Exam 1 Flashcards
(288 cards)
1
Q
God of Medicine year? what happened?
A
Aesculapius aka Asclepios 800 BC Son of Apollo and Coronis Zeus hit him with a lightning bolt Became God of Medicine with a temple and cult
2
Q
what is God of Medicine represented by?
A
Represented by staff and serpent
Staff: cedar (long lived, durable)
Serpent: wisdom, energy, healing forces
Currently the symbol of the Osteopathic profession
3
Q
Hippocrates gen hx
A
–460 to 377 BC
–Physician on the Greek island of COS or KOS
–20th generation of the cult of Aesculapius
4
Q
Greek Islands
Cos
A
- Empiric approach
- Condition of the Patient, past activities
- External appearance very closely observed
- Touch, smell, even tasting of patient
- Lifestyle important
–Baths, diet, exercise
•Emphasis on the patient rather than disease
5
Q
Greek Islands
Cnidos
A
- Extensive categories of disease
- Symptoms organized by organ affected
- Treatment for each disease was simple and “sparse”
- Emphasis on the disease
6
Q
Caduceus
hx?
A
•Symbol of Mercury/ Hermes
–The wings
- Said to have thrown his staff between two serpents to break up a fight
- Never used for medicine until 1800’s
- Symbol of AMA
7
Q
AT still born
A
•Born in Lee County Virginia, 1828
8
Q
AT still moved… where first?
A
•Moved to Northeast Missouri in 1837
9
Q
AT stil’s father’s occupation
A
- Methodist minister
- Supported family as an itinerant physician and farmer
10
Q
how did at still get –Early exposure to anatomy
A
- Young “Drew” better hunter than farmer
- Assisted his father on rounds
11
Q
at still’s Kansas Experience
A
- Father was appointed to Kansas Territory as missionary to Shawnee Indians
- Still was farming and then decided on career in medicine studying with his father.
- Elected to quasi-legal Free Kansas Legislature in 1857 to combat proslavery forces in state
12
Q
•Civil War 1860
A
•Surgeon with 21st Kansas Militia in northern cause
–Rank of Major
–Served for 2 years
•Resumed career as orthodox physician
13
Q
Calomel
A
•a rapid acting cathartic
–Contained mercury creating poisoning
- Stomatitis, gangrene of the buccal mucosa,
- Loss of teeth
- Severe intestinal cramps, bloody stool
14
Q
how treat •Acute nasal catarrh in late 1800’s
A
- Carbolic acid as an inhaler or nasal spray
- Sulfuric acid as a spray
- Tannic acid as an injection
- Aconite and belladonna tincture every hour
- Arsenic internally or as a cigarette for paroxysmal cases
15
Q
Aconite
A
–wolfsbane, a rapid acting poison used as an antipyretic, diuretic, diaphoretic
16
Q
Belladonna
A
–=‘deadly nightshade’ source of atropine, anticholinergic, used for diarrhea, asthma
Arsenic internally or
17
Q
Meningitis epidemic
A
1864
•Lost three daughters
father died of infectious dz
brother addicted to morphine
18
Q
1874
A
- severed ties to regular medicine
- Moved to a more receptive Kirksville, Missouri
- •A.T. Still, Magnetic Healer
19
Q
1876
A
ill with typhoid for 6 months, 1876, he became an iternant physician traveling Missouri
20
Q
“Lightening Bone Setter”
A
AT still
21
Q
“ flung to the breeze the banner (of osteopathy)”
A
•June 22, 1874
22
Q
Greek roots: what does osteopathy mean?
A
OSTEON was originally not just bone but flesh in general.
PATHOS referred to the deep things, particularly emotion, in each of us which yearn to be expressed
“deep meaning yearning to be expressed in flesh”
23
Q
•Four principles of osteopathy
A
–The person is a unit of body, mind and spirit
–The body possess self regulatory mechanisms
–Structure and function are reciprocally interrelated.
–Rational treatment is based on the above.
24
Q
Clinic in Kirksville
A
1889
25
when did at still decide to call osteopathy, osteopathy?
1889
26
First School Chartered
1892
27
First Class combo of students
•The first class was 15 men and 3 women
great activist of women
28
American School of Osteopathy
1898
## Footnote
* The original course was 4-5 months long
* Rapidly increased to two years
–Two terms of five months each for two years
• Cost $500.00
29
Women in Osteopathy
•First woman faculty hired 1893
Nettie Bolles, D.O
30
National School of Osteopathy
1895
## Footnote
–Formed in Kansas City by two graduates of the second class, Elmer and Helen Barber
31
Pacific College of Osteopathy
1896
–Founded in Anaheim, soon moved to Los Angeles
32
Northern Institute of Osteopathy
1896
## Footnote
–Founded in Minneapolis
33
Approximately one-fifth of all graduates of osteopathic schools before 1910 were
women
34
•longest and most comprehensive curriculum?
