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OPP III > Final Exam > Flashcards

Final Exam Flashcards

1
Q

Left Kidney

A
  • Tail of pancreas
  • Rib 11
  • Rib 12
  • Diaphragm
  • Psoas
  • QL
  • Transversusabdominus
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2
Q

R Kidney

A
  • Duodonum
  • Rib 12
  • Diaphragm
  • Psoas
  • QL
  • Transversusabdominus
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3
Q

Sympathetics

Kidney

A

T10-L1

Superior & Inferior
Mesenteric Ganglia

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4
Q

Sympathetics

Ureter

A

T10-L1

Superior & Inferior
Mesenteric Ganglia

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5
Q

Sympathetics

Bladder

A

T12-L2

Superior & Inferior
Mesenteric Ganglia

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6
Q

Parasympathetics

Kidney

A

Vagus

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7
Q

Parasympathetics

Ureter

A

Upper –Vagus

Lower –S2-4

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8
Q

Parasympathetics

Bladder

A

S2-4

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9
Q

What is Still Technique?

A

A specific, nonrepetitivearticulatorymethod that is indirect then direct

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10
Q

Still Technique Steps

A
  1. Place in the position of ease.
  2. Apply force vector (compression or traction)
  3. Continue applying force as move through restrictive barrier.
  4. Return to neutral and reassess
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11
Q

What is FPR?

A

A system of indirect myofascial release treatment.

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12
Q

FPR Steps

A
  1. Place in neutral position to diminish tension.
  2. Apply force vector (compression, traction, torsion) until release is felt.
  3. Return to neutral and reassess.
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13
Q

Do you remember the L5 Rules?

A

If the sacrum is rotated R on R oblique axis 
L5 is…
Rotated –LEFT (opp.)
Sidebent–RIGHT (towards axis)

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14
Q

Cardiovascular

Sympathetics

A

T1-5ish
Ganglia????
Cervical chain ganglia

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15
Q

Cardiovascular

Parasympathetic

A

CNX –Vagusn.

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16
Q

Vagusn.

Where does that come from again?

A
  • Jugular foramen
  • Occipital-mastoid suture
  • CNIX, CNX, CNXI, int. jugular vein
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17
Q

What regulates blood pressure in your body?

A

Autonomic Nervous System
RAA System
Adrenal glands
Baroreceptors

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18
Q

If

A

BP of 140/90

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19
Q

If >60yo, when should pharmacologic treatment should be initiated for HTN?

A

BP of 150/90

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20
Q

If

A

BP of 140/90

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21
Q

Fatigueand SOBare the most common symptoms of CHF, but what are some other ones?

A 
Anorexia
Nausea
Early satiety
Abdominal fullness or pain
Nocturia
Confusion
Disorientation
Sleep and mood
disturbances
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22
Q

What are the two main goals for CV treatment?

A
  1. Autonomic balance.

2. Improve arterial, venous, and lymphatic circulation.

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23
Q

When encountering a patient with pathology (i.e. CHF), you want to think…

A

1.What systems are involved here?
•Respiratory, cardio, nervous, endocrine, GI, lymphatics, immune, etc.
2.What is the associated anatomy?
•i.e. Psoasmuscle association with kidney and ureters.
•Innervation–afferent, efferent, somatic, autonomic.
3.But what is going on with THIS PATIENT, the individual sitting in front of me?
•Where is his or her AGR and SDs?
•Other comorbidities?
•Emotionally, financially, lifestyle, insight/personal motivation.

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24
Q

Sagittalplane

A

transverse axis

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25
Q

coronal plan

A

ap axis

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26
Q

transverse plane

A

vertical axis

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27
Q

sacroiliac axis

A

sacrum on ilia

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28
Q

resp axis

A

craniosacral

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29
Q

iliosacral axis

A

ilia on sacrum

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30
Q

HVLA technique

reading

A

Page 39-40

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31
Q

Epigastric thrust HVLA for flexed and extended dysfunctions (mid and low-thoracic areas).

reading

A

Pages 108

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32
Q

Knee in back HVLA for flexed and extended dysfunctions (T2-T12)

reading

A

Pages 109-110

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33
Q

Cross hand pisiform “Texas Twist” HVLA for flexed dysfunction (T5-T12

reading

A

Page 111

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34
Q

Spinous process thrust HVLA for flexed and extended dysfunctions (T1-T4).

reading

A

Page 107

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35
Q

Muscle Energy Technique.

reading

A

page 43-45

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36
Q

Muscle energy for occipitoatlantal (OA), atlantoaxial (AA) and typical cervical (C2-C7) dysfunctions

reading.

A

page 92-94

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37
Q

HVLA technique indications, precautions and safety rules.

reading

A

page 39-40

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38
Q

biomechanics and diagnosis

reading

A

page 77

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39
Q

last card for the 17th

A

….

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40
Q

Typical cervical HVLA

reading

A

page 89

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41
Q

Last card on the 24th

A

…

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42
Q

HVLA technique indications, precautions and safety rules

reading

A

Page 39-40

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43
Q

OA and AA biomechanics and diagnosis.

reading

A

page 76-77

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44
Q

OA HVLA technique

reading

A

page 84

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45
Q

AA hvla technique

reading

A

page 85

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46
Q

Upper respiratory tract infections (URI) are typically viral in origin. Decreased host resistance and associated inflammation can lead to secondary bacterial infection. Visceral afferent impulses from the upper respiratory tract facilitate the upper thoracic spinal cord segments, leading to increased sympathetic tone to the structures of the head, neck and lungs. OMM is applied to improve function and motion of these areas. The overall goals are to:

A
  • Improve arterial supply
  • Improve venous and lymphatic drainage
  • Reduce muscle spasm and improve breathing
  • Reduce discomfort
  • Balance autonomic reflex disturbances
  • Improve immune function
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47
Q

While treating the entire patient Osteopathically, you especially need to focus on improving function and motion in the upper thoracics, upper ribs, cervical region, relevant Chapman’s reflexes and cranial mechanism. Addressing dysfunction at the occipitoatlantal (OA) and atlantoaxial (AA) areas is vital due to their influence on the jugular foramen

A

Approximately 85% of the venous drainage from the head courses through the internal jugular veins. They pass through the jugular foramen, which is formed at the junction of the occiput and temporal bones along the occipitomastoid suture. The venous drainage through this low pressure system can be impaired by increased tension in the suboccipital region resulting from OA and AA dysfunction.

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48
Q

Important pearl

A

treating upper thoracic and upper rib dysfunction first will make the cervical spine and cranial mechanism easier to treat

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49
Q

Muscle energy modifications

A

the HVLA techniques covered today can be easily modified into muscle energy techniques (Chicago-style muscle energy). The setups are somewhat different than the muscle energy techniques already covered for OA and AA and both are clinically effective.

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50
Q

Diagnosis – the occiput is rotated right and sidebent left in relationship to the atlas (posterior occiput on the right). OA RR SL

A
  • Same setup as HVLA.
  • After engaging the barrier, instruct the patient to gently turn their head to the right. Maintain contraction for approximately 3 seconds.
  • Instruct patient to relax.
  • Wait until the muscles completely relax (approximately 2 seconds).
  • Re-engage the barrier.
  • Repeat above sequence a total of 3-5 times (until no further improvement of motion noted).
  • Reassess.
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51
Q

Diagnosis – the atlas is rotated right in relationship to the axis (right posterior atlas). AA RR

A
  • Same setup as HVLA above.
  • After engaging the barrier, instruct the patient to gently turn their head to the right. Maintain contraction for approximately 3 seconds.
  • Instruct patient to relax.
  • Wait until the muscles completely relax (approximately 2 seconds).
  • Re-engage the barrier.
  • Repeat above sequence a total of 3-5 times (until no further improvement of motion noted).
  • Reassess.
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52
Q

Chapman’s points

upper lungs

A

anterior between ribs 3-4 close to the sternal border; posterior between T3-T4 near spinous processes

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53
Q

Chapman’s points

lower lungs

A

anterior between ribs 4-5 close to the sternal border; posterior between
T4-T5 near spinous processes

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54
Q

Chapman’s points

bronchus

A

anterior between ribs 3-4 close to the sternal border; posterior midway
between the TP and SP of T2 on the posterior aspect of the TP

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55
Q

Chapman’s points

nose:

A

anterior costochondral junction of 1st rib; posterior, place finger under the jaw
angle, like you are drawing a line across the face to parallel the line of the mouth and
pushing the finger backward until you come in line with the TP of the vertebrae

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56
Q

Chapman’s points

tonsils:

A

1st and 2nd intercostal space close to the sternum; posterior surface of C1 TP,
midway between the median line of the neck and the tip of the TP
sinuses: 3 ½” from the sternum, on the upper edge of 2nd rib and in the 1st intercostal
space above; posterior midway between the TP and SP of C2 on the superior aspect of
the TP

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57
Q

Chapman’s points

middle ear:

A

upper edge of the clavicle, just beyond where it crosses the 1st rib;
posterior upper edge of the posterior aspect of the tip of C1 TP

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58
Q

Chapman’s points

pharynx:

A

front of 1st rib ¾-1” toward the sternum from where the clavicle crosses the
rib; posterior midway between the SP and TP of C2, on the post aspect of the TP

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59
Q

Chapman’s points

larynx:

A

upper surface of 2nd rib, 2-3” from the sternum; posterior midway between the
TP and SP of C2 on the superior aspect of the TP

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60
Q

respiratory diaphragm innervation

A

along with cervical spine 3-5/phrenic nerve

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61
Q

upper thoracic dysfunctions

A

especially extended segments
palpatory changes at T2-T4 on the left with respiratory problems (viscerosomatic
changes)

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62
Q

Upper rib dysfunction many times

A

associated with upper thoracic dysfunction

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63
Q

Cervical dysfunction

A

affecting the superior, middle and inferior cervical ganglia

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64
Q

Pertinent autonomics:

A

Cord segments T1-6

Synapses occur in the upper thoracic and/or cervical chain ganglia

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65
Q

Somatic dysfunction at the thoracolumbar junction

A

(especially flexed segment T10-
L2) can facilitate increased sympathetic tone to the adrenal glands which can lead to
weakening of the immune system if chronically present. Can also impair toxin
excretion via the kidneys and intestines with chronic somatic dysfunction.

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66
Q

Scoliosis greater than 75 degrees (severe)

A

compromises respiratory function

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67
Q

OA, AA, cranial base (vagus nerve), occipitomastoid sutures

A 
Vagus nerves (cranial nerve 10)
Also have ipsilateral distribution
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68
Q

Somatic dysfunction affecting the cranium

A

(SBS compression, occipitomastoid
compression affecting jugular foramen), occiput, atlas and remainder of cervical
spine may alter drainage of the sinuses, function of the diaphragm

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69
Q

Superior, middle, and inferior cervical ganglia, and sphenopalatine ganglia affecting

A

the production of mucus and nasal congestion

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70
Q

lymphatic and myofascial relationships

A 
Galbreath technique
Thoracic inlet
Respiratory diaphragm
a. Lower thoracics
b. Lower ribs
c. Upper lumbars
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71
Q

Clavicles affecting the

A

anterior cervical fascia

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72
Q

Sacrum/coccyx/Ganglion impar

A

increased sympathetic tone in the thoracic spinal region

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73
Q

Immune triangle

A

sternum (thymus), right lower ribs (liver), left lower ribs (spleen)

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74
Q

Visceral OMT directed to the lungs/bronchi/respiratory epithelium/pluera, but not

A

during an acute exacerbation

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75
Q

Contraindications and cautions regarding treatment

A

1) No forceful direct treatments (depending on severity of illness)
2) HVLA to the thoracic spine relatively contra-indicated due to initial increase in sympathetic activity
3) Do not overtreat and tire the patient
4) Do not use treatment positions that aggravate patient’s breathing or pain (relative caution)
5) Thoracic pump technique in COPD patients
6) Visceral techniques in the acute phase

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76
Q

FPR handout Ferrill 2015

A

Oct 13

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77
Q

Otitis media FOM3 p 920-921

A

Oct 13

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78
Q

Increased Lymphatic Flow in the Thoracic Duct During Manipulative Intervention

A

Oct 13

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79
Q

OC In the Common Cold and URI-Kania

A

Oct 13

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80
Q

Last slide of oct 13

A

…

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81
Q

Chief Complaint: 38 y/o black female presents with nasal congestion, copious mucus production, and a scratchy throat for the past week. The mucus was initially clear, but has been yellow-green for the past 2-3 days. She had a low grade fever and chills on the first day, but none until yesterday when her temperature was recorded at 102.2. Also complains of fullness bordering on pain in her ears.

