OSM III Midterm Flashcards
What are enthesopathies and what is a common example?
- weakness of attachment point of tendon or ligament to bone (heals in 8 wks)
ex: plantar fasciitis heel pain
What are 4 common Muscular (also Tendinous) causes of Neck Pain? (S/LC/SC/LS)
Scalene, Longus Coli, Splenius Capitis, and Levator Scapulae SD
What are common neurological causes of Neck Pain?
- Scalene and Pec Minor can compress the Brachial Plexus
- Facet or disc damage
What are release enhancing maneuvers and integrated neuromuscular release maneuvers that can be added to Myofascial Release?
REM: breathing
NRM: activating related muscles to more quickly/effectively release myofascial restrictions
- becomes ACTIVE if this is added
What is the most common type of Muscle Energy Technique?
post-isometric relaxation
- only technique that requires ACTIVE force (pt. is actively moving)
What must you ALWAYS remember to do when using Facilitated Positional Release techniques?
FLATTEN THE CURVE!!!
- flatten curve and add compression, THEN place in indirect position and hold for 5 seconds before release
How are Still’s Techniques executed?
- place pt. in indirect position, THEN add COMPRESSION (5 lbs) or traction, and move them THROUGH the restrictive barrier to the physiological barrier
What are two major contraindications for HVLA that ONLY apply to CERVICAL HVLA?
Rheumatoid Arthritis and Down’s Syndrome
- due to Alar ligament that surrounds the dens of C2
How does the OA like to move?
How does the AA like to move?
How do C2-7 like to move?
OA: check flexion/extension
-sidebending and rotation are in OPPOSITE direction
AA: ONLY ROTATION
C2-7: check flexion/extension
- sidebending and rotation are in SAME direction
How does a Type 1 Thoracic Mechanic differ from a Type 2 Thoracic Mechanic?
Type 1: TONGO
- NEUTRAL, group, opposite directions (ex: RR/SL)
Type 2: single segment, either FLEXED or EXTENDED
- sidebend and rotate in the SAME direction
What are the Thoracic Rule of 3’s?
T1-3 : spinous/transverse processes at SAME LEVEL
T4-6: spinous process 1/2 segment BELOW transverse
T7-9: spinous process FULL segment below transverse
T10: spinous FULL segment below transverse
T11: spinous 1/2 segment below transverse
T12: spinous and transverse process at SAME LEVEL
What are the 5 structures used to diagnose innominate dysfunction and what are the two motion tests utilized?
structures: ASIS, PSIS, Iliac Crest, pubic bone, medial malleolus
motion tests: ASIS compression and STANDING forward bending test
What does the Seated Forward Bending Test tell you when diagnosing the Sacrum?
- side that is (+) will be opposite the axis if TORSION or on same side if UNILATERAL
What is the BITE mnemonic and what is it used for?
What are the normal motions of the ribs?
- used for Rib treatments
BITE = treat BOTTOM rib if INSPIRED SD, treat TOP rib is EXHALED SD
Ribs 1/2, 8-10 - Bucket Handle Motion
Ribs 3-7 - Pump Handle Motion
Ribs 11/12 - Caliper Motion
What muscles are utilized for treating Exhaled Rib Dysfunctions?
Rib 1 - Ant/Med. Scalene Rib 2 - Post. Scalene Rib 3-5 - Pec. Minor Rib 6-8 - Serratus Ant. Ribs 9/10 - Latissimus Dorsi Ribs 11-12 - Quadratus Lumborum
What is the common Compensated Zink Pattern?