Pacific College
–4 terms of 5 months each (20 months)
–Large basic science component
35
Tuition
•$300 - $350 at most other schools
36
first state to license DO'S
Vermont
## Footnote
•Vermont legislator treated by H.L. Spangler, D.O.
37
•Allopaths first attack on Osteopathy
YEAR?
1893
## Footnote
–Tried to make practicing osteopaths grads of reputable med school
–MO Legislature eventually does not pass bill
38
1897
Celebration of Licensing Bill in Missouri
39
American Association for the Advancement of Osteopathy founded
•1897
–Dues $1.00
–Now known as American Osteopathic Association (The “AOA”)
40
Founding of Associated Colleges of Osteopathy
1898
now American Associated Colleges of Osteopathic Medicine
–Set standards for schools
–Member schools to adhere to standards
41
AOS did not teach surgery until
1900
42
–“There has never been one single voice raised against Osteopathy except by men of other medical schools. We have been looked down upon, criticized, ridiculed, called “faddists,” masseurs and everything but gentlemen.”
•Arthur Hildreth, D.O.
–Legislators slowly became aware that allopaths did in fact discriminate against Osteopaths
43
A. T. Still publishes
•1902
–“Philosophy of Osteopathy and Mechanical Principles of Osteopathy”
44
A Mandatory three-year program set by ACO in
1904
45
ASO stands for
American School of Osteopathy
46
Flu Epidemic of 1918
* 40 million worldwide died of swine flu
* 650,000 in US
* Medical treatment – calomel, aspirin, strychnine
* D.O.s rejected drug treatment using manipulation directed at sequlae of pneumonia
Techniques still in use today
47
Flu Epidemic of 1918 tx: DO v MD
DO:
flu = 0.2% mortality
pna = 10% mortality
MD:
flu = 12-15% mortality
pna = 25% mortality
48
added course in materica medica to meet legislative demands
1924 Chicago school
49
Flexner Report: admission requirements
–High school diploma required in 1920
–Two years of college required by 1930’s
–MD institutions (often University based) had implemented early 1920’s
50
A. T. Still Research Institute year?
1909
51
Louisa Burns
–spinal lesions in a rabbit model
–Studies indicated that artificially produced strains in specific vertebral segments produced changes in related organ and tissue
–Continued her work until 1950s
52
J.S. Denslow
•1939
–Characteristics of muscle activity in relation to palpatory diagnosis
53
I. M. Korr
•(with Denslow) 1945
–Concept of the facilitated segment
54
California 1940s
•California DO’s professional problems
–Poorer educational opportunities
–Lack of public recognition
–Decline in OMT
–Organized medicine in the state attempting to eliminate the profession through legislation then though absorption
55
California Merger
* California Osteopathic Association 1943
* Encouraged to amalgamate with MD’s
–Granting of M.D. to all CA licensed DOs
–Elimination of osteopathic licensing boards
–Convert Osteopathic College of Medicine into medical school
contract signed 1961
•Approximately 85% of DO’s traded their degrees
56
California Merger Effects
* If the DO’s could be licensed as MD’s
* Their role as physicians no longer questioned
* 1974, California Supreme Court overturned Proposition 22 and reinstated the Osteopathic Licensing Board
* 1977 the College of Osteopathic Medicine of the Pacific opened.
57
OMT
•Hands-on techniques designed to alleviate somatic dysfunction.
58
Models of Manipulation
1. Biomechanical model
2. Respiratory/Circulatory model
3. Neurological model
4. Metabolic-Energy model
5. Behavioral model
59
which Models of Manipulation can be viewed as the core that links these models together.
Musculoskeletal system
60
Biomechanical Model
* Structural/Posture
* Most commonly used
* Directed toward the treatment of the musculoskeletal system
* Example - whiplash
* Remove restrictions to:
–Optimize function/structure
–Improvement of Motion
–Relief of Pain
61
Respiratory/Circulatory Model
Influence the movement of fluid, such as lymph or blood
Focus on cellular respiration
DO=Deliver Oxygen!
