Midterm OS Flashcards
Osteopathic tenet #1
The body is a unit; the person is a unit of body, mind, and spirit
Example: Low back pain could lead to depression → treat as one
Osteopathic tenet #2
The body is capable of self-regulation, self-healing, and health maintenance
Osteopathic tenet #3
Structure and function are reciprocally interrelated
Osteopathic tenet #4
Rational therapy is based upon an understanding of body unity, self-regulatory mechanisms, and the inerrelationship of structure and function
What is somatic dysfunction?
The impaired or altered function of related components of the somatic (bodywork) system including:
- Skeletal
- Arthrodial
- Myofascial structure
- Pneumonic → SAM
- Related vascularture, lymphatic, and neural elements
- Pneumonic → VLAN (A=and)
What dysfunctions can scoliosis cause?
Scoliosis is a somatic dysfunction and can cause dysfunction of the heart and lungs due to changes in anatomy
What are consequences of somatic dysfunction regarding vertebra and nerves?
Interactions between the vertabra and the nerves they protect may cause change in visceral function, or vice versa
How do you diagnose somatic dysfunction?
TART !!!!
*usually 2 or more but 1 is sometimes sufficient enough
TART ??
T = tissue texture abnormalities
A = asymmetry
R = restriction of motion
T = tenderness
Words associated with tissue texture abnormalities
Temperature, Drag, Texture, Edema, Bogginess (feeling of sponginess due to fluid), Elasticity, Dryness, Oiliness, Scars, Contractinon, Flaccidity (not contracted), Spasm, Ropey (stringy)
How do you name somatic dysfunction?
Direction in which motion is freer (likes to go) = name of somatic dysfunction for what it WILL DO
Example: elbow extended somatic dysfunction → elbow does NOT LIKE TO FLEX, does like to extend
What is acute somatic dysfunction?
Impairment or altered function of related components of the body framework system that is characterized by one or more of the following:
- Pain, erythema (redness), relative warmth, increased moisture/bogginess, vasodilation, edema, tenderness, tissue contraction
What is chronic somatic dysfunction?
Impairment or altered function of long-standing duration of related components of the body framework system characterized by one or more of the following:
- Itching, paresthsia (numbness or tingling), a palpable sense of tissue dryness, coolness, tissue contracture, fibrosis tenderness, pallor
Difference between contraction and contracture
Contraction: the process of which a muscle becomes or is made shorter and tighter
Contracture: develops into chronic or continued process
Tissue texture abnormalities - acute words
Erythematous, hot/increased warmth, bogginess, edema, spasm, tissue contraction
Tissue texture abnormalities - chronic words
Pale/blanching, cool, ropey, stringy, scar, doughy
What is somatic dysfunction treatable with?
OMT !! = osteopathic manipulative treatment
How do you treat somatic dysfunction with OMT?
OMT - the therapeutic application of manullary guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction
What is active ROM?
The PATIENT does the moving
“Patient is active”
What is passive ROM?
DOCTOR does the moving
“Patient is passive”
Passive ROM > Active ROM
What barried is the end of active ROM?
Physiologic barrier
Normal barriers
If further than anatomic barrier, can break
What is physiological barrier?
Limit of active motion
What is anatomic barrier?
Limit imposed by anatomic structure
What is elastic range?
Range between the physiologic barrier and anatomic barrier
*The end of passive motion
What is restrictive barrier?
Function limit that abnormally diminishes the normal physiologic range
Graphical form of somatic function barrier
What are OMT indications for treatment?
Somatic dysfunction → more obvious
Visceral dysfunction → not completely obvious (example: asthma exacerbation → kirksville crunch)
What are OMT contradictions? (AKA DO NOT DO OMT)
NO somatic dysfunction
**Patient DOES NOT CONSENT**
INAPPROPRIATE clinical situation
What are some possible post-OMT symptoms?
Worsening of symptoms, behavior problems, irritability, pain, sorenss, headache, dizziness, flu-like symptoms, treatment reaction, and tiredness (reported by pediatric patients, 9% of study)
How can you avoid post-OMT symptoms?
History and physical exam → allows operator to ascertain avoidable risks
Appropriate choice of technique (risk vs benfit ratio)
Appropriate application of technique
Hydration and rest (post-OMT soreness similar to post-exercise soreness)
Mesomorphic body type
- Muscular or strudy body build (average guy)
- Mid-ranges of ROM
- Characterize by relative prominence of structures developed from the embryonic mesoderm
- Example: Harrison Ford
Ectomorphic body type
- Thin body build
- Long and linear frame (tall and lean)
- Tend to have higher ROM
- Characterized by relative prominence of structure developed from embryonic ectoderm
- Example: Scottie Pippen (basketball player)
Endomorphic
- Heavy (fat) body build
- Obese, increased fatty tissue
- Tend to have lower ROM
- Characterized by relative prominence of structures developed from embryonic endoderm
- Example: president Howard Taft
What may jaundice indicate?
Cirrhosis (per DSA)
What may cyanosis indicate per “Critial clinical observation DNA”?
Reaction to cold - Raynaud’s disease
-Children with tetralogy of fallot exhibit bluish skin during episodes of crying or feeding
What factors create asymmetry?
