Hgf Flashcards
Pedriac patients
Dr. Nichols
Children do not have SD bc more mobility in joints
False
Are kids small adults
No
Infants, school age kids, adolescents
Very young kid
May be held by parent while doing technique or exam
More calm and relaxed better evaluation
Warm your hands
Treatment modalities for young kids
No HVLA
ME difficult to perform in young kids
Articulately, stills, fpr, cs, cranial
Red flags kids
Neck pain, fever, hip pain, ortalni barrlow test do
Not for meningitis or heal broken bones
Kid issues
Torticollis, colic, poor sucking, sinusitis , gerd growing pain,
Cranial treatment
Poor suckle, infant constipation, birth trauma
Condylar decompression
BMT
Msk pain OMT
Examine joint above and below
Ortho exam too
Send home with exercise!
Stretch, strength training
Infants spinal curvature
C spine has slight lordosis, which increases as baby can support his/her own head
Thoracic kyphosis and lumbar lordosis have yet develop
Spinal curvature is very immature
Infants joints
Articulations are cartilagoinous
Bones infants
Maximum flexibility
Sutures infants
Not formed , freest
6 week baby wont stop crying, bloated and gassy
Posterior cervical muscle hypertonicity, compression of occipital condylar, incomplete lactose absorption, increased stress during gestation
Alllll-treat neck cranially, look at abdomen so have more open hiatus and get and spit up, but can still check it and see if restrictions also maybe gas drops for baby
Helmets baby
Decrease cranial rhythm and head has fluctuations dont wanna lock down will effect them
Hard baby head
Had premature closing of sutures
Babies heads are
Squishy and have movement , lots of cartilaginous connections, OA decompression bc nerves come out of here
Cranial dysfunctions infants resolve
With crying and suckling
At 6 weeks if not better
Occipital is the cranial bone most susceptible to dysfunction
Infants head accommodates to pelvic outlet during birth -usually birt trauma
Cranial SD
Birth trauma MCC
Occiput
Most commonly dysfunctional
Cnxii, ix occiput
Poor suck
Cnx occiput
Reflux, vomiting, colic
Cnxi occiput
Colic, muscular dysfunction
Temporal bones
Affects the most cranial nerves
Internally rotated temporal bone
Increase likelihood of OM
Operative vaginal delivery (forceps)
Cnxi-.lateral rectus palsy
Cnvii->facial palsy
2 month old boy bald spot on back of head difficulty following you to left
Left occiput no hair
Spasm of the left sternocleidomastoid
Left trapezium in spasm
Which is most likely cranial strain parter
Right lateral strain
Synostotic vs positional plagiocephaly
Sternocleidomastoid issue-positional, see with baby in car seats a lot , bald spot
Synostotic-
OMT infant
Indirect please , short but frequent, sessions
BMT onc ranial SD, condylar decompression, BLT, MFR to diaphragms and junctions
-suboccipital release
Toddler 1-4
Ossification increases
-some bones become fused
Increased falls, learning to walk
Lots of bands to the noggin
School age
Cranium ossified fully
Epiphyseal plates still open -rapid growth ->growing pain Leg length discrepancy -short leg syndrome -functional scoliosis
Scoliosis screening
Against screening asymptomatic kids
D-fair evidence is ineffective or that harms outweigh benefits
No significant disease better than screening only
American academy of PEDS
Do not support any recommendation against scoliosis screening
-do forward bending test
Adolescents
Epiphyseal plates closing/closed
Innominate fuse by age 20
Sacrum fuse in late adolescents
Adolescent athletes are susceptible to somatic dysfunction
- watch for hypermobility
- what contraindications?