A 
What is the most likely diagnosis?
Which OPP treatment model will be helpful?
Circulatory
Biomechanical
Metabolic
Behavioral
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82
Q

Circulatory Model (Lymph)

A

Open Sibson’s fascia

Drain anterior and posterior cervical regions to enhance drainage of lymph

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83
Q

Sibson’s Fascial Release

A

Patient is supine

Stand on their right side facing the head

Right hand fingers curl into Sibson’s fascia

Left hand and arm support the right upper extremity

Rhythmically abduct and flex the RUE while increasing pressure over Sibson’s fascia

Repeat on the left side reversing hand holds

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84
Q

CERVICALFASCIA

paragraph

A

”The cervical fascia consists of fibrous connective tissue which invests the organs of the neck, ensheathesthe muscles, nerves and vessels, and fills the tissue interstices. It binds the cervical structures into functional units by dividing the neck into a series of planes and compartments”

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85
Q

ORGANIZATIONOFCERVICALFASCIA

Organized as concentric rings and cylinders that can be divided into

A

Vertebral Compartment
PrevertebraleFascia

Visceral Compartment
Buccopharyngealand PharyngobasilarFascia, PretrachealFascia and Fascia Alar

Vascular Compartment
Carotid Fascia

MusculofascialCollar

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86
Q

organization of cervical fascia creates

A

compartments and fascial spaces for muscles, visceral, nerves, vascular and lymphatic structures and maintains the mechanical, neural and circulatory integrity of the cervical region. It further contributes to transmission of forces between head, neck and thorax

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87
Q

LAYERSOFTHECERVICALFASCIA

A

A.Subcutaneous tissue
B.Masticator fascia, Submandibular fascia and Sternocleidomastoid-Trapezius Fascia
C.Strap muscle fascia and Prevertebral(perivertebral) fascia
D.Visceral fascia and carotid sheath

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88
Q

Treating posterior compartment

A

Stand on one side of the supine patient

Rest cephalad hand on their forehead

Gently grasp the posterior aspect of the neck

Rhythmically turn their head toward the same side while pulling the musculature toward you

Repeat on the other side

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89
Q

Treating anterior compartment

A

Stand on one side of the supine patient

Rest cephalad hand on their forehead

Gently grasp the anterior aspect of the neck

Rhythmically turn their head toward the same side while gently pulling the musculature toward you

Repeat on the other side

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90
Q

Treating the vascular compartment

A

While seated behind the supine patient

Place one hand on the mandible and the other on the ipsilateralclavicle to stretch the vascular compartment

Use a rhythmic stretch

Repeat on the other side

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91
Q

Other Treatment for uri

A

Address pressure points for the sinuses

Finish with a thoracic lymphatic pump

Treat Chapmans’ points (balance anterior to posterior points)

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92
Q

What is the biggest complaint about sinusitis or URI?

A

Sinus pressure

How can you help that?
Address the superior cervical ganglion (OA, AA)

Why?
Affects nasal congestion and mucous production

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93
Q

Last slide for Oct 15

A

…

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94
Q

Anatomic factors that affect breathing

A 
•Upper thoracic vertebrae
–Mechanical effects
–Sympathetically mediated viscerosomaticreflexes (T1-6)
•Ribs
•Sternum
•OA
–parasympatheticallymediated viscerosomaticreflexes
•Accessory muscles of respiration
•Anterior cervical fascia
•Thoracic diaphragm
–C3-5 (phrenic nerve)
–Upper lumbars(diaphragmatic crus)
•T10-12 and the lower ribs
–Connection to diaphragm
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95
Q

Dysfunction of the Thoracic Pump

A

•Over 150 joints are involved in the respiratory mechanism.

  • Somatic dysfunctions of the “pump” have direct effects on the viscera
    • decreased arterial supply
    • decreased venous drainage
    • decreased lymphatic drainage
    • decreased responsiveness of the respiratory mechanism to body demands (acid/base, oxygen demand, CO2 removal)
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96
Q

Seated vertebral myofascial release

A
  1. The child is seated with physician behind them.
  2. The physician’s thumbs are placed on the transverse processes of the segments to be treated. The physician most often will have each thumb on a different segment. The fingers wrap around the thorax for stabilization.
  3. This is a direct treatment. Engage the area focusing on the myofascial planes surrounding the vertebrae by working with rotation, sidebendingand flexion/extension. Then begin to work outwardly to engage the surrounding tissues of the diaphragmatic crus,andthe diaphragm. Remember, the focus is within the myofascial structures, not the articular.
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97
Q

Seated upper thoracic and sternal MFR

A

The upper rib-vertebral-sternal complex is often a hot-bed of somatic dysfunction in people with asthmatic and related disorders.

  1. Contact the sternum, upper ribs, and upper vertebrae (if possible).
  2. Directly engage the barrier by moving the ribs, sternum, and vertebrae in whatever way is necessary to bring myofascial release to the entire upper thoracic region.
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98
Q

Seated rib FPR

A
  1. Gently grasp both the anterior aspect of the rib, lateral to the costochondral junction, and the posterior aspect over the rib angle, as close to the costotransverse junction as possible.
  2. Disengage the rib by using a pincer grasp (a gentle anterior-posterior force)
  3. Once the rib is disengaged gently rock the rib along its long axis until a release is felt.
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99
Q

General Screening Assessment

ribs

A

Assessment of the ribs should happen in conjunction with the thoracic vertebral evaluation
TART changes over the rib angles
Tenderness
Asymmetry: prominent rib angles
Tissue texture changes
When you find motion restriction/somatic dysfunction of vertebral segments, you should automatically look at the ribs as well.
The ribs attach to the vertebral segments at the same level and above (for example, rib 3 attaches at T2 and T3).
Restricted motion of one will affect the other

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100
Q

ANTERIOR ASSESSMENT

ribs

A 
Can be in the seated or supine position (we will do supine today)
Observe global breathing patterns
Chest v abdominal breathing
Rate, rhythm, ease of breathing
Assess motion of the following areas:
Ribs 1-5 (Pump handle motion)
Ribs 6-10 (Bucket handle motion)
Assess for the anterior counterstrainpoints
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101
Q

POSTERIOR ASSESSMENT

ribs

A

Best done in the prone position
Assess
Ribs 11-12 (Caliper motion)
Posterior counterstrainpoints

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102
Q

Anterior Counterstrain

ribs

A
  • Found along the mid clavicular line, or along the mid axillary line
  • Often associated with exhaled sd
  • Treated
  • Knee contralateral
  • flexion and side bending towards the tender point (more flexion with anterior points and more side bending with lateral points)
  • Rotation is usually towards the tender point.
  • Hold for 120 seconds!!
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103
Q

Posterior Counterstrain

ribs

A
  • Found along the posterior rib angles
  • Often associated with inhaled sd
  • Treated
  • Knee ipsilateral
  • slight extension, side bending away to elevate the posterior part of the rib,
  • Rotation usually away from the rib tender point.
  • Hold for 120 seconds!!!!
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104
Q

pump handle ribs motion

A

more flexion

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105
Q

bucket handle ribs motion

A

more sidebending

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106
Q

Muscle Energy: Exhaled ribs 1 and 2

A

rib 1 is middle and anterior scalene

rib 2 is posterior scalene

rib 1 hand straight on face

rib 2 face is turned away with hand on forehead

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107
Q

Muscle Energy: Inhaled pump and bucket handle ribs

A

pectoris minor

picture

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108
Q

muscle energy exhaled ribs 3-5

A

picture

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109
Q

Muscle Energy:Exhaled ribs 6-10

A

lats

picutre

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110
Q

Muscle Energy: Inhaled caliper ribs

A

iliolumbar

  • Caudadhand over ASIS
  • Cephaladhand over posterior lateral aspect of ribs 11 or 12
  • Anterior lateral vector
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111
Q

Muscle Energy:Exhaled ribs 11-12

A
  • Caudadhand over ASIS
  • Cephaladhand over posterior medial ribs 11 or 12
  • Anterior vector
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112
Q

Chief Complaint: 68 y/o white male presents with a severe productive cough for the past week. Mucus is thick and creamy white. He admits to getting easily winded climbing a flight of stairs and needs to stop halfway up. Denies any fever or chills. He has come to the clinic today due to his wife’s insistence.

  • 5’11’’ 168# T = 96.8 BP = 135/80 R = 24 P = 100 Pulse-ox = 85%
  • General: Alert and oriented in 3 spheres, underweight; sits leaning forward with hands supporting him on the edge of the table and obviously dyspneic
  • EENT: no AV nicking, no retinal hemorrhages OU; tympanic membranes pearly gray, nasal mucosa pink and somewhat dry; tonsils without enlargement or exudate; oral mucosa and pharynx pinkish-gray and somewhat dry
  • Neck: no adenopathy palpated, but scalenesprominent
  • Heart: RRR without S3, S4 or murmur but sounds distant; PMI not detected
  • Thorax: barrel-chested
  • Lungs: relatively clear to auscultation bilaterally with scattered rhonchi, deep breathing triggers cough
  • Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities, muscle tone normal although muscles atrophic
  • What is the most likely diagnosis?
  • Which OPP treatment model will be helpful?
A 
–Biomechanical
•Need to make diaphragm more mobile
•Need to improve the bellows function of the ribcage
•Need to address scalenes/1strib
–Respiratory/Circulatory/Lymph
•Need better air exchange
•Avoid thoracic lymphatic pump technique
–Neurological
•Viscerosomatics
–Metabolic
•Breathing is hard work and many with COPD cannot breathe while eating
–Behavioral
•smoking cessation
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113
Q

Diaphragm

A

If one thinks of the hemi-diaphragm as an upside-down ladle, then the bowl is the domed portion of the upper diaphragm and the handle is the crus.
Then the ribs outline the rim of the bowl.
The handle is attached to the anterior lumbar vertebrae.

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114
Q

Diaphragm

Principles of MFR

A

Direct: Identify the restrictive barrier in multiple planes. Engage the tissue in opposition to the pattern of dysfunction. Load a constant force on the area of greatest restriction. Wait for the tissues to unwind or release.
Indirect: Identify the position of free motion in all planes. Place the tissue into the position of ease and maintain this until the tissues release.

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115
Q

MFR for the Diaphragm

A
  • Stand behind seated patient. Placing patient so that their center of gravity is close to yours will make the biomechanics of the technique easier and allow you to use your arms and torso to support the patient.
  • Place finger pads under the anterior costal margin and contact the diaphragm.
  • Assess where the greatest area of restriction is. The restriction may be in the mediastinum or the lumbar spine.
  • Expand your anatomical awareness and try to think in 3 dimensions.
  • Use the patient’s torso to place them into the barrier (direct) or position of ease (indirect).
  • Use MFR principles to resolve the somatic dysfunction.
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116
Q

Still Technique

A
  • Place the dysfunctional tissues into their position of ease.
  • Add a force vector (usually compression) through the dysfunctional tissues.
  • Move the tissues through the restrictive barrier.
  • It works better to correct the saggitalplane last.
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117
Q

Still Technique for the First Rib(seated)

INHALED

A

Brace opposite hand on the table with the elbow locked in extension.