- Bone deformity
- Joint deformity
- Kyphoscoliosis
- Dress, occupation, mental attitude, habit
- Sacral base unleveling
- Lower extremity defects
- Somatic dysfunction
Graphical form #2 of somatic dysfunction barrier
What is plane regarding motion?
Flat surfaace on which a straight line joining any two points on it would wholly lie
What is axis regarding motion?
Straight line around which an object rotates
Coronal/frontal/lateral plane ??
Bisects the body into front and back halves
What is the associated axis with frontal plane?
Saggital horizontal axis
What motions do you do in frontal plane?
Sidebending, adduction, abduction
Sagittal/ Antero-posterior plane ??
Bisets the body into right and left halves
What axis is associated with the sagittal plane?
Frontal horizontal axis
What motions do you do in sagittal plane?
Flexion and extension
Horizontal/Transverse plane ??
Divides the body into superior and inferior halves
What axis is associated with horizontal plane?
Vertical axis
What motion do you do in horizontal plane?
Rotation
What characteristics does motion have?
Direction (flexion, extension, sidebending, rotation)
Range (actual measurements in degrees)
Quality (smooth, ratcheting, restricted)
What is ELASTIC end feel of ROM?
Like a rubber band
→Myofascial dysfunction
Scar tissue, somatic dysfunction
What is ABRUPT end feel ROM?
Osteoarthritis or hinge joint
What is HARD end feel of ROM?
Somatic dysfunction
→Skeletal or arthrodial dysfunction
Osteoarthritis, RA, somatic dysfunction
What is EMPTY end feel of ROM?
Stops due to guarding (patient doesn’t allow the motion due to pain)
→Vascular dysfunction
Peripheral vascular disease, thoracic outlet syndrome, somatic dysfunction
What is CRISP (or empt) end feel of ROM?
Involuntary muscle guarding as in pinched nerve
Neural dysfunction
Herniated disc, thoracic outlet syndrome, somatic dysfunction
What is static (flexibility)?
Maximal ROM a joint can achieve with an externally applied force
Define flexibility
ROM in a joint or group of joints or the ability to move joints effectively through a complete ROM
What is dynamic (flexibility)?
ROM an athlete can produce and speech at which he/she can produce it
What is stiffness (flexibility)?
Reduced ROM of a joint or group of joints
What is a functional unit of the spine?
Two vertebrae, their associated neurovasculature, and other soft tissues
What segment of spine displays the greatest motion?
Cervical spine
ROM - SPINE
- Complicated system of articulations and bondy segments
- Concept of COUPLED MOTION
- Serve to protect the spinal cord while providing a basical support for the axis for the upper body
What is coupled motion?
Consistent association of a motion along or about one axis, with another motiona bout or along a second axis. The prinicple motion cannot be producted without the associated motion occurring as well
Linkage of joints
By linking multiple structures together you will get incrased ROM (shoulder-spine, spine-hip/pelvis)
Specific joint assessment requires joint isolation for accurate measurement and evaluation
Osteogenesis imperfecta
Issue with bone generation - easy fractures
Ehler-Danlos syndrome
Collagen dysfunction, joint hypermobility, and stretchy skin
Alport syndrome
Deafness and kidney dysfunction
Menkes disease
Copper deficiency
Kinky hair, growth failure, deterioriation of nervous system
What is brighton criteria?
Criteria to diagnose Ehlers-Danlos syndrome in addition to the Beighton scale
Major criteria - Brighton criteria
Beighton score of >4
Arthralgia for longer than 3 months in 4 or more joints
Beighton scale
Screening technique for hypermobility
4/9 joints = hypermobility
All-or-nothing test (no degree)
Minor criteria - Breighton criteria
- Beighton score of 1-3
- Arthralgia (>3 months) in 1-3 joints
- Or back pain >3 months
- Or spondylosis, spondylolysis, spondylolisthesis
- Dislocation or subluxation in more than one joint, or in one joint on more than one occasion
- Three+ soft tissue lesions (epicondylitis, tenosynovitis, bursitis)
- Marfanoid habitus
- Skin striae, hyperextensibility, thin skin, or abnormal scarring
- Ocular signs: drooping eyelids, myopia, antimongoloid slant
- Varicose veins, hernia, uterine or rectal prolapse, or mitral valve relapse
Requirement for Ehler-Danlos diagnosis?
Anyone of the following:
- Two major criteria
- One major plus two minor criteria
- Four minor criteria
- Two minor criteria and unequivocally affected first degree relative in family history
What is EMPTY or BOGGY end feel ROM?
Lymphatic dysfunction
Lymphedema, visceral dysfunction (CHF), acute injury (sprained ankle), somatic dysfunction
ROM L-spine flexion?
40-90
ROM L-spine rotation?
3-18
ROM L-spine sidebending?
15-30
ROM L-spine extension?
20-45
ROM Elbow flexion?
140-150
ROM elbow extension?
0- (-)5
ROM elbow supination/pronation?
90
ROM wrist flexion?
80-90
ROM wrist extension?
70
ROM wrist adduction/ulnar deviation?
30-40
ROM wrist abduction/radial deviation?
20-30
ROM knee flexion?
145-150
ROM knee extension?
0
ROM ankle dorsiflexion?
15-20
ROM ankle plantarflexion?
50-65
ROM ankle inversion?
20
ROM ankle eversion?