Improve Respiratory Capacity
Reduce work of breathing
Example - Pneumonia
Also useful in Cardiac conditions
62
Neurologic Model
* Influences sensory, motor, or autonomic nervous systems or associated reflexes
* Impingement
* Specific areas:
–Thoracic and upper Lumbar spine for Sympathetics
–Cervical region
–Nervous system as a whole
* Viscerosomatic reflexes
* Example - peristalsis
63
Metabolic-Energy Model
* Focus on the inherent energies or forces of the body
* Cranial and sacral motions
* Fluid fluctuations
* Brain functioning
* Conservation of Energy
64
Behavioral Model
* Interplay of mind and body and spirit
* Anxiety, stress can respond well to hands-on treatment = emotional release
65
primary mechanism for communicating with patients
Touch
66
•Primary diagnostic tool of DO's
Touch
## Footnote
•Hands ‘remember’ patients and feel of certain conditions.
67
pathway of touch
* signals ascend the spinal cord to reach the dorsal column nuclei in the caudal medulla
* Through thalamus and onto the postcentral gyrus of the parietal cortex.
68
•highest representation in Sensory homunculus
•Hands and Fingers
69
palpation progress from superficial to deep
1. Superficial fascia and subcutaneous tissues
2. Muscles,
* Note: Tone, Contraction, Contracture, Spasm, Bogginess, Ropiness, Stringiness
3. Tendons, ligaments
4. Bone
70
Posterior Symmetry: observation
ØThe inion
ØThe midline of the vertebrae
ØThe midline of the sacrum
ØThe midline of the coccyx
ØA point midway between both Malleoli
71
Physiologic Curves
Adult spine has 4 normal Coronal curves:
–CERVICAL are convex forward - “Lordotic curve”
–THORACIC are convex backward - “Kyphotic curve”
–LUMBAR are convex forward - “Lordotic curve”
–Fused Sacrum is convex forward
–Technically speaking- lordosis and kyphosis refer to pathological states
72
vertebral disorders
73
Lateral Assessment
74
Gravity Line
75
Points of Lateral Symmetry
* Posterior to apex of coronal suture
* External Auditory Meatus
* Humeral Head
* Middle of L-3 Vertebra
* Femoral head
* Just behind mid-knee
* Just anterior to lateral malleolus
76
center of gravity for the entire body
~ 5 cm anterior to second sacral vertebra
77
Anterior Postural
Deviation
ØBody leans forward anteriorly deviating from plumb line
ØWeight is supported by metatarsals
78
Posterior Deviation
Posture
ØBody leans backwards, deviating posteriorly from plumb line
ØBalance maintained by anterior thrust of pelvis and hips
ØMarked lordosis from mid-thoracic spine down
79
Military-Bearing
Posture
Ø“Chest out, stomach in”
ØHead tilt posteriorly
ØC-spine and T-spine normal
ØChest elevated with anterior cervical and posterior thoracic deviation
ØIncreased lumbar lordosis
ØAnterior pelvic tilt
ØKnees extended
ØAnkles plantar flexed
80
Swayback Posture
–Head forward
–C-spine/T-spine increased curves
–Lumbar lordosis decreased
–Posterior tilt of pelvis
–Hip and knee hyperextended
81
Flat Back
Posture
–Head forward
–C-spine slight increase in lordosis
–T-spine upper slight kyphosis then flattens in lower
–Lumbar lordosis flattened
–Hips and knees extended
82
M affected by sway back posture
tight/overactive
* rec ab, hamstring, tensor fascia late (IT band)
inhibited: weakened
* ab obliques, iliopsoas, multifidus, thoracic extensors, gluts
83
M affected by flat back posture
tight/overactive:
* rec ab, psoas, glut
inhibited/weakened:
* back extensors, multifidus, iliacus
84
Axes of Motion
Perpendicular to each
of the three planes
Sagittal/A/P (z)
Frontal/lateral (x)
Longitudinal/vertical (y)
85
Planes and Axes: flex/extension
ØSagittal plane
ØFrontal/lateral axis
86
Planes and Axes: Rotation
ØHorizontal/transverse plane
ØLongitudinal/vertical axis
87
Planes and Axes: Side bending
ØFrontal plane
ØSagittal(A/P) axis
88
Somatic dysfunction definition?
general effect?
is AN IMPAIRED OR ALTERED FUNCTION OF THE SOMATIC SYSTEM:
SKIN, FASCIA, MUSCLE, ARTHRODIAL, AND RELATED VASCULAR, AND NEURAL ELEMENT.
Brings about deleterious effects on the health when present.