L/R/L/R is COMMON, R/L/R/L is UNCOMMON
What do these Parasympathetics control:
- CN3
- CN7
- CN9
- CNX
- S2-S4
- eye
- lacrimal, palatine, submandibular glands
- parotid
- cardiopulmonary and GI
- colon, rectum, GU
What are the Sympathetic lvls for:
- Head/neck/upper esophagus
- Heart
- Lungs
- Upper GI/lower esophagus
- Small Intestine/Ascending Colon
- Descending Colon and Sigmoid Colon/Rectum
- T1-T5
- T1-T6
- T1-T7
- T5-T10
- T9-T11
- T12-L2
What are the Sympathetic lvls for:
- Adrenal
- Genitourinary Tract and Bladder
- Ureters (Upper and Lower)
- Upper and Lower Extremities
- T5-T10
- T10-L2
- Upper: T10-T11 and Lower: T12-L2
- Upper: T2-T7 and Lower T11-L2
What do the Vagus N. and S2-S4 Pelvic Splanchnic Ns. innervated?
S2-S4 = descending colon, rectum, reproductive organs, bladder, pelvis, lower ureter
Vagus N. = does everything else
there is NO innervation of the EXTREMITIES or VASCULAR SYSTEM by parasympathetics
What are the differences in set-up and force for Supine HVLA Type 1 SD, Type 2 F SD, and Type 2 E SD?
Type 1: sidebend pt. AWAY from doctor
- thrust down to segment on hand
Type 2 F: sidebend pt. TOWARDS doctor
- thrust down to segment on hand
Type 2 E: sidebend pt. TOWARDS doctor
- thrust on segment ABOVE hand
- hand supports vertebrae BELOW dysfunction
What are the differences in set-up and hand-placement for Prone HVLA Type 1 and Type 2 SD ?
Type 1: stand on SAME side as PTP
- PTP hand facing CAUDAD
Type 2 F: stand on OPPOSITE side as PTP
- PTP hand facing CEPHALAD
technique NOT used for EXTENSION SD
What is Compression Neuropathy?
What are 3 systemic causes of neuropathy? (P/H/D)
- functional or pathological change in the peripheral nervous system due to nerves becoming entrapped as they pass through a narrow passage
- pregnancy, hypothyroidism, diabetes
What is the difference between 1st, 2nd, 3rd, 4th, and 5th degree nerve damage? (N/A/N)
1: Neuropraxia (focal damage of myelin fibers)
- least severe
2. Axonotmesis (injury to axon, myelin sheath intact)
- Neurotmesis (injury to axon and endoneurium)
- Neurotmesis (injury to axon, endoneurium, perineur)
- Neurotmesis (injured axon, endo, peri, epineurium)
- most severe; surgery required to restore neurons
What does C5 Root innervate in the arm (motor, sensation, reflex)?
M: deltoids and biceps
S: lateral arm
R: bicep
What does C6 Root innervate in the arm (motor, sensation, reflex)?
M: wrist extension and elbow flexion
S: radial forearm and thumb/index fingers
R: brachioradialis
What does C7 Root innervate in the arm (motor, sensation, reflex)?
M: wrist flexion, elbow/finger extension
S: middle finger
R: triceps
What do the C8 and T1 Roots innervate in the arm (motor and sensation)?
C8: finger flexion; ulnar forearm and small finger sense
T1: finger abduction; medial arm sensation
What is radiculopathy?
- pain caused by compression of the spinal nerve that radiates in the distribution of the defined nerve root
How are these tests performed and what are they used to diagnose?
Spurlings Test
Adson Test
Hoffman Test
Testing Cervical Nerve Roots
S: extend/rotate neck toward symptomatic side
- look for exacerbation of pain
- Dx: cervical radiculopathy
A: elevate chin/head toward affected side while inspiring; look for obliteration of radial pulse
- Dx: Thoracic Outlet Syndrome
H: firmly grasp middle finger and snap dorsal side, look for flexion of thumb and index finger
- Dx: cervical myelopathy
What are 3 locations for Radial Nerve Entrapment?
- High on Humerus (usually humerus fracture)
- wrist drop, tricep involvement, weak elbow flexion
- Radial Tunnel (repetitive rotatory movements)
- also heavy manual labor
- pain/tenderness of lateral epicondyle
- wrist drop/pain with resisted supination
- At Wrist (sensory branch pinch by brachioradialis)
- sensation change over posterolateral hand
What is Wartenberg’s Syndrome or “Handcuff Neuropathy”?