10-20
What are the 5 ostepathic models? (based on DSA)
Biomechanical
Behavioral (biopsychosocial)
Metabolic/energetic/immune
Neurologic
Respiratory/Circulatory
Biomechanical model of osteopathy
MSK system → muscles, bones, tendons, ligaments, fascia
Integumentary
Body and its response to gravity
Problem list - example: Xanthelasma; acanthosis nigracans
Interventions: evaluate and treat somatic dysfunction
Neurologic model of osteopathy
Nervous system
→ brain
→ Spinal cord
- MSK
- Autonomic
- Parasympathetic
- Cranial nerves (III, VII, IX, X)
- Sacrum (S2-4)
- Sympathetic (T1-L2)
- Parasympathetic
Interventions: treat regions associated with viscerosomatic innervations of heart, lungs, and liver
Circulatory/respiratory model of osteopathy
Cardivascular → includes lymphatic system
Respiratory
HEENT
Genitourinary
Problem list - example: SOB with exertion; hypertension
Interventions: treat ribs; treat regions associated with viscerosomatic innervations of heart and lungs
Metabolic/energetic/immune modeul of osteopathy
Gastrointestinal
Lymph organs (spleen, liver, thymus, tonsils, appendix, lymph nodes)
Endocrone (hypothalamus-pituitary-adrenal axis)
Problem list - example: impaired fasting glucose; hyperlipidemia
Interventions: encourage proper diet; consider medications for lipids/glucose
Behavioral (biopsychosocial)
Psychiatry
→Behaviors that influence health
→Behaviors that influence health decisions
Problem list - example: marijauna use; poor exercise habits
Interventions: educate on marijuana cessation; educate on proper diet/exercise
What system is each osteopathic model influenced by to improve homeostasis?
Musculoskeletal system
What is the thought process regarding the 5 osteopathic models? (DSA)
Evaluting a patient’s problem
Formulating a treatment plan
Viscoelastic material
Any material that deforms according to rate of loading and deformity
Define stress
The force that attempts to deform a connective tissue structure
Define strain
The percentage of deformation of a connective tissue
Hysteresis
The energy loss in the connective tissue system from the difference between the loading and unloading characteristics
- Stretching CT into its’ plastic deformational range with bring about a lengthening of the tissue
Define creep
Connective tissue under a sustained, constant load (below failure threshold), will elongate (deform) in response to the load
Define bind
A palpable restriction of connective tissue mobility
Define ease
The direction in which the CT may be moved most easily during deformational stretching
→Palpated as a sense of tissue “looseness,” or laxity or greater degree of mobility
Define fascial continuity
Fascial restrictions in one area of the body, will create connective tissue restrictions (pulls) at a distance away from teh site of the initial restriction
→Results in abnormal myofascial and joint mobility
Tight-loose relationship
“For every tightness, there is a three-dimensionally related looseness. Commonly, the looseness is in exactly the opposite direction from the tightness”
Newton’s third law
“When two bodies interact, the force exerted by one is equal in magnitude and opposite in direction to the forces exerted by the other”
Hooke’s law
The strain (deformation) placed on an elastic body is in proportion to the stress (force) placed upon it
Wolff’s law
Bone will develop according to the under stresses placed upon it
*this concept extends to fascia too
Sherrington’s law (of reciprocal innervation)
When a muscle (agonist) receives a nerve impluse to contract, its antagonists simultaneously receive an impulse to relax
Example: elbow flexion - biceps contract, triceps relax
Direct OMT
Go towards and eventually through the restrictive barrier
Indirect OMT
Go away from the restrictive barrier
Define soft tissue OMT
Directly applied to the muscular and fascial structures of the body
- Also affects associated neural and vascular elements
- Facilitates improvement of articular motion
- History fundamental to OMT
- Wide range of applications of force including:
- Perpendicular, longitudinal, inhibitory
Myofascial release OMT
Direct or indirect
A form of myofascial treatment that: engages continual palpatory feedback to acheive release of myofascial tissues
Integrated neuromusculoskeletal release (INR) OMT
Direct or indirect
Treatment system in which combined procedures are designed to streat and reflexibely release patterned soft tissue and joint related restrictions
dMFR
- Identify restrictive barrier in the myofascial tissues
- Engage restrictive barrier with a loaded, constant, directional force until the tissue releases and motion is restored
iMFR
- Tissue position of ease is identified
- Engage with directed pressure
- Guide the tissues along the line of least resistence until free movement of all tissues is achieved
What anatomical structures does soft tissue include?
Fascia
Muscles
Organs
Vasculature
Lymphatic
Nerves
Define fascia
- A complete system with blood supply, fluid drainage, and innervation
- Comprises the largest organ system in the body
- Composed of irregularly arranged fibrous elements of varying density
- Involved in tissue protection and healing of surrounding systems
IT IS NOT TENDONS, LIGAMENTS, OR APONEUROSIS
Fascial anatomy - what are the CT layers mostly composed of?
Collagen fibers
Elastin fibers
-Contained in a amorphous matrix of hydrated proteglycans (PGs), which mechanically links the collagen fiber networks in these structures
Fascia is composed of?
ECM - 95%
Cells - 5% (macrophage, neutrophil, plasma cell, fat cell, lymphocyte, mast cell, fibroblast)
What is the continuity of fascia?
Perimysium (fascia) to peritendineum to periosteum
What are the four layers of fascia?
