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High Yield Exam Material > Basic Treatment Principles > Flashcards

Basic Treatment Principles Flashcards

1
Q

Somatic Dysfunction

A

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

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2
Q

Viscerosomatic SD

A

typically has a rubbery tissue texture change

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3
Q

Arthrodial SD

A

usually a bony end feel at the restrictive barrier

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4
Q

Muscular SD

A

has a tight, tense end feel

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5
Q

SD associated with strain/counterstraintender points

A

have more tenderness

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6
Q

Predisposing Factors to SD

Posture

A

Habitual
Occupational
Active (sports related)

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7
Q

Predisposing Factors to SD

Gravity

A

Body habitus(obesity, pregnancy)

Weight-bearing

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8
Q

Predisposing Factors to SD

Anatominc Anomalies

A

Vertebra or facets

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9
Q

Predisposing Factors to SD

Transitional Areas

A

OA, thoracic inlet, TL junction, LS junction

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10
Q

Predisposing Factors to SD

Muscle Irritability

A

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

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11
Q

Predisposing Factors to SD

Physiologic

A

locking of a joint

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12
Q

Predisposing Factors to SD

Adaptation to

A

stressors

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13
Q

Predisposing Factors to SD

trauma

A

trauma

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14
Q

Predisposing Factors to SD

Compensation for

A

other structural deficits

Short Leg
Muscle Imbalance

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15
Q

ArthrodialSomatic Dysfunction

A

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.

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16
Q

2 main theories of SD etiology

A

Proprioceptive
Nociceptive

It is probably a combination of the two –nociceptiontriggers the SD and proprioceptionmaintains it

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17
Q

Proprioceptive Theory

A

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

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18
Q

Extrinsic Reflex System

A

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

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19
Q

Monosynaptic Reflex (Simplified)

A

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

Ex: patellar tap/knee jerk

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20
Q

Monosynaptic Reflex in Reality

A

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)

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21
Q

How the gamma gain is altered

A

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

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22
Q

Spinal Facilitation

A

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

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23
Q

Somatosomatic

A

Defensive reflex

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24
Q

Viscerovisceral

A

Distension of the gut causing increased contraction of the gut muscle

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25
Q

Somatovisceral

A

Stimulation of abdominal skin inhibits gut activity

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26
Q

Viscerosomatic

A

Upper back pain with an MI

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27
Q

How does OMT work?

A

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.

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28
Q

High Velocity Low Amplitude (HVLA)

A

“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

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29
Q

Barrier Mechanics

A

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

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30
Q

HVLA Steps

A

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.

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31
Q

HVLA Mechanisms

A

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

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32
Q

But What is the Pop?

A

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!

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33
Q

HVLA Indications and Dosage

A

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!

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34
Q

HVLA Contraindications –Absolute*

A

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

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35
Q

HVLA Contraindications -Relative

A 
Acute herniated nucleus pulposus

    Acute radiculopathy

    Acute whiplash / severe muscle spasm / strain/sprain

Osteopenia/ Osteoporosis

Spondylolisthesis

Metabolic bone disease

Hypermobilitysyndromes

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36
Q

Muscle Energy Technique (MET)

A

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.

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37
Q

MET Steps

A

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

38
Q

Isometric

A

no length change –most common

39
Q

Isotonic

A

length change –good for hypotonic, reflexively inhibited muscles

40
Q

Concentric

A

shortening –“the patient wins”

41
Q

Eccentric

A

lengthening –“the doc wins”

42
Q

IsolyticEccentric

A

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

43
Q

Isokinetic

A

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

44
Q

MET Mechanisms By Type of Activating Force*

A

Post-Isometric Relaxation

Joint Mobilization Using Muscle Force

Respiratory Assistance

OculocephalogyricReflex

Reciprocal Inhibition

Crossed Extensor Reflex

45
Q

Post-Isometric Relaxation

A

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.

46
Q

Joint Mobilization Using Muscle Force

A

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.

47
Q

Respiratory Assistance

A

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.

48
Q

Oculocephalogyric Reflex

A

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.

49
Q

Reciprocal Inhibition

A

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

50
Q

Crossed Extensor Reflex

A

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.

51
Q

MET Indications

A

SD

52
Q

MET Contraindications

Absolute*

A

Absence of somatic dysfunction

Lack of patient consent and/or cooperation

Oculocephalogyricreflex technique in someone with recent eye surgery or trauma

53
Q

MET Contraindications

Relative

A

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)

54
Q

MyofascialRelease Technique (MFR)

A

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.

55
Q

Direct MFR

A

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

56
Q

Indirect MFR

A

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

57
Q

MFR Mechanisms

A

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.

58
Q

MFR Steps -Indirect

A

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

59
Q

MFR Steps -Direct

A

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

60
Q

MFR Indications

A

Somatic dysfunctions involving myofascialor other connective tissues

61
Q

MFR Contraindications

Absolute*

A

Absence of somatic dysfunction

Lack of patient consent and/or cooperation

62
Q

MFR Contraindications

Relative

A

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

63
Q

Osteopathy in the Cranial Field (OCF)

A

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

64
Q

OCF Mechanisms

A

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.

65
Q

OCF Steps

A

Balanced membranous tension

Exaggeration

Directing the tide

Direct

Disengagement (articular/suture release)

66
Q

OCF Indications

A

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

67
Q

OCF Indications in Pediatrics

A

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

68
Q

OCF Contraindications

Absolute*

A

Increased intracranial pressure

Acute intracranial bleeding

Skull fracture

Acute cerebrovascular accident

69
Q

OCF Contraindications

Relative

A

Coagulopathies

Space occupying lesion in cranium

70
Q

Strain/CounterstrainTechnique (S/CS)

A

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

71
Q

S/CS Steps*

A

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

72
Q

Formation of a Tenderpoint*

A

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.

73
Q

But what about tender points in fascia or ligaments?

A

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

74
Q

S/CS Mechanisms

A

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

75
Q

S/CS Indications

A

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

76
Q

S/CS Contraindications

Absolute*

A

Absence of somatic dysfunction

Lack of patient consent and/or cooperation.

77
Q

S/CS Contraindications

Relative

A

Patient who cannot voluntarily relax

Severely ill patient

Vertebral artery disease

Severe osteoporosis

78
Q

Lymphatic Technique*

A

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

79
Q

Lymphatic Technique Mechanisms

A

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.

80
Q

Lymphatic Technique Steps

A

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

81
Q

Lymphatic Technique Indications

A

Edema, tissue congestion, or lymphatic stasis

Infection

Inflammation

82
Q

Lymphatic Technique Absolute Contraindications

A

Aneuresisif not on dialysis

Necrotizing fasciitis (in area involved)

Lack of patient consent and/or cooperation

83
Q

Lymphatic Technique Relative Contraindications

A

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)

84
Q

Soft Tissue Technique (ST)

A

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.

85
Q

ST Manipulation Styles

A

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.

86
Q

ST Mechanisms

A

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

87
Q

ST Indications

Somatic dysfunction including:

A

hypertonic muscles

excessive tension in fascialstructures

abnormal somato-somatic and somato-visceral reflexes

88
Q

ST Indications

Clinical conditions that would benefit from:

A

enhanced circulation to local myofascialstructures

improved local tissue nutrition, oxygenation, and removal of metabolic wastes

improved local and systemic immune responsiveness

89
Q

ST Indications

As an adjunct to additional manipulative treatment in order to:

A

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

90
Q

ST Absolute Contraindications*

A

Absence of somatic dysfunction

Lack of patient consent and/or cooperation

91
Q

ST Relative Contraindications

A

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

High Yield Exam Material (7 decks)

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