89
Neural Reflexes
When afferent impulses from muscle and an abdominal organ enter the spinal cord at the same level, there is crosstalk between the 2 reflexes.
reduction of muscle hypertonicity = reduces neural stress reflexes to the organ.
Abnormal activity in neural circuits is a fundamental of osteopathic practice.
90
FACILITATION
•pool of neurons (one or more segments of the spinal cord) in a sub-threshold state that less afferent stimulation is required to trigger the discharge of impulse.
91
Acute V Chronic Somatic Dysfunction Findings:
hx
•Memory of an injury, recent . MORE TENDER
Long-standing impairment
92
Acute V Chronic Somatic Dysfunction Findings: Pain
Acute sharp, severe
dull ache
93
Acute V Chronic Somatic Dysfunction Findings
skin
Warm, moist, acute red reflex, inflamed
cool, dry, decrease sweating, scaly, pale itchy, blemished skin, thin pigmentation
94
Acute V Chronic Somatic Dysfunction Findings
Mobility
•range not always restricted but sluggish.
Limited ROM due to chronic contracture or development of fibrosis
95
Acute V Chronic Somatic Dysfunction Findings
Musculature
hypertonia
contracture but decreased tone that feels mushy flaccid, fibrotic & ropy.
96
Acute V Chronic Somatic Dysfunction Findings
tissues
Boggy, edematous congested soft tissue
•chronic congestion doughy, (poor lymphatic pump)
97
Acute V Chronic Somatic Dysfunction Findings
visceral
•effects are minimal
effects are common
98
Acute Red Reflex
area on the skin that responds to stimuli by turning red after stimulation by palpation.
•Positive sign: Redness which remains longer than the rest of the area tested.
99
Acute Red Reflex mechanism
SNS response = vasoconstriction.
* BUT overpowered by braykinins = local vasodilitation = warmth and redness.
•Indicates either acute S/D in that segmental area, or S/D secondary to visceral dysfunction innervating that segment.
100
restrictive barrier is a result of
somatic dysfunction
101
Parameters of Somatic Dysfunction
1. position: via palpation
2. restriction of mvmt
* –“going toward or up against the barrier”
3. direction in which motion is freer
* less restricted.
* “going away from the restrictive barrier”
* This is our naming convention.
102
Palpatory Diagnosis
Segmental Asymmetry
how-to
* Operator on side of dominant hand
* Thumbs placed over transverse processes
* Allow to sink through the sub-cutaneous
* Contact transverse processes
103
TYPE I spinal mechanics
and naming
always neutral
* L1-3NSRRL
* sidebending preceeds rotation, with rotation occuring to the side opposite sidebending = SXRY
* Two or more segments involved
104
Type II spinal mechanics
and naming
•sidebending in a non-neutral position, rotation of one segment must preceed sidebending. Rotation and sidebending occur to the same side.
* T 4 E Rr Sr
* E/F: position that makes it symmetrical: freedom of mvmt
• Non-neutral spine : active or passive flexion or extension will change the position of the vertebra.
105
where are type ii spinal dysfunc found?
–Found at apex or extremes of Type I curves at transitional areas or by themselves .
Apex is the mid point of the curve (most angulated)
106
type ii spinal disfunction occur..
–result of trauma/abrupt twisting
107
A segment is restricted in sidebending to the left, rotation to the right, and backward bending or forward bending will not effect the position of the posterior transverse processes
name!
L2-4 (N) SRRL
108
fryettes THIRD PRINCIPLE
•When motion occurs in any one plane within a joint or region, motion in all other planes of that joint will be influenced.
ex: •If a vertebral unit was flexed, its range of sidebending and rotation would be reduced.
109
A man presents to your office with acute pain on the lower lumbar spine, unable to straighten his back. He was trying to pick up a box while bent forward and leaning over to the right. What is the most likely somatic dysfunction that you will palpate?
## Footnote
A.L1-L5 NRRSL
B.L1-L5 NRLSL
C.L3 ESLRL
D.L3 FSRRR
E.L3 FRRSR
E
110
Which muscles are involved in a Type II
intrinsic M of spine
111
Which muscles are involved in a Type I
erector spinae
112
myofascia
Muscles grow within and are enveloped by fascia
Contraction and motion of the muscles are guided by fascia
113
Tendon
Insertion INTO bone
Sharpey’s fibers
* avulsion fx
114
Golgi Tendon Organ location
–Located at the myotendinous junction
115
Muscle Spindle location
–Located in belly of muscle
116
muscle lengthens OR shortens....
muscle spindle conveys this information
* Lengthening leads to contraction (Stretch Reflex.)