Abdominal complaints
Para OA, AA, pelvic splanchnic
Sympathetic
Chapman apppendix
Tip of 12th, tp of t11
Intestine chapman
Below Asia
Colon chapman
It band
Rectum
Inner thigh
Poor sucking feeding
Cranial-condylar decompression
Gerd
Cranial may be useful, esp if gerd
Viscerosomatics-oa, aa, T5-t9
Constipation omt
Treat dysfunction at viscerosomatic levels
Treat pelvic dysfunction
Mesenteric release
Paraspinal inhibition
Head neck symp
T1-4
Chapman respiratory
Nasal sinuses
Larynx, pharynx, tonsils
Ok
Nasal sinuses
Ant-inferomedial clavicle, lateral to SC jucntion, superior second rib at midclavicular line
Posterior-mastoid process
Larynx
Ant-superior second rib, just medial to sinuses CR
Post-just lateral to spinous processes of C2 (larynx, pharynx, tongue, all sinuses)
Pharynx
Anterior-inferior first rib at sternocostal junction
Post-juts lateral to spinous process of C2 (larynx, pharynx, tongue, all sinuses
Tonsils
Ant-lateral manubrium
Middle ear
Ant-superior clavicle, about 2 -3 cm lateral to SC jucntion
Post-base of occiput at OA joint
Lymphatics
Always open the thoracic duct first
Upper respiratory
Many techniques
-sinusitis-sinus milking techniques, cranial lifts
Otiti mmedia-ear pull, galbreath, muncie technique
Lower respiratoy
Asthma-rib raising, myofascial , assess for and treat any inhalation or exhalation dysfunctions
Pneumonia-similar to asthma treatment..at least from an omt standpoint
9 year old male ab pain, 2-3 bowel movement per week hard a painful. Decreased appetite. Where TTA
Constipation in kids is common.
T10-l2 colon
11 year old female asthma using inhaled daily and rescue inhaled daily. What sad
Inhalation dysfunctio. Ribs 2-10
If using rescue inhaler-step up therapy
14 month old male crying and fever right tympanic membrane inflamed, T 103
Lymphatic, galbreath,cranial, check for internal rotated temporal bone, ear pull,
17 year old male runner complaine knee pain . Tender calcaneous. What have .. positive ober
Plantar fasciitis and it band restriction
11 year old less active, inhaler, SOB in winter, voice sounds like whale. Tart for sympathetic
T2-T6
Ribs?
2-6 pump handle inhalation dysfunction
What rib treat
Bottom rib six treat first
Asthma neuro
B2 agonist->sm m bronchodilation
Immune asthma
Blunt airway inflammatory response
Biomechanical asthma
Treat rib dysfunction->improve thoracic cage respiratory mechanics
-rib and t spine me BLT fpr
Behavioral asthma
Avoid triggers, use meds prior to known exposure
Resp circ asthma
Ribraise, lymphatic tax-> improved pressure differentials in thoracic cage
-rib raising , thoracic pump
3 year old runny nose, fever congestion, tugging on ears, tired, not sleeping
Bulging tympanic membrane, puss bottom of ear. What describe
Erythematous, bulging with purulent effusion
Most likely diagnosis
Acute suppurative otitis media
Otitis media micro
Pneumonia
HI
Moraxella cat
Antibiotics acute otitis media
Give it a few days
4 year old boy clear running nose congestion, HA, cough, less appetitie, no fever, throat red ,ears are
Pearly translucent intact with effusion-look good just with fluid
Galbreath
Diagnosis
Viral uri with serous effusion
Younger age Eustachian tube
Decreased Eustachian tube angle and shorter and have mor gerd and spit up why they have ear infections
OMT otitis media
Reduced recurrence of titis media
OMT for it
Sinus drainage, galbreath, submandibular walking, pre post auricular drainage, cervical drainage, ear pull, BMT cranial,
Kid pain and do what
Nothing and observe-its normal growth pain
Percentage of pregnant women report low back pain
60%
Why pregnant back pain
Changes in maternal structure and biomechanics