Hand on affected side is placed on the anterior chest.

Place medial hand on rib head to monitor it. The forearm becomes a fulcrum as the technique progresses.

Lateral hand applies a compressive vector force from the elbow to the rib head to decrease tension on the joint capsule.

Lift the elbow cephalad while maintaining the compressive force throughout the arc.

This mimics the “up in front” position of the inhaled rib

Continue moving the elbow cephalad and then posteriorly while maintaining the compressive force.

As you move the elbow posteriorly and inferiorly, the rib head is now pushed through the physiologic barrier.

You may feel it “clunk” back into place.

Recheck to ascertain resolution of the somatic dysfunction.

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118
Q

Still Technique for the First Rib(seated)

EXHALED

A

Place medial hand on rib head to monitor it.

Lateral hand applies a compressive vector force from the elbow to the rib head to decrease tension on the joint capsule.

Place medial hand on rib head to monitor it.

Lateral hand applies a compressive vector force from the elbow to the rib head to decrease tension on the joint capsule.

Lift the elbow cephalad while maintaining the compressive force throughout the arc.

This mimics the “up in back” position of the exhaled rib.

Continue lifting the elbow cephalad and swing it anteriorly while maintaining the compressive force throughout the arc.

This mimics the “up in back, down in front” position of the exhaled rib.

As you move the elbow superiorly and anteriorly, the rib head is now pushed through the physiologic barrier.

You may feel it “clunk” back into place.

Recheck to ascertain resolution of the somatic dysfunction.

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119
Q

Still Technique for Thoracic and Lumbar Vertebral Somatic Dysfunction(seated)

A
  • Check for area of greatest restriction.
  • Identify the SD within the AGR.
  • Can use head & neck as a lever for treating upper Tswith compressive force coming from top of head, through neck to SD.
  • For lower Tsand Ls, place your hand on one of the patient’s shoulders and your opposite axilla on the other shoulder. Compress from both shoulders to the level of the SD.
  • If there are multiple SDs, treat the worst one first. Place it in the position of ease and then quickly check the other SDs. If they are not apparent, don’t treat them. They are compensatory SDs.
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120
Q

still steps for spine

A

position of ease

compression

through restrictive barrier

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121
Q

STILL TECHNIQUE for RIBS

inhaled

A
  • Rib(s) held in inhalation are more anterior and move more freely anteriorly.
  • Rotation of the thorax anteriorly to the opposite side of the affected rib should put the tissues into ease.
  • Hold the posterior portion of the rib to move it anteriorly.
  • Rotate the ipsilateral shoulder anteriorly to the opposite side.
  • Add compression with your hand on the shoulder (and your axilla on the other shoulder).
  • Return the ipsilateral shoulder posteriorly.
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122
Q

STILL TECHNIQUE for RIBS

exhaled

A
  • Rib(s) held in exhalation are more posterior and move more freely posteriorly.
  • Rotation of the thorax posteriorly to the opposite side of the affected rib should put the tissues into ease.
  • Hold the anterior portion of the rib to move it posteriorly.
  • Rotate the ipsilateral shoulder posteriorly to the opposite side.
  • Add compression with your hand on the shoulder (and your axilla on the other shoulder).
  • Return the ipsilateral shoulder anteriorly.
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123
Q

Uncontrolled Asthma- Ferrill

A

Oct 21

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124
Q

OMT and Asthma in Peds-Ferrill

A

oct 21

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125
Q

Article- Difficulty Breathing-Kania

A

Oct 21

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126
Q

Article-Lymphatic Pump Treatment- Kania

A

Oct 21

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127
Q

Last slide for the 21

A

….

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128
Q

22nd is same objectives as 21st

A

…

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129
Q

Foundations 2ndedition, p. 473-4

A

…

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130
Q

Adult Primary Cancers –Bone Metastases

A
  • Breast
  • Prostate
  • Lung
  • Kidney
  • Thyroid
  • (BLT with kosher pickle)
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131
Q

The pathways of spread include

A

(1) direct extension, (2) lymphatic or hematogenous dissemination, and (3) intraspinal seeding (Batson plexus of veins).

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132
Q

Adult Primary Cancers -Spinal Cord Metastases

A
  • Lung
  • Breast
  • Colon
  • Sarcoma
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133
Q

Adult Primary Bone Cancers

bone marrow

A

–Multiple Myeloma (most common –peaks between age 50-60)
–Lymphoma
–Leukemia

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134
Q

Adult Primary Bone Cancers

matrix and fibrous tumors

A

–Osteosarcoma(most common –75% in age 20 or younger)
–Chondrosarcoma(age 40 or older)
–Ewing Sarcoma (80% 20 yrs or younger)

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135
Q

Adult Joint Involvement

tumor

A
  • Metastatic process
  • Primary tumor
  • Paraneoplasticsyndromes (intrathoracictumors)
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136
Q

Hypertrophic osteoarthropathy from bronchogenic carcinoma causes

A

clubbing of the fingers and toes and a polyarthritis that resembles rheumatoid arthritis – knees, ankles, and wrists are most commonly affected

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137
Q

Adult Muscle and Skin Involvement

cancer

A
  • Tumors can metastasize to muscles and cause pain and decreased function due to muscle or nerve compression
  • These masses may be small and deep-seated
  • Dermatomyositisand polymyositishave a progressive proximal muscular weakness and is associated with lung and gastric cancer 50% of the time
  • Acanthosisnigricansis associated with gastric or abdominal malignancies
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138
Q

Dermatomyositis and polymyositis may precede a malignancy by

A

days or years – skin manifestations include a purplish erythema – dx via muscle bx, increased ESR and muscle enzymes, and abnormal EMG.
Acanthosis nigricans – hyperpigmented, hyperkeratotic skin lesion in the flexor areas of axillary, neck, or anogenital areas is assoc with gastric or abd malignancies

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139
Q

Pediatric Cancer Incidence

A 
•Leukemias(26.5%)
–Acute lymphoblastic leukemia (19%)
•CNS tumors (17.7%)
•Lymphomas (14.6%)
•Other (10.3%)
–Thyroid (4%), melanoma (3.4%)
•Soft tissue sarcoma (7%)
•Germ cell (6.4%)
•Bone tumor (5.3%)
•Neuroblastomas(4.8%)
•Renal tumor (3.9%)
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140
Q

Leukemia

A

may present with bone pain secondary to marrow hyperplasia as well as fatigue, pallor, ecchymoses, infection, fever, anorexia, weight loss
Extremity lesions present with pain subsequent to trauma but the trauma may not be causing the pain
CNS tumors often present with a headache in addition to ataxia and gait abnls, seizures or cranial nerve palsies – look for history of a headache while sleeping and absence of a family hx of migraines
Sudden onset of back pain that worsens when supine – may need an MRI
Neuroblastomas – most common extracranial solid tumor of childhood – paraspinal tumors may extend into the neural foramina and cause signs and symptoms of nerve root or spinal cord compression – bone mets very common esp skull

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141
Q

Pediatric Cancer

A

•Malignant musculoskeletal tumors account for approximately 12% of malignant neoplasms of childhood
•Most common are:
–Osteosarcoma–during puberty, around the knee
–Ewing’s sarcoma
–Rhabdomyosarcoma
•Pain is the most common presenting symptom

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142
Q

Pediatric Cancers –Bone Metastases

A
  • Neuroblastoma
  • Wilmstumor
  • Osteosarcoma
  • Ewing sarcoma
  • Rhabdomyosarcoma

account for more than 60% of childhood cancers
Leukemia, bone tumors, neuroblastomas can cause bone or muscle pain

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143
Q

history for onc

A
  • Previous cancer dxand tx
  • Dxevalfor cancer
  • Occupational and exposure history
  • Signs/symptoms specific to the 5 organs from which bone metscommonly arise
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144
Q

Bone Metastases Incidence

A
  • Cancer causes less than 1% of back pain in the general population
  • 98% of known cancer patients who present with back pain have underlying metastases
  • Up to 1/3 of patients with cancer develop metastases to the spine
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145
Q

need to aggressively investigate bone pain in cancer pts because

A

they could destabilize the axial skeleton and encroach upon the spinal cord or cauda equina

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146
Q

Bone Metastases

A
  • Pain is the most common presenting symptom
  • Localized, constant bone pain is the hallmark
  • Often begins as dull and intermittent but worsens steadily, often over several days or weeks
  • Pain at night and at rest is common
  • Common sites are the vertebral column (espthorax), skull, humerus, ribs, pelvis,
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147
Q

Potential for pathologic fracture if pain with weight-bearing

A

Requires radiographic and laboratory evaluation

Bone scan may be needed to find occult lesions

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148
Q

bone metasteses red flags

A
  • Unexplained musculoskeletal pain
  • Pain in spine or proximal extremities (hips, thighs, shoulders) that doesn’t correlate with a known injury
  • Night or rest pain
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149
Q

bone metastasis pain referral patterns

A
  • High cervical spine mets–posterior headache
  • C7-T1 –interscapularpain
  • T12-L1 –flank, iliac crest, or sacroiliac joint
  • Sacral destruction –saddle distribution
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150
Q

physical exam for cancer

A
  • Differentiate between bone and joint pain
  • If passive motion of the adjacent joint isn’t painful then be more alert to a cancer possibility
  • Specific exam of the common neoplasticprimary sites
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151
Q

Imaging Studies for cancer metastasis

A
  • Plain film radiography is the most specific for metastatic disease –will detect 70% of vertebral tumors
  • Obtain radiograph of the entire long bone for all painful sites
  • Multiple lesions are characteristic of metastatic disease
  • Lytic: lung, thyroid, kidney
  • Blastic: prostate
  • Mixed: breast, cervical, testicular, ovarian
  • Bone scan should be done if there is lesion on xrayor on a pt with a known primary cancer and negative xray
  • CT scan of the chest, abdomen, and pelvis to look for primary cancer
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152
Q

The metastases may occur in any bone

A

but most involve the axial skeleton (vertebral column, pelvis, ribs, skull, sternum), proximal femur, and humerus, in descending order of frequency. The red marrow in these areas with its rich capillary network, slow blood flow, and nutrient environment facilitates implantation and growth of the tumor cells. Metastases to the small bones of the hands and feet are uncommon and usually originate in cancers of the lung, kidney, or colon.
(Kumar, Vinay. Robbins & Cotran Pathologic Basis of Disease, 7th Edition. Saunders Book Company, 082004. 26.1.2.6.3).

Carefully inspect xrays for the type and extent of disease, presence of multiple lesions within the same bone, and the involvement of adjacent joints.
Xray is limited because 40-50% of the trabecular bone must be destroyed before it becomes evident on imaging
Bone scans can identify lesions as small as 2mm

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153
Q

Seldom diagnostic for metastatic disease except

A

–Immunoelectrophoresisfor multiple myeloma
–Prostate-specific antigen (PSA) for prostate CA
–CBC to evalanemia and thrombocytopenia
–Serum alkaline phosphataseto evalbone turnover
–Serum creatinine
–Calcium

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154
Q

Anemia and thrombocytopenia are common in extensive metastatic ds because

A

tumor cells displace hematopoietic cells
Hypercalcemia common with bone mets – undetected it causes significant morbidity – can lead to sudden death secondary to cardiac arrhythmia

155
Q

Biopsy

A
  • Confirm or restage metastatic disease in a pt with a known primary tumor and no history of bone disease
  • Evaluate a lesion in a pt without a known primary tumor
  • Obtain tissue for hormonal and immunohistochemicaleval
156
Q

Biopsy is rarely helpful in determining the unknown primary tumor

A

history, PE, and imaging studies are more likely to identify it

157
Q

Tumors on plain xray may have abnl such as

A

periosteal elevation, cortical destruction with a “moth-eaten” appearance, and an apparent soft-tissue mass

158
Q

cancer treatment

A
  • Pain management (opiates)
  • Assessment for impending fracture
  • Chemotherapy, radiation, systemic radionucleotides, hormone therapy, bisphosphonatetherapy
  • Surgery
  • Emotional/Spiritual support
  • Nutritional
  • OMT
159
Q

Bone pain thought to result from stimulation of

A

endosteal nerve endings, microfracture through weakened bone, or periosteal stretching from tumor growth

160
Q

Why treat a cancer patient with OMT?