- compression of superficial radian nerve in the forearm (where handcuffs would be placed)
- causes numbness, tingling, pain in nerve distribution
AKA Cheiralgia Paresthetica
What are three syndromes associated with Median Nerve entrapment?
Pronator Syndrome, Anterior Osseous Syndrome, and Carpal Tunnel Syndrome
Pronator Syndrome
- occurs where median nerve passes between superficial and deep heads of pronator teres muscle
- seen with repetitive pronating motions
- pain with resisted forearm pronation
Anterior Osseous Syndrome
What test is used to test for compression?
- anterior interosseous nerve is the deep motor branch of the median nerve (distal to pronator teres; innervates flexors)
- NO SENSORY SYMPTOMS; Test w/”OK” sign –> patient unable to hold/resist tip to tip of thumb and index finger
- splint elbow in 90 degrees of flexion (12 wks)
Carpal Tunnel Syndrome
What are two tests used to check for compression?
- MOST COMMON compression syndrome (as nerve passes with flexor tendons under the flexor retinaculum) –> sensation INTACT
- night-time numbness of lateral 3 1/2 digits, thenar atrophy, wrist pain
- common in repetitive motion jobs and pregnancy; splint with 30 degrees of hand extension
Tests: Tinel’s Test (tap) and Phalen’s Maneuver
Cubital Tunnel Syndrome
What are two tests used to check for compression
- MOST COMMON compression seen in the elbow (ulnar nerve entrapment)
- seen in baseball pitchers, prolonged elbow flexion, external compression, thickened cubital tunnel retinaculum (Can’t turn key in a door)
Tests: Tinel’s Test and Froment’s Sign (patient must flex thumb in order to pinch paper between 1st and 2nd digit = weak adductor pollicis and interosseous Ms)
Thoracic Outlet Syndrome
What are the 3 sites of compression?
- compression of brachial plexus and/or Subclavian vessels
sites: scalene triangle, costoclavicular passage, pec minor attachment to coracoid process - weakness of arm exacerbated by overhead activites
What are 4 tests that can be used to check for Thoracic Outlet Syndrome? (MC/ER/WH/A)
- Military/Costoclavicular Maneuver
- both arms back
- East/Roos Test (90 degree arms and flex hands)
- Wrights HyperABduction Test
- abduct arm out
- Adson’s Test
What does the L1/L2 Root innervate in the leg (motor and sensation)?
M: hip flexion
S: inguinal crease (L1) and anterior thigh (L2)
What does the L2/L3 Root innervate in the leg (motor and sensation)?
M: knee extension
S: anterior thigh (L2) and anterior thigh above knee (L3)
What do the L4/L5/S1 Roots innervate in the leg (motor, sensation, reflex)?
L4:
M: ankle dorsiflexion
S: medial leg/foot
R: knee jerk (patellar)
L5:
M: extensor hallucis longus
S: lateral leg, dorsal foot
S1:
M: ankle plantarflexion
S: lateral and plantar foot
R: ankle jerk (Achilles)
Meralgia Paresthetica
How can you test for it?
- compression of Lateral Femoral Cutaneous N. under the inguinal ligament at the inguinal canal (L2/L3)
Sx: numbness/burning on anterolateral thigh (won’t put anything in pockets)
Test: Tinnel’s Sign 1 cm medial and inferior to ASIS
What are the two branches of the Common Fibular N. and what do they innervate?
