Exam 1 Flashcards
1
Q
10 step screening exam
A
- Gait/Posture
- Standing Spine Sidebending Test
- Standing Flexion test
- Seated Flexion Test
- Seated Upper Extremity Motion
- Seated Trunk Tests
- Seated Cervical Motion
- Supine Thoracic Cage Motion
- Lower Extremity Motion
- Pelvis Landmarks
2
Q
Brief Screen:
A
- Posture: assess major landmarks (shoulder heights, iliac crest heights, popliteal creases, arches, thoracic kyphosis, lumbar lordosis, etc.)
- Scan for TART changes in the cervical, thoracic, and lumbar spine. If TART changes are present, use segmental motion testing to check for vertebral somatic dysfunction
- Standing flexion test. If positive, check pelvic landmarks (ASIS, PSIS, pubic symphysis) for pelvic somatic dysfunction
- Seated flexion test. If positive, check sacral landmarks (sacral sulci, ILAs, may confirm laterality with backward bending test and pelvic rock) for sacral somatic dysfunction.
3
Q
If there is an extremity complaint
A
investigate those areas further for orthopedic pathology and somatic dysfunction (ex: FABERE, anterior drawer test, Apley’s, Etc.)
4
Q
Cervical Diagnosis
A
Manual of Selected Osteopathic Techniques, p. 76-77
5
Q
Thoracic and Lumbar Diagnosis
A
Manual of Selected Osteopathic Techniques, p. 25-8
6
Q
OPP SOAP Subjective
A
(This can be combined into an easy reading paragraph)
Onset
Setting
Timing
Course
Assoc Sx.
Alleviating/aggravating factors
Prior occurrence
Quality
Location
Radiation
Severity
Perceived cause
Risk factors
Previous work up
ROS: (CP=chest pain, SOB=shortness of breath, N/V/D=nausea, vomiting/diarrhea)
Past Medical Hx [Conditions, illness, hospitalizations, injuries, surgeries, immunizations, tests]
[For OMT, we like to know birth Hx, sports Hx and trauma Hx, as well as if the person wore braces]
Meds:
Allergies:
Social Hx: [Tobacco, alcohol (etoh), illicit drugs, caffeine, work, diet, occupation, exercise]
Family Hx: [Parents, children, grandparents, siblings, other (aunts, uncles…)]
7
Q
OPP SOAP Objective
A
(Focused PE based on CC)
Vitals:
General:
Neck:
Cardio:
Pulm:
GI:
MSK: (ROM, tone, strength, tremors, ortho tests…)
Neuro: (CN, reflex, SLR, rhomberg…)
Osteopathic (NMM/OMM): This should include screening (gait, body type, scoliosis, lordosis, kyphosis), TART findings, & specific segmental somatic dysfunctions
8
Q
OPP SOAP Procedure
A
(this is your omt, injxn…)
Must have consent (verbal, written)
Techniques or procedure type
Pt and doc perception of improvement
Complications
CPT code: (icd-9) OMT 1-2 regions 98925 OMT 3-4 regions 98926 OMT 5-6 regions 98927 OMT 7-8 regions 98928 OMT 9-10 regions 98929 [icd-10 codes most likely will be different]
9
Q
OPP SOAP Assessment
A
(Usually your top four diagnosis; you can put differential diagnosis [ddx] under each)
10
Q
OPP SOAP Plan
A
(this should include tests, medication, education, therapeutic procedures, what to expect, anticipatory guidance, exercises)
11
Q
Articulatory Technique
A
p.31
12
Q
Balanced Ligamentous Tension/Ligamentous Articular Strain
A
p.33-34
13
Q
Strain/Counterstrain
A
p.37-38
14
Q
High Velocity, Low Amplitude
A
p.39-40
15
Q
Lymphatic Technique
A
p.41-42
16
Q
Muscle Energy
A
p.43-45
17
Q
Myofascial Release
A
p.47
18
Q
Soft Tissue
A
p.51-52
19
Q
Still Technique
A
p.53
20
Q
Facilitated Positional Release
A
p.89-90
21
Q
DiGiovanna, Schiowitz, and Dowling. An Osteopathic Approach to Diagnosis and Treatment, 3rd Ed. 2005
A
Aug 3 PDF
22
Q
Inguinal Ligament CS technique
A
❖TP is superior surface of pubic tubercle
❖ Pt: supine
❖ Technique: flex both legs 90 degrees and place on doc’s thigh. Move leg on tender side under the opposite leg. Adduct the femur. Internally rotate the femur by moving the ipsilateral foot towards yourself until the TP resolves
❖ Hold for 90 seconds
❖ Recheck
23
Q
Inguinal Ligament CS Location
A
24
Q
Iliacus (Psoas) CS Technique
A
❖ TP is 2 in inferior and 2 in medial from ASIS (press post-laterally)
❖ Pt: supine
❖ Technique: stand on tender side. Flex patient’s legs, externally rotate the legs and place them on your thigh. Flex, sidebend toward the TP until it resolves
❖ Hold for 90 sec
❖ Recheck Insert pic
25
Iliacus (Psoas) CS Location
TP is 2 in inferior and 2 in medial from ASIS (press post-laterally)
26
Low Ilium (SI) CS Technique
❖ TP is on lateral ramus of the pubic bone anterior surface
❖ Pt: supine
❖ Technique: flex the tender side only (90 degrees); add abduction if needed for resolution of pain
❖ Hold for 90 sec
❖ Recheck
27
Low Ilium (SI) CS Location
28
Lateral Trochanter CS Technique
❖ TP is on the lateral surface of the femur 0-15 cm distal from great trochanter in the ITBand
❖ Pt: prone
❖ Technique: doctor is seated supporting the pt’s leg on his thigh. Slightly flex the hip, add abduction (generally more than flexion) and internal rotation (sometimes)