Body fluid circulation
Hormonal changes
Treating SD
Adapt to structure and hormone changes, discomfort and better functionality
Scoliosis
Do not increase with preg but may get pain and premature birth
RA
Improved symptoms with preg
-increased cortisol
Anklylosing spofylitis
Aggravated by preg due to increased stress on SI joints
Low back pain
Exaggerated lordosis, forward neck, ligament laxity, down shoulder, weakness and separation of abdominal msucles, widening and increased mobility SI joint, anterior tilt of pelvis, compression due to fluid
Pelvis preg
Anterior tilt leads to lordosis which increase thoracic kyphosis to forward head
29 yo pref at 37 weeks . Back pain for months but unbearable. Worse with activity better with rest. Can radiate down thighs, less sleep, worse pain at night . What find
Decreased ROM of lumbar spine
Back pain etiologies
Postural, msucle week, si joint laxity,
Posterior pelvic pain
Distal and lateral to lumbosacral jucntion
Don’t find neuro
Visceral disease and low back pain
Uti and nephrolithiasis
Alarm finding
Severe paint hat interferes with function, particularly non positional persistent pain at night
Increased pain w cough, sneezing, valsava
Neuro
-by history or on exam
—like bladder REFER ON
Radicular pain
Usually herniated disc from mechanical pressure from baby
Lightening pains, numbness along ilioinguinal and genitofemoral
Risk factors lbp
History back pain
Multiparity
Higher BMI
Smoking
Age
Strenuous work
Pain during menstruation
Increase in interstitial fluid
6.5 L over course of prednisone and metabolic demand
Hormone
Increase estrogen, progesterone and adrenal hormones promotes fluid retention
What increase
CO blood volume
Plasma volume
What decrease
Systemic vascular resistance
Blood pressure
Hematocrit
First trimester
SVR decreases
CO increases
Second trimester
SVR drops 35-40% until mid second trimester
CO continues to increase
Third trimester
Supine position get decrease CO, SV< and increase HR
BP returns to pre pregnancy levels
19 yo preg 34 weeks. Soft bumps over her vulvar region that are non tender. What’s happening
Recommend patient sleep in left lateral recumbent position and apply pressure to the area she has varicose vein
If supine enlarging uterus compress ivc and lower venous return to heart and cause varicosities
Lymphatic stress
Decrease in efficiency caused by fascial torsion, organ hypertrophy and diaphragm restriction leading to less effective pressure gradient
Third trimester, varicosities
May also need stool softener
19 year old 37 weeks low back pain awakens her at night why does back hurt more at night that day. What causes it
Stagnant hypoxia of neural and vertebral tissues at night
She’s compressing ivc since waking up on back…getting pelvic congestion leading to stagnant hypoxia of neural and vertebral tissues
Venous
Pulse and respiration change pressure gradients between abdomen and thorax
- change in volume of ab organs
- increase ab cavity pressure
Cns congestion
-HA< nausea, light headed
Resting minute ventilation
Increases 50% from large tidal volume.
RR
Unchanged f
Progesterone
Stimulates respiration and respiratorydrive
Big picture
More fluid to tissue and not coming back
Dependent edema
Moves back into the vasculature due to osmotic gradient and direct pressure on ivc by uterus
Decrease flow in pelvis
Stagnant hypoxia of neural and vertebral tissue
Delayed low back pain that wake up in middle of night
Relaxin
Elevate 1st trimester then decline and stable
Widening of SI joints and pubic symphysis start week 10
Women back ain’t and relaxin
Have more
Progesterone
Respiration!!!