Deep: anterior compartment of leg
- tibialis anterior, extensor digitorum longus/brevis
- extensor hallicus longus
Superficial: lateral compartment of leg
- fibularis longus and brevis
Common Fibular N. Compression
L4-S2 (3rd most common compression neuropathy)
- compressed at fibular neck
- “Strawberry Pickers” –> time spent squatting
Sx: pain along proximal 3rd of lateral leg
- FOOT DROP with slapping gait
- exacerbated during plantarflexion and foot inversion
Anterior Tarsal Tunnel Syndrome
L4-S2; deep fibular nerve compression at INFERIOR EXTENSOR RETINACULUM
Sx: pain over dorsomedial foot, worse at rest
- weakness of extensor digitorum brevis
- compression from shoes
Tx: Hiss Whip for foot bones, remove compression
Tarsal Tunnel Syndrome
- compression of posterior tibial nerve in tarsal tunnel behind the medial malleolus with overlying FLEXOR RETINACULUM
- motor to plantar muscles and sensation of plantar aspects
What is the difference between Radiculopathy, Myelopathy, and Neuropathy?
R: pinching of nerve roots as they exit the spinal cord or cross intervertebral disc
M: compression of spinal cord itself
N: damage to peripheral nerves; weakness, numbness, pain in hands/feet
Sciatica
- pain from lower back that is felt along distribution of sciatic nerve in the lower extremity (IS A SYMPTOM)
- most caused by Sacroiliac Ligament weakness (“Heel Strike” while running)
- pain on walking/long periods of sitting, getting up from seated position (use armrests or thighs to push up)
What is the most protective factor against Chronic Low Back Pain?
REGULAR EXERCISE
What are the 4 most common causes of Low Back Pain?
Mechanical causes = 97% of cases
Musculoskeletal (nonspecific) - 70%
Spondylolisthesis (degenerative disc) - 10%
Radicular (disc vs stenosis) - 7%
Compression Fracture - 4%
Sprain/Strain/Overuse Syndrome and Low Back Pain
What are the 3 most commonly strained muscles (P/E/Q) and what are the 2 most commonly sprained ligaments (I/S)?
- MOST COMMON cause of acute low back pain, also present in chronic overuse (injury and stress)
muscles: paraspinals (multifidus/rotatores), Erector Spinae, Quadratus Lumborum
ligaments: Iliolumbar (pregnant) and Sacroiliac ligaments
- aching over injured structure
Piriformis Syndrome and Low Back Pain
What test is used to help diagnose?
- hypertonic piriformis muscle causing sciatic nerve entrapment
- causes aching/burning in gluteal region w/parasthesia down posterior thigh (worse with sitting)
Test: FAIR test or physical exam
Psoas Syndrome and Low Back Pain
What two tests are used to help diagnose?
- hypertonic psoas muscle (T12-L4 –> greater trochanter)
- pt. hunched/flex lumbar spine to splint, pain at thoracolumbar junction or hip pain (worse with standing/extending straight)
Test: Thomas Test or Pelvic Side Shift or palpation
What is the Pelvic Side Shift?
- laterally translate innominate to test for preference
- with psoas syndrome: hypertonic muscles pull lumbars/midline to the left, shifting the pelvis to the opposite side
- resolves w/relaxation of psoas
Short Leg Syndrome and Low Back Pain
What test is used to help diagnose?
- anatomical leg length discrepancy causing sacral base unleveling leading to MSK stress imbalance
- presents similar to overuse syndrome and will likely have pain in affected structures ABOVE the low back
- common with scoliosis pts.; worse with walking/activity
Test: Pelvic Side Shift –> translates AWAY from short leg (WILL NOT resolve with manipulation); also compare medial malleolus
What is the treatment for Short Leg Syndrome?
- HEEL LIFT THERAPY
- treat only if discrepancy is > 5mm or > 1/5 inch; add 1/8-1/16 inch every 2 wks with final lift being 1/2-3/4 of measured discrepancy
- acute change in leg length = REPLACE FULL DISCREPANCY IMMEDIATELY
Degenerative Disc Disease and Low Back Pain
- degeneration due to stress and inflammation of nociceptors (60-80% of adults > 49 with radiographic findings)
- worse when bending forward, sneezing, coughing
- diagnose with radiography
Spondylolysis and Low Back Pain
What is seen on imaging?