A
  • Why not?
  • Empowers patients to live until they die.
  • Comfort of touch
  • Emotional support –reduces tension and stress
  • Pain reduction
  • Optimization of function especially visceral
161
Q

Indications for OMT

cabcer

A
  • Somatic dysfunction
  • Pain including post-surgical pain (ex: pt who is post-sternotomyor thoracotomyfor a lung CA)
  • Prevention or treatment of immobility-related complications in a bed-ridden patient (ex: atelectasisor constipation)
  • Treatment of extremity lymphedema(ex: UE after masectomy)
162
Q

Primary indication for omt with cancer patients

A

Primary indication is musculoskeletal pain associated with SD but not directly related to the tumor
Foundations: “initiation of rib raising should be preceded by tx of significant vertebral and rib SD to prevent exacerbation of visceral facilitation” – do gentle rib raising and focus on releasing ribs at the same time!

163
Q

Contraindications for OMT

A
  • Treatment in the immediate vicinity of the cancer because of the risk of hematogenousspread
  • HVLA because of risk of pathologic fracture of weakened bones
  • Lymphatic pumps and effleurage due to risk of lymphogenousspread??
164
Q

Evidence that physical exercise may reduce risk for breast and colon cancers perhaps through

A

improved immune function

Passive lymphatic techniques are fine – MFR for the thoracic inlet and abd diaphragm as well as pectoral traction

165
Q

Lab Handout for Hospitalized Pt

A

Oct 29

166
Q

last card for the 29th

A

…

167
Q

Manual of Selected Osteopathic Techniques,

A

178

168
Q

47 y/o female presents to her primary care office c/o right sided upper extremity pain and swelling that began one year ago after radiation treatment for breast cancer.

  1. What is my differential diagnosis (DDx)?
  2. Given that DDx, what questions do I need to ask?
  3. Given that DDx, what physical exam do I have to perform to help me decide which it is?
  4. What kinds of osteopathic structural findings might I see in this patient looking at them from a:
A

a) Biomechanical perspective
b) Neurological perspective
c) Lymphatic (Respiratory-Circulatory) perspective

169
Q

Biomechanical perspective

A

Check out ALL those beautiful anatomical connections from the upper extremity to:
Cervical spine
Thoracic spine
Ribs
Lumbar spine
Sacrum
Generally long restrictor muscles which will cause vertebral Type I dysfunctions
Rib elevation or depression
Sacral restriction that do not make sense with the model you have learned

170
Q

Check out ALL those beautiful anatomical connections from the upper extremity to:
Cervical spine
Thoracic spine
Ribs
Lumbar spine
Sacrum
Generally long restrictor muscles which will cause vertebral Type I dysfunctions
Rib elevation or depression
Sacral restriction that do not make sense with the model you have learned

A

Somato-somatic reflexes

Upper extremity:
SNS T1-4
PNS: NONE

Breast:
SNS T3-5 (2-6)
PNS: NONE

SO: look for Type II dysfunction in these areas

171
Q

Lymphatic perspective

A 
Breast
Axillary nodes (3/4)
Apical nodes
Internal thoracic nodes
May go to contralateral breast
May go to rectus abdominusand the subperitonealand subhepaticplexi
172
Q

Lymphatics

A
  • Continuous structure from the interstitial space, through terminal lymphatics, vessels, nodes and into central circulation
  • Baffles
  • Removal of part of the structure
    • Passive movement through interstitial space
    • Regeneration of vessels
    • Collateral circulation
173
Q

Indications for OMT in the patient with cancer

A

Somatic dysfunction
Pain associated with somatic dysfunction (not pain associated with tumor)

When to think about osteopathic evaluation and treatment
Post-surgical
Bed-ridden
Lymphedema
Constipation
Atelectasis
Pneumonia

In general
indirect techniques (BLT, SCS, etc)
or gentle direct or indirect soft tissue/myofascial

174
Q

Contraindications in treating a patient with cancer

A

Risk of hematogenous spread is high
 Vertebral cancers (as a result of Batson’s plexus): NO OMT in the vertebral spine

Direct techniques directly over area of tumor

Direct techniques in the presence of loss of boney integrity
Risk of lymphatogenousspread is high
Lymphatic techniques relatively contraindicated

175
Q

Lymphatic techniques relatively contraindicated

A

However, consider that patients who do a moderate amount of exercise daily during treatment tend to do better overall than those who don’t. Lymphatic pumps do not move as much lymph as moderate exercise will…

If you have concerns, use other techniques to passively affect lymphatic flow rather than actively
Example: Myofascial release to the thoracic inlet rather than thoracic lymphatic pump

176
Q

Thoracic inlet

treatment

A

Evaluate rotation of thoracic inlet
Posterior hand on spinous processes of T1-3 (ish)to encourage rotation into the barrier (DIRECT)
Anterior hand along infraclaviculararea (manubrium/ribs/proximal clavicles)
Both hands engage barrier firmly
Patient takes several deep breaths while the physician continues to take up the slack and encourage rotation into the barrier

177
Q

Sutherland’s
lymphatic
treatment sequence

A 
• One hand palpates the area
worked on, other hand on top
introduces a gentle vibratory
motion
• Areas to address:
   • Upper left thorax
      • Inferior and medial
motion
   • Epigastric area
      • Superior and posterior
motion (“lift”)
   • Inferior to umbilicus
      • Superior and posterior
motion (“lift”)
178
Q

go over sacrum diagnosis and treatment

A

in book

179
Q

Sutherland’s Lymphatic Technique TOS p 134-139

A

nov 4th, just the box?

180
Q

Lymph article post- Huzij

A

nov 4th

181
Q

Lymphatic chapter page FOM 3rd ed- Huzij

A

nov 4th

182
Q

last slide for nov 4th

A

…

183
Q

Osteopathic Principles

A

• 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.

184
Q

40 y.o. Male: Hx
• R leg swelling (calf) over last 24 hrs
• 4/10 pain, ache, Increases when standing on leg
• ROS: No fever, SOB or Chest pain.
• PMHx: None. PSHx: Appe 1 wk ago. SHx: 2
beers/wk. 1 cigar/wk. Runs 30 min 4d/wk. Healthy
Diet.
• T 97.9, B 120/78, P 89, R 10
• CV: RRR. Pulm: CTAB no M.
• MS: Eryth RLE popliteal fossa to achiles, 1+
pitting edema, pedal pulses palpable bilaterally
• Neuro: motor/sensory intact bilateral LE
• OSE: T11-L2 SRRL. Decreased abdominal and
pelvic diaphragm motion
• Compression U/S (most appropriate initial test):
4 cm clot of R femoral vein extending from
popliteal fossa proximally

diagnosis

A

• Deep Venous Thrombosis (DVT)

185
Q

40 y.o. Male: Plan

A

• Work up for etiology
• Decreased activity, LE elevation, Heat,
Compression stockings
• Anticoagulatnts: Coumadin, Heparin, LMWH,
Apixaban, Rivaroxaban

186
Q

40 y.o. Male: Plan OMM

A
  • Fascial Pattern Compensation
  • Open Thoracic Inlet
  • Fascial restriction points of LE
  • Pelvic/Thoracic Diaphragm Redoming
  • Pedal/Thoracic Lymphatic Pump (anticoagulated)
  • SNS LE: T10-L3, PNS: None
187
Q

OMM: Risks with dvt

A 
• Acute fracture in area being treated, modify
technique
• Embolism
• Theoretical risk metastasis in CA
• No evidence of harm
• Animal models show reduction in tumor
formation
188
Q

Transitional Zones

A
  • Occipitoatlantal
  • Cervicothoracic
  • Thoracolumbar
  • Lumbosacral
189
Q

Fascial Restriction Points

A
  • Thoracic Inlet (1st)
  • Posterior Axillary Fold
  • Antecubital Fossa
  • Carpal Tunnel
  • Inguinal Ligament
  • Popliteal Fossa
  • Achilles Tendon
190
Q

Inhibition

A

• Provide increasing compression to area of
restriction
• As fluid drains and area releases, compress
further

191
Q

Effleurage

A 
• Ensure Restrictions Open 1st,
Proximal to Distal
• Effleurage: Continuous moving
compression to move fluid
distal to proximal
192
Q

Last card for nov 5th

A

…

193
Q

Manual of Selected Osteopathic Techniques,

A

pages 307-310

194
Q

How does one perform visceral manipulation?

A

Requires precise recall of anatomy and 3-D spatial organization

This is essentially a myofascial technique that applies stretch to the restricted/constricted “ligament”

Can hold an organ and stretch the patient so that a ligament or duct is stretched (gallbladder, hiatal hernia, hepatic and splenic flexures)

Can hold one point/organ with one hand while the other hand stretches another point/organ

May need to treat with a “rebound” technique to remind the ligament of its initial length (liver)

195
Q

Indications for Visceral Manipulation

A

Nausea

Gastroesophageal reflux

Constipation

Liver congestion

Gall bladder dysfunction

High sympathetic tone in the viscera

Malabsorption from the intestines

Congestion of the intestines

Adhesions, scars

Mechanical small bowel obstruction

196
Q

Contraindications to Visceral Manipulation

The following symptoms on palpation:

A

Nausea and vomiting*

Sweating

Tachycardia

Syncope

Dizziness

Guarding and pain on rebound

197
Q

Contraindications to Visceral Manipulation

A

Acute infection: appendicitis, peritonitis, diverticulitis, cholecystitis, gastroenteritis, etc.

Ruptured viscera

Acute blunt-force trauma

Aortic aneurysm

Ischemic bowel

Gallstones (relative)

Cancer (relative)

Bowel obstruction (relative)

Pregnancy (relative)

IUD (relative)

Lack of consent

198
Q

Sequence of treatment of the colon

A

Start by correcting any structural pelvic somatic dysfunctions

Then release the plexi

Then release the cecum

The ileocecalvalve

Ascending colon

Hepatic flexure

Transverse colon

Splenicflexure

Descending colon

Sigmoid colon

199
Q

abdomen ganglion from superior to inferior

A

celiac ganglion

superior mesenteric gaglion

inferior mesenteric ganglion

200
Q

Treatment of Pre-Aortic Plexi

A

Stand next to the supine patient.

Place fingers of both hands (one re-inforcingthe other) along linea alba above the umbilicus.

Gently let your fingers sink into the tissues until you reach the plexi.

Maintain pressure and await a fascialrelease. There may be a few that occur on your way toward the plexi.

To stimulate the plexi, one can perform gentle, repeated rebounds.

201
Q

which structures in the abdomen are retroperitoneal

A 
S = Suprarenal glands (aka the adrenal glands)
A = Aorta/IVC
D = Duodenum (second and third segments [some also include the fourth segment] )
P = Pancreas (only head, neck, and body are retroperitoneal. The tail is intraperitoneal)
U = Ureters
C = Colon (only the ascending and descending colons, as transverse and sigmoid retain mesocolon)
K = Kidneys
E = Esophagus (not including the part inside the abdominal cavity)
R = Rectum
202
Q

Treatment of the Cecum

A

Treatment is performed when there is restricted mobility/motility.

Patient is supine on the table with knees flexed

With gentle fingers (don’t lock the PIP and DIP joints), or both thumbs or the lateral curve of your fingers, slid along the iliac fossa until you palpate the cecum.

Push the lateral aspect of the cecum anteromedially.

Push the medial aspect of the cecum inferolaterally.

Push the inferior aspect of the cecum superolaterally.

Once this has been released, treat the iliocecal valve by placing the thenar eminence over the valve and applying pressure medially and then laterally until there is freer motion.