Drive mechanical change in thoracic change
Subcostal anlge up
Ap diameter up and circumference up
Compensat for 4 cm raise in diaphragm so total lung capacity not down
Fluid retention also
Indications
SD, scoliosis or structural condition associated with reggedema
Contraindications
Premature labor or rupture of membranes
Labor premature-before 37 weeks and contraction of uterus and soft cervix
Absolute contraindications
Undiagnosed vaginal bleeding, prolapsed umbilical cord, placental abruption, ectopic preg, placenta previa, threatened or incomplete abortion, severe pre eclampsia/eclampsia(low seizure threshold)
biomechanical
Postural and structural
Neuro
Viscerosomatic and nervous system
Resp circ
Arterial venous lymphatic using msk
Met energetic
Energy body
Behavioral
Exercise, Renata, eating well, stretching
Exercise
Better for back pain
What is appropriate
Fascial diaphragms
-thoracic inlet, thoracoabdominal diaphragm,
First trimester
History, PE,
Treat-SD and hyperemesis gravidarum treat areas C2 and T5-t9
Postural exam, thoracic inlet, thoracic cage, pelvic
Biomechanical
Spine, ribs, pelvis, sacrum
Neuro
T10-l2 pelvic organs
S2-s4 pelvic organs
Behavioral
Smoking alcohol, sexual behavior
Metabolic energetic
Prenatal vitamins
Hyperemesis gracidarum
C2, T5-t9
Second trimester
Monthly visits
Evaluate for SD
Pelvis rotating anterior about right and left axis (forward torsion)
Increased pelvic tile, increase lumbar lordosis, compensatory increase of thoracic kyphosis, may give cervical strain
Treat second trimester
Fascial release
Treat sacrum and pelvis
Carpal tunnel! From edema
- palliative tratment
- stretches, night time splinting
Biomechanical
Spine, low back pain, sacral pelvis, abdominal wall MFR
Neuro
CTS myofascial release
Rep circ
Rib raising , diaphragm
Metabolic energetic immune
Prenatal vitamins
Constipation-pelvic diaphragm release, stool softener, laxatives
Behavioral
Self care home stretches, exercise as tolerated
Can treat supin through second trimester
Yup
Third trimester
Mechanical and structural
Back pain, gait, constipation, gerd,
Increase interstitial fluid
Uterus size up
-edema, hypotensive when supine***, diaphragm working overtime
Treat
Edema with MFR, ST< lymphatics (effleurage and pet)
Upper gi T5-9
Adrenal ovaries t10-l2
Avoid cv4 -cause contractions , but can do cranial
Pelvic diaphragm for constipation
Biomechanical
Low back pain, gait changes, feet innovate, sacrum
Neuro
T5-9
T10-l2 ovaries/uterus
S2-4 bladder
Resp circ
Lymphatic emphasis-effleurage/petrissage
Metabolic energetic immune
GERD-sucralfate, ranitidine, cimetidine
Behavioral
HoTN-drink fluids
GERD-elevate head of bed, dietary modifications
Build psychological support for delivery
Preparatory stage last 4 weeks have weekly visits
Structural balance and lymphatic flow, build support
Evaluate inlet: iliopectineal line/pube to sacrum
Mid pelvis: structures between inlet and outlet
Outlet: pubic bones, iscial tuberosities
——this is to evaluate pelvic diameter to anticipate delivery problems
Labor
Lumbosacral region and pelvis and use MFR soft tissue
Thoracic spine soft tissue for sympathetic innervation
Expect labor dysfunction
Innominate, sacrum, pubic symphysis
Biomechanical
Pelvic/sacrum/lower T/lumbar
Neuro
Seizure activity clonus
Pain control
Resp circ
Making sure pt is up and moving-blood clot protection monitor swelling BP
Metabolic energetic immune
Liquid diet
Monitor fluids
Blood sugars
Behavioral
Make sure pt is in control
Movement as tolerated
Labor prob
Rupture pubic symphysis
Rupture pubic symphysis
Separation greater than 1 cm
<1%
Audible crack
Acute pain to back or thighs have waddeling gait and feel gap
Treat
Bed rest in lat recumbent
Pelvic binder to reduce
OMM indirect myofascial
May cause pain in subsequent pregnancies
Post partum first visit
SD, treat prior to resolution of hormonal Chang’s
-relaxin (stay for 6 weeks) so treat before go away
Sacrum-anterior sacral base and cranial extension!!! Fatigue depression
Second visit 4-6 weeks
Structural, SD, assess contraception,
Exercise in preg benefits
Cardiorespiratory function
Enhances psychological well being
Decrease risk of comorbidities due to sedentary lifestyle
Exercise preg
30 min or more moderate most days
Avoid preg
Falling, high risk, hot yoga valsava maneuver (increase BP)
Don’t go above 6000 feet
Contraindications to aerobic exercise relative
IUGR
Unevaluated maternal cardiac arrhythmia
Absolute contraindications xercise
Incompetent cervix Multiple gestation (triplets) IUGR Persistent second or third trimester bleeding Placenta previa Premature labor Ruptured membranes Preeclampsia/HTN
Dr Hansel low back pain 3rd trimester
OMT safe and effective to improve pain functioning third trimester 12 step protocol
Muscle imbalance and exercise prescription
Dante
17 yo achy and deep left hip pain . Softball pitcher and pain month after returning to play father right ankle sprain. Worse running and pitching, better rest. At a 5 and sharper and more severe during exarcbating factors . Is this muscle imbalance ?