Pannicular fascia (panniculus) “outer shell”
Axial and appendicular facia (investing layer - around muscles)
Meningeal facsia
Visceral fascia
Pannicular fascia
- Outermost layer
- Derived from mesenchyme
- Surrounds entire body (except orifices - mucous membranes)
- Outer layer: adipose tissue
- Inner layer: membranous and adherent (generally) to the out portion
Axial and appendicular fascia
- Investing layer
- Internal to pannicular layer
- Fused to the panniculus
- Surrounds all the muscles, the periosteum of bone, and peritendon of tendons
- Honeycomb look on electron micrograph
What does the endomysium form?
A continuous lattic connecting all the muscles fibers in the fascicle
Compartment syndrome
Swelling of muscles causing compression of nerves and blood vessels
→Fasciotomy surgery
Meningeal fascia
- Surrounds the nervous system
- Includes the dura
Visceral fascia
Surrounds the body cavities (pleural, pericardial, and peritoneum)
What does fascia provide for the MSK system?
Mobility and stability
Considered elastic and contractile
Supports/stabilizes (maintain balance)
Assists in production/control of motion
Postural functions
Sensory functions and OMT ??
Slide 60 of soft tissue lecture
~20% of cutaneous high-threshold mechanoreceptors supplying the skin also have receptive fields in the subcutaneous tissue
- Stretch receptros for muscles/proprioception (balance)
- Only 25% in muscle
- 5% consists of free endings in fascia
Indications for soft tissue
- Diagnostically to identify areas of restricted motion, tissue textural changes, and sensitivty
- Feedback about tissue response to OMT
- Improve local and system immune response
- Provide general sense of relaxation
- Enhance circulation to local myofasical structures
- Provide general state of tonic stimulation
Relative contradictions to soft tissue OMT
Acute injuries
Severe osteporosis (lateral recumbent may be applied)
Absolute contradictions to soft tissue OMT
Fracture or dislocation
Neurologic entrapment syndromes
Serious vascular compromise
Local malignancy
Local infection (cellulitis, abscess, septic arthritis, osteomyelitis)
Bleeding disorders
Lack of patient consent
Indications for MFT/INR OMT
- Somatic dysfunctions (almost all soft tissue or joint restrictions)
- When high velocity low amplitude (HVLA) or muscle energy is contraindicated
- Consider iMFR
- When counterstrain may be difficult secondary to pateint inability to relax
Relative contradictions to MFR/INR OMT
Infection of soft tissue or bone
Fx, avulsion, or dislocaiton
Metastatic disease
Soft tissue injuries: thermal, hematoma, or open wounds
Post-op patient with wound dehiscence
Rheumatological condition involving instability of cervical spine
DVT or anticoagulation therapy
Absolute contraindications of MFR/INR OMT
Absence of somatic dysfunction
Lack of patient consent
Soft tissue OMT
Tissue texture abnormalities
Treatment goals?
Stretch and incrase the elasticity of shortened myofascial structures to return symmetry
Improve local tissue nutrition, oxygenation, and removal of metabolic waste to normalize tissue texture
Soft tissue OMT
Assymetry of muscles
Treatment goals?
Hypertonic muscles/muscle spasm
Goal: return symmetry and normalize tone
Soft tissue OMT
Tenderness
Treatment goals?
Release fascia
Soft tissue OMT
Restricted (abnormal neurologic activity)
Treatment goals?
Normalize neurologic activity (pain, guarding, and proprioception) and improve abnormal somato-somatic and somato-visceral reflexes
Principles of soft tissue OMT (1/2)
- Patient comfort
- Physician comfort: to minimize energy expenditure
- Initially - applied forces are very gentle and low amplitude
- Force applied rhythmically (1-2 seconds of stretch) followed by a similar time frame releasing that stretch
- As soft tissue is responding - the applied force can be increased to increase the amplitude
- Rate typically stays the same
Principles of soft tissue OMT (2/2)
- Forces should be comfortable for patient
- Can be discomfort but tolerable
- DO NOT allow your hands to created friction bysliding across or rubbing the skin
- Physician’s hand should carry the skin and subcutaneous tissues in applying the activating force
- Technique continued until desired effect is acheived
Stretch - parallel traction
Increase the distance between origin and insertion (parallel with muscle fibers)
Knead (perpendicular traction)
Repetitive pushing of tissue perpendicular to muscle fibers
Inhibition
Push and hold perpendicular to the fibers at the musculotendinous part of the hypertonic muscle
Hold until relaxation of tissue
MFR - thoracolumbar release
- Diagnose restrictions in three planes
- Treat myofascial restriction by taking tissues to direct or indirect barrier
MFR - Activating forces - inherent forces
Using the body’s PRM (primary respiratory mechanism)
MFR Treatment Endpoint
- A three dimensional release is often palpated as:
- Warmth
- Softening
- Increased compliance/ROM
- The continuous application of activating forces no longer produces change
- When finished, recheck of the tissue demonstrates symmetry
MFR activating force - physician-guided force
After engaging a barrier or point of ease:
- Physician sequentially guides the tissue or joint through various positions
- Follow a shifting pattern of ease until path of dysfunction is retracted and released
MFR - activating force Springing/Vibration
Places hands on a dysfunction
Apply variable degrees of pressure and/or frequency of force causing springing in the structure which activates release of the tissues
MFR - activating force - Patient cooperation
Patient is aked to move in a specific direction to aid in mobilizing specific areas of restriction
MFR activating force, respiratory cooperation
Pateint inhales or exhales at request of physician
- Full cycle of respiratory effort
- Particular phase of respiration
- Breath holding
- Coughing or sniffing
Release enhancing maneuvers (REMs) of INR
Make the treatment process more efficient
- Breath holding (goal to alter both intrathoracic and intrabdominal pressure)
- Prone and supine (arm swinging maneuvers)
- R/L cervical rotation
- Isometric limb and neck movements
- Pateint evoked movement from cranial nerves (eye, tongue, jaw, oropharynx)
Where does somatic dysfunction belong on SOAP note?