- defect/stress fracture of the pars interarticularis; usually asymptomatic with most pain at L5 vertebrae
- seen in young athletes due to repetitive stress/developing bones (worse with hyperextension)
- see “Scotty Dog” on lumbar X-Ray (break forms collar on dogs neck)
Spondylolisthesis and Low Back Pain
How is it diagnosed?
- anterior displacement of vertebrae secondary to bilateral pars defects seen in pts. with inc. age (osteoarthritis) or those with bilateral spondylolysis
diagnose with palpable ‘step-off’ on physical exam
Spinal Stenosis and Low Back Pain
What is the “Shopping Cart” Sign?
- narrowing of neural foramen/central canal causing unilateral numbness in L4/L5/S1 nerve roots
- pts flex and lean forward because numbness inc. with extension, standing, or walking (look like they are hunched over a shopping cart)
Cauda Equina Syndrome and Low Back Pain
- massive disc herniation compressing the cauda equina causing numbness and tingling in perineum (saddle anesthesia, dec. anal sphincter tone)
- trauma inc. risk; condition progressively worsens
EMERGENT SITUATION –> get spinal decompression ASAP (diagnose with MRI)
What are 4 ‘Red Flag’ signs for Low Back Pain that would need imaging and emergent management?
- Progressive lower extremity weakness (radiculopathy)
- Saddle anesthesia/loss of bladder/bowel control
- Cauda Equina syndrome
- deep bone pain/unexplained weight loss
- neoplasm
- fever and chills –> osteomyelitis
Why is imaging usually avoided in Low Back Pain?
- start with conservative treatment since the majority of pain will resolve in < 12 weeks
- imaging incurs risk of radiation and cost (time + $) with a low likelihood that it will alter disease or treatment
- ONLY ORDER if there is progressive neurological deficits
What are 4 contraindications for Large Intestine Visceral OMT and Small Intestine Visceral OMT? (I/O/S/S)
- active infection, colon obstruction, abdominal surgery in last 3 weeks, splenomegaly
What is the Sympathetic and Parasympathetic innervation for the colon?
Proximal 2/3
- S: T10-11, Lesser Splanchnic (Sup. Mesenteric Gang)
- P: Vagus N.
Distal 1/3
- S: T12-L2, Least Splanchnic (Inf. Mesenteric Gang)
- P: Sacral Splanchnic N. (S2-S4)
What is the palpable location of the Celiac, Superior Mesenteric, and Inferior Mesenteric Ganglia?
What structures do they supply in the GI tract?
Celiac: midway between xiphoid and sup. mesenteric
- distal esophagus –> proximal duodenum
- gallbladder, liver, spleen, part of pancreas
Sup M: midway between xiphoid and umbilicus
- distal duodenum –> proximal 2/3 colon
- part of pancreas
Inf. M: midway between sup. mes and umbilicus
- distal 1/3 of colon of transverse colon –> rectum
What are the Anterior and Posterior Chapmans points for:
Ileocecal Valve Ascending Colon Right 2/5 Transverse Colon Left 3/5 Transverse Colon Descending Colon Sigmoid Colon
- right upper lateral thigh (above 2)
- right mid lateral thigh (above 3)
- right lower lateral thigh (above knee)
- left lower lateral thigh (above knee)
- left mid lateral thigh (above 4)
- left upper lateral thigh (above 5)
Posterior: triangular area reaching from transverse processes of L2-4 to crest of ileum
What are the Sympathetic and Parasympathetic innervations for the Duodenum and Small Bowel?
Duodenum
- S: T9, Greater Splanchnic N. (Celiac Ganglion)
- P: Vagus N.
Small Bowel
- S: T10-11, Lesser Splanchnic N. (Sup. Mesenteric G)
- P: Vagus N.
