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OMM > OMM Fall 2020 HVLA > Flashcards

OMM Fall 2020 HVLA Flashcards

1
Q

Describe the steps involved in the Lumbar roll (L1-L5):

  1. Where is the physician?
  2. Where is the patient?
  3. Where is the hand placement?
A

First, with Patient seated, perform screen and diagnosis of Lumbar area.

  1. Soft tissue
  2. Lie patient w/ good side down (If post. process on L, then patient lies on right side)
  3. Have patient grab your arm - pull them to flatten their back – ME
  4. Place index above dysfunctional segment and middle finger on the dysfunctional process
  5. Straighten patient’s lower leg and flex the upper leg until motion is felt at the restricted segment
  6. Rotate patient until you feel motion ABOVE the segment
  7. Apply traction; HVLA on exhalation
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2
Q

Describe the steps involved in the Lumbar Stroll:

*NOTE: don’t have to check in flexion or extension

A
  1. Patient supine with fingers interlaced at base of neck
  2. Stand at head of table, and grasp under the elbow firmly with hand.
  3. Sidebend the patient TOWARD the dysfunction
  4. Roll patient away from the dysfunction
  5. Support the ASIS during the stroll

ex: If L5 Rotated Right
SB - Right; Stroll Left

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3
Q

Describe the steps involved in Kirksville crunch

How is a flexed function different from an extended dysfunction?

A
  1. The patient lying on back
  2. Stand on OPPOSITE side of dysfunction (If SRL, stand on right side)
  3. Patient crosses arms with DYSFXN side on top
  4. Rotate patient towards you
  5. Place thumb on transverse process of dysfunctional segment
  6. Cradle head, sidebend and rotate
  7. HVLA on breath

Flexed: Stabilize the segment below, thrust above
Extended: Stabilize the segment, thrust below

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4
Q

Describe the steps involved in Texas twist:

Counterclockwise indicates ____ sidebending. Clockwise indicates _____ sidebending.

A
  1. Patient lies on stomach
  2. Place thenar eminence of one hand and hypothenar eminence of other on either side of spinous process. Both hands face in opposite directions
  3. Gently compress downward
  4. Position yourself directly over the restricted segment. Take up the slack (compression and twisting)
  5. HVLA on exhalation

Counterclockwise: Left sidebending (restriction = can’t sidebend left; SB right)

Clockwise: Rt. sidebending (restriction = can’t sidebent right; SB left)

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5
Q

Describe the steps involved in prone rib (1-2).

A
  1. Patient lies prone with head resting on chin, and arms hanging of the side of the table
  2. ID which is the posterior (elevated portion) - at head of table
  3. Sidebend patient’s head AWAY from the raised rib (If post. on the right, SB left)
  4. Rotate patients head TOWARD rib (same side as dysfunction)
  5. Your arms are crossed - 1 hand over rib medial to rib angle, the other hand stabilizes head
  6. HVLA towards rib angle
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6
Q

Describe the steps involved in HVLA of the OA

  1. If the OA does not want to translate to the right? It is Sidebent _____, Rotated _____.

The position of ease is ______.
The barrier is ____.
For OA, Sidebending and rotation are positioned _____ the barrier

A

Sidebent Right, rotated Left

*towards the barrier:

  1. Sidebend Left (ear to chest)
  2. Rotate Right

*flex, physician pivots to side, engage barriers

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7
Q

Describe the steps involved in HVLA of the OA

  1. If the OA does not want to translate to the left, it is Sidebent _____, Rotated _____.

Sidebending and rotation are positioned into the barrier. What is the barrier?

A

SB left, rotated right

  1. SB right
  2. Rotate Left

*flex head, physician pivots to side and engages barrier

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8
Q

Describe the steps involved in HVLA of the AA.

A
  1. Test rotation at 45 degree angle
  2. Rotate patient’s head to restrictive barrier (thumbs on zygomatic arch)
  3. Fine tune to barrier - rotatory impulse
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9
Q

Describe the steps involved in HVLA of the cervicals with rotational emphasis

  1. For rotational emphasis, you take the SB to the position of _____ and the rotation to the _______
A

Sidebend to Ease and Rotation to Barrier

Ex: If FSRL
Tx: SB Left (ear towards chest), Rotate Right

  • thumbs on zygomatic bone
  • flex head, rotate and then sidebend ear to chest
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10
Q

Describe the steps involved in HVLA of the cervicals with translatory emphasis

For translatory emphasis, Sidebending is to the _______ and rotation is to the position of _____

A

Sidebend to barrier and Rotation to Ease

Ex: FSRr
Sidebend: Left
Rotate: Right

  • thumbs on zygomatic bone, Index finger (MCP joint) against restricted segment
  • flex head, rotate and then sidebend ear to chest
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11
Q

What is the direction of impulse for:

  1. OA and upper cervicals?
  2. Middle cervicals?
  3. Lower cervicals?
A
  1. thumb to eyes
  2. middle finger to nose
  3. pinky finger to chin
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12
Q

Describe HVLA for the radial head

  1. If the radial head is held in supination, how do you treat?
  2. If the radial head is pronated, how do you treat?
A
  1. Supinated – Restricted in pronation
    –“Bird beak pose”
    –Flex elbow and pronate wrist towards restrictive barrier
    (thumb monitors radial head or hand blade in antecubital fossa)
  2. Pronated – restricted in supination
    - -put arm in supination – “extend arm” and apply force vector upward
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13
Q

Describe HVLA for anterior fibular head

A
  1. Stand on OPPOSITE side of dysfunction
  2. Place pillow under knee to avoid locking
  3. Grasp foot with caudad hand
  4. PIP - internal rotation, Plantarflex
  5. Place thumb on Fibular head
  6. HVLA
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14
Q

Describe the flow of lymph from the capillaries

A
  1. pre-collector vessels (superficial and deep)
  2. collecting vessels
  3. Lymph nodes and spleen
  4. Rt. lymphatic duct
  5. Thoracic duct into venous circulation
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15
Q

Lymphatics: True/False: Fluid is forced out of the arterial part of the capillary bed when the net hydrostatic pressure is greater than the net osmotic pressure.

It is forced into the venous end of the capillary bed when the net hydrostatic pressure is less than oncotic pressure.

A

True

  • no tight jxns in capillaryies
  • anchoring filaments attach capillaries to fascia (keep capillaries open when interstitial pressure inc.)
  • valves ensure unidirectional flow
  • lymph hearts between valves: cyclically contract - lumph pumps
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16
Q

Lymphatics: Which of the following is correct about lymph fluid?

a. lymph formation creates pressure gradients that drive lymph movement through lymphatic vessels
b. lymphatic vessels drain fluid from the tissue and and continuously provide information about the tissue to the immune system
c. lymph vessels transport microbial antigens, tissue antigens, toxins, cytokines, apoptotic cells from tissue to regional lymph nodes

A

all of the above

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17
Q

Lymphatics: Failure of the lymphatic system has been implicated in the pathogenesisof cardiovascular disease, infection, intestinal disease, autoimmunity, inflammation and edema.

True/False - Interventions that improve lymph flow may relieve edema and treat infection by enhancing the circulation of immune cells, inflammatory mediators and pharmaceuticals

A

True

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18
Q

Lymphatics: Physical therapy has been shown to increase lymph flow in humans and animals. Examples of PT include:

  1. Exercise
  2. Passive limb rotation
  3. Massage/Lymphatic drainage
  4. Pneumatic comparession
  5. OMT

What are examples of osteopathic techniques that were designed to enhance lymph circulation?

A
  1. Lymphatic pump techniques
    - -enhance flow through vessels
    * thoracic, abdominal, splenic, liver, pedal pumps
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19
Q

Lymphatics: Explain the results of the study involving the effects of manually applied intermittent pulsation pressure to rat ventral thorax(s) on lymph tract.

A

*LPT enhanced the uptake of the probe by lymphatic system and its transport from tissue to blood

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20
Q

Lymphatics: Dogs were surgically instrumented to measure thoracic duct lymph flow. Results showed increased lymphatic flow, however, which of the treatments provided the greatest increase in lymphatic flow?

A

The greatest increases were seen during abdominal pump and exercise

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21
Q

Lymphatics: The lymph nodes act as the site of antigen processing. They circulate up to 40x/day.

True/False - It is believed that OMT may redistribute lymph pools, thereby enhancing lymph flow and immune surveillance. LPT helps to mobilize lymph-borne factors and pharmaceuticals (that protect against infectious and inflammatory diseases) into circulation.

A

True

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22
Q

Lymphatics: Who helped quantify the amount of lymph that can be pumped?