❖ Hold for 90 sec
❖ Recheck
29
Lateral Trochanter CS Location
30
Posterior Lateral Trochanter Cs Technique
❖ TP is on the superior lateral surface of the posterior greater trochanter
❖ Pt: prone
❖ Technique: doctor is standing with knee on table under the pt’s thigh; add in a moderate amount of extension, some abduction and a whole lot of external rotation until the TP resolves
❖ Hold for 90 sec
❖ Recheck
31
Posterior Lateral Trochanter Cs Location
32
Posterior Medial Trochanter Cs Technique
❖ TP is 3-5 mm inferior to the greater trochanter between the posterior medial surface of the shaft of the femur and the posterior lateral surface of the ischial tuberosity
❖ Pt: prone
❖ Technique: grasp leg on tender side and place your knee under the thigh; slightly extend the leg, moderately externally rotate it and bring the leg across the midline with adduction until the TP resolves
❖ Hold for 90 sec
❖ Recheck
33
Posterior Medial Trochanter CS Location
34
Anterior Lateral Trochanter CS Technique
❖ TP is 5-7 cm lateral and inferior to the ASIS but anterior and superior to the greater trochanter
❖ Pt: supine
❖ Technique: flex hip 70-90 degrees; add abduction and external rotation until the TP resolves
❖ Hold for 90 sec
❖ Recheck
35
Anterior Lateral Trochanter CS Location
36
High Ilium Sacroiliac (HISI) CS Technique
❖ TP is 4-5 cm lateral to PSIS
❖ Pt: prone or supine (picture is prone)
❖ Technique: doctor is standing on affected side; extend leg and slight abduction until TP resolves
❖ Hold for 90 sec
❖ Recheck
37
High Ilium Sacroiliac (HISI) CS Location
38
Mid pole Sacroilliac (ilium in flare superior) (MPSI) CS Technique
❖ TP is 3-4 cm inferior to PSIS in the divot in the muscle just lateral to the sacrum. Approach the TP from the lateral side
❖ Pt: prone
❖ Technique: doctor is standing on affected side; slightly flex the hip and knee; add in abduction (major component of this treatment) and some external rotation of the hip until the TP resolves
❖Hold for 90 sec
❖ Recheck
39
Mid pole Sacroilliac (ilium in flare superior) (MPSI) CS Location
40
Piriformis CS Technique
❖ TP is in the belly of the piriformis 8-9 cm medial and slightly superior to greater trochanter (but can be anywhere along the track of the muscle)
❖ Pt: prone
❖ Technique: doctor is seated on side of TP. Suspend pt’s leg off table and rest the leg on your thigh. Flex the hip to about 135 degrees, abduct slightly via the knee and internally or externally rotate the knee until the TP resolves
❖ Hold for 90 sec
❖ Recheck
41
Piriformis CS Location
42
High Ilium Out Flare (HIFO) CS Technique
❖ Seen in coccydynia
❖ TP is at sacrococcygeal joint or on the coccyx
❖ Pt: prone
❖ Technique: doctor is standing on affected side; raise (extend) the affected side just enough to be able to adduct the leg over the other leg and then adduct the leg
❖ Hold for 90 sec
❖ Recheck
43
High Ilium Out Flare (HIFO) CS Location
44
Sacral Tenderpoints CS Technique
❖ Found along the median crest of the sacrum
❖ They would be located on the spinous and transverse processes of the sacrum if it were not fused
❖ The sacrum fuses around age 25 so if the patient is younger than that the TPs will be on the respective transverse and spinous processes ❖
Pt: prone
❖ Technique: doctor is standing and will apply gentle pressure to the opposite part of the sacrum of where the TP is located
❖ For example if it is a PS1 right point, the doctor will push on the left ILA
❖ Hold for 90 sec
❖ Recheck
45
Sacral Tenderpoints CS Location
46
Sacral Reading
Manual of Osteopathic Technique pages 149-154, 157-158, 161-162, 164-168, 171-175, 179-181.
Foundations for Osteopathic Medicine 3rd ed chapter 41 and pages 759-760 (PDF in Aug 6)
47
Manual of Selected Osteopathic Techniques, Furlano and Prest
pages 346-52
48
Osteopathic Manipulative Medicine Guidelines for the Hospitalized Patient, Graham, pages 52-55
pdf on Aug 12
49
Osteopathic Considerations in Systemic Dysfunction, Kuchera and Kuchera,
a. pages 124-129 (down to the genital/reproductive system section on p. 129)
PDF aug 12
50
Osteopathic Considerations in Systemic Dysfunction, Kuchera and Kuchera,
b. pages 133-139 (not the sections on prostatitis or dysmenorrhea)
PDF aUG 12
51
Manual of Selected Osteopathic Techniques by Furlano and Prest:
p. 127-128, 193-195
52
Manual of Selected Osteopathic Techniques by Furlano and Prest:
p. 305, 306, 113, 116-7 (p.118-119 optional)
53
Osteopathic Principles
* 1. The human being is a dynamic unit of function
* 2. The body possesses self-regulatory mechanisms that are self-healing in nature
* 3. Structure and function are interrelated at all levels
* 4. Rational treatment is based on these principles.
