Lectures 7, 8, & 9 Flashcards
The student will be able to define an Osteopathic Structural Examination. The student will be able to define static analysis and motion testing. The student will be able to define the different types of motion. The student will be able to define the different types of motion barriers.
Osteopathic Manual (Manipulative) Medicine
Application of Osteopathic philosophy, structural diagnosis, and the use of OMT in the diagnosis and management of the patient.
CRITERIA FOR DIAGNOSING A SOMATIC DYSFUNCTION
(S; Sensitivity) T:Tenderness Abnormal sensitivity of the tissue. Pain is what the patient complains about (subjective); tenderness is what you find when you palpate their tissues (objective). A: Asymmetry R: Restricted range of motion T:Tissue texture changes Ropy, boggy, pliable, compressible, rough, edematous \_\_\_\_\_\_\_\_\_\_ -Need at least 2 to have SD -If one is tenderness then need 3. -compare L and R sides for diferences
Most important 2 criteria for diagnosis SD?
restricted ROM and tissue texture changes
forces used in OMM
flexion (sagittal-AP), extension (sagittal-AP), side bending (frontal-coronal), rotation (transverse-horiz)
anatomic barrier
PHYS MOVES absolute limit of passive motion - its the final barrier limited by bone, muscle, ligament
-if you pass this limit = injury
physiologic barrier
PT MOVES -limit of active motion - what individuals can do themselves
restrictive barrier
- a limit that abnormally dimishes normal physiologic ROM
- caused by somatic dysfunctions, surgery muscle tightness, chronic dieases, swelling, scar tissue….
- IF NOT THE SAME ON BOTH SIDES THEN CLEARLY SOME SD
elastic barreir
- not a true barrier
- range between the physiologic and anatomic barriers
extrinsic force (OMT)
- (OUT OF)
- Treatment forces which are not supplied by the patient.
- Operator effort; thrusting, springing, traction, etc.
- Gravity.
- The use of a mechanical table (one that moves the patient).
intrinsic force (OMT)
- (IN)
- Voluntary or involuntary forces from within the patient that assist in manipulation.
- Respiration.
- Muscle contractions.
- Involuntary motions of the cranium and visceral organs.
active force (OMT)
Patient voluntarily performs a physician directed action.
Passive force (OMT)
Patient refrains from voluntary muscle contractions.
Osteopathic Manual (Manipulative) Treatment
Therapeutic application of manually guided forces by an Osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by a somatic dysfunction.
Direct movement
Engagement of the restrictive barrier carrying the dysfunctional component (somatic dysfunction = SD) TOWARD OR THROUGH THE BARRIER.
indirect movmenet
- The motion barrier is disengaged.
- The dysfunctional body part (SD) is moved AWAY FROM THE RESTRICTIVE BARRIER and towards a point of balanced or decreased tissue tension in all planes or directions.
purpose of both indirect and direct movments?
to increase ROM
transitional areas are areas where
- Areas in the body where most dysfunctions can be found.
- Those areas that have the most mobility or are transition points within the: musculoskeletal system. Head/neck. Neck/thorax. Thorax/lumbar. Lumbar/sacral.
- Most SD’s will develop here because of the increased motion within these areas.–>Most people can adapt to these…it is when they don’t that they seek your help.
HVLA
- An articulatory manipulative procedure whereby the barrier or end-point of joint motion is engaged directly, carrying the dysfunctional component through the barrier in order to bring about an increase in freedom and range of motion.
- A quick motion over a short distance that may often produce an auditory noise (pop).
- Direct technique.
- Passive.-pt cant be doing anything
- Extrinsic.
- use is determined by pts condition
- Pt feels instant relief
- may overstretch ligaments if done too freqeuntly
- perform once or twice a week
HVLA treats…
BONY not MUSCULAR SD.
highest injury potential treatment
HVLA
over stretched ligaments can… (due to HVLA)
weakened ligaments = instability of the joint
HVLA mech of action:
gamma and alpha motor neuron inhibition due to stretch of spindle and Golgi apparatus mechanisms
After HVLA immediate change in muscle tone is due to
mimediate change in neural activity
How does HVLA trust change the neural activity
A sudden stretch or change in position of the joint alters the afferent output of the mechanoreceptors (of joint capsule), resulting in release of the muscle hypertonicity.
benefits and precautions of HVLA
- Very efficient use of physician’s time.