Yup
Postural balance
Condition of optimal distribution of body mass in relation to gravity
Postural imbalance
Ideal body mass distribution not acheived
Tensegrity
Body is a System within even minor changes in one body region may affect significant biomechanical, tensile, and ergonomic changes elsewhere
Have continuous tension members and discontinuous compression members
OPP and tensegrity
Bone held together by CT and muscles which balance strength and stability.
Hypomobility
Hypermobility elsewhere
Hypermobility
Results in compensatory hypomobility elsewhere
Hypomobility example
Spine fixed in one spot, Moe movement above and below
Example hypermobility
Pitcherhave anterior shoulder capsule weakness shoulder pulled forward and stabilized
Right shoulder lower then left pulled forward
Postural decompensation scoliosis
Coronal plane-scoliosis changes
Horizontal-rotational changes
Sagittarius plane-kyphosis and/or lordotic Changes
Risk factors for postural decompensation
Gravitation strain Congenital Alternated Proprioception input Stress Hormonal imbalance Nutritional Aging
Gravitation strain
Spinal curve increase in response to the vertical load imposed by gravity
Change 10% a year
Trauma: positioning and/or tasks
Bend over studying
Factory working
Truck driver
Aging
Altered response to gravity forces, injury and healing
Physician stress: insufficient healing response to injury
Muscular splitting while tissue heals may continue after healing
Damage to Proprioception
Altered firing pattern-need to retrain balance
Homeostatic mechanism
Postural compensation
Homeostatic reserve overwhelmed
Postural imbalance
Postural strain
Increase over time
Homeostatic compensation: static dynamic relationship
Center of gravity shifts with changes of position
Posture compensates to keep us upright
Postural change in one plane modifies posture in the other two plane
———needs to be balance in dynamic motion
Chronic postural strain
Asymmetric stress
Early functional symptoms and structures change during remodeling to accommodates postural change
Eventually bones start to change become compressed in from and bigger in back
Ventilation different with scoliosis
Yea! Structural
Where are segmental facilitation
Cross over sites-zinc patterns
Spices of curves-mid thoracic problem , mid lumbar where balance point is
Sherrington law
When a muscle receives a nerve impulse to contract, its antagonists receive, simultaneously , an impulse to relax
Pseudoparesis: postural msucles and movement muscles
Postural-shortening, hypertonicity, facilitation
Movement-inhibited, stretched, hypotonic
Commmon compensatory
80% of healthy
LRLR
Uncommon compensatory
20% healthy RLRL
Lower crossed syndrome
Tight erector spinae and iliopsoas and weak abdominals and inhibited gluteals
Kinda flexed
Flexor tight extensors inhibited
Signs lower cros symptoms
Increase sacral flexion, increased lordosis, increased flexion of hip and knees, hypermobility in sagittal and coronal planes in l4-l, L5-a1 levels, sitting up from C-Spine and forward bending test are dysfunctional
Hypertonic muscles of lower cross
Iliopsoas, rectus femoris, QL, TFL, hamstrings, piriformis, LE short adductors
Hypotonic lower cross
Anterior tibialis, gluteus, vastus medialis, perineal, abdominals,
Iliopsoas
Inability to stand straight-knees flexed l1-2 SD, pain referral to back and groin; positive Thomas test
Quadratics lumborum
Pain referral to groin and hip; exhalation 12th rib SD; diaphragm restriction
Hamstring
Pain sitting or walking; pain disturbs sleepl pain referral to posterior thighs; limited straight leg raising
Piriformis
Pain down posterior thigh; may entrap sciatic nerve; perpetuated by SI dysfunction; associated with pelvic floor dysfunction, dyspareunia, prostadynia
Adductors
Pain referred to inguinal ligament , inner thigh and medial knee
Gastroc soleus complex