Assessment
Where does OMT performed or recommended belong on SOAP note?
Plan
According to Adverse Childhood Experience Study (ACES), how many types of childhood trauma are there?
10
What are the five personal types of childhood trauma according to ACES?
- Physical abuse
- Verbal abuse
- Sexual abuse
- Physical neglect
- Emontional neglect
What are the 5 (related to other family members) types of childhood trauma according to ACES?
- A parent who’s an alcoholic
- A mother who’s a victim of domestic violence
- A family member in jail
- A family member diagnosed with a mental illness
- The disappearance of a family member through divorce, death, or abandonment
What are survivors of childhood trauma 5,000% more like to do?
Attempt suicide, have an eating disorder, or become IV drug users
Define muscle energy
The patient’s muscles are actively used on request, from a precisely controlled position, in a specific direction, against a distinctly executed physican counterforce
- Active and direct technique
- Cannot be used if patient is in a coma, uncooperative, too young to follow commands, or unresponsive
What is eccentric contraction?
Muscle tension allows the origin and insertion to separate, in effect to lengthen the muscle
What is concentric contraction?
Contraction of a muscle resulting in the approximation of the origin and insertion, to shorten the muscle
What is isotonic contraction?
A concentric or eccentric contraction against a steady but yeilding counterforce, allowing a constant tone (constant weight)
What is isokinetic contraction?
A concentric contraction in which the joint motion is at a constant rate/speed (weight can vary)
Example: keeping the same RPMs on a bike while changing resistance
What is isolytic contraction?
A type eccentric contraction in which the muscle’s concentric contraction is overpowered by a stronger counterforce (weight is greater than maximal effort) leading to a lengthening of the muscle
What is isometric contraction?
The distance between the origin and the insertion of the muscle is maintained at a constant length (neight eccentric nor concentric)
Example: Wall squats, without sliding down the wall
What is the goal of Post-Isometric Relaxation?
Muscle relaxation
*MOST COMMON FORM OF MUSCLE ENERGY*
What are the physiologic basis of Post-Isometric Relaxation?
- Immediately after an isometric contraction, the neuromuscular apparatus is in a refractory state during which passive stretching may be performed without encountering strong myotatic reflex opposition
- With muscle contraction, there may also be increased tension on the Golgi organ proprioceptors in the tendons; this inhibits the active muscle’s contraction
What is the force of contraction for Post-Isometric Relaxation?
Sustained gentle pressure (10-20 lbs)
What is the initial set-up for Post-Isometric Relaxation?
Physician passively moves patinet into the restrictive barrier (direct)
What are the next steps after initial set up for Post-Isometric Relaxation?
- Patient contracts away from the restrictive barrier (indirect)
- Physician resists the contraction towards the restrictive barrier (direct) for 3-5 seconds so the origin and insertion of the muscle remain at the same distance (no movement)
- Both patient and physician completely relax (1-2 seconds) and then the patient is passively moved into the new barrier
- This process is repeated 3-5 times or until no new barriers are reached
- RE-EVALUATE!!
Muscle energy - sequences of technique (picture with words)
What is the goal of Reciprocal Inhibition?
To lengthen a muscle shortened by cramp or acute spasm
What is the physiologic basis of Reciprocal Inhibition?
When a gentle contraction is initiated in the agonist muscle, there is a reflexive relaxation of that muscle’s antagonist group
Example: cramping hamstring (agonist), contraction of quad (antagonist)
What is the force of contraction for Reciprocal Inhibition?
Think ounces, not pounds of pressure
What is technique for Reciprocal Inhibition?
- Initial setup: passive movement into the restrictive barrier (direct)
- Patient contracts TOWARD the restrictive barrier (direct)
- Patient relaxes and after complete relaxation, is passively placed into the new restrictive barrier
- Example of a diagnosis: hypertonic hamstrings
What is the goal of Crossed Extensor Reflex?
Used in the extremities where the muscle that requires treatment is in an area so severely injured (ie fracture or burns) that is cannot be manipulated or is inaccessible
Example of diagnosis: hypertonic right hamstring
What is the physiologic basis for Crossed Extensor Reflex?
This form of muscle energy technique uses the learned cross pattern locomotion reflexes in the CNS. When the flexor muscle in one extremity is contracted voluntarily, the flexor muscle in the contralateral extremity relaxes and the extensor contracts
What is the force of contraction for Crossed Extensor Reflex?
Think ounces, not pounds of pressure
What is the goal of Oculocephalogyric Reflex?