203
Q

Treatment of the Sigmoid Colon

A

Treatment is performed when there is restricted mobility/motility.
Patient is supine on the table with knees flexed.
With gentle fingers (don’t lock the PIP and DIP joints), or both thumbs or the lateral curve of your fingers, slid along the iliac fossa until you palpate the sigmoid colon.
Push the lateral aspect of the sigmoid superomedially toward the umbilicus.
Then place your fingers just above the pubic symphysis and push the sigmoid and small intestine superiorly toward the umbilicus.
There should be the perception of a fascial release.

204
Q

Treatment of the Sigmoid Colon pictures

A

Displace toward medial

Displace toward lateral

205
Q

Note the mesentery of the small intestines

A

The root runs from the left side of L2 to the right sacroiliac joint.
The sigmoid mesocolonic attachment arises on the medial aspect of the left psoas muscle, curves over the iliac vessels and ends lying over the 3rdsacral segment.

206
Q

Treatment of the Mesentery (Lift)

overview

A

This technique can relieve venous congestion and edema in the intestines, improve immune function and absorption of nutrition
Technique also addresses part of the “central chain” or “central tendon” which refer to the fascial connection from the base of the sphenobasilar symphysis to the perineal body via the pre-tracheal fascia, mediastinum, the central tendon of the diaphragm, the midline of the abdominal cavity from which all of the organs arose via invagination of the gut cavity during embryology to the pre-sacral fascia.

207
Q

Treatment of the Mesentery (Lift)

A

This direct technique is best performed after mobilizing the cecum, ileocecalvalve and sigmoid.

Do not perform this technique if there is a recent abdominal incision, acute ischemic bowel disease, bowel obstruction, etc.

Patient is supine or in the left lateral recumbent position.

Physician stands on the patient’s right side or behind them.

Place your finger tips at the left border of the mesenteric region and curl the fingertips.
Then push them gently toward the patient’s spine and toward their right side until a restrictive barrier is engaged.

Maintain this position, taking up slack as releases occur, and hold until no further improvement is detected.

208
Q

last card for the 19th

A

…

209
Q

“Effect of Osteopathic Manipulative Treatment on Incidence of Postoperative Ileus and Length of Stay in General Surgical Patients,” Baltazar G, Betler M, et. al

A

nov 23

210
Q

“The primal nature of core function: In rehabilitation & performance Conditioning,” Wallden M, just the sections “Milk & chilies”, “Bloating,” and “Wheat, rice, soy and stress”

A

nov 23

211
Q

Management of Infantile colic. BMJ 2013;346:f4102 doi: 10.1136/bmj.f4102 (POSTED

A

nov 23

212
Q

Perry R, Hunt K, Ernst E. Nutritional supplements and Other Complimentary Medicines for Infantile Colic: A systematic review. Pediatrics. Originally published online March 28, 2011; DOI: 10.1542/peds.2010-2098 (posted

Optional

A

nov 23

213
Q

Chapmans Reflexes

Esophagus

A

Anterior: 2nd intercostal space bilaterally close to sternum

Posterior: Midway between the spinous process and tip of the transverse process of T2 bilaterally. (same as bronchus)

214
Q

Chapmans Reflexes

stomach (hyperacidity)

A

Anterior: In the left 5th intercostal space between the mid-clavicular line and sternum

Posterior: Midway between the spinous process and tip of the transverse process on the Left 5th and 6th thoracic vertebrae

215
Q

Chapmans Reflexes

liver

A

Anterior: In the right 5th and 6th intercostal space between the mid-clavicular line and sternum

Posterior: Midway between the spinous process and tip of the transverse process on the Right 5th, 6th and 7th thoracic vertebrae

216
Q

Chapmans Reflexes

gall bladder

A

Anterior: In the right 6th intercostal space between the mid-clavicular line and sternum

Posterior: Midway between the spinous process and tip of the transverse process on the Right 6th and 7th thoracic vertebrae

217
Q

Chapmans Reflexes

pancreas

A

Anterior: Right 7th intercostal space close to the costochondral junction

Posterior: Midway between the spinous process and tip of the transverse process on the Right 7th and 8th thoracic vertebrae

218
Q

Chapmans Reflexes

small intestines

A

Anterior: Intercostal spaces between 8-9, 9-10, 10-11 near cartilaginous attachments bilaterally

Posterior: Midway between the spinous process and tip of the transverse process on the Left 8-9, 9-10, 10-11 thoracic vertebrae

219
Q

Chapmans Reflexes

intestines (spastic constipation or colitis)

A

Anterior: 1-2’’ area extending from greater trochanter to an inch above patella on anterolateral aspect of femur bilaterally

Posterior: Bilateral transverse process of L2 to L4 creating a triangular area reaching across the iliac crest

220
Q

Chapmans Reflexes

intestinal peristalsis (constipation)

A

Anterior: Bilaterally in the muscle tissues between the ASIS and the Greater Trochanter

Posterior: Costovertebral junction of the 11th rib on the Right

221
Q

Chapmans Reflexes

pyloris

A

Anterior: Anterior Midline of the Sternum (angle of Louis to xiphoid)

Posterior: Right costovertebral junction of the 10th rib

222
Q

Chapmans Reflexes

appendix

A

Anterior: Tip of the right 12th rib, upper edge

Posterior: Inter-transverse space between 11th and 12th thoracic vertebrae on the Right

223
Q

Chapmans Reflexes

Stomach (peristalsis)

A

Anterior: In the left 6th intercostal space between the mid-clavicular line and sternum

Posterior: Midway between the spinous process and tip of the transverse process on the Left 6th and 7th thoracic vertebrae

224
Q

Sympathetics

Cord segments T5-T9

A

stomach, duodenum,

225
Q

Sympathetics

pancreas

A

(T7 on the right)

226
Q

Sympathetics

gall bladder

A

(T6-8 on the right)

227
Q

Sympathetics

small intestine

A

(may encompass T8-12)

228
Q

Sympathetics

all receiving innervations via the greater splanchnic nerve and the celiac ganglia

A 
stomach, duodenum,
pancreas (T7 on the right)
gall bladder (T6-8 on the right)
229
Q

Sympathetics

proximal 2/3 of the large intestine

A

(may encompass T8-12)

230
Q

Sympathetics

both receiving innervations via the superior mesenteric ganglion primarily and the celiac ganglion secondarily

A 
small intestine (may encompass T8-12)
proximal 2/3 of the large intestine
231
Q

Sympathetics

distal 1/3 of the large intestine

A

Cord segments T12-L2

receiving innervation via the inferior mesenteric ganglion

232
Q

Somatic dysfunction in the thoracic spine

A

(especially extended segment T5-9) can facilitate increased sympathetic tone to the stomach and pylorus leading to decreased mucous secretion in the stomach and delayed pyloric sphincter relaxation (increased contraction of the sphincter)

233
Q

Parasympathetic innervations:

A 
Vagus nerves (cranial nerve 10) serve the organs from the esophagus through the proximal 2/3’s of the large intestine
The pelvic splanchnics (S2-4) serve the distal 1/3 of the large intestine
234
Q

Somatic dysfunction affecting the cranium (SBS compression, occipitomastoid compression affecting jugular foramen), occiput, atlas and remainder of cervical spine may alter

A

vagal function and the organs it serves, particularly decreasing acid production In the stomach

235
Q

Cervical dysfunction

A

affecting the anterior cervical fascia and esophagus, vagus, phrenic nerves

236
Q

Respiratory diaphragm

A

(along with cervical spine 3-5/phrenic nerve)

237
Q

Rib dysfunctions, many times associated with

A

thoracic dysfunctions

238
Q

Clavicles affecting the

A

anterior cervical fascia and esophagus

239
Q

Lymphatic and myofascial relationships

A

(Sibson’s fascia bilaterally, thoracic inlet, upper ribs, thoracic outlet, diaphragm, T-L junction and lower ribs)

240
Q

Psoas major and its attachments relative to the

A

respiratory diaphragm and root of the mesentery

241
Q

Scoliosis may compromise

A

GI function

242
Q

Respiratory diaphragm,

A

its pumping effect on the abdominal viscera, plus oxygenation as well as lymphatics

243
Q

Peritoneal fluid and absorption of fatty acids (chylomicrons) occurs

A

via the lymphatics

244
Q

Esophagus

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level: T2-8/10

Facilitation Level:T1-6

Ganglia Celiac

245
Q

gallbladder

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T5-9

Facilitation Level:T5R

Ganglia Celiac

246
Q

stomach

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T5-9

Facilitation Level:T5-9L

Ganglia Celiac

247
Q

liver

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T6-9

Facilitation Level:T5R

Ganglia Celiac

248
Q

spleen

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T6-8

Facilitation Level:T7L

Ganglia Celiac

249
Q

pancreas

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T6-9

Facilitation Level:T7R

Ganglia Celiac

250
Q

small intestine

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T8/9-11/12

Facilitation Level:T10-11

Ganglia Superior mesenteric

251
Q

ascending transverse colon

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T10/11-L1/2

Facilitation Level:T10-11

Ganglia Superior mesenteric

252
Q

appendix

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:T10

Facilitation Level:T12

Ganglia Superior mesenteric

253
Q

descending sigmoid colon rectum

Sympathetic Spinal Level:

Facilitation Level:

Ganglia

A

Sympathetic Spinal Level:L1-2

Facilitation Level:T12-L2

Ganglia inferior mesenteric

254
Q

Keep in mind that what may be presenting as abdominal pain may have its source in

A

the rotatores and/or multifides muscles.

255
Q

“Heartburn” may be a trigger point in the

A

external oblique muscle

256
Q

Projectile vomiting and belching can be triggered by palpation of points in the

A

posterior abdominal wall bilaterally.

257
Q

Diarrhea can result from trigger points in the

A

lower abdominal muscles

258
Q

stomach acidity chapmans points

A

left 5th rib space

259
Q

liver gallbladder chapmans points

A

right 6th intercostal space

t6 right

260
Q

appendix chapmans points

A

tip of 12 left rib

t11 right

261
Q

pyloric stenosis chapmans points

A

middle of sternum

t7 right

262
Q

liver chapmans points

A

right 5th intercostal space

t 5 right

263
Q

pancreas chapmans points

A

right 7th rib

t7 right

264
Q

small intestines chapmans points

A

ribs 8 9 and 10 bilateral

9 10 11 t spine left side

265
Q

spleen chapmans points

A

left 7 or 8 rib

t 7 left

266
Q

stomach peristalsis chapmans points

A

left 6th intercostal space

267
Q

intestinal peristalsis chapmans points

A

t 9 or 10 right

asis bilateral

268
Q

Stomach hyperacidity chapmans points

A

intertransverse space, midway between the spinous and transverse processes, between 5th and 6th vertebrae on the left

269
Q

rectum chapmans points

A

medial femur below ischial tuberosity bialteral

270
Q

colon chapmans points

A

anterior femur bilateral

tips of lumbar tps bilateral

271
Q

hemorrohoids and rectum chapmans

A

si joing bilateral

272
Q

I think all the referred pain points should be chapmans points

A

?

273
Q

hemorroids

A

ischial tuberosity bilateral

274
Q

Colon (spastic constipation or colitis)

A

TP of L2 – TP of L4 a triangular area reaching across to the iliac crest

275
Q

Intestinal peristalsis (constipation) chapmsnas points

A

between ASIS and greater trocanter

276
Q

Pyloric stenosis chapmans point

A

manubrial-sternal junction down the front of the sternum

277
Q

Stomach hyperacidity chapmans point

A

intertransverse space, midway between the spinous and transverse processes, between 5th and 6th vertebrae on the left

278
Q

Broad ligament and prostate points are along

A

lateral femur

279
Q

sympathetic innervation

A

Sympathetic innervation is supplied by cell bodies in the spinal cord and fibers that terminate in the prevertebral ganglia(celiac, superior, and inferior mesenteric ganglia); these are the preganglionic neurons.