What are the Anterior and Posterior Chapmans Points for:
Small Intestines
Spleen
Pancreas
Appendix
Small Intestines:
- A: 8-10 intercostal spaces
- P: between T8-9/T9-10/T10-11
Spleen:
- A: LEFT 7th intercostal space
- P: LEFT between T7-8
Pancreas:
- P: RIGHT between T7-8
Appendix:
- RIGHT 12th rib tip
What are 5 contraindications for Liver Visceral OMT? (F/M/T/H/H)
- fractures/dislocations
- malignancy of lymphatics
- trauma
- acute hepatitis
- friable hepatomegaly (mono or sickle cell anemia)
What is the Sympathetic and Parasympathetic innervation for the Liver?
Sympathetic: T7-9
- Greater Splanchnic N.
- Celiac Ganglion
Parasympathetic: Vagus N. (CN X)
What are the Anterior and Posterior Chapman’s Points for:
Liver
Gallbladder
Liver
- A: RIGHT 5th intercostal space
- P: RIGHT between T5-6/T6-7
Gallbladder
- A: RIGHT 6th intercostal space
- P: RIGHT between T6-7
posterior chapmans points are halfway between Transverse and Spinous processes, between the vertebral segments
What is the Sympathetic and Parasympathetic innervation for the Ureters, Bladder, and Pelvic Organs?
S: T12-L2, Least Splanchnic N. (Inf. Mesenteric Ganglion)
P: Sacral (Pelvic) Splanchnic N. (S2-S4)
What are the Anterior and Posterior Chapman’s Points for:
Adrenals
Kidney/Ureters
Bladder
Urethra
Adrenals
- A: 2-2.5” above/1” lateral to umbilicus (bilaterally)
- P: intertransverse spaces between T11-T12
Kidney/Ureters
- A: 1” above/1” lateral to umbilicus (bilaterally)
- P: intertransverse spaces between T12-L1 (K)
- P: intertransverse spaces between L1-L2 (U)
Bladder
- A: periumbilical or umbilical
- P: superior edge of L2 transverse process
Urethra
- A: inner edge of pubic ramus near symphysis
- P: superior edge of L2 transverse process
What is the main lymphatic drainage for the low pelvis?
External Iliac
- includes internal iliac and some posterior sacral
Coding and Billing
What are the 3 components required for History or Objective?
What is always required for any billing?
- Signs and Symptoms (HPI)
- 1-3 = brief, > 3 = extended
- ROS
- 1 = problem foc., 2-9 = extended, 10+ = complete
- Past History (2/3 = complete)
- need at least 1 from PMH/SH/FH
CHIEF COMPLAINT is ALWAYS REQUIRED
Coding and Billing
What is the requirement for the Physical Exam to be classified as:
- Problem Focused
- Expanded Problem Focused
- Detailed
- Comprehensive
- 1-5 elements
- 6+ elements
- 2 bullets in 6 systems (12 or more bullets total)
- 2 bullets in 9+ systems (“complete physical exam”)
Coding and Billing
What are the 3 components required for Medical Decision Making and how are they scored?
Which of the components must always be included in having at least 2/3 done?
- Number of Dx and Tx
- self-limited or established dx = 1 pt
- established dx but worsening = 2 pt
- new, no additional eval = 3 pt
- new with additional eval = 4 pt
- # of medical data reviewed
- reviewed or ordered, discussed w/pt = 1 pt
- DECISION to review old stuff - 1 pt
- independent (self) review = 2 pt
- RISK
- minimal = 1 self-limited or minor
- low = 2 self-limited, 1 stable chronic, 1 new uncomp.
- moderate = 2+ stable chronic, undiagnosed new w/ uncertain prognosis
- HIGH = eminent threat or severe exacerbation of 1+ chronic illnesses
RISK is always required for the 2/3 to meet or exceed billed complexity
How can OMT be billed during a clinical visit?
What are the 4 components of the Procedural Note if OMT is done in clinic?
- can be billed if decision to use OMT was made during visit, otherwise procedure and visit cannot be billed same day
PN:
- Consent - benefit/risk/cost/alternatives/side effects
- Description - body regions and technique
- Disposition - response to tx and complications
- Follow Up Plan - post-procedure care