54
SD Definition
Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements
55
30 y.o. Male:
* c/o abdominal pain and bloody urine x 24hr
* Pain radiates to right groin, 10 out of 10 level
* +N, +V x2, can’t lay still
* ROS: Chills, RLQ pain, Mild backache, works as landscaper in AZ
* PMHx: Obese, Hypercholesterolemia.
PSHx: Neg
* SHx: 4+ sodas/d, Rare water intake, +Tob
* Med: Fish Oil
* Vitals: T 99, BP 145/90, P 99 •Abd: No mass/organomegally/TTP/rebound
* MS: + Right CVA TTP
* OSE: T10-11 R paraspinal hypertonicity, R Iliacus TP, R diaphragm crus restriction
* UA: moderate blood
* KUB: negative
* VUR: 3 distinct 4 mm hyperecoic masses, R mid-ureter, mild R hydronephrosis
* Acute Nephrolithiasis Plan:
* Oral hydration, Opioid pain med, Ca Channel or Alpha 1 antagonist.
* Urology referral (Multiple stones or \>5mm)
* OMM
56
Urologic Anatomy General
* Kidneys are Retroperitoneal
* R Kidney and Duodenum
* L Kidney and Tail Pancreas
57
Urologic Anatomy Muscles
* Diaphragm
* Psoas
* Quadratus Lumborum
* Transversus Abdominus
* Rib 11 and Internal Oblique
* Rib 12 and Quadratus Lumborum insert pic
58
Urologic Anatomy Other Structures
* Adrenals
* Arcuate Ligaments
* Rib 11 (L), Rib 12 (B)
* Bladder
* Ureters
* Pubic Symphysis
59
Urologic Anatomy Autonomics •SNS:
* Kidney T10-11
* Ureter T10-L1
* Bladder T12-L2
* Sup/Inf Mesenteric Ganglia
60
Urologic Anatomy Autonomics •PNS:
* Kidney/Upper Ureter Vagus
* Lower Ureter/Bladder S-4
61
OMM Approach to the kidney
* T10-L2, OA, Sacrum
* Lymphatics
* Sup/Inf Mesenteric Ganglia
* Psoas •Diaphragm
* Ribs 11 & 12
* Kidney, Ureters
62
ME: Internal Oblique & Quadratus Lumborum
* Patient Prone, Stand opposite side to be treated
* Caudad hand grasp ASIS, Cephalad hand stabilize Rib 11 (then treat Rib 12 separately)
* Pull ASIS posteriorly, stabilize rib to barrier
* Patient pull ASIS to table, operator resist, stretch to new barrier, repeat x2-3
* Treat bilaterally
63
Re-dome Diaphragm
* Direct Muscle Energy
* Barrier in sidebending and rotation
* Activating force inhalation (5 sec)
* Refine barrier on exhale
* Repeat x 2
* Indirect MFR & Graduated Restrictive Techniques Also Lab Manual page 305
64
Iliacus (Psoas) Counterstrain
* TP is 2 in inferior and 2 in medial from ASIS (press post-laterally)
* Pt: supine
* Technique: stand on tender side. Flex patient’s legs, externally rotate the legs and place them on your thigh. Flex, sidebend toward the TP until it resolves
* Hold for 90 sec
* Recheck
65
Chapmans: Kidney
* Ant: 2.5 cm Lateral and Superior to the Umbilicus •Post: Between Transverse Processes of T12 & L1, bilaterally
* Tx: circular motion at point
* Treat Anterior than Posterior
66
Visceral: Kidney pt doesn't move
* Start Lateral to Umbilicus on Medial border of Ascending/Descending Colon
* Move Cephalad until contact Anterior/Inferior aspect of Kidney
* Exhalation: Move kidney Cephalo-Medially
* Inhalation: Hold position
67
Visceral: Kidney pt moves
* Patient Supine
* Operator hand on patient’s quadratus lumborum providing anterior pressure
* Patient flexes, externally rotates, abducts, then extends ipsilateral hip
* Repeat 3-4 times
68
16 y.o. Female:
* “it hurts when I pee”
* HPI: 2 day duration, smelly urine, urinating small amounts often
* ROS:mild lower abdominal pain, occasionally feels hot/cold, fatigue, no vaginal discharge
* PMHx: UTI 3 yrsago, cleared with one round of ABX tx
* Family: none significant
* Social: drinks 2 energy drinks daily, sexually active, one lifetime partner
* Trauma: none recently
* Meds: OCP
* Allergy: Sulfa drugs
* Vitals: T 100.2, BP 110/68, P 84, R 20
* Gen: AAOx3, NAD but is pale/fatigued
* Abdominal: soft, -masses, -Lloyd’s, + suprapubic tenderness, -rebound/rigidity/guarding, -McBurney’s
* Genital: no discharge, no signs of trauma or inflammation
* OSE: T10-11 FRSR with paraspinalmuscle hypertonicity, left SI joint restriction, left superior pubic shear, left anteriorly rotated innominate
* Spot UA: +RBC +WBC +leukocyte esterase +nitrites
Dx:
* Urinary tract infection
* Somatic dysfunction
* Thoracic region
* Pelvic region Plan:
* Urine culture with sensitivity
* Antibiotic therapy
* Encourage fluids
* Discuss good hygiene
* OMM
69
Bladder Chapmans pt anterior
Around the umbilicus and on the medial pubic symphysis Bilateral
70
Urethra Chapmans pt anterior
medial pubic symphysis, on the upper edge bilateral
71
Urethra, bladder posterior chapmans pt
upper edge of TP of L2 Bilateral
72
OMM Plan for 16 year old girl
* Facilitate respiratory/circulatory function
* Treat Chapman’s reflex points
* Balance autonomics
73
•Facilitate respiratory/circulatory function
* Open thoracic inlet
* Treat abdominal diaphragm
* Treat pelvis especially pubic symphysis and pelvic diaphragm
74
•Balance autonomics for 16 year old girl
* Treat thoracicsand lumbarsbecause sympatheticsto the bladder originate in the T10-L2 region
* Treat sacrum, SI joints because parasympatheticsto the bladder originate in S2-4 (pelvic splanchnic nerves)
75
Still Technique
Passive, combined direct/indirect technique thought to be utilized by AT Still
76
Still Technique Steps
* Move the tissue/joint into its position of ease (this is your dx)
* Exaggerate the position of ease to relax the tissue
* Introduce a vector of force no greater than 5 pounds through the affected tissue
* Using the force vector as a lever, carry the affected tissue towards and through the initial restriction
* A palpable release is often felt as the coupled force vector and tissue motion takes the tissue past its area of previous restriction
* The force vector is then released and the tissue is returned to neutral and retested.
