Basic Treatment Principles

Question 1

Somatic Dysfunction

Answer 1

Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascialstructures, and related vascular, lymphatic and neural elements.

Question 2

Viscerosomatic SD

Answer 2

typically has a rubbery tissue texture change

Question 3

Arthrodial SD

Answer 3

usually a bony end feel at the restrictive barrier

Question 4

Muscular SD

Answer 4

has a tight, tense end feel

Question 5

SD associated with strain/counterstraintender points

Answer 5

have more tenderness

Question 6

Predisposing Factors to SD

Posture

Answer 6

Habitual
Occupational
Active (sports related)

Question 7

Predisposing Factors to SD

Gravity

Answer 7

Body habitus(obesity, pregnancy)

Weight-bearing

Question 8

Predisposing Factors to SD

Anatominc Anomalies

Answer 8

Vertebra or facets

Question 9

Predisposing Factors to SD

Transitional Areas

Answer 9

OA, thoracic inlet, TL junction, LS junction

Question 10

Predisposing Factors to SD

Muscle Irritability

Answer 10

Emotional stress
Infection
Somatic or visceral reflex
Muscle stress (overuse, overstretch, underpreparation, accumulation of waste products)

Question 11

Predisposing Factors to SD

Physiologic

Answer 11

locking of a joint

Question 12

Predisposing Factors to SD

Adaptation to

Answer 12

stressors

Question 13

Predisposing Factors to SD

trauma

Answer 13

trauma

Question 14

Predisposing Factors to SD

Compensation for

Answer 14

other structural deficits

Short Leg
Muscle Imbalance

Question 15

ArthrodialSomatic Dysfunction

Answer 15

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.

Question 16

2 main theories of SD etiology

Answer 16

Proprioceptive
Nociceptive

It is probably a combination of the two –nociceptiontriggers the SD and proprioceptionmaintains it

Question 17

Proprioceptive Theory

Answer 17

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

Question 18

Extrinsic Reflex System

Answer 18

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

Question 19

Monosynaptic Reflex (Simplified)

Answer 19

Afferent limb from a sensory receptor > spinal cord > efferent limb to a somatic or visceral structure

Ex: patellar tap/knee jerk

Question 20

Monosynaptic Reflex in Reality

Answer 20

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)

Question 21

How the gamma gain is altered

Answer 21

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

Question 22

Spinal Facilitation

Answer 22

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

Question 23

Somatosomatic

Answer 23

Defensive reflex

Question 24

Viscerovisceral

Answer 24

Distension of the gut causing increased contraction of the gut muscle

Question 25

Somatovisceral

Answer 25

Stimulation of abdominal skin inhibits gut activity

Question 26

Viscerosomatic

Answer 26

Upper back pain with an MI

Question 27

How does OMT work?

Answer 27

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.

Question 28

High Velocity Low Amplitude (HVLA)

Answer 28

“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

Question 29

Barrier Mechanics

Answer 29

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

Question 30

HVLA Steps

Answer 30

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.

Question 31

HVLA Mechanisms

Answer 31

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

Question 32

But What is the Pop?

Answer 32

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!

Question 33

HVLA Indications and Dosage

Answer 33

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!