These nerve fibers synapse with postganglionic neurons in the ganglia, and the fibers leave the ganglia and reach the end organ along the major blood vessels and their branches. Rarely, there is a synapse in the paravertebral(chain) ganglia, as seen with sympathetic innervation of other organ systems.

280
Q

The vagusnerve, (CN 10th), innervates the

A

esophagus, stomach, gallbladder, pancreas, first part of the intestine, cecum, and the proximal part of the colon.

281
Q

The vagus exits the cranium

A

via the jugular foramen (along with the accessory and glossopharyngeal nerves).

282
Q

The pelvicnerves innervate the

A

distal part of the colon and the anorectal region.

283
Q

Consistent with the typical organization of the parasympathetic nervous system, the preganglionicnerve cell bodies

A

lie in the brainstem (vagus) or the sacral spinal cord (pelvic). Axons from these neurons run in the nerves to the gut (vagus and pelvic nerves, respectively), where they synapse with postganglionicneurons in the wall of the organ, which in this case are enteric neurons in the gut wall.

284
Q

Sympathetic overview

A 
Tends to inhibit GI function
Frequently activated in pathological situations
Inhibits smooth muscle
Induces contraction of sphincters
Regulates blood flow in the GI tract
285
Q

parasympathetic overview

A

Activates physiological processes in the gut wall
Allows filling of the stomach to occur without an increase in intraluminal pressure
Generally involved in relaxation of sphincters
Contraction of smooth muscle layers in the colon
Controls the caliber of the internal anal sphincter

286
Q

gastric receptive relaxation reflex =

A

distention of the stomach results in relaxation of the smooth muscle in the stomach;

287
Q

Sympathetically Driven Symptoms

A 
Constipation
Bloating
Pain
Contraction of sphincters
Increased vasomotor tone (may lead to decreased mucus production in stomach and intestines)
288
Q

ParasympatheticallyDriven Symptoms

A 
Nausea
Vomiting
Diarrhea
Hypermotility
Relaxation of sphincters
Increased mucus secretion
Increased acid production in the stomach
289
Q

If increased vasomotor (sympathetic) tone leads to decreased mucus production in stomach (and/or parasympathetic activity causes increased acid production in the stomach), what is the end result?

What is the medical treatment approach?

A

Gastritis, Ulcers (peptic and duodenal), GERD

Antacids, H2-blockers, PPIs, antibiotics

290
Q

why is bowel function important?

A

Elimination of wastes

Maintain homeostasis

291
Q

post-operative ileus

A

Failure to pass flatus or stool for 3/6 days after surgery

Transient impairment of function and motility

292
Q

etiology of post op ileus

A

Mechanical irritation
Edema of tissues –mesentery and intestine
Inflammatory molecules which cause the
Activation of inhibitory neural reflexes
Medications, particularly opiates

293
Q

Nerve impulses that occur at the site of GI injury travel to the prevertebral ganglia along the spine and the afferent fibers

A

are sensitive to capsaicin. If you treat neonatal animals w/ capsaicin, it ablates the the sensory nerves from the gut. If you take the animals to surgery later, they have decreased ileus. Studies have shown increased sympathetic activity and increased catecholamines in the post-op period. Blocking the impulses has mixed response.
Opioids don’t inhibit bowel motility, they increase it, but also increase uncoordinated contractions so there is an increase in tone, but a decrease in transit.

294
Q

standard medical treatment for post operative ileus (poi)

A 
Nasogastricsuctioning
Rectal stimulation
Ambulation
Medications
-laxatives
-erythromycin
-metoclopromide
-cisapride
-alvimopan
-methylnaltrexone
Gum chewing –stimulates the gastrocolicreflex?
NSAIDs
Thoracic epidural analgesia with lidocaineor bupivacaine
295
Q

medical treatment for poi explained

A

NG around for > 100 years, no beneficial effect on POI
Mobilization (rectal stimulation), no beneficial effect on POI\
Laxatives – no randomized studies
E-mycin – no effect on POI, effective for neuropathic ileus
Metoclopromide – no effect on POI
Cisapride – off market d/t cardiac dysrhythmias
Alvimopan – in trials, risk of bone fx, abn tissue growth, ? MI
Methylnaltrexone – failed late-stage trial in US
Gum chewing stimulating gastrocolic reflex?

296
Q

hazards of medical treameent for poi

A 
Electrolyte imbalance
Dehydration
Gastric perforation
Nasal irritation or erosion of mucosa
Infection
Rectal perforation
Impaired nutrition
Delayed healing
Increased pain from withholding of opiate pain reliever
Increased bleeding due to anti-platelet activity from NSAID
Gastric mucosal erosions from NSAID
Other adverse effects of NSAIDs
Meningitis/spinal headache from epidural analgesia
Cost
297
Q

Sympathetic: Increased Tone pathophysiology

A

Increased vascular tone –decreased O2 and nutrients to the tissues
Decreased peristalsis

298
Q

Lymphatics pathophysiiology

A

Impaired flow increases tissue congestion
Impaired nutrient absorption from the intestines
Congestion increases the likelihood of fibrosis, and susceptibility to infection

299
Q

Herrmann

A

317 surgical cases treated with OMT,
1/317 developed ileus (0.3%)
92 surgical cases without OMT,
7/92 developed ileus (7.6%)

300
Q

Crow, Gorodinsky

A

Length of stay in patients given OMT = 11.8 days

Length of stay in patients not given OMT = 14.6 days

301
Q

Baltazar, et. al

A

Length of stay in patients given OMT = 6.1 days

Length of stay in patients not given OMT = 11.5 days

302
Q

the Arndt-Schultz law

A

Weak stimuli accelerate physiologic activity
Medium stimuli inhibit physiologic activity
Strong stimuli halt physiologic activity

303
Q

Intrinsic nerve control

A

system of the autonomic plexiwithin the wall of the intestine. Synapses between visceral afferents, the parasympathetic and sympathetic occur here. Pleximodify autonomic activity according to the local needs of that region of the intestine to move bolus, digest, etc

304
Q

Interstitial cells have properties of

A

both fibroblasts and smooth muscle cells.

305
Q

how does visceral manipulation work

A

stimuli>sensors mechanical and chemical>brain and spinal cord and enteric nercous system>effectors ( motilitys secretion and blood flow)

306
Q

Adhesions, scars, inflammation in these areas can negatively effect motion within the intestines in these places.

A

between stimuli and sensors

between sensors and enteric nervous system

307
Q

Secretory granules are released from enteroendocrine cells

A

(EEC) by chemical and mechanical stimuli

308
Q

OMT Concepts

A

Arterial, venous and lymphatic circulation
Vertebral segmental function to allow proper nerve flow to the viscera
Chapman’s reflexes for proper function of the viscera.
Visceral techniques to address restriction of mobility and motility of the viscera (ala Dr. Barral)

309
Q

visceral joints and sliding surfaces

A

◦Peritoneum
◦Pericardium
◦Pleura
◦Meninges

310
Q

Visceral joints attachments

Double layer system

A

serous fluid creates suction between surfaces of the peritoneum, etc.

serous membranes and serous fluid is analogous to cartilaginous surfaces and synovial fluid.

311
Q

Visceral joints attachments

Ligamentous system

A

folds of peritoneum or pleura binding an organ to the wall of the cavity or to another organ

Not present for structural stability like skeletal ligaments

312
Q

Visceral joints attachments

Turgor and Intracavitary pressure

A

hold the viscera in place, remain constant in mass, yet stick together

313
Q

Visceral joints attachments

Mesenteric system

A

folds of peritoneum that support the nerves, arteries, veins and lymphatics of the small and large intestines

314
Q

Visceral joints attachments

Omental system

A

folds of peritoneum that join 2 elements of the digestive tract together and has a neurovascular role

315
Q

what is a visceral somatic dysfunction

A

Any restriction, fixation or adhesion limits mobility and motility, along with viscerospasm and tethering (ptosis).
Diaphragm moves about 20,000 times per day.
Heart beats about 100,000 times per day
Approximately 30-50 cc’s of blood is ejected from the left ventricle per beat causing a wave propagation through the arteries.

316
Q

what causes visceral somatic dysfunctions

A 
Infection/inflammation
Trauma
Surgery
Pregnancy
Scoliosis/short leg syndrome
Craniosacral dysfunction
317
Q

palpation of the abdomen

A 
Evaluate for:
◦Painfulness
◦Differences in tension
◦Position of the organ
◦Tone of the organ
318
Q

Case Presentation #1

Chief Complaint: 74 y/o male complains of abdominal pain that is crampy in nature, occurring in waves that crescendo and then ease. These symptoms have been present for the past week and are progressively worsening. His last bowel movement was 3 days ago, small hard turds, not the usual amount he passes. Normally has a bowel movement every 1-2 days. Has had similar episodes over the past several months, but this is lasting longer (the others were for only a day or 2) and is much more severe. His appetite is reduced as he feels queasy. Diet typically is low in fiber as fiber worsens his symptoms. He denies vomiting, hematochezia or melena.

Allergies: none
Meds: lisinopril, 20 mg daily; Lipitor, 40 mg. daily; ASA 81 mg. daily
PMHx: hypertension, hyperlipidemia,
PSHx: 3-vessel CABG 4 years ago, appendectomy at 25 years old
Soc Hx: married, former smoker 1 ppdfor 40 years, quit 10 years ago; drinks 2 cups of coffee qd
FamHx: both parents are deceased, father with prostate cancer and mother of old age; 1 brother with ankylosing spondylitis and hyperlipidemia, and 2 sisters with hyperlipidemia and Crohn’s disease; he has 3 children, one with hypertension; has 8 grandchildren, all healthy
ROS: weight has been creeping up over the past 2 years, male pattern baldness is present, dry skin, but has that every winter; specifically denies angina or shortness of breath

5’8’’ 175# T = 97.2 BP = 130/78 R = 16 P = 90
General: Alert and oriented in 3 spheres, appropriately groomed, appears to be uncomfortable due to abdominal pain
EENT: extraocular muscles intact, fundus with mild AV nicking but no papilledema, external auditory canals partially occluded with cerumen, tympanic membranes pearly gray with landmarks easily visualized; nasal mucosa congested, tonsils atrophic and without exudate; oral mucosa pink and moist, teeth in good repair with an upper partial plate, tongue midline on protrusion
Heart: RRR without S3, S4 or murmur; midline sternotomy scar present
Lungs: clear to auscultation bilaterally
Abdomen: soft to palpation; tenderness noted diffusely with increased tenderness in the left lower quadrant; no organomegaly; no rigidity or guarding; quiet bowel sounds auscultated in all quadrants except left lower quadrant where they are absent; oblique scar in right lower quadrant present; rectal exam reveals no masses; stool is positive for occult blood.
Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities, muscle strength is strong and symmetrical and sensation to light touch is intact in all 4 extremities

A

…

319
Q

1 Differential

A 
Bowel obstruction/Ileus
Inflammatory bowel disease (Crohns/UC)
Tumor
Ischemic bowel
Adhesions
Constipation
Fecal impaction
Diverticulitis
Hypothyroidism
320
Q

1 Osteopathic considerations

A 
Sympathetics?
◦T10/11-L2, Inferior mesenteric ganglion
Parasympathetics?
◦S2-4
Lymphatics?
◦Sibson’s, respiratory diaphragm, pelvic diaphragm
321
Q

Chapman’s Small Intestines

A

Anterior: Bilateral 8-9th, 9-10th, and 10-11th intercostal spaces close to the costochondral junctions
Posterior: Bilateral 8-9th, 9-10th, and 10-11th intertransverse spaces midway between the spinous process and the tip of the transverse process

322
Q

Anterior Chapmans for spastic constipation Right femur

A

an area 1-2” anterolateral aspect of the thighs along the femure starting at the greater trochanter and extending to within an inch of the knees

Upper fifth corresponds with the cecum
Middle 3/5’s corresponds with ascending colon
Last 1/5 represents hepatic flexure and first 2/5’s of transverse colon

323
Q

Anterior Chapmans for spastic constipation left femur

A

an area 1-2” anterolateral aspect of the thighs along the femure starting at the greater trochanter and extending to within an inch of the knees

Upper fifth corresponds with the sigmoid
Middle 3/5’s corresponds with descending colon
Last 1/5 represents splenic flexure and last 3/5’s of transverse colon

324
Q

posterior chapmans for spastic constipation or colitis

A

Bilaterally, from the transverse process of L2 to L4, a triangular area reaching across to the crest of the ilium

325
Q

chapmans atonic constipation

A

Anterior: Bilaterally in the muscle tissues between the ASIS and the Greater Trochanter
Posterior: Bilaterally along the 11th rib at the costovertebral junction.