77
Seated Still Technique for the thoracic and lumbar spine regions
(Manual p. 127-128)
78
Supine Still Technique for anterior and posterior innominate rotations and superior innominate shears
Manual p. 193-195
79
Where does the sympathetic innervation of the heart have its origins?
Cord segments T1-5(6) Synapses occur in the upper thoracic and/or cervical chain ganglia
80
Sympathetic fibers to the heart do have a right-and left-sided distribution
Right sided fibers pass to the right deep cardiac plexus -innervate the right heart and sinoatrial (SA) node
Left sided fibers pass to left deep cardiac plexus –innervate left heart and atrioventricular (AV node)
81
What is the result of hypersympathetic activity (tone) to the right side of the heart (SA node)?
Supraventricular tachyarrhythmias
Sinus tachycardia
Paroxysmal supraventricular tachycardia (PSVT)
82
What type of somatic dysfunction can increase sympathetic activity (tone) to the heart?
Upper thoracic dysfunction (especially extended segments)
Upper rib dysfunction, many times associated with upper thoracic dysfunction
Cervical dysfunction –affecting the superior, middle and inferior cervical ganglia
83
Where does the parasympathetic innervation of the heart have its origins?
Vagus nerves (cranial nerve 10)
Also have ipsilateral distribution
Right vagus –innervates the sinoatrial (SA) node
Left vagus –innervates atrioventricular (AV) node
84
What is the result of hyperparasympathetic activity (tone) to the right side of the heart (SA node)?
Sinus Bradycardia
85
What is the result of hyperparasympathetic activity (tone) to the left side of the heart (AV node)?
AV Blocks
86
What is the course of the vagus nerve (cranial nerve 10)?
Originates on the medulla
Exits the skull via the jugular foramen between the occipital and temporal bones
Has connections with the first 2 cervical somatic nerves
Enters the chest via the thoracic inlet
87
What types of somatic dysfunction can affect the vagus nerves?
Occipitomastoid compression affecting the jugular foramen
Occiput, atlas and axis (upper cervical spine)
Thoracic inlet
Upper thoracics
Upper ribs
Clavicles
Lower cervicals
Cervical fascia
ECT.
88
Lymphatics Overview
Lymphatic drainage from heart and lungs primarily carried back to the heart via the right lymphatic duct
Courses through the thoracic inlet on the way back into the heart
Driven by synchronized diaphragmatic function and muscle activity –overall body movement
OMM, in dog studies, can improve lymphatic flow by 4-5 times
Exercise can improve lymphatic flow by 30+ times
We can combine both for the benefit of the patient
89
What are some areas of somatic dysfunction that can negatively affect lymphatic flow?
Thoracic inlet
Respiratory diaphragm
Lower thoracics
Lower ribs
Upper lumbars (psoas major muscle)
Sympathetics
90
Larson, Beal and Nicholas have reported palpatory changes at? with cardiac problems
T2-T4
91
Chapman’s Reflexes
A viscerosomatic reflex mechanism
Associated with palpable nodules deep to skin and subcutaneous tissue
Can be used for diagnosis and treatment
Can be used to affect heart, renal and adrenal function
92
allostatic load
Somatic dysfunction anywhere affects the individual locally and globally (entirely)
Stressors/imbalance that takes them closer to the threshold of symptoms and disease-activates SNS-HPA couple
93
Somatic dysfunction is frequently associated with hypersympathetic activity
Example –upper thoracic dysfunction may be associated with local hypersympathetic tone to innervated structures but also a global increase in sympathetic tone throughout the body
Overall, the entire individual is closer to their threshold for firing , more susceptible to imbalance and closer to the threshold for symptoms and disease
94
Increased allostatic load may contribute to breakdown of the
cardiovascular, immune, renal, gastrointestinal and central nervous systems
95
Our Job
to work knowingly with the system to allow health to manifest itself
96
As a result, multiple layers of dysfunction are removed to allow
the underlying health to shine through
97
It is not a sequence of wresting holds to mindlessly apply to
Disease Condition
98
Osteopathy is art and science integrated into
one
99
The overall result of a competently applied Osteopathic treatment is to improve
the health, function and motion of the individual
100
Epigenetics -do our genes (DNA) just randomly think for themselves?