Question 34

HVLA Contraindications –Absolute*

Answer 34

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

Question 35

HVLA Contraindications -Relative

Answer 35

``` Acute herniated nucleus pulposus  Acute radiculopathy  Acute whiplash / severe muscle spasm / strain/sprain ``` Osteopenia/ Osteoporosis Spondylolisthesis Metabolic bone disease Hypermobilitysyndromes

Question 36

Muscle Energy Technique (MET)

Answer 36

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.

Question 37

MET Steps

Answer 37

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

Question 38

Isometric

Answer 38

no length change –most common

Question 39

Isotonic

Answer 39

length change –good for hypotonic, reflexively inhibited muscles

Question 40

Concentric

Answer 40

shortening –“the patient wins”

Question 41

Eccentric

Answer 41

lengthening –“the doc wins”

Question 42

IsolyticEccentric

Answer 42

a quick movement –used to treat fibrotic or chronically shortened myofascialtissues

Question 43

Isokinetic

Answer 43

concentric or eccentric where the length change occurs at a constant velocity

Question 44

MET Mechanisms By Type of Activating Force*

Answer 44

Post-Isometric Relaxation Joint Mobilization Using Muscle Force Respiratory Assistance OculocephalogyricReflex Reciprocal Inhibition Crossed Extensor Reflex

Question 45

Post-Isometric Relaxation

Answer 45

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.

Question 46

Joint Mobilization Using Muscle Force

Answer 46

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.

Question 47

Respiratory Assistance

Answer 47

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.

Question 48

Oculocephalogyric Reflex

Answer 48

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.

Question 49

Reciprocal Inhibition

Answer 49

When a gentle contraction is initiated in the agonist muscle, there is a reflex relaxation of that muscle’s antagonistic group.

Question 50

Crossed Extensor Reflex

Answer 50

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.

Question 51

MET Indications

Answer 51

SD

Question 52

MET Contraindications Absolute*

Answer 52

Absence of somatic dysfunction Lack of patient consent and/or cooperation Oculocephalogyricreflex technique in someone with recent eye surgery or trauma

Question 53

MET Contraindications Relative

Answer 53

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)

Question 54

MyofascialRelease Technique (MFR)

Answer 54

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.

Question 55

Direct MFR

Answer 55

a myofascialtissue restrictive barrier is engaged for the myofascialtissues and the tissue is loaded with a constant force until tissue release occurs.

Question 56

Indirect MFR

Answer 56

the dysfunctional tissues are guided along the path of least resistance until free movement is achieved.

Question 57

MFR Mechanisms

Answer 57

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.

Question 58

MFR Steps -Indirect

Answer 58

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

Question 59

MFR Steps -Direct

Answer 59

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

Question 60

MFR Indications

Answer 60

Somatic dysfunctions involving myofascialor other connective tissues

Question 61

MFR Contraindications | Absolute*

Answer 61

Absence of somatic dysfunction Lack of patient consent and/or cooperation

Question 62

MFR Contraindications | Relative

Answer 62

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

Question 63

Osteopathy in the Cranial Field (OCF)

Answer 63

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

Question 64

OCF Mechanisms

Answer 64

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.

Question 65

OCF Steps

Answer 65

Balanced membranous tension Exaggeration Directing the tide Direct Disengagement (articular/suture release)

Question 66

OCF Indications

Answer 66

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

Question 67

OCF Indications in Pediatrics

Answer 67

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

Question 68

OCF Contraindications | Absolute*

Answer 68

Increased intracranial pressure Acute intracranial bleeding Skull fracture Acute cerebrovascular accident

Question 69

OCF Contraindications | Relative

Answer 69

Coagulopathies Space occupying lesion in cranium

Question 70

Strain/CounterstrainTechnique (S/CS)

Answer 70

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

Question 71

S/CS Steps*

Answer 71

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

Question 72

Formation of a Tenderpoint*

Answer 72

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.

Question 73

But what about tender points in fascia or ligaments?

Answer 73

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

Question 74

S/CS Mechanisms

Answer 74

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

Question 75

S/CS Indications

Answer 75

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

Question 76

S/CS Contraindications | Absolute*

Answer 76

Absence of somatic dysfunction Lack of patient consent and/or cooperation.

Question 77

S/CS Contraindications | Relative

Answer 77

Patient who cannot voluntarily relax Severely ill patient Vertebral artery disease Severe osteoporosis

Question 78

Lymphatic Technique*

Answer 78

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

Question 79

Lymphatic Technique Mechanisms

Answer 79

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.

Question 80

Lymphatic Technique Steps

Answer 80

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

Question 81

Lymphatic Technique Indications

Answer 81

Edema, tissue congestion, or lymphatic stasis Infection Inflammation

Question 82

Lymphatic Technique Absolute Contraindications

Answer 82

Aneuresisif not on dialysis  Necrotizing fasciitis (in area involved) Lack of patient consent and/or cooperation

Question 83

Lymphatic Technique Relative Contraindications

Answer 83

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)

Question 84

Soft Tissue Technique (ST)

Answer 84

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.

Question 85

ST Manipulation Styles

Answer 85

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.

Question 86

ST Mechanisms

Answer 86

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

Question 87

ST Indications Somatic dysfunction including:

Answer 87

hypertonic muscles excessive tension in fascialstructures abnormal somato-somatic and somato-visceral reflexes

Question 88

ST Indications Clinical conditions that would benefit from:

Answer 88

enhanced circulation to local myofascialstructures improved local tissue nutrition, oxygenation, and removal of metabolic wastes improved local and systemic immune responsiveness

Question 89

ST Indications As an adjunct to additional manipulative treatment in order to:

Answer 89

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

Question 90

ST Absolute Contraindications*

Answer 90

Absence of somatic dysfunction Lack of patient consent and/or cooperation

Question 91

ST Relative Contraindications

Answer 91

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