A

Norman Gevitz

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23
Q

Lymphatic: In Dr. Hodge’s experiment, lymph flow was measured with their patients (dogs) under anesthesia. They collected the lymph and measured the flow during baseline, during 4 min abdominal LPT and post-LPT. The concentration of protein, leukocytes, cytokines, chemokines, and ROS were measured and comparisons were made between the timepoints.

What was found?

A
  • 1st 4 minutes: baseline steady
  • Within 1 minute LPT: inc. leukocytes, remains elevated through LPT
  • At 8 minutes: LPT was stopped leukocyte concentration returned to baseline

**significant, transient increase in lymph articulation; not significant change in MAP

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24
Q

Lymphatic: During administration of LPT, leukocyte flux was increased in the lymph.

True/False - All cells were increased including B cells with different isotypes (IgA and IgG). After 4 minutes of LPT 10 fold cells were found in the circulation. Furthermore, memory and effector cells were present

A

True

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25
Chronic pain: The biomechanical model involves the musculoskeletal system (postural muscles, spine and extremities). It is responsible for posture and motion of the body in space. In cases of dysfunction, OMM can be used to re-establish normal function. What are examples?
Foot orthotics (improve posture - dropped arches, leg length inequality) *consider meds and surgery as indicated
26
Chronic pain: The respiratory model is associated with the thoracic inlet, thoracic and pelvic diaphragms and the rib cage. It affects mechanics of repiration, circulation and lymphatic drainage. Emphasis is on unimpeded delivery of oxygen and nutrients as well as removal of waste products. If these things do not happen, tissue health will be affected (impact other systems). What are OMT therapies?
- decrease somatic dysfunction in fascia, muscle, tissues associated with respiration, circulation, and lymph * meds/surgery as indicated
27
Chronic pain: The neurological model is associated with the CNS, PNS, ANS and viscerosomatics. It is responsible for the coordincation and integration of body functions as well as maintenance of homeostasis. It also addresses the neurologic aspects of pain. True/False - OMM in this model helps to normalize neural function such as treating a viscerosomatic reflex or treating the OA (incerase PNS and decrease SNS; relaxing).
True *consider meds/surgery as indicated
28
Chronic pain: The metabolic-energetic model is associated with viscera and endocrine glands and diet (processed foods inc. inflammation and pain). It functions in the maintenance of homeostasis (most function = least amount of energy). Omm helps to remove ________ dysfunction that can cause an inefficient use of energy.
removes somatic dysfunction *consider meds/surgery
29
Chronic pain: The behavioral model evaluates mental, emotional and spiritual states and lifestyle choices. True/False - The musculoskeletal system and emotional states can reflect each other. This is where OMM can help.
True *consider patient education/medications
30
Chronic pain: Pain is a complex process that involves afferent input from the body and is modulated through the spinal cord, limbic system and cerebral cortex. True/False - Pain is subjective. It is considered chronic if it lasts longer than 12 weeks. It is possible for patients to consciously affect their experience of pain through the cerebral cortex. If this happens, chronic pain becomes a biopsychosocial problem in addition to physical.
True types: - -acute/chronic - -malignant/non - -nociceptor induced (musculoskeletal/visveral) - -neuropathic, referred or SNS maintained (reflex sympathetic dystrophy, chronic regional pain syndrome
31
Chronic pain: True/False - Different medications target different aspects of pain (NSAIDS target inflammation, gabapentin targets neuropathic pain)
True *see article about chronic pain meds
32
Chronic pain: Regional pain (not in dermatome or other distribution) that is associated with changes in sensation (e.g. allodynia), motor, autonomic (sweating, vasomotor) and/or skin changes. It is most often in the distal limb. It presents as two types.
Chronic regional pain syndrome *imaging/tests not demonstrated to be helpful
33
Chronic pain: Chronic regional pain refers to regional pain with changes in sensation, motor, autonomic, and skin. It occurs in the distal limb. What are the two types of chronic regional pain syndrome?
1. Type I "regional sympathetic dystrophy" - -90% - -no peripheral nerve damage 2. Type II CRPS - -peripheral nerve damage *
34
Chronic pain: True/False: Regional Pain (Chronic regional pain syndrome) is similar to fibromyalgia in that it is thought to be secondary to central sensitization. Initial injury could cause hypersympathetic stimulation and facilitation of the area. It tends to develop 4-6 weeks after the initial injury (fracture, crush, sprain, surgery) and usually requires multidisciplinary team approach to treat successfully.
True
35
Chronic Pain: The most successful approach to treating chronic pain is multi-disciplinary (treat physical symptoms and experience of pain) due to the fact that it has interdependent psychosocial and physical elements. What are the aspects of the biopsychosocial model associated with chronic pain?
1. Psychological - -how patient represents pain to self - -"I am disabled" 2. Social - -how patient presents pain to others OR influences of social cues on a person't behavior - -"other people need to help me" *does patient have secondary gain (attention from others or others doing their chores?
36
Chronic pain: Multi-disciplinary teams can involve physicians (PCP, pain management, psychiatrists), psychologists, PT/OT's, dieticians and medical social workers. There is a wide variety of approaches to the problem which has multiple roots. True/False - Studies have shown this approach leads to decreased experience of pain, decreased functioning, and lower rate of return to work.
False * decreased pain, increased functioning, inc. return to work * psychological effects: decrease catastrophizing, self reported disability and depression
37
Low back pain: Questions that should be asked when a patient presents with low back pain include: 1. Has this happened before? 2. Have you had imaging in the past? 3. Injuries? Car accidents? 4. Surgeries? 5. What does the patient do for work? for fun? What are red flags? a. pain that lasts > 6 weeks b. night pain c. incontinence/urinary retention d. pain that radiates past the knee e. pain worsens with valsalva maneuver
All of the above and: - age <18 or > 50 - major trauma (or minor in elderly) - fever, chills, night sweats, weight loss - immunocompromised - unremitting pain - saddle anesthesia - rapidly progressing neuro deficit - H/o cancer, IVDU, GI or GU surgery
38
Low back pain: A 65 year old patient presents with lower back pain. He states it is not worsened by coughing. Denies worsened pain with forward flexion, extension or rotation. Denies worsening with hyperextension. Admits improvement when supine. You suspect
Facet syndrome * osteoarthritis in lumbar facets (can refer pain - not dermatomal) * joint injections/nerve block to joint space help * at least 5/7 criteria for lumbar facet pain
39
Low back pain: ________ is a stress fracture of the pars interarticularis. It is MC seen in ages < 26 years and in athletes who extend their backs (gymnasts, divers, volleyball). Neuro exam tends to be normal unless it is more than grade II (>50% slippage).
Spondylolisthesis * X-ray in flexion and extension views * Grading 1-V * "stepoff" sometimes palpable (only when grade IV - 3/4 of vertebral body)
40
Low back pain: Spondylolisthesis is graded according to Meyerding's system. It is based upon how much of the upper vertebrae is displaced forward on the lower one. Grading is from I to 5. ``` Grade I = _____ slippage Grade II: 26-50% slippage Grade III: 51-75% slippage Grade IV: 76-100% slippage Grade V: ____ slippage ```
Grade I: 0-25% | Grade V: > 100%
41
Low back pain: A patient presents complaining of low back pain. You note on PE that her trunk is flexed forward with ipsilateral sidbending. What do you suspect? How do you treat?
Unilateral psoas syndrome *uni or bilateral Uni: Forward flexion of trunk; ipsilateral sidebending *Tx flexed upper lumbars, then treat psoas
42
Low back pain: A patient presents complaining of lower back pain. On examination, you note psoas tightness. His ipsilateral side is contracted, while the contralateral side is overstretched. What do you suspect? How do you treat?
Quadratus lumborum syndrome * psoas tightness * parasthesias Treat the attachments of the QL (lumbar vertebrae, iliac crest/pelvis, and rib 12).
43
Low back pain: A patient presents with tightness and aching around L5-S2. He states he has pain that radiates down past his knee (compressed sciatic nerve) resulting in referred pain and parasthesia. You perform a PE and not a tender point in the belly of the piriformis muscle. You suspect