326
Q

Structural considerations case #1

A 
◦Pelvis
◦Sacrum
◦Lumbar
◦Thoracic/Rib raising
◦Abdomen: cecum, sigmoid, mesentery
◦Thoracic inlet
◦Diaphragm
◦OA/ OM suture/CV4
327
Q

Case number 2

Chief Complaint: 32 y/o female complains of diffuse abdominal pain that bothers her during the night and before meals. Tums or Rolaids relieves the discomfort. Doesn’t care for spicy food. Drinks colas as she doesn’t like tea or coffee as they are too bitter. Occasionally finds food “backing up” into her throat, sometimes hours after she has eaten. Bowels move daily with formed stool. Denies hematochezia or melena.
Allergies: PCN
Meds: Tums or Rolaids, ibuprofen for daily headache
PMHx: irregular menses,
PSHx: none
Soc Hx: married, but separated from her husband who is currently deployed in Afghanistan; former smoker ½ ppdfor 10 years, quit 2 years ago; drinks 2-16 ounce diet colas qd
FamHx: both parents have diabetes mellitus Type 2 and hypertension; grandparents are deceased because of heart attack; brother and sister are healthy; she has no children
ROS: amenorrheic for the past four or five months; quit using birth control 6 months ago as it seemed pointless given the marital stress and husband’s deployment

5’6’’ 200# T = 97.2 BP = 100/64 R = 14 P = 78
General: Alert and oriented in 3 spheres, overweight and appropriately groomed
EENT: extraocular muscles intact, fundus without AV nicking or papilledema, external auditory canals partially occluded with cerumen, tympanic membranes pearly gray with landmarks easily visualized; nasal mucosa congested, tonsils atrophic and without exudate; oral mucosa pink and moist, teeth in good repair, tongue midline on protrusion
Heart: RRR without S3, S4 or murmur
Lungs: clear to auscultation bilaterally
Abdomen: obese, soft to palpation; tenderness noted in the epigastric region; no organomegaly; no rigidity or guarding; normal bowel sounds auscultated in all 4 quadrants; rectal exam reveals no masses; stool is negative for occult blood.
Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities

A

…

328
Q

2 differential

A 
GERD
Gastric ulcer
Duodenal ulcer
Cholycystitits
Cholylithiasis
Pregnancy
329
Q

2 osteopathic considerations

A 
Sympathetics?
◦T5-9, Celiac ganglion
Parasympathetics?
◦Vagus
Lymphatics?
◦Sibson’s, respiratory diaphragm, pelvic diaphragm
330
Q

2 Chapmans points considerations

A

Chapman’s points for stomach -hyperacidity
Chapman’s points for stomach –peristalsis
Chapman’s points for esophagus

331
Q

2 structural considerations

A 
◦Thoracic
◦Arcuateligament
◦Abdomen
◦Diaphragm
◦Thoracic inlet
◦Hyoid
◦OA/OM suture/CV4
332
Q

Case #3

Chief Complaint: 47 y/o female complains of upper abdominal pain that bothers her during and after meals. Tums or Rolaids does not relieve the discomfort. Doesn’t care for spicy food like pizza. Feels gassy after eating cucumbers, onions, and French fries. Bowels move daily with formed stool. Denies hematochezia or melena. Her right shoulder aches off and on, but has painted a bedroom recently.
Allergies: sulfa
Meds: Synthroid, 75mcg daily
PMHx: hypothyroidism
PSHx: tubal ligation
Soc Hx: married, former smoker 1 ppdfor 20 years, quit 2 years ago; drinks 2 cups of coffee qd
FamHx: both parents have hypertension; grandparents are deceased because of heart attack; 2 brothers and 1 sister are healthy; she has 3 children, all healthy
ROS: menses are regular, monthly

5’5’’ 155# T = 97.2 BP = 130/78 R = 14 P = 78
General: Alert and oriented in 3 spheres, overweight and appropriately groomed
EENT: extraocular muscles intact, fundus without AV nicking or papilledema, external auditory canals partially occluded with cerumen, tympanic membranes pearly gray with landmarks easily visualized; nasal mucosa congested, tonsils atrophic and without exudate; oral mucosa pink and moist, teeth in good repair, tongue midline on protrusion
Heart: RRR without S3, S4 or murmur
Lungs: clear to auscultation bilaterally
Abdomen: soft to palpation; tenderness noted in the right upper quadrant region; no organomegaly; no rigidity or guarding; normal bowel sounds auscultated in all 4 quadrants; rectal exam reveals no masses; stool is negative for occult blood.
Neuro: CN 2-12 intact; DTR’s 2/4 in both upper and lower extremities

A

…

333
Q

3 differential

A 
Cholycystitis
Cholylithiasis
GERD
Gastric ulcer
Duodenal ulcer
334
Q

3 osteopathic considerations

A 
Sympathetics?
◦T6-8 on the right, Celiac ganglion
Parasympathetics?
◦Vagus
Lymphatics?
Sibson’s, respiratory diaphragm, pelvic diaphragm
Chapman’s points for liver/gallbladder
335
Q

structural considerations

A 
◦Thoracic
◦Abdomen, organs, transversusabdominis
◦Diaphragm
◦Lumbar region, psoas
◦Thoracic inlet
◦OA/ OM suture/CV4
336
Q

Case #4

Chief Complaint: 18 m/o male was brought to the office on an urgent visit as his mother complains that he is having numerous episodes of vomiting and diarrhea. This started about 36 hours ago with some vomiting, and then the loose stools developed. She’s changing his diaper every 2 hours. She’s not sure whether he has urinated as it is difficult to distinguish from the diarrhea. Baby takes a bottle readily, but throws it all up about 15-20 minutes later. She has been giving him Pedialyteto drink as that is what the on-call nurse mentioned to her yesterday when she had called about her baby. He has been running a slight temperature, highest was 100.5. Mother mentioned that she believes the assistant mis-weighed her child as he was 26 pounds at his last well baby visit 2 weeks ago.
Allergies: none
Meds: Tylenol for the fever
PMHx: current on his vaccinations
PSHx: none
Soc Hx: first child in this family, parents are non-smokers
FamHx: both parents healthy although maternal grandmother recently had a diarrheal illness
ROS: negative other than above

33’’ 25# T = 100.2 BP = not checked R = 20 P = 100
General: Alert, but appears ill, somewhat listless
EENT: extraocular muscles intact, positive red reflex, external auditory canals partially occluded with cerumen, tympanic membranes pearly gray with landmarks visualized; nasal mucosa normal, tonsils without exudate; oral mucosa pink and moist, 4 teeth erupted in mandible and maxillae, tongue midline on protrusion
Heart: RRR without S3, S4 or murmur
Lungs: clear to auscultation bilaterally
Abdomen: soft to palpation; tenderness noted throughout the belly; no organomegaly; no rigidity or guarding; hyperactive bowel sounds auscultated in all 4 quadrants; diaper looks like there is scant formed fecal matter and is reasonably soggy.
Neuro: CN 2-12 grossly intact

A

…

337
Q

Case #4 differential

A 
Gastroenteritis
◦Rotavirus
◦Norwalk-like viruses
Intussusception (What would likely be found in the diaper?)
Dehydration
338
Q

case #4 osteopathic considerations

A 
Sympathetics?
◦T10-11 (May encompass from T8-T12)
◦Superior mesenteric ganglion (primary)
◦Celiac ganglion (secondary)
Parasympathetics?
◦Vagus, S2-4
Lymphatics?
◦Sibson’s, respiratory diaphragm, pelvic diaphragm
Chapman’s points for Small Intestines
Chapman’s points for Stomach/Peristalsis
339
Q

case #4 Structural considerations

A 
◦Pelvis
◦Sacrum
◦Lumbar
◦Thoracic/Rib raising
◦Thoracic inlet
◦Respiratory and Pelvic Diaphragms
◦OA/OM suture/CV4
340
Q

PARTSOFHISTORYIMPORTANTTOKIDS

A

Mother’s pregnancy history:
G2P2002
Unremarkable, high stress job and a move at about 6 months gestation
No trauma, no prescription or illicit drug use, no tobacco use

Birth history
41 wkgestation
9 hour labor, 2 hours hard labor
Mother delivered on her left side
No instrumentation or augmentation
APGARS 6/10 at one minute, 10/10 at 10 minutes; no interventions needed
Very quiet the first 24 hours, then started crying more

Social history
Lives at home with mom, dad and 2 year old brother
No tobacco exposure
No family history of food allergy
No pets
No childcare at this point
Sleeps 2 hours at a stretch and breastfeeds in between
No bottles
No pacifier (he spits it out)
~8-10 wet/soiled diapers per day
Mother returning to work in 3 weeks, is stressed about childcare
Cries inconsolably every night from 6-9:30

341
Q

COLIC DEFINED

A 
Scientific-defined for research efforts
Wessel criteria (1954)
Crying and fussing more than
3 hours per day
3 days a week
For more than 3 weeks

Inconsolable, excessive crying associated with hypertonicity, perceived pain, borborygmus, wakefulness

Cyclic

Onset 2-6 weeks old and lasts typically 3 months

342
Q

Parents will bring their child in for any crying that is beyond their inability to handle or understand.

A

For research and medical communication purposes, Wessel’s Criteria are still used today as a benchmark for defining infantile colic.

343
Q

THE DIFFERENTIAL for colic

A

Infection –meningitis, encephalitis, sepsis, pneumonia, UTI, osteomyelitis, septic, toxic synovitis, AOM, herpes stomatitis, oral thrush, gastroenteritis, herpangina, insect bites, cellulitis, infectious arthritis
Trauma –non-accidental trauma (skull fracture, intracranial bleed, rib fracture, pneumothorax, long bone fracture, intra-abdominal blunt trauma), accidental trauma (falls), corneal abrasion, hair tourniquets (digits, penis, clitoris)
Metabolic –inborn error of metabolism, electrolyte abnormality, acid/base derangement, hypoglycemia
Foreign body –oral, nasal, ear, pharynx, eye
GI –intussusception dehydration constipation, GERD, hernia
CV –SVT, congenital heart disease
Environmental: neglect, hunger

344
Q

CURRENT THOUGHTS ON THE PATHOPHYSIOLOGY AND ETIOLOGY OF COLIC

A 
Dietary
Psychological
Gastrointestinal
Hormonal
Neurological immaturity
345
Q

Dietary

Breastfeeding:

A

Prospective cohort study of 856 mother infant dyads
Maternal questionnaires at 1 and 6 weeks regarding feeding sources, presence of colicky behavior, maternal anxiety and alcohol consumption
Breastfeeding did not have a protective effect on the development of colic
Maternal anxiety was positively correlated with colic

346
Q

Dietary

Food Sensitivites

A

RCT conducted among exclusively breastfed infants with colic (90 completed the trial)
Average cry-fuss time over 48 hours was 630-690 minutes
Active arm: mother’s excluded cow’s milk, eggs, peanuts, tree nuts, wheat, soy, and fish. Control arm: mothers continued to consume these foods
Outcomes assessed after 7 days as the duration of cry-fuss behavior over 48 hours using charts
End point 25% reduction in cry-fuss behavior over 48 hour period after 7 days of dietary intervention
Result: objective 21% of babies in the low allergen diet group had less cry-fuss time

347
Q

Psychological

A

The relationship between maternal post-partum depression and colic
Ante-partum stress and depression and colic
Association is clear—what is not clear is if there is an etiological relationship
Maternal/familial stress and depression anxiety causes colic?
Colic causes maternal/familial stress, depression and anxiety?
Or they just exist together?