* Shortening leads to inhibition.
RATE of change in LENGTH
117
Afferent Neural components
118
static v dynamic response to contraction of extrafusal fibers
•When the spindle is stretched slowly, afferent signals are transmitted in proportion to the degree of stretch.
* “Static” response… steady signals while the spindle is being stretched.
•When the length of the spindle increases suddenly, the afferent nerves are stimulated especially powerfully.
* “Dynamic” response
* MUSCLE CONTRACTS/RELAXES POWERFULLY.
119
Underlying Principles of Soft tissue techniques
GO Slow, do not “surprise” muscle or tissues
Prevents reactive contraction of muscles via action of muscle spindles
120
Golgi Tendon organ detects muscle
TENSION
And then inhibits M to prevent development of too much tension on M
121
Lengthening reaction
tension and therefore inhibitory effect is extreme it leads to relaxation of the entire muscle
golgi tendon reflex
122
Reciprocal Inhibition
engage flexors so extensors can relax
123
5.Crossed extensor reflex
–Stretch reflex to R biceps causes relaxation of L biceps
124
Hypertonia
causes and result
Causes Include:
* Pain
* Postural strain
* Spinal facilitation
* Supraspinal influence
* Psychological stress
Can then limit movement across a joint and decreased function!
125
4 goals of myofascial treatments:
1. relax contracted M
* decrease pain --\> allow normal ROM --\> decrease o2 demand of M
2. increase circulation to area of ischemia
3. increase venous and lymph drainage
* decreases local swell/edema
* allows removal of harmful metab waste products
4. stimulatory effect on stretch reflex in hypotonic M
126
Direct Technique of restrictive barrier
move towards barrier and push past
127
indirect technique on restrictive barrier
away from restrictive barrier
shorten to try and relax
128
Direct MFR (myofascial release)
–a restrictive barrier is engaged for the myofascial tissues; the tissues is loaded with a constant force until tissue release occurs.
129
Indirect MFR
dysfunctional tissues are guided along the path of least resistance until free movement is achieved
130
Soft Tissue techniques - stretching
Separation of the origin and insertion of a muscle and/or attachments of fascia and ligaments
* Lateral or Perpendicular Stretch
* Force the tissue at right angles to the long axis of the muscle or tissue.
* Linear or Longitudinal Stretch
* Force tissue in direction of long axis or moving from origin and insertion.
131
Soft Tissue techniques - inhibition
•The application of steady pressure to soft tissues to reduce reflex activity and produce relaxation
132
•Effleurage, Petrissage, Tapotement
•Lymphatic techniques
133
fascia definition
what type of tissue is it made of?
sheet of fibrous tissue that envelops the body beneath the skin, encloses muscles and groups of muscles, and separates their several layers or groups
Loose or dense irregular connective tissue.
134
Functions of Fascia
–Packaging
–Protection (cushioning)
–Posture
–Passageways (conduit for vessels and nerves)
135
Architecture of the fascia
* series of concentric tubes.
* critical for metabolic activity and immune surveillance
136
FOUR MAJOR LAYERS of fascia
1. Pannicular
2. Axial and Appendicular
3. Meningeal
4. Visceral
137
Pannicular layer of fascia
overall layer
highly variable fat content
* Platysma and facial muscles are embedded within this layer.
* Can be sub-divided
138
Axial and Appendicular layer of fascia
•Gives rise to the investing fascia of or epimysium of the axial muscles of the body and is continuous with the appendicular (investing) fascia in the extremity.
as two tubes of fascia separated centrally by the vertebral column
* TP’s separate.
* Anterior – Hypaxial
* Posterior – Epaxial
139
Meningeal fascia
•Surrounds the neural structures
includes dura mater
terminats with development of epineurium that surr peripheral N
140
Visceral fascia
* Organ into septae packing function and allowing access routes for metabolic channels.
* Fascia acts as a skeleton for the organ.
* “visceral ligaments” = not true ligament but condensation of fascia that loosely anchors an organ in the body cavity.
141
Components of fascia: cellular components
–Fibroblasts
–Myofibroblasts
–Macrophages
–Mast cells
142
Components of fascia: Extracellular Matrix components
–Collagen fibers
–Elastic fibers
–Laminin and Fibronectin
143
Fibroblasts
•Principal cell type of fascia =- maintains homeostatis
* synth/secrete cytokins, collagen, fibronectin, connective tissue ground substance
144
what monitors and maintains the appropriate degree of tension in the connective
Fibroblasts
respond to growth factors and inflammatory substances
145
Tensegrity
Balance of structures is maintained by stresses distributed throughout
operation which allows motion and maintains structure - concrete, stable, fluid
146
Patterns of Fascial Strain found....