- May be longer lasting.
- Immediate relief for the patient.
HNP (herniated nucleus pulposis = herniated disc), acute whiplash, post-surgical, vertebral artery ischemia, anticoagulation therapy, hemophilia.
HVLA is what kind of treatment?
passive extrinsic
what is the prolem with HVLA? How to avoid?
when the pt doesnt RELAX. Not passive. Muscle spasms?
need to make sre that the pt is comfortable with the treatment. Also can use other soft tissue techniques to loose up and relax pt/tissues
golgi tendons measure
measuretension
muscle spindles
measure how fast something is moving
very sensitive to changes in length – involved with the facilitated segment (or SD)
bringing restriction back to its physiological
stretch/mvoement of HVLA thrust–> changes afferent output of mechanoreceptors –> changes muscles hypertonicity—> allows joint to go back to normal
muscle energy
- A form of manipulation in which the patient uses their muscles, on request, from a precisely controlled position, and in a specific direction, against a physician’s counterforce.
- The physician takes the body region into its barrier and the patient pushes back against them.
- Direct technique.
- Patient is active.
- Must be able to follow directions to assist in treatment.
- Extrinsic and intrinsic.
isometric muscel energy
- change in the tension of a muscle without approximation of its origin or insertion
- muscle is same lenght throughout
- correct a SD
isotonic ME
- Approximation of the muscle origin and insertion without change in its tension.
- The patient pushes with greater force than the physician.
- The patient wins.
- Used to tone muscle or will strengthen a physiologic weak muscle.
isolytic ME
- Contraction of a muscle against resistance -while forcing the muscle to lengthen.
- The physician overcomes the patient.
- The physician wins.
- Used to break up scar tissue, adhesions, or fibrous tissue
ME mechanism of action
This mechanism sets the baseline level of activity in Alpha-motor neurons and helps to regulate muscle length and tone.
ME physiologic principle of isometric technique
Isometric technique resets the intrafusal and extrafusal muscle fiber lengths during the post-contraction relaxation phase;
true treatment phase of ME
when youre taking up the slack during the refractory period … NOT when the patient is pushing against you
when is ME most effective?
Most effective when a specific joint or muscle is involved and when patient cooperation and operator forces can be well controlled.
when to NOT use ME
- Not to be performed on patients with low vitality who could be further compromised by adding active muscular exertion.
- Fractures.
- Severe neuromuscular injuries involving potential treatment sites.
- Patient cannot follow directions.
- Proper patient positioning cannot be achieved.
soft tissue
- A procedure directed toward tissues other than the skeleton while monitoring response and motion changes using diagnostic palpation.
- AKA- MYOFASCIAL TREATMENT
- Direct technique.
- Patient is passive.
- Extrinsic and intrinsic (monitoring what Pt is doing )
- –> NOT WORKING ON BONE SPECIFICALLY
applications of soft tissue
- Relax tight muscles.
- Stretch passive fascial structures.
- Enhance circulation to local myofascial structures.
- Improve local tissue nutrition, oxygenation, and removal of metabolic wastes.
- Improve abnormal somato-somatic and somato-visceral reflex activity.
- Identify areas of somatic dysfunction.
- Observe tissue response to manipulation.
- Improve local and systemic immune responsiveness.
- Provide a general state of relaxation.
- Prepare the tissues for further treatment.
mechanisms of soft tissue techniques
1) Tractional technique (stretching). -Origin and insertion of the myofascial structures being treated are longitudinally separated.(Cervical stretching).
2) Kneading. -Rhythmic, lateral stretching of the myofascial structure in which the origin and insertion are held stationary and the central portion of the structure is stretched (like a bowstring (Thoracolumbar soft tissue prone).