Piriformis syndrome * compress sciatic nerve * tenderpoint/trigger point in the belly of piriformis muscle * associated with muscular imbalance in pelvis
44
Low back pain: A patient presents complaining of pain with walking. Pain is a "cramping pain in the buttocks, thighs and legs" and weakness (neurogenic claudication). She states it improves with forward bending and rest. You decided to perform a bicycle test to differentiate between vascular and neurogenic claudication because you suspect ______
Spinal stenosis * may have vascular and neurogenic at the same time * vascular: walking, doesn't improve w/ forward bending * if secondary to nerve impingement: objective weakness, atrophy and asymmetric weakness
45
Low back pain: A patient presents complaining of pain that radiates from the lower back to the buttocks and the back of her thigh down to her foot (in dermatomal L5 or S1 distribution). You suspect sciatica. What are common causes of sciatica?
- herniated disc in lumbar spine - compressed nerve root from pedicles, discs, ligamentum flavum, facet capsule, faraminal ligaments NOTE: sciatica only develops in 35% of patients with true disk herniation
46
Low back pain: True/False - Radiculopathy is a general term for any referred pain from nerve root irritation
True
47
Low back pain: True/False - If pain is referred in a non-dermatomal patttern, it is more likely referred pain that does not derive from nerve root irritation (i.e. trigger points, ligaments, facet joints) or psychogenic.
True NOTE: sciatica is dermatomal
48
Low back pain: A patient presents complaining of lower back pain. On PE you note: 1. preceding ligament weakness/spinal instability after sudden motion in flexion or extension 2. objective atrophy, muscle weakness and sensation changes 3. pain worsens with sitting and valsalva maneuver
Disc herniation * primary healing complete by 12 weeks * can be confused with facet and SI irritation (both refer pain into the leg; facet can refer pain past knee)
49
Low back pain: List the dermatomes of the deep tendon reflexes most often associated with disc herniations 1. Patellar 2. Achilles 3. Tibialis 4. Flexor hallucis longus
1. Patellar - L4 2. Achilles (ankle jerk) - S1 Muscles: 3. Tibialis anterior - L4-L5 (deep fibular) 4. Flexor hallucis longus - L5 - S2 (anterior tibial)
50
Low back pain: A patient presents complaining of lower back pain, along with referred pain in the groin, SI and lateral thigh. On PE you note restriction in sidebending at the lumbosacral area. What do you suspect?
Iliolumbar ligament * compress L4/L5 nerve roots * referred pain = point tenderness over iliolumbar ligament * inter-transverse ligament of lumbar vertebrae to anterior and post. parts of SI joint * laterally to iliac crest
51
Low back pain: In the case of shortleg syndrome, what should be used for treatment in the case of anatomic accomodation?
1. Anatomic - -heel lift 2. Secondary cause - -OMM and stretching *foot orthotics (combo w/ heel lift may impact functional scoliosis)
52
Low back pain: True/False - To correct postural anormalities such as pes planovalgus (short leg syndrome), you always want to use OMM in conjunction with the heel lift, and orthotics to help the body adjust. It is possible you may not need as much of a heel lift.
True
53
Low back pain: Functional stability is dependent upon 1. Core muscles 2. Low back muscles 3. Lats and glut muscles 4. Ligaments and fascia (biotensegrity) List the muscles
1. Core - -transversus abdominis, rectus abdominis, obliques, iliopsoas - -stabilize spine 2. Low back muscles - -erector spinae, multifidus, quad lumborum 3. Lats and gluts - -stabilize thoracolumbar fascia
54
Low back pain: True/False - Functional stability is based on biotensegrity, a biomechanical explanation for the function integration of musculoskeletal components (e.g. may have low back pain just from fascial tightness).
True
55
Low back pain: True/False - It is important to consider lack of adequate muscle tone as potential causes of back pain in certain situations.
True *muscle slings b/t shoulders/abdomen, hamstrings/glutsn max and thoracolumbar fascia
56
Low back pain: SI joint pain has been controversial due to the fact that the joint itself has limited motion, and that motion is hard to measure. Potential issues of the SI joint include: 1. Joint surfaces and capsules 2. Ligaments spanning joint 3. Muscles in the area Explain the roles in the surfaces/capsules and ligaments
1. Surfaces/capsules - -pain sensitive 2. Ligaments - -complex architecture, proprioception, innervated
57
Low back pain: True/False - The sacrum is stable through "force closure" with ligaments, fascia/muscles and "form closure" from how bones fit together. Ligament laxity in pregnancy has been reported to be associated with the SI joint with 50% demonstrating pain in this region compared to only 1% with true sciatica.
True
58
Innervations: List the innervations of the following muscles 1. Psoas major 2. Piriformis 3. Biceps femoris 4. Tibialis anterior 5. Fibularis longus 6. Gluteus medius
1. Psoas major - -L1-L3 2. Piriformis - -L5-S2 3. Biceps femoris - -L5 - S2 (tibial, long); L5-S2 (common fib, short) 4. Tibialis anterior - -L4-5 (deep fibular) 5. Fibularis longus - -L5-S1 (superficial fib) 6. Gluteus medius - -L4-S1 (superior gluteal)
59
HVLA: Thrust mobilization is a type of direct technique that uses high velocity, low amplitude (HVLA) forces after the restricted segment is positioned agaisnt the restrictive barrier in all planes. True/False - It involves a quick, short thrust with small-moderate amounts of force delivered by the operator in an effort to move the joint through the restrictive barrier and restore normal motion.
True *improved joint motion = quick
60
HVLA: True/False - HVLA is the best known of all manipulative techniques "bone setters" and is considered "passive" because the physician provides the treating force while the patient remains passive.
True
61
HVLA: 1. ____ suggests a moment of force that travels into and through the barrier. It implies a short duration, and is the goal of HVLA. 2. _____ suggests movement with as much force as can be mustered. It is not the motion we want.
1. Impulse 2. thrust - -pop can, egg
62
HVLA: True/False - Indications and uses for HVLA are specific to joint mobilization. Indications include sub-acute and/or chronic articular somatic dysfunction (not for acute injuries).
True
63
HVLA: The goal of manipulation is to restore maximal pain free movement to the musculoskeletal system in postural___1___ Duration of benefit from effective manipulation depends on the identification and correction of the __2___ of the dysfunction.
1. postural balance | 2. origin
64
HVLA: Somatic dysfunctions can be categorized into 1. Limited mechanical stress (yard work, athlete, motor vehicle accidents) 2. Chronic mechanical stress (computes, factory workers, students) 3. Visceral disease (gallbladder, cardiac, COPD) What are consequences of somatic dysfunction?
- dec. mechanical efficiency/inc. joint stress - facilitation of spinal segment - soft tissue contractures (overuse/disuse)
65
HVLA: Forms of manipulation include: 1. Modification of soft tissue restriction by techniques that include direct or indirect stretch, active resistance (muscle energy), Still technique and strain/counterstrain 2. Mobilization of bony restriction by articulation or thrust (HVLA) 3. Normalization of inherent motion (craniosacral mechanism) The type of manipulation is dependent upon examination of the patient. What is a vital aspect of examination for somatic dysfunction?
TART findings 1. Tenderness 2. Asymmetry (anatomic landmarks) 3. Restriction of motion (firm, distinct barrier) 4. Tissue texture changes * all TART NOT created equal * taRt = thrust (inc. motion restriction) * TarT = counterstrain (inc. tenderness, inc. tissue texture)
66
HVLA: What should be performed prior to HVLA?
Soft tissue * dec. hypertonicity * inc. resiliency of tissues around dysfxn * relax/reassure patient * less force needed w/ relaxed muscles/tissues
67
HVLA: Because HVLA techniques function to gap the joint (stuck drawer), the operator must be well versed in the anatomy. True/False - An audible "pop" may coincide with joint gapping, however, production of a pop is NOT the therapeutic goal
True
68
HVLA: The following are the basic principle of HVLA - 1. Accurate diagnosis 2. Choice of vectoring force 3. Engage the restrictive barriers 4. Do NOT back off the stacked barrier before you thrust (balance and control) 5. Apply a very specific HVLA thrust True/False - The restrictive barriers should be engaged in all planes being used to lock out other hoints not being targeted (immoblilize one joint and engage forces to another one). It should be done to avoid overloading the tissues and without causing patient guarding.
True
69
HVLA: The following are the basic principle of HVLA - 1. Accurate diagnosis 2. Choice of vectoring force 3. Engage the restrictive barriers 4. Do NOT back off the stacked barrier before you thrust (balance and control) 5. Apply a very specific HVLA thrust The HVLA thrust should have ___ force, ____ distance, rapid acceleration and short duration without hesitation. It should be precise enough to stop short of the anatomical barrier.