•found at transitional zones
common compensatory patterns - Zink
147
The Major Transverse Diaphragms
and correlation with the
Common Compensatory Pattern (CCP)
1. Tentorium cerebelli
2. Thoracic outlet/inlet
3. Respiratory diaphragm
4. Pelvic diaphragm
148
Adaptation to Stress – Postural, mechanical
Fibroblasts increase collagen production and ground matrix in response to mechanical stress (Wolff's law)
Fibroblasts morph into myofibroblasts and exhibit contractile properties.
increase in collagen = increase strength at cost of flexibility
increase collagen and increase contriction = adhesions and degragement of fasical planes
149
Effects of the Adaptation to Stress
block fluid flow = decrease o2 delivery, decrease removal of toxic metabolities
150
effects of Adaptation to Stress for M
Muscles become hypertonic
Development of tender points
Development of trigger points
* Taut band of muscle with hyperirritable focus palpated as discrete nodule
Referral pattern of pain
Points Activate Nociception
151
Fibrosis
proliferation of ECM = scarring/hardening of organ
152
mechanotransduction
txmission of forces across cell membrane that initiates mvmt of cell and metabolic changes within cell
153
Robert Zapolsky: stress on anxiety and depression
* Anxiety: stress response chronically active
* Depression: stress response suppressed or overly active
154
Allostasis
•“The maintenance of stability through change.”
155
Allostatic Load
Stress
## Footnote
•Short-term gains with Long-term Losses
represents the cost to the organism of repeated exposure to stress.
156
Development of Spinal Curves
- Birth-whole spine is a C-curve
- 13 months-lumbar spine neutral
- 3 years-lordosis begins to appear
- 8 years-lordosis obvious
- 10 years-clear adult stance
157
T-Spine Functional Divisions
158
Functional Landmarks: spine of scapula
T3
159
Functional Landmarks: inferior angle of scapula
T7
160
Functional Landmarks: iliac crest
L4
161
Functional Landmarks: suprasternal notch
rib 2
T4/T5
162
Functional Landmarks: angle of louis
T4
aortic arch superior
@ bifurcation of trachea
163
Functional Landmarks: xiphoid process
T9
164
Rule of 3’s
–Spinous processes are very long and overlap each other in a relationship of 3’s
– T1-T3 spinous processes are at the same level as the vertebral body of their segment
– T4-T6 project one half segment below
– T7-T9 one full segment
– T10-T12:
* T10 one full segment below
* T11 one half segment below
* T12 at the same level as vertebral body
165
Ribs restrict
lateral flexion and unilateral joint motion
166
Shingle effect of SP’s
can restrict extension
167
in the thoracic, articular facets face
BUL
back, up (superior), lateral
168
Spinal Motion in Breathing
169
Muscles of Respiration: inhalation
Diaphragm-attaches to lower ribs and sternum
- Crura anchors at L1, L2, L3
- External intercostals
accessory: SCM, scalenes
170
Muscles of Respiration: exhalation
–Rectus abdominus
–Internal and external oblique
–Transversus abdominus
–Internal intercostals
Accessory-passive recoil
171
Viscerosomatic Reflexes
General Organ Schematic
•T1-T6
–Organs above diaphragm (lungs, heart, eyes)
•T5-T9
–Organs just under the diaphragm (stomach, gall bladder)
•T9-T12
–Organs in between T5-T9 and T12-L2 (ovaries, kidney, upper ureter)
•T12-L2
–Organs just above pelvic diaphragm (sigmoid colon, bladder, uterus)
172
* Patient presents with back pain. On forward bending you find a rib hump on the right that begins at the spinous process of T7 and ends at spinous process of T10. The TPs in that area are all rotated to the right and do not change in flexion or extension.
* What is your diagnosis written in “shorthand”?
T8-T11NSlRr
173
Counterstrain is an example of \_\_\_\_\_\_\_\_, __________ technique
indirect, passive
174
Muscle energy and HVLA are examples of _________ techniques
direct
175
Muscle Energy
the patient’s muscles are actively used against physician counterforce
176
is recognized as the original developer of muscle energy technique
who is credited as primary sources of concept?
Dr. Fred Mitchell, Sr.
T. J. Ruddy, D.O. and Carl Kettler, D.O.
177
Hx of Fred Mitchell and his contributions to osteopathy
–Mitchell first published his work in 1958 in the Yearbook of the American Academy of Osteopathy.