3) Inhibition. -Sustained deep pressure over a hypertonic (tight) myofascial structure. (Suboccipital tension release, trapezius pinch).
when not to use soft tissue?
cellulitis
strain and coutner strain
- An osteopathic system of diagnosis and indirect treatment in which the patient’s somatic dysfunction, diagnosed by (an) associated myofascial tenderpoint(s), is treated by using a passive position, resulting in spontaneous tissue release and at least 70% decrease in tenderness.
- Indirect technique.
- Passive.
- Extrinsic and intrinsic. (PT PLACED IN POSITION BUT NEED TO SAY WHERE PAIN IS GONE IN CERTAIN POSITIONS. ALSO YOU ARE FEELING FOR WHAT THE TISSUES ARE DOING)
SHUTS OF GAMMA
strain and counter strain phys is treating the…
neuromuscular reflex rather than the tissue stresses
S/CS- The time of onset of joint dysfunction is not the strain itself, but
a strain is the body’s reaction to strain–a panic reaction and too rapid attempt to return to a neutral position==body thinks that it injured itself = tender point
mechanism/treatment of s/cs
Markedly shorten the muscle that contains the malfunctioning muscle spindle by applying a mild strain to its antagonists.
treat:counter the strain by reintroducing the original strain (which is the position of ease).
fine movement muscles have many
muscle spindles to sense changes in muscle legnth
s/cs is associated with…
tender points or Jone’s points
tender points are located and measure..
DEEP in muscle tendon ligament or fascia
Measure 1cm across or less
-muscle THINKS that it has been injured since it moved so fast
s/cs - The nearer to the midline the TP’s are found, the
the more flexion and/or extension will be needed in relation to sidebending and/or rotation.
anterior points treated with FLEXION
posterior points treated with Extension
when to not use S/cs
- Positions that cause dizziness or radicular (radiating) pain.
- Extreme forward bending of the thoracolumbar spine in osteoporotic patients.
cranial
- A system of diagnosis and treatment by an Osteopathic practitioner using the primary respiratory mechanism and balanced membranous tension.
- Also referred to as craniosacral secondary to the relationship between the cranium and sacrum through the dural attachments.
- Direct and indirect: Indirect on adults/Direct on children.
- Passive.
- Extrinsic and intrinsic: Involuntary.
crainail primary respiratory mechanism
- Inherent motility of the CNS.
- Fluctuation of the CSF.
- Articular mobility of the cranial bones.
- The mobility of the reciprocal tension membrane (dura).
- The articular mobility of the sacrum between the ilia.
when to not use crainial
acute head trauma
MYOFASCIAL RELEASE TECHNIQUES definition
- A system of diagnosis and treatment which engages continual palpatory feedback to achieve release of myofascial tissues.
- Direct and indirect.
- Passive.
- Extrinsic and intrinsic.
- Monitoring and following the tissues for their release.
myofascial release techniques can also be used on but not normally first route of treatment…
BONY DISFUNCTIONS
direct myofascial release
A restrictive barrier is engaged for the myofascial tissues; the tissue is loaded with a constant force until tissue release occurs.
indirect myofascial release
Dysfunctional tissues are guided along the path of least resistance until free movement is achieved.
patient is in charge in which treatment?
myofascial release technique - must keep moving with the patient
when to not use myofascial release
Flare-up of symptoms in patients with immunologic disorders (Lupus) and Fibromyalgia (FM).
Springing Treatment
A low velocity/moderate amplitude (LV/MA) technique (direct, passive, extrinsic) where the restrictive barrier is repeatedly engaged to produce an increased freedom of motion.
Articulatory Treatment
A low velocity/moderate to high amplitude technique (direct, passive, extrinsic) where a joint is carried through its full range of motion with the therapeutic goal is to increase its range of motion.
Activating force is either springing (see above) or repetitive concentric movements of the joint through its restrictive barrier.
Functional treatment
An indirect (passive, extrinsic, intrinsic) technique that involves finding the dynamic balance point of the tissues and either applying an indirect guiding force, holding the position, or adding compression to exaggerate the position and thus allowing for spontaneous readjustment. General myofascial release, FPR (facilitated positional release), and Still all have similar characteristics to this.