To affect reflex muscle contractions using eye motion
What is the physiologic basis for Oculocephalogyric Reflex?
Force of contraction?
The eye movements reflexively affect the cervical and truncal musculature as the body attempts to follow the lead provided by the eye motion
Force is exceptionally gentle
Example diagnosis: OA E RRSL ??
What is the goal of Respiratory Assistance?
Improve body physiology with the patient’s voluntary respiratory mechanisms
What is the physiologic basis of Respiratory Assistance?
Force of contraction?
The muscular forces involved in these techniques are generated by the simple act of breathing. This may involve the direct use of the respiratory muscles themselves, or motion transmitted to the spine, pelvis, and extremities in response to ventilation motions. The Physician usually applies a fulcrum a/g which the respiratory forces can work.
Force - exaggerated respiratory motions
Example diagnosis: sacral dysfunction
What is the goal of Isolytic Lengthening?
To lengthen a muscle shortened by contracture and fibrosis
Example diagnosis: contracture of the bicep
What is the physiologic basis for Isolytic Lengthening?
It is postulated that the vibration used here has some effect on the myotatic units in addition to mechanical and circulatory effects.
What is the force of contraction for Isolytic Lengthening?
Maximal contraction that can be comfortably resisted by the physician (30-50 lbs of pressure)
What is the goal of Isokinetic Strengthening?
To reestablish normal tone and strength in a muscle weakened by reflex hypertonicity of the opposing muscle group
Example of diagnosis: Weak quadriceps due to shortened/hypertonic hamstrings
What is the physiologic basis for Isokinetic Strengthening?
Where asymmetry of range of motion exists, there is also the potential for asymmetry in muscle strength
Further restoration of strength can be accomplished through the use of an Isokinetic contraction (length change occurs at a constant velocity)
Typically, concentric contractions are used, where the muscle is permitted to shortened, but at a controlled slow rate
What is the goal of Joint Mobilization using Muscle Force?
Restoration of joint motion in an articular dysfunction
Example of diagnosis: Anteriorly rotated pelvis
What is the physiologic basis of Joint Mobilization using Muscle Force?
Hypertonicity of musculature across a joint can cause distortion of articular relationships and motion loss
This increase in muscle tone tends to compress the joint surfaces, and results in thinning of the intervening layer of synovial fluid and adherence of the joint surfaces
Restoration of motion to the articular results in a gapping, or reseating, of the distorted joint relations with reflex relaxation of the previously hypertonic musculature
What is the force of contraction of Joint Mobilization using Muscle Force?
Maximal muscle contraction that can be comfortably resisted by physician (up to 30-50 lb of pressure depending on the joint treated)
What is the goal of Using Muscle Force to Move one Region of the Body to Achieve Movement of Another Bone or Region?
Treat somatic dysfunction
Example diagnosis: Inferior clavicle
What is the physiologic barrier of Using Muscle Force to Move one Region of the Body to Achieve Movement of Another Bone or Region?
For some dysfunctions, it is often more effective to move one body structure by moving another body structure adjacent to it.
Muscular force is used to move the first structure and that body part’s response to the muscle force is transmitted to yet another part of the body.
What is the force of contraction of Using Muscle Force to Move one Region of the Body to Achieve Movement of Another Bone or Region?
Sustained gentle pressure (10-20 lb of pressure)
What are the indications for Muscle Energy?
- Balance muscle tone
- Strengthen reflexively weakned musculature
- Improve symmetry of articular motion
- Enhanve the circulation of body fluids (blood, lymph, and interstitial fluid)
- Lengthen a shortened, contractured, or spastic muscle group
*Versatile to use in combination with other osteopathic manipulative techniques*
What are the factors influencing successful Muscle Energy?
- Contract too hard
- Contract in the wrong direction or counterforce in the wrong direction
- Sustain the contraction for too short a time (<3 seconds)
- Not giving accurate instructions
- Not telling patient
- Do not relax apporpriately following contraction (1-2 seconds)
What are some contraindications to Muscle Energy?
- Local fx
- Local dislocation
- Moderate-severe segmental insability in the C-spine
- Evocation of neurologic sx or signs on rotation of the neck
- Low vitality
- Unable/unwilling to follow verbal commands
In what situations could using muscle acitivty (Muscle Energy) be worsened?
Post-surgical patient (internal bleeding may be caused)
Immediately following an MI
Recent eye-surgery (use of Oculocephalogyric reflex)
What has Muscle Energy been shown to cause (contraindications wise)?
Tendon avulsion (with inappropriate force in an 85 year old man)
Rib fx in a patient with osteoporosis
Anterior chamber intraocular hemorrhage (in a patient just post cataract removal and lens implant surgery)
**The point - muscle energy is safe… if done correctly in the right situations**
Articulatory Approach - basics definition
“Springing” techniques
Low velocity/high amplitude (slow movement/long distance)
Passive and Direct technique
Articulatory Approach - more in depth definition
- Gentle and repetitive motions through the restrictive barrier to restore physiologic motion
- Applicable with the restrictive barrier is in the joint or periarticular tissues
- Can be applied vertebral as well as extremity somatic dysfunction
- May be used on a single joint or an entire region
Articulatory Technique Indications
Well tolerated by:
- Arthritic patients
- Elderly or frail
- Critically ill or post-op patients
- Infants or very young patients
- Patient unable to cooperate with instructions
Articulatory Technique
*The patient should be comfortable and able to relax*
*At no time is the anatomic barrier joint motion exceeded*
Articulatory Technique - Contraindications
Relative: vertebral artery compromise (avoid combination of rotation and extension in the cervical spine)
Absoulte:
Local fx or dislocation
Neurologic entrapment syndrome
Serioius vascular compromise
Local malignancy/infection
Bleeding disorders
Comparison of Muscle Energy Technique (MET) and Articulatory Technique (ART)
How did AT Still have bodies to study?
