CV cases and techniques- Angland + Ramey Flashcards
Indications of HVLA
Somatic dysfunctions with firm, distinct barriers.
Goal: restore motion and function.
Other benefits: reducing muscle hypertonicity, stretching of shortened musculature, increasing fluid movement, and reducing pain.
Relative contraindications of HVLA
- Acute herniated nucleus pulposus
- Acute radiculopathy
- Acute whiplash, severe muscle spasm, strain, sprain
- Osteopenia, osteoporosis, osteoarthritis
- Spondylolisthesis
- Metabolic bone disease
- Hypermobility syndromes
Absolute contraindications of HVLA
- Rheumatoid arthritis
- Lack of pt consent
- Absence of SD
Safety rules for HVLA
- Do not thrust if setup is more than minimally uncomfortable
- Do not thrust is setup produces neurological symptoms
- Localize the barrier and maintain localization throughout the setup. The more localized, the less force is needed.
- If it does not feel right or the barrier feels “rubbery” rather than firm, do not thrust. Re-evaluate and/or choose a different technique.
Kirksville Krunch for type II thoracic dysfunction
EX: T5 FRSR
Stand to the left of the patient- opposite the posterior transverse process
- Have patient either interlock their fingers with their hands behind their neck or cross their arms over their chest, with the arm on the same side as the posterior transverse process on top
- Roll patient to the left, place caudal thenar eminence under the right transverse process of T5 and roll pt back onto your open hand
- Control pt’s torso through their elbows by placing the them in your epigastrium. Support pt’s head and neck with your cephalad hand and forearm
- Use your cephalad hand to introduce left sidebending to T5 by translating pt’s body to the right. Extension is achieved by keeping the pt’s shoulders close to the table. (Flexion would be achieved by curving the pt’s body toward you). Left rotation is automatic bc your thenar eminence is posterior to the right transverse process.
- Engage the barrier. Instruct pt to inhale and exhale, taking up the slack and maintaining localization during exhalation.
The final corrective force is a quick, posterior thrust from your epigastrum toward your caudal thenar eminence.
Kirksville Krunch for Rib dysfunctions
EX: right inhaled rib 8
Best for ribs 2-10
- Pt’s arms are crossed over chest and grabbing their shoulders. Arm on top should be the same side as the dysfunctional rib.
- Roll the pt to the left and place your open, flat, caudal thenar eminence under the inferior margin of the posterior rib angle of 8 (for an exhaled dysfunction, place your hand under the superior margin of the rib margin)
- Place pt’s elbows in your epigastrium and support pt’s head and neck with your cephalad hand and forearm.
- Use your cephalad hand to introduce right sidebending to rib 8 by translating the pt’s body to the left
- Engage the barrier. Instruct pt to inhale and exhale, taking up the slack and maintaining localization during exhalation.
The final corrective force is a quick, posterior thrust from your epigastrum toward your caudal thenar eminence.
Prone cross hand pisiform thurst (Texas twist)
EX: T7 FRSR
Works best for flexed segments T5-T12 because the vector of force is directly anterior which induces extension to the area
Stand to the left of the pt, opposite the posterior transverse process
- Place your right thenar eminence over the right transverse process of T5. Place left hypothenar eminence over the left transverse process of T6
- Maintain firm contact over both transverse processes and apply an anterior, superior force to the right transverse process of T5. Apply an anterior, inferior force to the left transverse process of T6- creates a twisting of the hands
- Maintain engagement of the rotation barrier and use both hands in unison to translate the dysfunctional segment to the right (induces left sidebending)
- The final corrective force is a quick, anteriorly directed thrust from your hands to the T5-T6 segment. Locking your elbows and using your body weight to deliver the thrust will help.
Balanced Ligamentous Tensions (BLT)
Uses the anatomical relationships in a joint to restore balance to boney and ligamentous relationships
A joint is kept in balance by the suspension system of ligaments attached to it. Throughtout normal motion, ligaments are almost never completely relaxed and reciprocal tension is maintained.
During dysfunction- ligaments are no longer balanced in relation to each other and one ligament may be more tight or loose than another ligament of the same joint. –> ligamentous articular strain (LAS)
Goal: rebalance ligaments and tighten a loose ligament
Reciprocal tension
The total tension present within the joint is constant.
With movement, ligaments adjust their tension burden back and forth (reciprocally) to maintain balance in the system.
Ligamentous strain disrupts joint tension balance and may or may not include microscopic tears and/or stretching of the ligaments.
Ligamentous articular strain
Injury moves a joint past its normal limit of motion and some ligaments are left strained and others weakened by the new unbalanced tension.
Weakened ligament allows future motion to continue in the new, extended range, which causes the joint to slip repeatedly into the initial pattern of injury.
Tightened ligament resists the joint moving back into normal motion. \
BLT is the treatment for LAS
Crimping
Refers to the configuration of fibers that make up a ligament and allow it to work as a spring, checking and balancing the pressures applied to the joint.
Crimps are vital to the proper functioning of a ligament.
When SD is introduced to a joint, the ligament is straightened, destroying the crimp.
Principles of Treatment for LAS
- Disengagement/decompression of the area until motion can be felt
- Exaggeration of the dysfunctional pattern (return the area to the position of injury)
- Balancing of the ligaments in a position of equal tension among the joint’s ligaments (often in the position of strain/dysfunction) until release or the cranial rhythmic impulse (CRI) is palpated.
BLT indications
- Relax contracted musculature
- Released tethered structures
- Restore symmetry
- Increase arterial circulation and venous/lymphatic drainage
Through normal function and range of motion, a decrease in pain and edema is obtained.
BLT can be applied to any dysfunction or strained ligament. Can be indirect, direct, or a combination of both.
