate interconnected movement of every tissue and structure of the body.
Models of diagnosis and treatment include articular, membrane and fluid.
OCF Steps
Balanced membranous tension
Exaggeration
Directing the tide
Direct
Disengagement (articular/suture release)
OCF Indications
Cranial Neuropathy-nerve entrapment
Bell’s palsy
Trigeminal neuralgia
Atypical facial pain
Headache
Sinusitis
Orofacialpain
Vertigo
Visual disturbances
Tinnitus
TemporomandibularJoint
Dysfunction
Malocclusions
Strabismus
Strain patterns of the
sacrum
Strain patterns of the axial and appendicularskeleton
OCF Indications in Pediatrics
Plagiocephaly
Torticollis
Feeding difficulties
Colic
Genetic disorders (e.g. Down syndrome)
Attention deficit hyperactivity disorder (ADHD)
Developmental delays
Dyslexia
Otitismedia
Strain patterns of the sacrum
Strain patterns of the axial and appendicularskeleton
OCF Contraindications
Absolute*
Increased intracranial pressure
Acute intracranial bleeding
Skull fracture
Acute cerebrovascular accident
OCF Contraindications
Relative
Coagulopathies
Space occupying lesion in cranium
Strain/CounterstrainTechnique (S/CS)
An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by an associated myofascialtender point, is treated by using a position of spontaneous tissue release while simultaneously monitoring the tender point.
Indirect technique
S/CS Steps*
Palpate for areas of increased sensitivity (tenderpoints)
Establish a pain scale (“this is a 10”)
Place the patient passively in a position that will eliminate this tenderness (pain scale 3 or less)
Maintain this position for 90 seconds while continuously monitoring the point (light touch)
Passively return the
patient’s body to its original position
Recheck the tenderpoint
Formation of a Tenderpoint*
Development of an inappropriate proprioceptivereflex caused by the gamma system
Rapid lengthening of myofascialtissuse > afferent feedback indicates possible damage from a strain > the body tries to prevent damage by rapidly contracting the myofascialtissue > this causes the antagonist muscle to rapidly lengthen and produces the inappropriate reflex and the tenderpoint
Nociceptivefeedback from the antagonist muscle is interpreted as a muscle strain (although one hasn’t occurred) > hypertonic myofascialtissue and restricted motion (SD)
A guarding reflex by the patient, without actual trauma, may also produce the inappropriate reflex.
But what about tender points in fascia or ligaments?
Trauma causes damage to myofascial tissues (myofibrils, microcirculation) > nociceptors alert CNS > tissue damage and chemical changes recruit more nociceptors and change intramuscular pressure and function > muscle fatigue due to decreased cellular metabolism >tenderpoint formation
S/CS Mechanisms
The already shortened and restricted tissues are initially further shortened, removing all internal stresses and resetting gamma gain and deactivating the nociceptors
Maintaining the comfortable position for 90 seconds allows local circulation to improve due to reduction of chronic sympathetic stimulation
Local inflammation and edema decrease as the noxious chemicals are carried away
Slowly returning to neutral
will passively stretch the connective tissues
S/CS Indications
Acute or chronic somatic dysfunctions
Somatic dysfunctions with a neural component like a hypershortenedmuscle
As primary treatment or in conjunction with other approaches
Somatic dysfunctions in
any area of the body
S/CS Contraindications
Absolute*
Absence of somatic dysfunction
Lack of patient consent and/or cooperation.
S/CS Contraindications
Relative
Patient who cannot voluntarily relax
Severely ill patient
Vertebral artery disease
Severe osteoporosis
Lymphatic Technique*
Lymphatic techniques are those designed to remove impediments to lymphatic circulation and promote and augment the flow of lymph. The purpose of lymphatic treatments is to improve the functional capacity of the lymphatic system, which includes maintenance of fluid balance in the body, purification and cleansing of tissues, and enhancement of immune response. As the lymphatic system is also involved in tissue nutrition and the absorption of macronutrients from the GI tract and interstitial fluids, treating the lymphaticscan theoretically improve tissue nutrition.
Direct technique
Lymphatic Technique Mechanisms
Lymphatic flow depends on several factors including diaphragmatic motion, gravitational forces, muscle contraction, and visceral motion.
Any treatment that reduces fascialrestrictions can theoretically improve lymphatic flow by optimizing the capacity of intrinsic lymphatic pumps.