Cholera outbreak in a group of Indians in KC
How old was Drew Still when he made a rope swing that cured his headache?
10 years old
Who was the first person to use sterile rubber gloves in surgery?
Dr. William Halstead
What happened in 1961 to threaten DOs?
A CA referendum was passed prohibiting the granting of new licenses to DOs in the state
What major battle of the Civil War did Dr. Still fight in? And what was his highest rank?
Battle of Westport (in KC)
Major
How many students were in the first osteopathic class?
22
→17 men
→5 female
What happened in 1910 that changed the face of medical education for MDs and DOs?
Abraham Flexner produced the Flexner Report with harsh criticism of medication education in the U.S.
When did AT Still fling the banner of osteopathy to the breeze?
10 AM on June 22, 1874
What year was XR first used diagnostically?
1896
Name 3-5 types of medications used in the mid-1800s?
Alcohol
Mercury
Calomel
Morphine
Cocaine
Purgatives
Cathartics
Who decreased mortality by 90% in an OB unit by introducing hand washing to medical students after cadaver lab?
Ignaz Semmelweiss
What happened in 1917-1918 that took 30 million lives?
Spanish flu pandemic
WWI took 15-18 million lives
How many children was Dr. Still left with when Mary Margaret died in 1859?
3
Who was the first person to systemically study XRs and use them diagnostically?
Wilhelm Rontgen
What did Abram and Andrew Taylor Still do for a living?
Methodist ministers and physicians
Who two things happened when Dr. Still started to spread his ideas?
He was formally removed from the Methodist Church and he was basically run out of town, fleeing to Macon, MO (at 45 years old)
Why was the Spanish Flu Pandemic in 1917-1918 improtant to the osteopathic profession?
Because death rates were significantly lower for those treated by DOs than those treated by MDs
What year did the American School of Osteopathy open?
1892, AT Still was 65 years old
How does the osteopathic physician help a patient to achieve homeostasis and health?
By treating the patient with OMM and medications as needed to maintain homeostasis by recognizing the patient as a whole and not just a disease
If a DO in CA in 1961 wanted to become an MD, what did they need to do?
Pay $65 and take 12 Saturday classes
What was the largest school of the healing arts in the US in 1900?
American School of Osteopathy
Who was the first woman to recieve a DO degree?
Jeanette Bolles, DO
Who conducted significant early osteopathic research and postulated the connective tissue model of somatic dysfunction?
Louisa Burns
How much was a two year course in Osteopathy in 1894?
$500
What was the % of ostepathic medical students in 2009-2010 who were identified as minorities?
40%
Who was the first minority AOA president in 1988-1989?
Marcelino Oliva, DO
What % of DOs in active practice less than 10 years are women?
56%
What year did DOs first mount an effort to get the right to serve in the military and civil servce? What year did they finally get those rights?
1917
Not commissioned until 1966 (rights were obtained in 1957)
What % of DOs in CA traded to MD?
85%
How many Marys did AT Still marry?
2
What year was osteopathy declared a cult by MDs? And what year was the revoked?
In 1922 the AMA labeled osteopathic medicine a cult
Revoked in 1955 with the Cline Committee Report
What year was the American Association for Advancement of Osteopathy (AAAO) started and what year did it change to the AOA?
1897
1901
In what state and year were DOs first licensed?
Vermont, 1896
What was the first year for inspection and approval for internships? Residencies?
Internships - 1936 (18 hospitals and 81 programs)
Residencies - 1947 (71 positions approved and 37 filled)
Who was the first female dean of a medical college? (DO or MD)
Barbara Ross-Lee
What year was the CA-incident resolved? And what effect did it have on DOs across the US?
1974 - the CA incident was a catalyst for DOs obtaining rights in all 50 states
From what college of osteopathic medicine did Marcelino Oliva graduate?
KCU
What happened in 1864 that made AT Still doubt the medicine of the day?
His children died from meningitis
What year was the KC College of Osteopathy and Surgery created?
1916
Who was the first African American present of the AOA?
William G. Anderson, DO
Who was the first female to graduated KCCOS in 1917 who also graduated in 1918?
Mamie Johnston, she retired from KCU in 1981 at the age of 92 years old
What year was the association of military osteopathic physicians and surgeons formed?
1977
What was the result of DOs not being able to serve in the military in the 1940s?
Increase in DO hospitals in the US
What is William G. Anderson known for other than president of AOA?
The Civil Rights Movement and his work with MLK
Who was the Surgeon General of the Army from 1996-2000?
Lieutenant General Ronald R. Blank
What year did DOs begin to be drafted into the military?