Probably not! Epigenetics look at the genes as responding to multiple environmental signals that go into them
Positive signals may produce positive epigenetic expression and vice versa
Epigenetic abnormalities may be passed on for multiple generations unless the environmental signals are altered
101
What are some negative environmental signals that may have a negative impact on gene expression?
Poor nutrition
Toxic thoughts/mental stress
Physical stress
Environmental toxins
Somatic dysfunction
Others???
102
Hypertension (HTN)
Affects a significant amount of the US population
Is a risk factor for coronary heart disease, congestive heart failure, ischemic and hemorrhagic stroke, renal failure and peripheral arterial disease
103
What is the most common cause of hypertension?
Essential
We don’t know what causes it
Harrison’s Principles of Internal Medicine describes multiple contributing factors including increased sympathetic activity Some antihypertensive medications work by reducing sympathetic effects
Renin-angiotensin-aldosterone system –involved in the regulation of arterial pressure via:
Angiotensin II (vasoconstrictor)
Aldosterone (sodium retention)
104
Renin is synthesized by the juxtaglomerular cells of the kidney in response to
Decreased pressure or stretch within the renal afferent arteriole (baroreceptor mechanism)
Sympathetic nervous system stimulation of renin-secreting cells
105
How can somatic dysfunction contribute to elevated blood pressure and hypertension?
Upper thoracic dysfunction can facilitate increased sympathetic tone to the heart
Increased heart rate
Increased stroke volume
106
Somatic dysfunction in the thoracic and lumbar regions
(especially T6-L2) can facilitate increased sympathetic tone to the adrenal gland and kidney
107
HTN and SD
Will facilitate catecholamine release from adrenal –resulting in increased cardiac output and peripheral resistance
Will activate renin-angiotensin-aldosterone system –resulting in vasoconstriction (increased vascular resistance) and sodium and fluid retention via aldosterone
108
Somatic dysfunction affecting the cranium (SBS compression, occipitomastoid compression affecting jugular foramen), occiput, atlas and remainder of cervical spine may alter
may alter carotid receptor function and contribute to alterations in blood pressure
109
OMM Integration
Treat the entire patient Osteopathically to overall reduce the allostatic load
Pay special attention to the cranial mechanism, cervicals, upper thoracics and thoracolumbar junction
Don’t forget Chapman’s reflexes
110
A 30 year old male presents for an initial routine physical. He has not seen a physician for 12 years and has no complaints.
Review of systems negative
Medical histories noncontributory
Vitals Temp 99.0F, BP 145/95, Pulse 70, Respirations 14 Physical exam –normal
What is the diagnosis?
MI
111
Myocardial Infarction (MI)
Many demonstrate autonomic imbalance
Dysfunction at T2-3 on left in patients with anterior wall MI Dysfunction at C2 and cranial base (vagus) with inferior wall MI
Most common cause of death within the 1st24 hours is ventricular fibrillation (50% occur within 1sthour)
Treat them sooner versus later
112
OMM Integration Goals for MI
Bring autonomic balance back to the cardiovascular system Prevent ventricular fibrillation
Reducing sympathetic tone will cause dilation of the coronary arteries –improved myocardial perfusion
Improve arterial supply and venous and lymphatic drainage to heart
113
Avoid HVLA technique (especially to the upper thoracics) during the initial management of MI.Why?
HVLA can cause a short-term increase in sympathetic activity
May result in vasoconstriction of coronary arteries and extend infarct
Again, treat the whole patient Osteopathically to improve function and motion but pay special attention to the:
Cranial mechanism (CV 4 helps balance autonomics)
Cervical spine (Vagus)
Upper thoracic spine and upper ribs
Thoracolumbar junction
Chapman’s reflexes affecting heart, adrenals and kidneys
Gentler techniques are initially a better option!
114
Heart Failure (CHF)
Clinical syndrome associated with:
Intravascular and interstitial volume overload
Inadequate tissue perfusion
Symptoms
Fatigue and SOB most common
Also see anorexia, nausea, early satiety associated with abdominal pain/fullness, confusion, disorientation, sleep/mood disturbances and nocturia
115
Heart Failure (CHF) Pathogenesis –progressive disorder
Something damages the heart muscle or reduces its ability to generate force (contract)
Many causes including coronary artery disease, MI, hypertension, toxic damage (excessive alcohol), viral infection, etc.
Regardless of cause, result is overall decline in pumping capacity of heart
Vicious downward spiral develops due to activation of neurohormonal systems
116
The Spiral of CHF
Decreased CO –unloading of high-pressure baroreceptors in left ventricle, carotid sinus and aortic arch
Afferent signals to CNS –releases ADH (antidiuretic hormone) Reabsorption of free water
Activation of sympathetic efferents to heart, kidney, peripheral vasculature and skeletal muscles
117
The Spiral of CHF Sympathetic stimulation of kidney associated with
Release of renin and activation of renin-angiotensin-aldosterone pathway
Salt and water retention
Vasoconstriction and increased vascular resistance
Myocyte hypertrophy
Myocyte death
Myocardial fibrosis
118
OMM Integration for CHF
Goal is to break into the downward spiral
Reduce intravascular and interstitial volume overload (improve renal function)
Improve tissue perfusion
Optimize cardiac function
119
OMM Integration for CHF Treat entire patient Osteopathically but especially pay attention to:
Cranial mechanism
Cervical spine
Upper thoracics
Thoracolumbar junction (kidneys and adrenals)
Lymphatics (thoracic inlet, respiratory and other diaphragms)
Proceed slowly -these patients can be very fragile!