Lymphatic treatments enhance lymphatic return by increasing the gradient for lymph and assisting the return of lymph from the lung, abdomen, and other tissues.
Lymphatic Technique Steps
Remove impediments to lymphatic flow starting centrally and moving peripherally
Evaluate diaphragms/fascia including thoracic inlet
Palpate tissues to evaluate presence of congestion/excess fluid
Utilize an extrinsic pumping motion that mobilizes lymphatic fluid through:
external pressure
changes in pressure gradients
oscillatory movements
Lymphatic Technique Indications
Edema, tissue congestion, or lymphatic stasis
Infection
Inflammation
Lymphatic Technique Absolute Contraindications
Aneuresisif not on dialysis
Necrotizing fasciitis (in area involved)
Lack of patient consent and/or cooperation
Lymphatic Technique Relative Contraindications
Cancer (immune system activation vs. lymphatic spread)
Osseous fracture or crushed tissue
Bacterial infections with risk of dissemination
Chronic infections with risk of reactivation (abscess, chronic osteomyelitis)
Diseased organ (treating thyroid in presence of hyperthyroidism)
Pregnancy (uterus/deep abdominal work)
Circulatory disorders (venous obstructions, embolism, hemorrhage)
Coagulopathies; patients on anticoagulants
Unstable cardiac conditions
CHF (Caution should be used to avoid mobilizing and returning an overwhelming amount of fluid to a compromised heart)
COPD (thoracic pump with
activation due to increased residual volume post treatment)
Soft Tissue Technique (ST)
A direct technique that usually involves lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion while monitoring tissue response and muscle changes by palpation.
ST Manipulation Styles
Stretching (traction) –forces are along the longitudinal axis
Kneading-forces are perpendicular to the longitudinal axis (like a bowstring)
Inhibition –forces are directed superficial to deep ususallyover a specific area of tension (tender point)
Effleurage –lymphatic treatment superficially from distal to proximal and peripheral to central.
Petrissageand skin rolling –deep kneading/squeezing of muscle tissue breaking adhesive bands from the skin to deeper tissue
Tapotement–repetitively striking the belly of the muscle with the hypothenaredge of the hand.
ST Mechanisms
Relaxes hypertonic muscles and reduce spasm
Stretches and increases the elasticity of shortened fascialstructures
Enhances circulation to local myofascialstructures
Improves local tissue nutrition, oxygenation, and removal of metabolic wastes
Improves abnormal somato-somatic and somato-visceral reflex activity, thus improving circulation in areas of the body remote from the area being treated
Identifies areas of restricted motion, tissue texture changes and sensitivity
Improves local and systemic immune response
Provides a general state of relaxation
Provides a general state of tonic stimulation by stimulating the stretch reflex in hypotonic muscles
ST Indications
Somatic dysfunction including:
hypertonic muscles
excessive tension in fascialstructures
abnormal somato-somatic and somato-visceral reflexes
ST Indications
Clinical conditions that would benefit from:
enhanced circulation to local myofascialstructures
improved local tissue nutrition, oxygenation, and removal of metabolic wastes
improved local and systemic immune responsiveness
ST Indications
As an adjunct to additional manipulative treatment in order to:
identify other areas of somatic dysfunction
observe tissue response to the application of manipulative technique
provide a general state of relaxation
provide a general state of tonic stimulation
prepare tissues for other types of manipulation
ST Absolute Contraindications*
Absence of somatic dysfunction
Lack of patient consent and/or cooperation
ST Relative Contraindications
Skin: Disorders which would preclude skin contact, e.g., contagious skin diseases, acute burns, painful rashes, abscesses, skin cancers, etc.
Fascia: Acute fasciitis(infectiousor autoimmune), acute fascialtears
Muscle: Acute muscular strains, acute myositis, muscle neoplasms.
Ligament: Acute ligamentoussprain, acute ligamentousinflammatory disorders, septic arthritis, primary or secondary joint neoplasms.
Bone: Acute fracture, osteomyelitis, primary or secondary bone tumors, osteoporosis
Viscera: Infectious or neoplasticenlargement of organs such as the liver and spleen. Gastric or bowel obstruction or distention. Acute organ pain, e.g., pyelonephritis. Undiagnosed abdominal or pelvic pain.
Vascular: Hematoma, deep venous thrombosis, uncontrolled bleeding disorders