HVLA IS
direct
passive
extrinsic
ME IS
direct
active
extrinsic & intrinsic
ST IS
direct
passive
extrinsic & intrinsic
S/CS IS
indirect
passive
extrnisic & intrinsic
CRANIAL IS
direct & indirect
passive
extrinsic & intrinsic
MYOFASCIAL IS
direct & indirect
passive
extrinsic & intrinsic
SPRINGING IS
direct
passive
extrinsic
ARTICULATORY IS
direct
passive
extrinsic
edema feel is..
boggy
painful weakness is often
musculoskeletal
painless weakness is often
neurologic
prior to treating the axial skeleton you should probably…
do a neurologic exam
symptoms pointing toward the need for neurologic exam…
- Numbness
- Tingling
- Weakness
- Bowel or bladder incontinence or retention
Osteopathic Structural Exam (OSE)
- The examination of a patient by an osteopathic practitioner with emphasis on the neuro-musculoskeletal system including palpatory diagnosis for somatic dysfunction and viscerosomatic change within the context of total patient care.
- MANY POSITIONS TO PROVIDE STATIC AND MOTION EVAL
- REPEAT THROUGHOUT VISIT
Static Analysis
-General observation of the fixed (lacking movement) posture using superficial anatomic landmarks to identify any anatomic asymmetries.
Motion Analysis
-includes gait and regional range of motion testing
static analysis give phys what info?
- Muscle Imbalances (tight muscles may raise or lower one side of a body part; weak muscle may let a body part droop)
- Strain patterns
- Somatic Dyfunctions (SDs)
- Neurologic disease
- Orthopedic disease or deformity
- Emotional states
motions are defined with respect to….
THE PATIENT.
So active motion is the PATIENT actively moving themselves.
the barrier of passive motion is
anatomic
need to use ___________ to determine normal ROM for the patient and their restricitive barriers.
active, passive, and intrinsic motions
ALSO NEED TO GET HISTORY (WHERE DOES IT HURT)
proper regional motion testing should include:
- The symmetry of motion
- The quality of motion (SMOOTH OR JERKY?)
- The feel of the end point (or “end feel”)
NORMAL END FEEL
Elastic
Hard (painless)
tissue approximation
Normal end feel in the neck? Not normal end feel for neck?
elastic=normal
tissue approximation and hard not usually in neck
normal end feel in the elbow and knee?
tissue approximation
abnormal end feel
guarding (or empty)=potentially serious condition
muscle spasm=more intense…POTENTIALLY SERIOUS DISORDER
DONT USE OMM IF END FEEL IS>…
GUARDING OR MUSCLE SPASM
which type of motion is assessed first?
ACTIVE ROM BEFORE PASSIVE ROM
ROM testing is used to document the
integrity of a joint or region, to determine asymmetries in motion, to guide treatment by the physician and to help the patients see the efficacy of treatments.
gait analysis look for
Length of stride Shoulder heights Arm swing Orientation of their feet Presence of limp
gravitational line goes through and evaluates?
ext auditory meatus lateral asp of head of humerous greater trochanter lateral codyle of the knee just anterior to lateral malleolus
Used to evaluated the AP curves of the spine
compare side to side..
head acromion process angle of scap iliac crest greater trochanter feet/ankles
HIP DROP TEST
testing iliac crests for movement abnormalities
when the RIGHT hip drops, the body and the lumbar spine side bend to the LEFT
With a positive test on the R for example the R crest is not dropped as far as the left so the lumbar spine will be bent to the right. AKA the left crest DROPED MORE so the SPINE ROTATED RIGHT!
standing flexion test tests for
iliosacral SD
flexion normal
down 2/3 of legs or more
extension normal
anterior shoulders behind heels
sidebending normal
hand to about the knee
seated flexion test tests…
sacroiliac SD
occipito-atlantal joint does the…
FLEXION AND EXTENSION. YES JOINT
atlantal-axial joint does the…
ROTATION. NO JOINT
Shoulder test:
- big hug = adduction
- reaches behind back and under = extension and internal rotation
- reaches up and over head= abduction and external rotation
pes plantus is
flat feet
SD named by the direction..
the motion LIKES to go.