120
Treatment fo CHF Exercise is a key and improves:
Autonomic nervous system function
Regional blood flow
Endothelial function
Skeletal muscle function
Quality of life
Exercise training can improve exercise duration as much as pharmaceutical agents (digoxin and ACE inhibitors)
We combine exercise, pharmacologic management and OMM for best possible outcomes
121
Mannino (1979) treated Chapman’s points for the adrenals and recorded
15 mmHg drop in systolic
8 mmHg drop in diastolic
Pretreatment BP: 150-200/95-120
Also found that serum aldosterone levels dropped 36 hours after OMT
122
Northup reported in 1961 a study of 100 hypertensive patients treated with OMT only
33 mmHg drop in systolic (199 to 166)
9 mmHg drop in diastolic (123 to 114)
123
The Kidney Kania Anatomy
A retroperitoneal organ placed at the level of T12-L1 surrounded by perirenal fat.
The fascia that encloses the kidney is funnel-shaped with the apex of the funnel cephalad and the mouth blending inferiorly in the adipose tissue of the iliac crest.
This fascia unites with its pair at the level of T12-L1 in front of the vertebrae.
Therefore, “tethering” of one kidney affects the other.
124
Why does this work? Dr. Kania’s Visceral Insights: to chapmans kidney points reducing BP
A “tethered” kidney places traction on the renal artery changing the cross-section from a circle to an ellipse, thereby changing laminar flow in the artery to turbulent flow.
This decreases the blood pressure in the afferent arteriole across the juxtaglomerular apparatus causing a release of renin.
A “tethered” kidney increases the neural input because of the stretch on the arterial supply.
Visceral OMT may help improve the above abnormalities.
125
Summary of Sympathetic Effects on the heart
Increased Sympathetic Tone:
Increases workload on the heart
Increases oxygen demand on the heart
Decreases oxygen supply to cardiac tissue Increases cardiac tissue irritability
Makes for a lousy environment for the heart to do its work.
126
Summary of Parasympathetic Effects
Increased vagal tone:
Decreases workload
Decreases tissue irritability/arrhythmias
Decreases morbidity/mortality rates
Makes for a happier environment for the heart.
Need a proper balance of sympathetic and parasympathetic tone for health!
127
Segmental Facilitation
Spinal segment receives exaggerated input from soma or viscera
Efferent motor and autonomic components of the spinal segment are maintained in a state of excitement
Further stimulation of the segment results in additional activation
Segment is hyperirritable and focuses the ascending or descending input to increase activity at the facilitated segment
Simplistically, it’s like turning up the amplifier (volume) on your stereo!
128
Louisa Burns, DO
Intrigued by the relationship of somatic dysfunction (SD) and somatovisceral effects
Induced SD at the atlas, T3 and left Rib 3 in rabbits
Allowed the rabbits to continue with SD for 2-8 months
Resulted in increased heart rate
Weakening of the pulse Irregular rhythm
Atlas lesions produced a greater variability in rhythm
129
Tx for HTN was not routinely performed until studies in the late 1940’s revealed a link between HTN and hemorrhagic stroke
FDR died of a cerebral hemorrhage while sitting for a portrait. He c/o “the worst H/A of my life,” slipped into a coma and died a few hours later. He had had HTN for several years prior to this occurrence.
130
Louisa Burns, DO Post-mortem results:
Irregular cross-striations in the myocardium (increased stiffness)
Increase in the growth of connective tissue in the myocardium (scar tissue = increased stiffness)
Minute hemorrhages in the myocardium
Increased edema between muscle fibers
Overfilling of blood vessels with crowding of the cells (thrombosis)
Loss of visible plasma layer within the vessels
131
Hemodynamic Effects of OMT Immediately after CABG Treatment that was provided
Post-op OMT applied to patients while in recovery and still unconscious and pharmacologically paralyzed
Control group received standard care without OMT
T-spine, ribs, diaphragm, sternum, upper cervical regions treated with BLT, MF
132
Hemodynamic Effects of OMT Immediately after CABG Results
Mixed venous blood is obtained from the pulmonary artery via a Swan-Ganz catheter
Mixed venous oxygen saturation (pulmonary artery blood) increased from 66.9% to 70.6% measured at 1 and 2 hours post surgery
Mixed venous oxygen saturation decreased in the control group
133
Hemodynamic Effects of OMT Immediately after CABG Cardiac Index REsults
Cardiac Index measures the amount of blood ejected by the left ventricle into systemic circulation in 1 minute/body’s surface area
The cardiac index measured immediately after surgery (before OMT) and immediately after OMT
Mean Cardiac Index increased from 2.86 to 3.37 in treated patients, 0.51 (p\<= 0.01), so more blood is circulating
Mean Cardiac Index in untreated patients increased by 0.14
134
Sleep Apnea
Significant predictor for coronary artery disease
High correlation in heart failure patients
Independently associated with hypertension
Hypoxia and hypercapnia increases sympathetic activation
Diurnal secretion of catecholamine absent in untreated Obstructive Sleep Apnea (OSA)
Muscle sympathetic nerve activity is elevated in patients with OSA and persists despite the administration of oxygen
Platelet activation is increased in OSA
Preliminary studies of CV4 can improve sleep in normal subjects
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So what else do we know as D.O.’s?