minimal force, short distance, rapid acceleration * without hesitation * speed important! strike fast! (just don't use a big hammer)
70
HVLA: Which of the following is a technique enhancer of HVLA? a. preparation of tissues (soft tissue or muscle energy) b. localizing the restricted segment about the planes involved c. respiratory reflex d. redirection of attention e. mild traction
all of the above * double thrust technique * adjust the Tx to fit the patient and your skill level * post-thrust pause * close contact with patient * attitude for success
71
HVLA: The following are forms of thrust mobilization: 1. Rotational 2. Translatory 3. Distraction When are they commonly used?
1. Rotational (cervical, lumbar) 2. Tranlatory (cervial, thoracic) 3. Distraction (added dimension to all areas)
72
HVLA: 1. ______ lever: when the force vector is applied directly at the bony landmark as the focal point (cervical, ribs, thoracic spine) 2. ____lever: when the force vector is directed from a distance to the dysfunction utilizing traction forces through myofascial components (lumbars)
1. Short lever 2. Long lever *methods of thrust: direct **
73
HVLA: There are several different theories/hypotheses that explain the mechanism of HVLA. Of the following, which is the most current hypoothesis? 1. Thrust forcefully stretches a contracted muscle producing afferent impulses from the muscle spindles to the CNS. CNS reflexively sends inhibitory impulses to the muscle spindle to relax the muscle. 2. The thrust forcefully stretches the contracted muscle pulling on its tendon, activating golgi tendon receptors and reflexively relaxing the muscle. 3. Thrust produces a cavitation effect in the joint. Sudden distraction of joint surfaces produces a nitrogen bubble, along with the noise and increased freedom of motion.
#3 *patient must be assured that the sound is harmless, as well as unnecessary
74
HVLA: Thrust techniques may be modified to accomodate for certain patients. Indications include: 1. pregnancy 2. children 3. guarding 4. pain What are absolute contraindications to HVLA technique?
- joint instability - severe osteoporosis - metastasis in area - osteoarthritis w/ ankylosis - severe discogenic spondylosis w/ ankylosis - osteomyelitis/infection in area - joint replacement - severe herniated disk w/ radiculopathy - congenital (klipperl-feil, chiari) - Down's (cervical) - RA (cervical) - vertebrabasilar insufficiency
75
HVLA: Which of the following is a relative contraindication of HVLA? a. mild/mod strain or sprain b. mild-mod osteoporosis c. osteoarthritis with moderate motion loss d. rheumatoid disease other than in spine
all of the above * minimal disc bulge/herniation * atypical joint/facet conditions * extreme hypermobile states
76
HVLA: Which of the following are amongst the guidelines for safety of HVLA: a. make an accurate diagnosis b. be aware of possible complications c. stop thinking, listen with your hands d. emphasize specificity...not force e. ask permission to treat
all of the above *Somatic dysfunction with joint restriction is an indication for thrust techniques (pain is not!)
77
OPP: Review the 4 tenets of Osteopathic Medicine
1. The body is a unit; the person is a unity of body, mind and spirit 2. The body is capable of self regulation, self-healing and health maintenance 3. Structure and function are reciprocally inter-related 4. Rational treatment is based upon the undertanding of the first 3 principles
78
OPP: Osteopathy is is a philosophy, science and art. 1. Its philosophy embraces the concept of the ____ of body structure and function in health and disease 2. It science includes the chemical, physical and biological sciences related to maintenance of health and prevention, cure and alleviation of disease. 3. Its art is the application of the _____ and _____ in the practice of osteopathic medicine and surgery in all its branches and specialties
1. Unity of body structure | 3. philosophy and science
79
L5 on sacrum: 1. For forward torsions (L on L, R on R) L5 follows what kind of mechanics? 2. For backward torsions (L on R/ R on L) L5 follows what kind of mechanics?
1. 1 letter (R/R or L/L) = Type I L on L = L5 SlRr R on R = L5 SrRl 2. 2 letters = Type II L on R = SrRr
80
L5 on sacrum: 1. For forward torsions (L on L, R on R) L5 follows what kind of mechanics? 2. For backward torsions (L on R/ R on L) L5 follows what kind of mechanics?
1. 1 letter (R/R or L/L) = Type I L on L = L5 SlRr R on R = L5 SrRl 2. 2 letters = Type II L on R = SrRr *direction sacrum rotated/axis
81
LIPLSIP
1. Legs 2. Innominate shears 3. Pubic shears 4. L5 (if not compensated) 5. Sacrum 6. Ilial rotations and flares 7. Psoas (T12 and pelvis must be fxnal first)
82
Sacrum: 1. Inhale - Sacral base ____ 2. Exhale - Sacral base ____ 3. Spinal flexion - Base moves 4. Spinal extension - Base moves
1. Extends 2. Flexes 3. Posterior 4. Anterior Lumbars flex: base flex Lumbars extend: SB extends
83
OPP: The osteopathic paradigm refers to the relationship between Host, Disease and Illness: 1. Healthy host + weak disease = illness 2. Healthy host + pathologic disease = illness 3. Weak host + weak disease = illness 4. Weak host + pathologic disease = illness True/False - The fundamental question associated with this is what factors are playing into this patient's illness and how do we treat the illness?
True
84
OPP: Common modifiable factors of the host include: - nutrition - exercise - exposure to pollutant - stress level - hours of sleep - mood - musculoskeletal dysfunction ** Treating musculoskeletal dysfunction can help to restore the host musculoskeletal and physiological balance through OMT of the thoracic spine, rib cage and diaphragm.
True * decrease work of breathing and improve lymphatics * object of physician is to find health
85
OPP: _____ is a combination of various manual techniques that affect host factors. The goal is to restore normal function to the joints and surrounding soft tissues to help normalize physiology (blood flow, lymphatics, nerve function) as much as possible.
OMM * joint-specific: articulation, HVLA * muscle specific: muscle energy, counterstrain * soft tissue: myofascial
86
OPP: _____ involves the musculoskeletal system (specifically postural muscles, spine and extremities). It is responsible for the posture and motion of the body in space. In the case of dysfunction, OMM can help to re-establish normal function.
Biomechanical *foot orthotics for posture (dropped arches, leg length inequality)
87
OPP: _____ is associated with the thoracic inlet, thoracic and pelvic diaphragms, and rib cage. These affect mechanisms of respiration, circulation and lymphatic drainage. Emphasis is on unimpeded delivery of oxygen and nutrients, and removal of waste products. If this doesn;t occur, tissue health will be affected and other systems (e.g. biomechanical) will be impacted.
Respiratory circulatory * OMM: fascia, muscles, * meds and surgery as indicated
88
OPP: ______ is associated with viscera and endocrine glands, as well as diet (high processed foods inc. systemic inflammation and persistent pain). The function is to maintain homeostasis with emphasis on obtaining the most function for the least amount of energy used.
Metabolic * OMM - remove SD that can cause inefficient use of energy * meds and surgery as indicated
89
OPP: _____ evaluates mental, emotional, and spiritual states and lifestyle choices.
Behavioral * musculoskeletal system and emotional states reflect each other (Omm can help) * patient education, medications
90
OPP: _____ Associated with the CNS, PNS (peripheral), ANS and viscerosomatics. It is responsible for the coordination and integration of body functions, and the maintenance of homeostasis
Neurologic * neurologic aspects of pain * OMM: normalize neural function (treat viscerosomatic reflex or OA -- inc. PNS activity and dec. sympathetic drive) * meds/surgery as needed
91
OPP: _____ refers to intervention before health effects occur through measures such as vaccinations, altering risky behaviors (e.g. poor diet, tobacco use), and banning substances known to be associated with disease or a health condition
Primary prevention
92
OPP: ____ involves screening to ID diseases in the earliest stages, before the onset of signs and symptoms (e.g. mammography and blood pressure testing)
Secondary prevention
93
OPP: ____ involves managing disease post diagnosis to slow or stop diseaase progression through measures such as chemotherapy, rehabilitation, and screening for complications
Tertiary prevention
94
SOAP: Which of the following is amongst the top 5 SOAP note mistakes? a. long chief complaint b. switching subjective vs. objective info c. WNL, intact or normal in review of systems or physical exam d. not documenting vital signs e. documenting specific somatic dysfunction in assessment instead of regions
all of the above
95
SOAP: The _____ portion of the SOAP note contains subjective observations that are verbally expressed by the patient (e.g. information about symptoms)
Subjective * cannot be verified (feelings, pain) * patient feels dizzy, reports falling down stairs
96