Relative contraindications of BLT
- Acute fractures
- Open wounds
- Acute thermal injury
- Soft tissue or bony infections
- DVT (threat of pulmonary embolism)
- Disseminated or focal neoplasm
- Recent surgery in area of proposed treatment
- Aortic aneurysm
BLT for restricted sternum
- Place heel of hand on the manubrium and rest fingers on sternal body.
- Apply a gentle posterior and interior compression to the manubrium until a point of equal tension is palpated among the ligamentous attachments of the sternum. You may bring the sternal body closer to the manubrium by flexing your fingers (this will increase the sternal angle of Louis) to find this balanced position.
- Fine tune this balanced position by inducing clockwise/counterclockwise and rotational motions to the sternum
- Hold this balanced position until a release is palpated
BLT for superior first ribs
May be used for either inhaled or exhaled
Pt is supine
Contact the superiro surface of the first rib heads with your thumbs b/l
Gently compress the ribs inferiorly until equal tension is palpated among the ligamentous attachments of the ribs
Hold this balanced position until a release is palpated and normal respiratory motion returns.
Supine BLT for rib dysfunctions
EX: exhaled right rib 4
May be used for inhaled or exhaled ribs 2-12
- Slide your hands underneath the pt’s rib cage on either side of the thoracic spine
- Contact the dysfuncitonal rib angles with your fingerpads
- Apply a gentle anterior pressure to disengage the ribs from their vertebral attachments
- While maintaining your anterior pressure, bring the ribs superiorly and laterally until equal tension is palpated among the ligamentous attachments of the ribs.
- Hold this balanced position until a release is palpated
On-side BLT for rib dysfunctions
EX: exhaled right rib 8
Pt lateral recumbent (dysfunctional side up)
- Contact right rib 8 and its anterior and posterior attachments by placing the index finger of one hand over the costovertebral junction and the index finger of your other hand over the costochondral junction with your thumbs along the lateral aspect of the rib
- Disengage the rib from its vertebral attachments by applying either an anterior or medial pressure
- Bring the rib superiorly and laterally until a position of equal tension is palpated among the ligamentous attachments of the rib
- Hold this balanced position until a release is palpated and normal respiratory motion returns.
On-Side BLT for Group Rib Dysfunctions
EX: Rib 6-9 inhaled on the right
Pt lateral recumbent (dysfunctional side up)
- Place both hands over the ribs 6-9 on the right, making broad contact.
- Gently compress the ribs toward the pt’s midline to disengage the ribs from their vertebral attachments
- Find a position of equal tension among the ligamentous attachments to the ribs by moving the ribs in all 3 planes
- Hold this balanced position until a release is palpated and normal respiratory motion returns.
Osteopathic principles
- The human being is a dynamic unit of function
- The body posses self-regulatory mechanisms that are self healing in nature
- Structure and function are interrelated at all levels
- Rational treatment is based on these principles
Secondary HTN
- Kidney problems
- Adrenal gland tumor/other adrenal disorders
- Congenital defects in blood vessels
- Medications
- Nutritional supplements
- Illegal drugs- cocaine and amphetamines
- Thyroid disorders
Medications that can cause secondary HTN
Birth control pills Cold remedies Decongestants Over the counter pain relievers caffeine Some prescription drugs
Pharmacologic treatment for those 60 and older
Initiate treatment at BP 150/90
Pharmacologic treatment for those 30-59
Initiate treatment at BP 140/90
Pharmacologic treatment for those that are diabetic or have nondiabetic chronic kidney disease
Same thresholds.
Initiate treatment at BP 140/90
Pharmacologic treatment for those less than 30
Initiate treatment at BP 140/90
SD affecting adrenals or kidneys
T6-L2
Tight psoas major
Can contribute to altered motion and function in the lower thoracic/lumbar region and diaphragm
- Will facilitate catecholamine release from adrenal- resulting in increased cardiac outputs and peripheral resistance. Vasoconstriction of renal artery
Myocardium chapman’s reflex
Anterior: b/w ribs 2-3 near sternal border
Posterior: between T2-T3 near spinous processes
Kidneys chapman’s reflex
1” lateral and 1” superior from from the umbilicus and intertransverse region of T12-L1
Adrenal chapman’s reflex
1” lateral and 2” superior from the umbilicus and intertransverse region of T11-T12
Medications JNC 8 for HTN
Thiazide diuretics, ACE, ARB, CCB
Titrate at monthly intervals until goal BP achieved
Tenets of osteopathy
- The body is a single unit of function
- The body is designed to be healthy and heal itself
- Structure and function are interrelated
- Rational treatment is based on these tenets
How long does troponin I staty in the blood?
7 days
How long does Troponin T stay in the blood?
10-14 days
What can make a false positive Troponin?
Kidney failure
What can make CK-MB falsely positive
Small intestine or uterus
Which enzyme can give a clue as to the severity of the infarct?
CK-MB
Heart Chapman’s point
T3 lateral to spinous process- superior
2nd intercostal space at the sternum
Bronchus chapman’s point
T2 lateral to spinour process- inferior
2nd intercostal space at the sternum
Lung chapman’s point
T3 lateral to spinous process- superior
T4 lateral to spinous process-interior
3rd, 4th intercostal space at sternum
Stomach chapman’s point
T5, T6 left lateral to spinous process- inferior
5th and 6th intercostal space at costochondral junctional left
Pancreas chapman’s point
7th right lateral to spinous process- inferior
7th intercostal space at costochondral junciton right
primary HTN
- white coat
- metabolic syndrome
- genetics/epigenetics
- salt intake
- obstructive sleep apnea
Discharge medications for MI
Beta blocker, nitroglycerin, clopidogrel (aspirin), statin, ACE inhibitor
initial management of MI
Order an EKG and cardiac enzymes