Increased sympathetic tone decreases perfusion via vasoconstriction
A rigid thoracic cage decreases the area in which the heart can move/relax (diastole)
Diaphragmatic restriction reduces the area in which the heart can move/relax (diastole)
Lymphatic congestion impairs gaseous exchange in the lungs
Lymphatic congestion encourages collagen formation (scar tissue)
Mechanical misalignment increases energy expenditure while remaining upright and even more with activity (abnormal gait can increase cardiac work up to 300%)
136
Serum Nitric Oxide Levels
Release of endothelial nitric oxide is postulated to be one of the reasons for the beneficial effects of exercise
Subjects tested after using a supine bicycle and after Dalrymple Pedal Lymphatic Pump, tested on separate days
Results:
Nitric oxide levels increased with exercise
Nitric oxide levels increased with DPLP comparably
137
Lymphatics
OMM, in dog studies, can improve lymphatic flow by 4-5 times
Exercise can improve lymphatic flow by 30+ times
We can combine both for the benefit of the patient
138
HVLA Indications, Precautions and Safety Rules
Page 39-40
139
Kirksville Krunch HVLA for Type II Thoracic Dysfunctions
Page 112
140
Kirksville Krunch HVLA for Inhaled and Exhaled Rib Dysfunctions
Page 280
141
Prone Cross Hand Pisiform Thrust HVLA for Flexed Dysfunction
Page 111
142
Balanced Ligamentous Tension Theory and Techniques
Pages 33-34, 273-277 and 301
143
38 y/o black male was referred to the office because of an elevated blood pressure on pre-employment physical for a position as a driver for FedEx. BP was 160/100 during the physical. Has been checking BP at Walmart and has readings of 146/86, 148/90, and 152/92. He denies any anginal symptoms, dyspnea, orthopnea, visual acuity changes, or claudication in extremities.
Allergies: PCN
Meds: ibuprofen a few times per week
PMHx: had frequent episodes of otitis media and pharyngitis as a child
PSHx: tonsillectomy and adenoidectomy
Soc Hx: single, smokes 1 ppd for the past 22 years; 6 pack of beer q Saturday; plays football with buddies on weekends in the fall; drinks 2-3 16 ounce Mt. Dew or colas qd
Fam Hx: both parents have diabetes mellitus Type 2 and hypertension; grandparents are deceased because of heart attack or kidney failure; brother has hypertension; sister has kidney disease
ROS: occasional heartburn; snores loudly; otherwise non-contributory
5’11’’ 220# T = 97.2 BP = 150/99 R = 16 P = 78
General: Alert and oriented in 3 spheres, overweight and appropriately groomed
EENT: mild AV nicking, no retinal hemorrhages OU; tonsils absent; remainder of exam normal
Heart: RRR without S3, S4 or murmur
Lungs: clear to auscultation bilaterally
Abdomen: soft to palpation; no tenderness; no organomegaly; no rigidity or guarding; normal bowel sounds auscultated in all 4 quadrants.
Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities
Primary Essential (Idiopathic) Hypertension Secondary Hypertension?
144
Primary Essential (Idiopathic) Hypertension –Causes?
White coat
Metabolic Syndrome
Genetics/epigenetics
Salt intake?
Obstructive Sleep Apnea
145
Secondary Hypertension -Causes?
Kidney problems (chronic renal disease)
Adrenal gland tumors/other adrenal disorders
Congenital defects in blood vessels
Medications: birth control pills, cold remedies, decongestants, over-the-counter pain relievers, caffeine and some prescription drugs
Nutritional supplements
Illegal drugs, such as cocaine and amphetamines
Thyroid disorders
146
What is normal blood pressure?
JNC 8
Did not specifically address the definitions of prehypertension and stage 1 and 2 hypertension as in JNC 7. Thresholds for pharmacologic treatment defined.
For ages 60 and older, initiate pharmacologic treatment at BP 150/90 and treat to goal
For ages 30-59, initiate pharmocologic treatment at BP 140/90 and treat to goal \< 140/90
Same thresholds and goals for adults \< 60 with diabetes or nondiabetic chronic kidney disease
For ages \< 30, initiate pharmocologic treatment at BP 140/90 and treat to goal \< 140/90
147
What should you evaluate and treat on the osteopathic structural exam? for htn
Somatic dysfunction affecting T1-T5(6) (and associated rib dysfunctions) may facilitate increased sympathetic tone to the heart.
Somatic dysfunction affecting T6-L2 can facilitate increased sympathetic tone to the adrenal gland and kidney. Tight psoas major muscle 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 output and peripheral resistance
Vasoconstriction of renal artery
Decreases glomerular filtration rate (GFR)
Will activate renin-angiotensin-aldosterone system –resulting in vasoconstriction (increased vascular resistance) and sodium and fluid retention via aldosterone
Chronic hypersympathetic tone may contribute to essential hypertension
Cranial dysfunction SBS compression, occipitomastoid compression affecting temporal bone and jugular foramen) may effect the hypothalamic-pituitary-adrenal (HPA) axis
Occiput, atlas and typical cervical dysfunction may alter carotid receptor function and contribute to alterations in blood pressure Clavicle dysfunction can affect the anterior cervical fascia and carotid arteries (baroreceptors)
Don’t forget the vagusnerve and it’s course!