348
Q

Physiological

GI related

A

Gut motility and neurological immaturity

Intestinal flora imbalance

349
Q

Physiological

Nuerobiological

A

HPA axis and adrenergic system feedback loops activated as a result of perceived danger or discomfort (on the part of the infant)
Epigenetic modulation in the limbic system may explain correlations between regulatory problems in the first months of life and behavioral/feeding problems later in life

350
Q

H. Pylori and Infantile Colic

A

Case control study (Saudi Arabia)

Used H. Pylori stool antigen testing

Case population
55 infants with colic per Wessel criteria
2-4 months age
45 (81.8%) tested positive for H. Pylori infection

Control population
30 infants without colic
Age, country of origin, gender and ethnicity matched
7 (23.3%) tested positive for H. Pylori infection

351
Q

TREATMENT OF COLIC

A 
Rule out organic disease
Reassurance, reassurance, reassurance
Dietary interventions
Supplements
Medication
Behavioral
Manual treatment/therapy
352
Q

TREATMENT OF COLIC

dietary interventions

A

Maternal diet restriction (big 5: gluten, dairy, egg, citrus, soy)
Formula changes
Herbal teas
Sugar water

353
Q

TREATMENT OF COLIC

supplements

A

High fat diet per mother or fats added to infant diet

Pro-and pre-biotics

354
Q

TREATMENT OF COLIC

medication

A

Simethicone
Dicyclomine
Methylscopalamine

355
Q

TREATMENT OF COLIC

behavioral

A

Quiet area/decreased stimulation
Vibration (car ride, sitting on the dryer, etc)
Intensive parental training

356
Q

TREATMENT OF COLIC

manual treatment/therapy

A

OMT
Chiropractic
Massage

357
Q

Other things that may work in treating colic

A

Fennel extract tea
Chamomile, vervain, licorice, fennel, balm mint
Fennel has analgesic effect

Sucrose/glucose solutions
Sweetness may induce analgesic effect

Manipulation (of any sort)
Several showed benefit, but lack of blinding, small ‘n’ limited usefulness of the studies
Studies not well funded or of good trial design
Need better studies

Probiotics
L reuterihas been found to be helpful in several studies

358
Q

OMT FORTHECOLICKYBABY

indications

A

Somatic dysfunction

Organic disease ruled out and “functional” cause is suspected

359
Q

OMT FORTHECOLICKYBABY

contraindications

A

??
Rule out organic disease
Follow contraindications for modalities

360
Q

OMT FORTHECOLICKYBABY

theory

A

Lies within the concept of facilitation and the long term effects it has on the nervous system

361
Q

Spinal facilitation is a core concept in osteopathic medicine and is important to understand

A

It is an anatomical and physiological process that helps us to explain how things that seem unrelated actually may be affecting one another. This is the core concept behind the viscero-somatic, viscero-viscero, somato-visceral and viscero-somatic reflexes. There is a lot of research going on in this area right now.

362
Q

Basic concept of facilitation

A
  • Nociceptive information comes in from a peripheral source (outside the CNS). This could be from viscera, muscle, bones, peripheral nervous tissue….anything outside the CNS.
  • This information bombards the CNS and decreases the firing threshold of those neurons (side dynamic range neurons). In effects, these neurons are facilitated—they are activated more quickly than neurons that have not been exposed to excessive nociceptive information.
  • These irritated (facilitated) neurons activate and facilitate neighboring neurons.
  • These neighboring neurons serve other tissues in the body and will then volley signals to the tissues they serve and cause issues distal to the original site of nociceptive information.
363
Q

Facilitation Example

A

A person has problems with chronic gastritis. That nociceptive information from the chronic inflammation of the stomach lining sends a volley along afferent fibers to the area of the spinal cord that serves the stomach with sensation, T5-7. Those fibers then synapse with wide dynamic range (WDR) fibers that synapse with many other neurons at that level. When the nociceptive information is chronic enough, or strong enough, those fibers get facilitated and their threshold for firing decreases. They also then facilitate the neurons next to them, or those connected by the WDR’s (these connections can be as far as 5-7 segments away from the original input level).
This nociceptive input causes a reflexive protective volley to go out to all the tissues that that level serves. So all of the muscles, viscera, etc, that is served by the T5-7 spinal cord will then show signs of irritation—pain and muscle spasm in the mid back, type 2 somatic dysfunctions as a result of the muscle spasm of the rotatores at that level, sensory changes in the skin supplied by T5-6 (along the midline at that level), and even core control problems as a result of motor input to the transversus and other core muscles. It can even affect the function of the lungs (chronic cough) and esophagus (spasm).

So this is how a person with persistent stomach pain also presents with mid-back pain, cough and a weak core musculature

364
Q

The gut as the pain generator:

A

The gut sends nociceptive information to the central nervous system via the visceral afferents (CN VII, IX and X) whose nucleus resides in the brainstem. This area gets facilitated. Notice that the nuclei for the visceral efferents (CN X) and motor efferents of CN IX and X are right next to the visceral afferents. Now these get facilitated and send protective information to those areas. We get reflex irritation as well as spasm in those areas. The stomach pain causes more stomach pain.

Note also that the dorsal rootlets of C1 and C2, which carry motor efferents to the upper cervical spine, are right there and they also get facilitated causing muscular hypertonicity. Stiff neck.

Note also that the nucleus of the trigeminal nerve is also right there. The trigeminal nerve is the primary sensory nerve to the cranium—it is the mediator of headache. When this nucleus gets facilitated, headache is the result.

365
Q

What is it goes the other way? The Head and neck as the pain generator:

A

When babies are born, a lot of force is placed through the system. The uterus generates up to 80 psi during the birth process. To absorb those forces properly, the baby’s body must be aligned well. It must be a vertex presentation with the head and neck aligned in such a way so that the forces are absorbed and dispersed through the cervical spine axially. When the head is turned or the body is in any other position, those forces get absorbed and dispersed into tissues not designed to tolerate those kinds of forces. Most commonly, these forces are taken up in the upper cervical spine and cranial base. What would the facilitation picture look like then?

Muscular tensions and pain from the upper cervical spine sends nociceptive information to the upper cord via C1 and C2 rootlets. The upper cord area gets facilitated, irritating the nuclei of the motor and visceral efferents which then send a volley to the gut causing increased gastric secretions, increased or decreased peristalsis and pain. The trigeminal nucleus also gets facilitated and causes headache.

This facilitation is why stiff necks cause headache (a clinical entity known as cervicogenic headache).

It is also part of why people with migraines also have nausea and vomiting.
It is the close physical relationship and interconnectedness of the central nervous system that makes it so that symptoms that appear to be unrelated may, in fact, be related.

366
Q

COLIC AND OTHER CHILDHOOD PROBLEMS

A

Prospective study comparing infants with and without severe colic during infancy and 10 years later.
Significantly increased incidence of
 Recurrent abdominal pain (abdominal migraine)
 Allergic diseases (asthmatic bronchitis, rhinitis, conjunctivitis, atopic eczema, food allergy)
 Psychological disorders (sleep disorders, aggressiveness, fussiness, ‘supremacy’)

367
Q

Children with personal history of migraine

A

208 kids aged 6-18 with headache history; 471 without
72.6% of children with migraine also had infantile colic
26.5% of children without headache had infantile colic

368
Q

Parents with migraine and their kids

A

Maternal migraine was associated with a more than 2-fold increase in prevalence of infantile colic

369
Q

Physical Exam for colic case

A

Vitals
RR40 HR130 Wt8# 6oz (increase of 1# over birth weight)
General: WDWN CM looks stated age, alert, active and interactive. Parental interaction appropriate.
Skin: PWD, no rashes, no bruising
HEENT: Anterior fontanelleis open and flat. Red-orange reflexes are positive in both eyes. Nose is clear. Mouth is clear. Strong and coordinated suck
Pulm: lungs CTA bilaterally
CV: regular rate and rhythm, no murmurs noted
GU: Normal male. Both testes are descended. His circumcised penis has healed
MSK:
Negortolani/Barlow, spine straight. No sacral dimple.
What would you look for on osteopathic structural exam?

370
Q

QUICKOMT FORTHECOLICKYBABY

High yield areas to evaluateand treat as necessary

A

OA
Suboccipitalinhibition/soft tissue

Mid thoracic
Rib raising

Thoracolumbar junction
Myofascial release

Lumbar spine
Myofascial, especially upper lumbars

Pelvic diaphragm
Myofascial release

371
Q

OMT for the child with colic should not only address the gut, but also the

A

cervical spine and head for reasons we already talked about (facilitation). This is just one treatment approach that includes treatment modalities and technique concepts taught in all US colleges and schools of osteopathic medicine. It is stuff you already know! All you need to do to be successful in treating babies is to learn to modify what you know to your patient.

372
Q

When we treat the pelvic diaphragm

A

we are directly addressing the mechanical input of the diaphragm and its affect on gut function by increasing the lymphatic return of the pelvic cavity into central circulation. We are also addressing the parasympathetic innervation to the gut by way of the pelvic diaphragms biomechanical influence on the sacrum.

373
Q

Lumbar MFR in this setting (infant) is aimed

A

and releasing the myofascial connections of the gut to the posterior abdominal wall—the mesenteric root as well as the fascial connections of the colon. Releasing the mesenteric root influences the function of the neurovascular supply to the gut.
This is an excellent technique for babies with constipation.

374
Q

By addressing the thoracolumbar junction

A

we are affecting the vertebral motion of the segment of the spinal cord that serves the gut, as well as augmenting function of the thoracic diaphragm which will help fluid exchange of the abdomen (aiding lymphatic return via the fenestrae of the diaphragm as well as the cisterna chyle).

375
Q

Rib raising in the infant is a bit different than in the adult.

A

The ribs of a young child are in a horizontal orientation, so the orientation of your hands and forces used will change as a result. It is also easier, and more effective, to treat both sides at once. This makes it easier to address vertebral dysfunctions at the same time as treating the rib dysfunctions.

376
Q

Treating the suboccipital musculature and OA joint will address

A

the parasympathetic system and its affect on the upper GI system via the vagus nerve, as well as the upper cervical musculature and vertebral dysfunction that may be associated with central facilitation (see the above facilitation discussion).

377
Q

Soft tissue/inhibition of oa

A

Also addresses upper cervical spine

378
Q

How often to treat colic

A

Depends-weekly is most often, usually
Gauge how much help parents need
Treat parents as well if necessary

379
Q

Assessment

1.Fussy baby

A

Most likely etiology colic. Differential diagnosis includes: (whatever it is you think may be the differential)

380
Q

Plan for colic

A

Potential etiologies and course of colic explained to parents. They desire to try food elimination first; handout and instructions given. Parents understand red flags to look for and will call with any concerns. Will return in one week for re-evaluation.

381
Q

Colic is tough

A

There are no great answers, lots of questions, lots of interesting research going on
Focus on helping parents cope

382
Q

OMT for colic is focused on

A

Augmenting GI circulation and respiratory motion

Treating viscero-somatic and/or somato-visceral reflexes

383
Q

Areas to focus on in the busy practice when baby has colic

A

Look at diaphragms
pelvic, thoracic diaphragm
Upper lumbars/Mesenteric root (lymphatic and venous circulation)
Mid-thoracic region (sympathetics/VSR)
OA/upper cervicals(parasympathetics/VSR)

384
Q

Last slide for Nov 23

A

…

OPP III (2 decks)

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