–In 1970, he gave his first 5 day tutorial.
–In 1979, after Dr. Mitchell’s death, his son (Fred L. Mitchell, Jr.) along with Moran and Pruzzo published a muscle energy manual still used by many Osteopathic Medical Schools today.
178
Post-isometric Relaxation
•Goal
–To accomplish muscle relaxation
•Physiologic Basis
immediately following an isometric contraction, the neuromuscular apparatus is in a refractory state and a passive stretch can occur without myotonic reflex opposition. The operator resists the contraction and then takes up the slack during the relaxation phase. It’s postulated that the Golgi tendon proprioceptors inhibit the active muscles contraction.
•Force of Contraction
–Sustained gentle pressure (10-20 lbs.)
•Example
–Hamstring muscle spasm
179
Joint Mobilization Using Muscle Force
•Goal
–To accomplish restoration of joint motion in an articular dysfunction.
•Physiologic Basis
–Distortion of articular relationships & motion loss results in a reflex hypertonicity of the musculature crossing the dysfunctional joint. The increased muscle tone compresses the joint surfaces, thinning the synovial fluid and causing adherence of the joint surfaces. Restoration of motion of the joint surfaces results in gapping or “reseating” of the distorted joint relations reflex relaxation of the previously hypertonic muscles.
•Force of Contraction
–Maximum muscle contraction that can be comfortably resisted by the physician (30-50 lbs.)
•Example
–Anteriorly Rotated Innominate
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Respiratory Assistance
•Goal
–To produce improved body physiology using the patient’s voluntary respiratory motion.
•Physiologic Basis
–The muscular forces in these techniques are generated by the simple act of breathing. This may involve the direct use of the respiratory muscles or motion transmitted to the spine, pelvis and extremities in response to ventilation motions. The physician usually applies a fulcrum against which the respiratory forces can work.
•Force of Contraction
–Exaggerated respiratory motion.
•Example
–Unilaterally Extended Sacrum
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Oculocephalogyric Reflex
•Goal
–To affect reflex muscle contractions using eye motion.
•Physiologic Basis
–Functional muscle groups are contracted in response to voluntary eye motion on the part of the patient. These movements reflexively affect the cervical and truncal musculature as the body attempts to follow the lead provided by eye motion. It can be used to produce very gentle post-isometric relaxation or reciprocal inhibition.
•Force of Contraction
–Exceptionally gentle
•Example
–Restriction of regional cervical rotation
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Reciprocal Inhibition
•Goal
–To lengthen a muscle shortened by a cramp or acute spasm.
•Physiologic Basis
–When a gentle contraction is initiated in the AGONIST muscle, there is a reflex relaxation in that muscle’s ANTAGONISTIC group.
•Force of Contraction
–Very gentle (THINK OUNCES, not pounds)
•Example
–Torticollis due to acute sternocleidomastoid muscle spasm
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Crossed Extensor Reflex
•Goal
–Used on the extremities where the muscles to be treated are severely injured and not able to be manipulated or inaccessible. (ex: burns or fractures)
•Physiologic Basis
–These ME techniques utilize the learned crossed pattern locomotion reflexes engrained in the CNS. When the flexor muscle in one extremity is contracted voluntarily, the flexor in the contralateral extremity relaxes and the extensor contracts.
•Force of Contraction
–Very gentle (think ounces, not pounds)
•Example
–Severe acute hamstring strain
**contraction (flex) on one side --\> relaxation (extension) on contralateral side**
* **flex of R leg = relaxation of L leg (extension)**
* **extend baby's leg and it tries to "push your resistance off" (via flex other leg)**
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Isokinetic Strengthening
•Goal
–To re-establish normal tone and strength in a muscle weakened by reflex hypertonicty of the opposing muscle group.
•Physiologic Basis
–In Isokinetic contractions, the length of change occurs at a constant velocity. Utilizing a concentric contraction, the muscle is permitted to shorten, but at a controlled slow rate.
•Force of Contraction
–Sustained gentle pressure (10-20 lbs.)
•Example
–Hamstring shortening (hypertonic) resulting in reflex quadriceps weakness.
**what you do @ gym - pt contract with resistence just less than pt's contraction - M approximates origin and insertion - controlled rate**
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Isolytic Lengthening
•Goal
–To lengthen a muscle shortened by contracture and fibrosis.
•Physiologic Basis
–It is postulated that the vibration used here effects the myotatic units in addition to mechanical and circulatory effects.