1967
Stress Hypertonic Muscles - Upper
- Upper trap - elevates scapula
- Sternocleidomastoid - together pulls head forward
- Levator scapulae - elevates scapula
- Pectoralis muscles - IR shoulder (major), scapula protraction (minor)
- Cervical erector spinae - cervical extension
- Scalenes - elevation of ribs
*these are muscles that get tight due to stress*
Stress Hypotonic Muscles - Upper
- Mid and lower trap - (mid) scapula retraction and (lower) depress scapula
- Latissimus dorsi - extension, adduction, and IR of humerus
- Deep cervical flexors
- Rhomboids - elevation and retraction of scapula
*become weak*
Stress Hypertonic Muscles - Lower
- Iliopsoas - hip flexion
- Quadratus lumborum - sidebending of trunk, depress rib 12
- Thoracolumbar erector spinae - spine extension
- Hamstrings - hip extension, knee flexion
- Rectus femoris - hip flexion, knee extension
- Piriformis - abduction of flexed hip, external rotation of extended hip
- Thigh adductors
- GastroSoleus complex - plantar flexion
*muscles that may get tight due to stress*
Stress Hypotonic Muscles - Lower
- Gluteus minimus - abduction of femur, IR
- Gluteus medius - abduction of femur, IR
- Gluteus maximus - hip extension
- Vastus medialis, intermedius, and lateralis - knee extension
- Rectus abdominis - flexion of spine
- Tibialis anterior - dorsiflexion
*muscles that may get less strong/weak due to stress*
Levator scapula stretch
Presents as pain in back of neck
For tx left side:
- Grasp back of chair with left hand and lean toward right knee
- Look down at right chest, “a pocket”
- Use right and to reach behind head and apply minimal pressure at occiput toward right knee. Recommended to use 4th and 5th digitis
- Inhale deeply and stretch further with exhalation
Scalene stretch
Presents as 1st or 2nd rib SD
For left side stretch:
- Use right hand to reach over head and grab just above the left ear
- Sidebend head away from affected side using force from hand on head
- Inhale deeply and stretch further on exhalation
*For added stretch, place hand of affected side under buttocks palm up - blocks linkage*
Prayer stretch for latissimus dorsi (can be hypertonic if workout and got tight)
Presents as shoulder extension SD
- Start on knees and place elbows on a chair in front of you
- Let chest drop and sit backward toward heels.
- Moving elbows closer together enhances stretch. Increasing lordotic curve in lumbar spine enhances stretch
Subscapularis (IR) Gravity Stretch
Presents as shoulder IR SD
For left side:
- Lying supine, abduct left arm 90 degrees and ER to restriction
- Inhale deeply and exhale fully for 3-5 seconds
Pectoralis major and minor stretch
Presents as shoulder IR SD
- Stand in doorway and place hands on door frame
- Lean forward at stretch
- Hold stretch for 10-60 seconds
- Vary height of hands to stretch different parts of the muscle
Scapular retraining (targets rhomboids)
Presents as shoulder IR SD
- Lying supine, push elbows posteriorly and squeeze scapular together
*chin tuck may enhance exercise*
Iliopsoas and rectus femoris stretch
Presents as hip flexion SD
For left side:
- Stand in front of a chair
- Place dorsal aspect of left foot on chair, keeping both knees slightly bent
- Push hips forward until stretch is felt
Lower extremity adductor stretch
Presents as hip adduction SD
- With back straight, sit as close to a wall as possible, soles of feet together
- Place hands on floor behind hips and press hands into the floor
- Arch back to initiate stretch
Trendelenburg sign
Patient stands on one leg
- With normal abductor strength, pelvis will stay level
- With abductor weakness, pelvis will tilt toward unsupported side
*picture shows weakness in right abductors*
Clamshell Exercise
Gluteus Medius - Ab/adductor strengthening
For left side:
- From a lateral recumbent position, flex hips to 45 degrees and flex knees to 90 degrees
- Keeping feet together, raise left knee ~6 inches while exhaling
- Return to starting position during inhalation
- Repeat 10-15 times per session
Piriformis stretch
Presents as pain/tenderness in buttock and posterior leg
For left side:
- Lay supine with left hip flexed and adducted and knee flexed. Place left foot lateral to right knee
- Place right hand on lateral aspect of left knee
- With exhalation, apply gentle pressure to pull knee further to right side of body
Quadratus Lumborum stretch
Presents as lumbar sidebending SD/low back pain
For left side:
- Stand with feet roughly shoulder width apart
- Reach right arm down to knee while looking toward the ceiling
- Inhale deeply
- On exhalation, look down and stretch hand further down leg
Stretching guidelines
- Stretch after exercise
- Hold stretch for 10-30 seconds (adults), 30-60 for older adults
- Should be comfortable, not painful
- Breathe freely, do not hold breath
- Do not bounce
- Do not lock joints
- Repeat stretch 2-3 times at least 3 days per week
Exercise guidelines
- Repeat exercise 8-12 times per set
- Perform 1-3 sets at least 3 days per week
- Focus on technique, not on number of repitions
- Prefer 3 times right than 10 times wrong
- Goal is to perform exercise continuously for 3 minutes
Balance training
- Balance on left leg with hands on hips. May hold onto something.
- Slowly reach out with right leg as far as possible without touching the floor
- Repeat with varying directions of right leg
Under what model of Osteopathic Care does OMT fall under?
Biomechanical
Under what model of Osteopathic Care could exercises/stretching fall under?
Behavioral