SOAP: The ____ portion of the SOAP note contains observation and factors that you can measure, see, hear, feel or smell
Objective * physical exam findings (always include General and any applicable system you examine, OMM*) * heart rate, bleeding
97
SOAP: The ____ portion of the SOAP note contains the diagnosis or condition the patient has including REGIONS of somatic dysfunction
Assessment * at least 2 DD * somatic dysfunction; body regions listed according to CPT code
98
SOAP: The ____ portion of the SOAP note refers to how you are going to address the patient's problems
Plan * follow up * performed OMT
99
SOAP: The patient's opintion, judgement, assumptions, beliefs fall under the
Subjective category *feels, did not want to, does not like, thinks, needs
100
SOAP: Factual content that can be acquired via the 5 senses, or counted and can be verified from multiple reporters falls under the _____ category
Objective *I saw, It sounded like, She was able to do ....
101
SOAP: True/False - The subjective portion of the SOAP note generally contains the patients Chief complaint along with HPI, OPQRST, Past histories, and ROS's
True
102
SOAP: OPQRSTA is often used to obtain information about the patient's current complaint. Another mnemonic is OLDCART. What does this assess?
``` Onset Location Duration Characteristics Aggravating factors Relieving factors Treatments ```
103
SOAP: ROS tips - Do not document within normal limits (WNL), instead state "patient denies having pain, vomiting, etc." Also, keep ROS to pertinent positive or negative. It it requires a sentence, it should be in HPI.
Eyes: denies wearing glasses or contacts. Denies blurred vision. GI: positive for nausea, vomiting, diarrhea.
104
SOAP: Which of the following needs to be included in the objective category? a. Vital signs b. Physical Exam (including TART) c. Diagnostic tests (lab work and Imaging) d. Patient complaint
A - C *MSK: ROM, strength, special tests (Thomas, Trendelenburg) *Neuro: reflexes, sensation *PE: Gen, HEENT, CV, Resp, Abd, Msk, Neuro, OMM Labs: CBC, CMP, etc.
105
SOAP: Components of the assessment include ICD 10 diagnosis (acute vs. chronic; localized vs. radicular; left vs. right; midline vs. bilateral) and Regions of somatic dysfunction. What are the regions?
0. Head/OA 1. Cervical 2. Thoracic 3. Lumbar 4. Sacral 5. Pelvic 6. Lower extremity 7. Upper extremity 8. Ribs 9. Abdomen/Diaphragm
106
SOAP: Components of the Plan include: a. Labs b. Procedures c. Medications d. Education (lifestyle, stretches)
All of the above * OMT - techniques * Follow up
107
SOAP: Remember to keep review of systems brief, bital signs are VITAL, and with regard to OMM documentation, list what should be included in the following parts: 1. Objective 2. Assessment 3. Plan
1. Objective: OMM TART findings and Dx (restriction and tenderness at OA, C3, etc.) 2. Assessment: Regions of somatic dysfunction (somatic dysfunction of Head/OA, cervial, etc.) 3. List OMT techniques performed, education, follow up
108
SOAP: True/False - OMM coding is based off of the number of somatic dysfunction regions (e.g. OA, cervical, thoracic) in the assessment. Each escalating region gets paid more. Regions are coded as: 1-2, 3-4, 5-6, 7-8, 9-10.
True
109
Glossary: _____ describes the sound made when cavitation occurs in a joint
articulatory pop
110
Glossary: _____ describes the formation of small vapor and gas bubbles within fluid caused by local reduction in pressure. This phenomenon is beliebed to produce an audible "pop" in certain forms of OMT
Cavitation
111
Glossary: _____ is an osteopathic technique employing a rapid, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint, and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Also known as thrust technique
HVLA
112
Glossary: _____ Any of a group of somatic dysfunctions involving the sacrum. These may be the result of restriction of normal physiologic motion or trauma to the sacrum
somatic dysfunctions of the sacrum
113
Glossary: _____ a positional term based on the Strachan model referring to a sacral somatic dysfunction in which the sacral base has rotated anterior and sidebent to the side opposite the rotation. The upper limb of the SI joint has restricted motion and is named for the side on which foward rotation had occurred. Tissue texture changes are found at the deep sulcus. L5 not described.
Anterior sacrum
114
Glossary: _____ a sacral somatic dysfunction in which the entire sacrum has moved anteriorly between the ilia. Anterior motion is freer and the posterior motion is restricted
Anterior translated sacrum
115
Glossary: _____ a physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis rotates posteriorly. L5 rotates in the direction opposite to the rotation of the sacral base. 2. Referred to as non-neutral sacral somatic dysfunctions (Archaic use). 3. A term by Fred Mitchell, Sr., DO, that describes the backward torsion as being non-physiologic in terms of the walking cycle.
backward torsion
116
Glossary: _____ 1. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved posteriorly relative to the pelvic bones. Backward movement of the sacral base is freer, forward movement is restricted and both sulci are shallow. 2. The reverse of bilateral sacral flexion.
Bilateral sacral extension (sacral base posterior)
117
Glossary: _____ 1. A sacral somatic dysfunction that involves rotation of the sacrum about a middle transverse axis such that the sacral base has moved anteriorly between the pelvic bones. Forward movement of the sacral base is freer, backward movement is restricted and both sulci are deep. 2. The reverse of bilateral sacral extension.
Bilateral sacral flexion (sacral base anterior)
118
Glossary: ____ 1. A physiologic rotation of the sacrum around an oblique axis such that the side of the sacral base contralateral to the named axis glides anteriorly and produces a deep sulcus. L5 rotates in the direction opposite to the rotation of the sacral base. 2. Referred to as neutral sacral somatic dysfunctions (Archaic use). 3. A group of somatic dysfunctions described by Fred Mitchell, Sr., DO, based on the motion cycle of walking.
Forward torsion
119
Glossary: _____ A positional term based on the Strachan model referring to a sacral somatic dysfunction in which the sacral base has rotated posterior and sidebent to the side opposite to the rotation. The dysfunction is named for the side on which the posterior rotation occurs. The tissue texture changes are found at the lower pole on the side of rotation.
Posterior sacrum
120
Glossary: ____ describes a sacral somatic dysfunction in which the entire sacrum has moved posteriorly (backward) between the ilia. Posterior motion is freer, and anterior motion is restricted.
Posterior translated sacrum
121
Glossary: ____ refers to a right rotation about a right oblique axis.
right on right (forward) torsion
122
Glossary: ____ Stroking movement used to move fluids.
Effleurage
123
Glossary: ___ Any recoverable deformation.
elastic deformation
124
Glossary: ____ Ability of a strained body or tissue to recover its original shape after deformation.
Elasticity
125
Glossary: ____ every change in form and function of a bone, or in its function alone, is followed by certain definite changes in its internal architecture, and secondary alterations in its external conformations (Stedman’s, 25th ed.); (e.g., bone is laid down along lines of stress).
Wolff Law
126
Glossary: During the loading and unloading of connective tissue, the restoration of the final length of the tissue occurs at a rate and to an extent less than during deformation (loading). These differences represent energy loss in the connective tissue system. This difference in viscoelastic behavior (and energy loss) is known as _______ (or “stress-strain”).
Hysteresis
127
Glossary: ___ a manual technique involving constant feedback to the osteopathic practitioner who is passively moving a portion of the patient’s body in response to the sensation of movement. Its forces are localized using the sensations of ease and bind over wider regions.
Fascial unwinding
128
Glossary: ___ an indirect treatment approach that involves finding the dynamic balance point and one of the following: applying an indirect guiding force, holding the position or adding compression to exaggerate position and allow for spontaneous readjustment. The osteopathic practitioner guides the manipulative procedure while the dysfunctional area is being palpated in order to obtain a continuous feedback of the physiologic response to induced motion. The osteopathic practitioner guides the dysfunctional part so as to create a decreasing sense of tissue resistance (increased compliance).
Functional method
129
Glossary: ___ a treatment system in which combined procedures are designed to stretch and reflexly release patterned soft tissue and joint-related restrictions. Both direct and indirect methods are used interactively.
integrated neuromusculoskeletal release (INR),
130
Glossary: ____ 1. A manipulative technique in which the goal of treatment is to balance the tension in opposing ligaments where there is abnormal tension present. 2. A set of myofascial release techniques described by Howard Lippincott, DO, and Rebecca Lippincott, DO.