Lymphatics including thoracic inlet (Sibson’s fascia), respiratory and pelvic diaphragm
Chapman’s reflexes
Myocardium = anterior between ribs 2-3 near sternal border; posterior between T2-T3 near spinous processes Kidneys = 1’’ lateral and 1’’ superior from the umbilicus and intertransverse region of T12-L1
Adrenals 1’’ lateral and 2’’ superior from the umbilicus and intertransverse region of T11-T12
Visceral OMT directed to the kidney
148
Medications JNC 8 for htn
Consider thiazide diuretics, ACE, ARB and/or CCB
Titrate at monthly intervals until goal BP achieved
149
55 y/o white male is evaluated in the hospital after having undergone stent placement in the left anterior descending coronary artery. He had chest heaviness during a Bruce protocol treadmill test with elevation of the ST segments across the precordium. Sublingual nitroglycerin and baby aspirin were administered and he was rushed to the cathlab for his procedure. He denies any anginalsymptoms or dyspnea currently. He denies orthopnea, visual acuity changes, or claudication in extremities. He does complain of pain in the upper left side of his back since the procedure. Troponins I and T were positive.
* Allergies: Sulfa
* Meds(Hx): ibuprofen daily for the previous 2 weeks for left shoulder ache; Toprol XL, 100mg qd; Lipitor, 10mg qd; admits that he does not take his medications consistently as he can tell when his blood pressure is high and will take it then.
* PMHx: hypertension for the past 7 years, hyperlipidemia, questionable diabetes mellitus Type 2: “my doc said something about my blood sugar being high but he didn’t say it was diabetes.”
* PSHx: vasectomy
* SocHx: married, smokes 1 ppdfor the past 37 years; a couple of highballs after work q hs; no exercise as he’s too busy with work; drinks 5 cups of coffee with Half and Half and sugar qd; works as mortgage broker
* Fam Hx: both parents have diabetes mellitus Type 2 and hypertension; grandparents are deceased because of heart attack or stroke; brother has hypertension; 2 sons, ages 16 and 18, are healthy
* Easily fatigued
* ? Mildly short of breath with exertion
* Left shoulder pain as mentioned above
* Occasional heartburn
* Snores loudly
* Pain in right groin
* PE:
* 5’9’’ 230# T = 97.2 BP = 140/90 R = 20 P = 78 O2= 98% RA
* General: Alert and oriented x3, overweight and appropriately groomed
* EENT: mild AV nicking, no retinal hemorrhages OU; no jugular venous distension; remainder of exam normal
* Neck: supple, no adenopathy, thyromegalyor carotid bruits noted
* Heart: Regular
* Lungs: clear to auscultation bilaterally
* Abdomen: soft to palpation; no tenderness; no organomegaly; no rigidity or guarding; normal bowel sounds auscultated in all 4 quadrants.
* Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities
* Where should we focus our exam?
* Complaints:
* Left shoulder pain
* Shortness of breath
* Reflux
* Groin pain
* Viscerosomatics:
* Sympathetic
* Parasympathetic
* Chapman's
* Disease Process:
* Heart
* Pericardium
* Diaphragm
* Stomach
* Pancreas
* Adrenals
150
How long does Troponin Istay in the blood?
7 days
151
How long does Troponin Tstay in the blood?
10-14 days
152
What can make a false positiveTroponin?
kidney failure
153
What can make CK-MB falsely positive?
small intestine or uterus
154
Which enzyme can give a CLUE as to the SEVERITY of the infarct?
CK-MB
155
Chapman’s Heart
T3 lateral to spinous process-superior, 2nd Intercostal space at the sternum
156
Chapman’s bronchus
T2 lateral to spinous process-inferior; 2nd Intercostal space at the sternum
157
Chapman’s lung
T3 lateral to spinous process-superior, T4 lateral to spinous process-inferior; 3rd, 4th intercostal space at sternum
158
Chapman’s stomach
T5,T6 Left lateral to spinous process-inferior; 5th and 6th intercostal space at costochondral junction Lef
159
Chapman’s kidney
L1 lateral to spinous process-inferior; 1cm superior, 1cm lateral to umbilicus
160
Chapman’s pancreas
T7 Right lateral to spinous process-inferior; 7th intercostal space at costochondral junction Right
161
Autonomics to the heart Sympathetic innervation
* T1-6
* Middle and Inferior Cervical Ganglia
162
Autonomics to the heart Parasympathetic innervation
* Vagus
* RIGHT--\> SA
* LEFT--\> AV
163
Areas to evaluate for 50 yo man
* Head (OA)
* Cervical
* Ganglia and accessory muscles
* Thoracic
* Chapman’s and Facilitated segments
* Ribs
* Chapmans and SOB
* Diaphragm
* Shoulder
* Heart
* Lungs
164
Discharge Meds for 50 yo man
* Beta Blocker
* Nitroglycerin
* Antiocoagulant
* ASA
* Clopidogrel
* Statin
* ACE-i
165
education for 50 yo man
* CAD
* HTN
* DM2
* Diet
* Exercise
* Smoking
* ETOH
* Stress
* Medications
166
FOM reading
Aug 6
167
What is the result of hypersympathetic activity (tone) to the left side of the heart (AV node)?
Ectopic foci
Ventricular tachycardia
Ventricular fibrillation
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