Nocturnal leg cramps; pain referral to upper calf instep and heel
Gluteus minimis
Pain when arising from a. Chair, pain referral to butt, lateral and or posterior thigh, pseudosciatica, antalgic gait and + trendelenberg sign
Gluteus mediums
Pain with walking ; pain referred to posterior iliac crests and SI joints + trendelenberg
Gluteus Maximus
Restlessness; pain sitting or walking up hill; antalgic gait
Vastus medialis
Buckiling knee; weakness going upstairs; thigh and knee pain; chondromalaxcia
Rectus abdominis
Increased lordosis; constipation
Tibialis anterior
Pain referral to the great toe and anteromedial ankle; foot may drag or trip when tired
17 yo pitcher how determine if decompensated
Biomechanical-visual inspection, ROM, gait
Neuro-balance and strength
Respiratory/circulatory: zinc pattern; lymphatic palpation exam
Metabolic: history and PE
Behavior/psych: history and PE
Pseudoparesis-patient perception
Lay on back flex one leg at the hip 12 inches and put down
Then repeat other side
Do side to side and compare for difference
One side heavier
Self locking mechanism
Form closure-bones how fir together
Force-muscle gravity fascia ligaments
Communicate perceived change to examiner
Pseudoparesis: patient perception with SI joint stabilization
Repeat same test, except introduce medial compression through iliac crests midway between the iliac crests and the greater trochanters
And the greater trochanter
Communicate perceived change to examiner
At iliac crest
Usually structures above the iliac crests=multifidus, latissimus dorsi, levator scapula, lumbar vertebrae and structures above and including the lubosacral junction
Midway between iliac and greater trochanter
Gluteus, SI joints, sacrum, innominate
Threough grater trochanter
Pelvic diaphragm, hamstrings, STL and structures below the pelvic diaphragm
In balanced
No pseudoparesis
Unbalanced
External stabilization necessary to eliminate signs
Firing pattern test
Touch muscle and extend leg and order of firing
Ipsilateral hamstring, ipsilateral gluteus maximus, contralateral erector spinae, ipsilateral e spinae
Most common see inhibited gluteus maximus
Abduction test
Lay side lift leg firing pattern
Ipsilateral gluteus medius, ipsilateral TFL, ipsilateral QL, ipsilateral e spinae
TFL fire and gluteus medius doesnt* most common
IT band chapman
Colon,
26 yo lbp after triathlon what lower cross finding for pseudoparesis
Left hypertonic rectus
Upper cross syndrome
Forward head posture increased lordosis (upper and mid cervical spine)and kyphosis (cervicalthoracic junction), protraction shoulders, internal rotation of humerus, c4-c5 cervicocranial and cervicothoracic junctions
Hypertonic postural muscles
Levator scapula, upper trapezius, pectorals, last, scm, scalenes, subscapularis, UE flexors
Movement hypotonic muscles (weak)
Deep neck flexors, serratus anterior, deltoid, UE extensors, rhomboids, supraspinatus, infraspinatus, mid and lower trapezius
SCM
Headache
Bilateral shoulder flexion
Check resting length latissimus and influence on thoracic and lumbar spines
Check pectorals
5 model muscle imbalance
Biomechanical-osteoarticular, ROM repair
Neuro-SD from pseudoparesis
Respiratory-optimize flow
Metabolis-OMT function, nutrition OMT, hydration sleep
Behavior-exercises and healthful living prescriptions
Hamstring normal
> 80 degrees flexibility
12 weeks stretching for 180 s
Stretching program was equally effective in terms of absolute improvement values for males with normal and limited hamstring flexibility
How long hold stretch
90s
Stretching
Increase ROM and joint mobility but 90 and 9 10 s no change
2-3 30 s
Aerobic exercise prior to stretching
Improve a lot vs static stretching
When evaluate CV and or respiratory systems when patient has what
Extreme fatigue after doing exercise
Pain above waist
Inability to maintain a conversation due to SOB
A strong CV disease family history or risk factors