Ligamentous articular strain technique
131
Glossary: ____ a system of diagnosis and treatment first described by Andrew Taylor Still and his early students, which engages continual palpatory feedback to achieve release of myofascial tissues.
Myofascial release
132
Glossary: ____ a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs.
direct MFR
133
Glossary: ____ the dysfunctional tissues are guided along the path of least resistance until free movement is achieved.
Indirect MFR
134
Glossary: Deep kneading or squeezing action to express swelling.
petrissage
135
Glossary: A non-recoverable deformation.
plastic deformation
136
Glossary: ___ a direct segmental technique in which a combination of leverage, patient ventilatory movements and a fulcrum are used to achieve mobilization of the dysfunctional segment. May be combined with springing or thrust technique.
positional technique
137
Glossary: 1. A system of diagnosis and treatment in which the osteopathic practitioner locates two related points and sequentially applies inhibitory pressure along a series of related points. 2. Developed by Dennis Dowling, DO.
progressive inhibition of neuromuscular structures (PINS)
138
LPT: True/False - LPT was shown to increase the lymphatic flux of protein, inflammatory mediators (i.e. cytokines), and reactive oxygen and nitrogen species.
True | Cytokines: pre-formed (IL-6, 8, 10, MCP-1, KC from ISF into lymph and into circulation)
139
LPT: abdominal lymphatic pump technique (LPT) was found to facilitate the release of immune cells and inflammatory cells into the thoracic duct lymph. When assessed whether or not LPT stimulates mesenteric lymphatics, what was found?
Compression directly on the abdomen can directly increase intestinal lymph flow * inc. leukocytes in 1st 2 min compared to baseline * transient inc.
140
LPT: According to Earl Miller, D.O., who developed the thoracic pump technique in 1920, “The normal circulation of body fluids is absolutely essential to normal activities of body function.” True/False - Consistent with Dr. Miller’s philosophy, by enhancing TDL flow, LPT may redistribute a large pool of lymph into circulation. Once in circulation, this LPT-mobilized lymph may protect against disease by: 1) removing inflammatory mediators from diseased tissue, or 2) transporting lymph that is biologically active to sites of infection and/or inflammation
True *He developed the thoracic pump technique in 1920 to relieve venous and lymphatic stasis and restore normal circulation
141
LPT: "We strike at the source of life and death when we got to the lymphatics". The previous quote is from: a. A.T. Still b. Earl Miller c. Charlotte Bronte
A.T. Still * infectious disease was common cause of death in his time * vaccination/antibiotics was underdeveloped
142
LPT: Famous 1920 JAOA article by R. Kendrick Smith, MD, DO, reported the success of the osteopathic approach to the influenza pandemic of 1918. True/False - This effort culminated in 2445 osteopaths responding in treating 110,122 patients with influenza, with a resulting mortality of 0.25%.
True *virology was infancy -- H. influenza was etiological agent
143
LPT: Which of the following is evidence for the use of OMT to enhance immunity and protect against pneumonia? a. OMT improved sputum production and shortened cough duration b. OMT decreased length of hospital stay and need for antibiotics in elderly with pneumonia c. OMT increased blood leukocyte numbers d. OMT enhanced vaccine specific antibodies (Hep. B and pneumococcal pneumonia)
All * OMT induced early plasma cytokine release/mobilization of population of blood dendritic cells * these results suggest LPT can enhance immune system and protect against pneumonia
144
LPT: LPT was then studied in rat models. Why were rates chosen? a. Larger than mice and easier to perform pump b. Infectious disease models c. Reagents available
All of the above
145
LPT: What were the important results of the rat study?
1. small animal model effect of LPT on lymph output 2. results similar to dog model *likely that human models will also benefit
146
LPT: With regard to the effects of LPT on pneumonia, the hypothesis was that LPT redistributes lymph-borne factors to the lung and provides additional protection against pneumonia. Which of the following is evidence in support of this? a. OMT dec. length of hospital stay and antibiotic use in elderly b. lymph augments lung inflammation c. LPT mobilized bioactive lymph into circulation
all of the aboveall of the above
147
LPT: What is the MC cause of community-acquired pneumonia?
S. pneumonia * inc. drug resistance * need to ID mechanism of protection by LPT (enhance delivery of antibiotics or boost innate immunity)
148
LPT: To determine if LPT can protect against pneumonia, rates were infected with strep pneumonia and separated into 3 test groups: 1. Control (no treatment or anasthesia) 2. Sham (light touch under anesthesia) 3. LPT (under anesthesia) The lungs and spleen were collected and analyzed for bacteria. What was found?
reduced in LPT rats (after 3 consecutive days of Tx w/ 4 min of LPT)
149
LPT: The next step was to test LPT as adjunctive therapy with antibiotics. 1. Control (PBS or Levofloxacin) 2. Sham (PBS, Levofloxacin) 3. LPT (PBS or Levo) What were the results?
LPT enhances the effect of antibiotics *combo Levo + LPT = inc. disease free at 96 hrs.
150
LPT: The abdominal lymphatic pump treatment was found to increase lymphatic flow, leukocyte concentration and flux of inflammatory mediators. It may provide protection during pneumonia by: a. reducing bacterial load on the lung b. facilitate the delivery of antibiotic to lung c. redistribute pools of protective lymph to the lung
All of the above future studies: - quantify pressure needed to inc. lymph output - inc. lymph flow affect inflammatory disease and edema - ID physiological effect of other forms of OMT
151
Ped Ortho: List the common locations of osteochondrosis 1. Osgood Schlatter 2. Singing-Larsen and Johansson disease 3. Legg-Calve Perthes disease 4. Sever disease 5. Little league shoulder
1. Tibial tubercle apophysis 2. Inferior pole of patella 3. Femoral head epiphyses 4. Calcaneal apophysis 5. Meidal epicondyle
152
Ped ortho: Developmental dysplasia of the hip refers to deficient development of the hip joint. Affected hips are typically unstable on PE in the newborn period, which is why all children should receive evals of their hips at each well child check. Children with mild dysplasia may have subtle radiographic findings. What are these findings? What are clinical findings?
Radiographic: 1. flattening of acetabulum 2. normal hips 3. subluxation/dislocation (if severe) Clinical: - -unilateral toe-walking gait (limited hip ROM) - -Galeazzi sign (asymmetric knee height; shorter on dislocated side) when pelvis is level on flat surface
153
Ped ortho: What are risk factors for the development of hip dysplasia?
- female gender - family Hx - breech presentation - oligohydramnios
154
Ped ortho: The following maneuvers may be used to determine if hip dysplasia is present 1. _______: performed with the patient's knees and hips flexed. The finger is on the greater trochanter, with the thumb on the knee. 2. ____: is the sign of the ball of the femoral head moving in and out of the acetabulum.
1. Barlow | 2. Ortolani
155
Ped ortho: What is the preferred imaging method to evaluate hip dysplasia in a child younger than 5-6 months? in a child older than 6 months?
1. < 5-6 mos - -Ultrasonography * false positive before 6 weeks 2. Radiographic evaluation - -ossification of femoral head
156
Ped ortho: Ultrasound landmarks for developmental hip dysplasia include Graf's classification (appearances of the bony acetabular modelling, bony rim, and cartilage roof triangle). What would you expect in a normal, Type I?
- good bony modelling - -sharp bony rim - narrow covering cartilage roof triangle
157
Ped ortho: Children who exhibit findings or increased risk factors for developmental hip dysplasia (w/ normal exam findings) should undergo imaging (US; 3-4 weeks or plain radiograph 4-5 months). True/False - based on strong research evidence, infants who manifest adventitial hip clicks do not require further imaging or referral to an orthopedic surgeon. They can go immediately to surgery.
True
158
Ped ortho: True/False - Children who have unstable hips on clinical exam should be referred to an orthopedist for treatment. Furthermore, if there are abnormal findings on radiographic eval (ultrasonography or plain radiograph), child should be referred to an orthopedist for eval and determination of appropriate management.
True
159
Ped ortho: Explain recommended treatment for hip disolocation in the following ages: 1. < 6 months 2. 6-18 months 3. > 12-28 months
1. < 6 mos - -abduction orthosis - -Pavlik harness (flex, abduct) 2. 6-18mo - -closed reduction (general anesthesia; hip spica cast) - -at 6 mos if orthosis fails 3. > 12-18 mos - -open hip reduction - -< 1/y if previous closed reduction
160
Ped ortho: Growth of the proximal femur occurs at the physis (growth plate). From infancy to maturity, there are significant developmental changes occuring in the proximal femur including: decreased cartilage thickness and vascularity, increased size of the bony epiphysis, and decreased growth potential. True/False - In Legg-Calve Perthes Disease, growth is arrested bone resorption occurs at the femoral head. What is the cause?
idiopathic ischemic necrosis of the capital (femoral head) epiphyses * disrupted blood supply (unknown cause) * otherwise healthy kids * weak, flattened, re-ossified, growth resumption
161
Ped ortho: A 5 year old female presents with a painless limp. Her mother states she has had the limp for a few weeks. She states she cries a lot due to suspected hip pain. On PE you note limited hip abduction and internal rotation when the hip is extended. Shortened extremity, and weak quadriceps and hip abductors (suspected muscle atrophy). What do you suspect? What is the next step?
LCPD (Legg-Calve) * 4-8y/o (maybe 18 mos) * MC females * unilat. or bilat. * shortened w/ unilat * hip pain, knee pain, thigh, buttock Evaluation: 1. H and P (famn Hx, meds) 2. Radiograph (pelvis, hips) 3. MRI
162
Ped ortho: A 5 year old female presents with a painless limp. Her mother states she has had the limp for a few weeks. She states she cries a lot due to suspected hip pain. On PE you note limited hip abduction and internal rotation when the hip is extended. Shortened extremity, and weak quadriceps and hip abductors (suspected muscle atrophy). What do you suspect? What is the next step?
LCPD (Legg-Calve) * 4-8y/o (maybe 18 mos) * MC males * unilat. or bilat. (10-15%) * shortened w/ unilat * hip pain, groin, knee pain, thigh, buttock Evaluation: 1. H and P (famn Hx, meds) 2. Radiograph (pelvis, hips) 3. MRI
163
Ped ortho: The following describes what classification of Legg-Calve Perthes Disease? Only anterior part of epiphysis is involved without collapse and sequestrum formation
Catterall group 1
164
Ped ortho: The following describes what classification of Legg-Calve Perthes Disease? -More anterior part of epiphysis involvement with collapse of the segment. The sequestrum appears as a dense oval mass with viable fragments on both medial and lateral sides.
Catterall group 2
165
Ped ortho: The following describes what classification of Legg-Calve Perthes Disease? -Only small part of epiphyses is not sequestrated. Central sequestrum collapse is great; lateral fragment is small and osteoporotic. Only a small portion of the posterior part is not involved.
Catterall group 3
166
Ped ortho: The following describes what classification of Legg-Calve Perthes Disease? AP and lateral view of the right hip showed that the whole epiphyses is sequestrated.
Catterall group 4
167
Ped ortho: Lateral pillar classification for Legg-Calve Perthes: 1. No involvement of the lateral pillar 2. More than 50% of the lateral pillar height is maintained 3. Less than 50% of the lateral pillar height is maintained
See Images (Anki)
168
Ped ortho: LCPD is a diagnosis of exclusion. Other diseases causing osteonecrosis of the femoral head (e.g. sickle cell disease, lupus, chemotherapy, chronic steroid use) must first be ruled out. True/False - Radiographic mimickers include multiple epiphyseal and Gaucher's disease, which typically affect bilateral hips.
True
169
Ped ortho: Treatment for LCPD involves early referral to the pediatric orthopedist when there is suspicion of LCPD. There is currently no cure for LCPD, thus, goals for treatment are to maintain a round femoral head and reduced hip, prevent/delay eventual arthritis, and preserve motion. How do we treat early disease? When is surgery used?
1. Early - -non-operative - -NSAIDS, protect weight bearing, limit physical activity, physical therapy for ROM 2. Surgery - -unresponsive to non-operative therapies - -contain ball within or deeper within the socket
170
Ped ortho: True/False - Children with Legg-Calve Perthes disease generally present with chronic limp and may have activity related pain. Pain or decreased ROM with hip internal rotation/abduction generaly indicates intra-articular hip pathology.
True * + trendelenburg gait * dec. hip motion (abduction, internal rotation)
171
Ped ortho: Slipped capital femoral epiphyses (SCFE) is the MC hip pathology affecting adolescents. It is caused by weakness in the physis (growth plate), allowing femoral neck to move anterior to (in front of) the femoral head. Up to 20% of diagnoses are delayed. What are risk factors for developing SCFE? In what population is it most common?
* onset: ~12.7 y/o * MC males * RF's: obesity **, metabolic (hypothyroidism), kidney disease * can have major short- and long- term consequences
172
Ped ortho: An 11 year old obese male presents to the clinic complaining of hip/groin pain. He admits to a painful limp. Reluctant to bear weight on the involved leg. States discomfort decreases when supine. You note on PE unilateral obligatory external rotation with passive hip flexion. You suspect
SCFE * hip/groin * acute or chronic (related to low energy trauma) * limited hip ROM (obligate ext. rotation w/ passive flexion) * stable = CAN bear weight * unstable = CANNOT bear weight * onset: 8 weeks
173
Ped ortho: An 11 year old obese male presents to the clinic complaining of hip/groin pain. He admits to a painful limp. Reluctant to bear weight on the involved leg. States discomfort decreases when supine. You note on PE unilateral obligatory external rotation with passive hip flexion. Imaging reveals right femoral head displaced medially from femoral neck. You suspect
SCFE * hip/groin * acute or chronic (related to low energy trauma) * limited hip ROM (obligate ext. rotation w/ passive flexion) * stable = CAN bear weight * unstable = CANNOT bear weight * onset: 8 weeks
174
Ped ortho: During evaluation for SCFE, a detailed hisotry and physical is extremely important. Pay attention to metabolic disorders. k Radiographs of the pelvis and hips should be taken as well as Labs. Explain what/how imaging should be done. What labs should be ordered. When is it appropriate to use an MRI?
Radiograph: - -AP pelvis w/ bilateral frog leg laterals (hips flexed and abducted) - -Klein's line - -single hip NOT adequate MRI: --only if X-ray is negative and high suspicion Labs: --BMP, TSH (<10y/o, weight <50th percentile, or suspected endocrine abnormalities)
175
Ped ortho: True/False - In SCFE hip pathology can present as pain referred to the knee. Obligate external hip rotation is a classic finding and can present as an out-toed gait. 30% of patients with SCFE are NOT overweight.
True * suspect SCFE, should NOT bear weight on affected extremity * refer for urgent eval!
176
Ped ortho: SCFE patients should be referred early to pediatric orthopedics when there is suspicion for SCFE. The goal for treatment is the prevention of worsening slippage, thus preventing downstream effects (osteoarthritis and avascular necrosis). Treatment is typically ______
operative *stabilize femoral head
177
Ped ortho: A 13 y/o female presents to the clinic complaining of gradual onset of pain with activity (running, jumping). She plays basketball at her local high school. On PE you note localized swelling in the region of the tibial tubercle. Tenderness on palpation and prominent tibial tuberosity. Pain with extension of the knee against resistance. Radiographic findings demonstrate a sliver of new bone formation at the tibial tubercle and fragmentation. You suspect
Osgood-Schlatter * apophysitis of tibial tuberosity * female (10-13) * male (12-15) * athletes * can be bilateral
178
Ped ortho: A 13 y/o female presents to the clinic complaining of gradual onset of pain with activity (running, jumping). She plays basketball at her local high school. On PE you note localized swelling in the region of the tibial tubercle. Tenderness on palpation and prominent tibial tuberosity. Pain with extension of the knee against resistance. Radiographic findings demonstrate a sliver of new bone formation at the tibial tubercle and fragmentation. You diagnose Osgood Schlatter. How would you treat?
1. Rest - -mild pain - some sport - -severe pain or limp - refrain from activity 2. Patellar strap - -dec. tension from patellar tendon - -dec. pain 3. Stretching/strengthening exercises * no long term sequelae normally (some have persistent bony prominence at site)
179
Ped ortho: Growth of the elbow is complex and involves 6 auxiliary ossification centers developing over a period of years. The capitellar apophysis (elbow) begins to ossify at age 1-2 years, and subsequent center appear every 2 years following. Fusion should be complete by 14-16 yeras of age (faster in girls). True/False - Because they have not fused in the young athlete, they are susceptible to the forces involve in overhead sports, especially throwing.
True * overuse = greatest immpact * best predictors of elbow pain = # pitches in a season
180
Ped ortho: Medial apophysitis (little league elbow) can be diagnosed clinically. Radiographs may show _____ of the medial epicondyle epiphysis. Some children may have an avulsion of a piece of the medial epicondyle epiphyses.
widening of medial epicondyle epiphyses *contralateral radiographs may help for comparison
181
Ped ortho: The primary treatment for medial apophysitis is rest for 4-6 weeks OR until the patient is asymptomatic. Ice can be applied for swelling, and oral analgesics for pain are adjuvant treatments. If there is a flexion contracture, what must be given?
Elbow extenion brace * athlete can continue general conditioning during rest period (core and shoulder strenthening) * pain gone = inc. throwing incrementally; supervised * most return by 12 weeks after Tx
182
Ped ortho: The differential diagnosis of postural kyphosis includes 1. Scheurman disease (pre-pubertal) 2. Congenital kyphosis Scheurman typically affects the _____ spine, causing excessive thoracic kyphosis that becomes apparent during the pre-pubertal growth spurt. Over 1/2 of children with kyphosis will have some back pain before reaching skeletal maturity
thoracic spine * 1/3 associated scoliosis (mild) * sharp angulation of the spine when bending forward (does not correct w/ hyperextension)
183
Ped ortho: You perform a physical exam on a 9 year old male. You note excessive thoracic kyphosis with sharp angulation of the spine when bending forward. It does not correct with hyperextension. On imaging you note vertebral end plate abnormalities and anterior wedging of >3 consecutive vertebrae. You suspect
Scheurman disease Tx: - -mild: observation (imaging ever 6mos until SK maturity; look for progression) - -PT (dec. back pain) - -brace (controversial; moderate to severe) - -spinal fusion (severe, symptomatic, progressive)
184
Rheumatology: A reumatologist is an internist or pediatrician who studies
musculoskeletal disaese and systemic autoimmune conditions (rheumatic diseases) Tx: - -inflamm. arthritis (psoriatiic, ankylosing spondylitis,) - -inlammatory myositis - -CT disorders (lupus, sjogren) - -Vasculitis - -other (sarcoidosis, uveitis)
185
Rheumatology: ____ an immune response directed against an antigen normally present within the body or host. It involves the immune response to an altered self antigen (T-cells/B-cells)
Autoimmunity
186
Rheumatology: True/False - naturally occurring autoantibodies are common in all immune-competent individuals. The presents of an autoantibody does not itself diagnose an autoimmune condition. They are often present for years prior to clinical presentation of autoimmune disease.
True *genetics, transfer (placental), hormones, infection
187
Rheumatology: describes calor (heat), dolor (pain), rubor (redness) and tumor (swelling)
Inflammation
188
Rheumatology: ____ disease has a primary target and secondary targets
Systemic
189
Rheumatology: THings to consider when examining a patient include: 1. Articular/non-articular 2. Inflammed or non-inflamted 3. Acute/Chronic 4. Monoarticular vs. oligo or poly 5. Symmetrical/asymmetrical 6. Duration of morning stiffness (inflamm.) 7. Symptoms impreove with rest (osteoarthritis) or with activity (RA) 8. Pattern of joint involvement
Know these
190
Rheumatology: _______ affects the weight bearing joints 1. knee 2. hip 3. PIP/DIP 4. 1st CMC 5. 1st MTP 6. C-spine 7. L-spine
Osteoarthritis
191
Rheumatology: _____ affects the small joints and spares the distal joints 1. MCP/PIP 2. MTP 3. Carpals 4. Elbow 5. Ankle 6. Knee 7. Shoulder 8. Hip 9. C1-C2
Rheumatoid arthritis
192
Rheumatology: A 45 year-old-female presents with a 10 year history of discoloration of her hands with cold exposure, which is now occurring in her feet. She reports worsening fatigue and was recently found to have a +ANA 1:1280 centromere pattern (normal: <1:80). She denies any other medical history, but does take her husband’s omeprazole everyday for symptoms of GERD. She also has required esophageal dilation twice in the past due to dysphagia. What’s the most likely diagnosis?
Systemic sclerosis (scleroderma) Associated symptoms: Limited vs. diffuse - calcinosis cutis - reynaud - esophageal dysfx (GERD) - sclerodactyly (tightened skin/fingers) - telangiectasis - insomnia
193
Rheumatology: What are common labs seen in systemic sclerosis?
Proteinuria Inc. Creatinine GERD symptoms
194
Rheumatology: A 28-year-old female presents with a 4 month history of worsening fatigue, joint pain and photosensitive skin rashes. She has a +ANA 1:1280 (normal: <1:80) and +Sm and +dsDNA antibodies. Labs reveal: proteinuria, hematuria, dec. WBC and ANA + What is the most likely diagnosis?
Lupus associated: - malar rash, reticular rash - oral ulcers - HA, fever - photosensitivity - arthralgia
195
A 40-year-old female presents with a 4 week history of worsening weakness in her arms and legs. She has difficulty arising from a chair without assistance. She takes no medications and denies any PMH. She has noticed photosensitive rashes on her face and hands. Her CPK is 14,000 U/L (normal: 25-300 U/L) with an ESR of 94 mm/hr (normal: 0-15 mm/hr). Labs: Inc. ESR and Aldolase What is the most likely diagnosis?
Dermatomyositis Associated: - periorbital edema - dysphagia - photosensitivity - proximal muscle weakness, myaligia - violaceous papules - calcinosis cutis - nail fold telangiectasia
196
54 year-old-male presents with joint pain and swelling in his hands and right knee. He also reports a history of iritis, a rash and problems with his nails. What is the most likely diagnosis?
Psoriatic arthritis associated: - oncycholysis with DIP arthritis - pencil in cup erosion - psoriasis - sausage toe
197
A 24 year-old-female presents with a 4 week history of joint pain in her feet and hands. She has difficulty getting out of bed in the morning and dressing herself. She is found to have a high titer anti-CCP antibody. Labs: + RF and Inc. ESR What is the diagnosis?
Rheumatoid arthrisis Associated: - -symmetric polyarthralgia - joint stiffness - synovitis - rheumatoid nodule
198
A 62-year-old female presents with worsening joint pain in her hands involving her PIPs, DIPs and thumbs bilaterally. She reports decreased grip strength and is taking meloxicam frequently. She also reports that her rings no longer fit. She denies any redness or warmth of her joints. She underwent a right total knee replacement 2 years previously. What is the most likely diagnosis?
Osteoarthritis * short term stiffness * pain weight bearing (hands, hips, knees, low back) Associated: - -polyarthralgia - bone pain - joint stiffness - low back and hip pain, knee pain
199
Rheumatic disorders are typically treated with medication (NSAIDS, DMARD's, Biologics and Corticosteroids). They may also involve surgery and non-medical approaches (diet, exercise, OMM). What OMM exercises may be used?
1. Soft tissue - -Tx neurovascular (muscular and fascial structures of joint) 2. Muscle energy - -improve restricted ROM in joints - -stretch tight muscles 3. Myofascial release - -Tx fascial/muscular tenion in joint - -improve ROM, stabilize posture/gait 4. Counterstrain - -Rheumatic disease
200
Rheumatic: HVLA can be used as a treatment for some rheumatologic disorders to improve biomechanical function and range of motion. When is it contraindicated?
**Cx: osteoporosis, frozen joints, unstable (cervical spine/C1-C2 in RA or spine in SNSA) * joint effusions * ankylosing spondylitis
201
Spinal mech: 1. When the spine is in neutral, SB to one side occurs with rotation to the ______ side 2. WHen the spine is extended, SB to one side occurs with rotation to the _____ side
1. opposite side - -groups > 2 segments 2. same side - -one vertebral segment restricted in motion - -facets control motion - -short segmental muscles (rotatores, mutifidi, transversarri) - -trauma/overuse *induce motion in one plane = restrict in other 2 planes
202
Spinal mech: Flexed dysfunction causes SB and rotation ____ from open side
Away *normal side closes, dysfunctional facet stays open
203
Spinal mech: Ext. dysfunction the facet on one side is held closed (in the extended position). Extension looks normal, but flexion reveals asymmetry. SB and rotation occur ____ the closed side.
toward Flexed: rotated Away Extended: rotated Toward
204
Spinal mechanics: True/False - Type I involves several vertebrae (long restrictors) including erector spinae and quadratus lumborum
True
205
Spinal mechanics: With active motion testing of the OA, the patient nods forward and the chin deviates to the right. When the patient tips the head back, the chin stays in the midline. What is the diagnosis?
OA ESlRr * chin toward right = right rotation * midline = normal on extension * Type I mechanics
206
Spinal mechanics: With the diagnosis of the AA rotated left, the spinous process of C1 is shifted toward the
Right
207
Spinal mechanics: OA motion has _____ flexion/extension, ____ rotation/sidebending, and is primarily a nodding joint.
10-15 flex/ext. 8 degrees rot/SB Flex: post. glide on condyles Ext: ant. glide
208
Spinal mechanics: If the AA rotates more easily to the right than the left then it is
AA rotated right
209
Spinal mechanics: Standard muscle energy you diagnose somatic dysfunction, place the segment INTO the barrier, and the patient pushes AWAY from the barrier toward neutral. In reciprobal inhibition, the segment is placed into the barrier and the patient pushes ______ the barrier
INTO the barrier agonist contracts - antagonist should relax *large muscles

OMM (11 decks)

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