•Force of Contraction
–Maximal contraction that can be comfortably resisted by the physician (30-50 lbs.) refer to slide 23
•Example
–Hamstring contracture
**resistance F against pt's contraction \> pt's contraction**
* **leads to forced "relaxation" --\> used to break up fibrosis**
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feather edge
the initial engagement of the restrictive barrier, where tension is just palpable.
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Muscle Energy Seq of Treatment
1. Accurate specific diagnosis of somatic dysfunction.
2. Physician positions the patient a the point of initial resistance, “feather edge”
3. The physician directs the patient to contract the appropriate muscles.
4. The physician applies a counterforce equal and opposite to the patient’s contraction.
5. The physician maintains forces until an appropriate patient contraction is felt at the articulation in dysfunction- this typically takes 3-5 seconds.
6. Complete relaxation by patient and physician.
7. The physician “takes up the slack” and repositions to the new restrictive barrier.
8. Steps 2-7 are repeated (usually 3-5 times) and culminate with a passive stretch.
9. Recheck the original somatic dysfunction.
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Indications for Muscle Energy
–Clinically relevant somatic dysfunctions,
* used to mobilize joints,
* to strengthen weak muscles,
* to stretch tight muscles and fascia and
* to improve circulation.
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Isometric
change in force but not length
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Isotonic
machine exercise - change in M length with fixed force
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Isolytic
contract into freedom of mvmt (contract fibrotic or chronically shortened myofascial tissues)
physician applies greater counterforce than pt F = golgi tendon relax
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Counterstrain
INDIRECT treatment
diagnosed by an associated myofascial tender point, is treated by using a position of spontaneous tissue release while simultaneously monitoring the tender point
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counterstain hx
Lawrence H. Jones
## Footnote
1955, when treating a man psoasitis & back pain.
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Tender Point
discrete, small, tense and edematous areas approximately the size of a dime
tender to an amt of P that usually does not cause pain
ØTender points can be located in ligaments, tendons, muscle or fascia.
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Proposed Mechanism of counterstrain
Øactivation of the muscle spindle, with a mismatch between alpha and gamma motor output.
Øgamma system was responsible for an inappropriate proprioception reflex.
* rapid shortening, then lengthening of the antagonist
end result is hypertonic myofascial tissue, restricted ROM and guarding by the patient
Muscle B in hypershortened state has no muscle spindle
input into spinal cord. To address this, the CNS increases
Gamma motor output to get muscle spindle to report.
III: joint not able to be returned to neutral because any
elongation of muscle B is interpreted as tearing because
of increased gamma tone to muscle spindle.
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Therapeutic Pulse
clue to the treatment time @ tender point
freq = same as cardiac = circulatory relationship
not present before positioning!
develops when position of ease is attained and disappears as myofasical tissue relaxes
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The amount of pressure needed to elicit a tender point is equivalent to
• amount of pressure required to blanch the nail bed of the diagnosing finger.
pressure will NOT produce tenderness in healthy tissue and does not radiate.
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Counterstrain tx pathway
1. Tender point localization
2. Establish tenderness assessment; “pain scale” (for our purposes, this will be a 10/10)
3. Continuously monitor the point
4. Place the patient passively in a position that results in the greatest reduction (\>70% with a goal of 100%) of tenderness at that point
a) First approximate position
b) Then fine-tune position through small arcs of movement (finding the greatest position of ease, usually fine-tune in multiple planes of motion).
5. Maintain the position for 90 seconds while continuously monitoring the point
6. Slowly return the patient passively to a neutral position
7. Re-test for tenderness at the tender point
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Significant Tender Point
If more then one tender point, treating the most significant point may resolve other tender points
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Maintaining the position of comfort for 90 seconds allows
proprioception firing to decrease in frequency and amplitude and for the mechanoreceptors to reduce stimulation of muscle contraction
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High Velocity Low Amplitude
* therapeutic force of brief duration that travels a short distance within the anatomic range of motion of the joint, and that engages the restrictive barrier in one or more planes of motion to elicit a release of restriction. Also known as a thrust technique.
* Direct, passive
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Pre-osteopathic usage of HVLA
•Hippocrates, Asian, bonesetters which had a European origin.•Hippocrates, Asian, bonesetters which had a European origin.
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Proposed Mechanism of HVLA
an overwhelming barrage of afferents from the muscle spindle which forces the CNS to turn down the gamma motor activity, as well as involvement of the golgi tendon mechanism from the forced stretch of muscles.
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Sequence of HVLA
* Position the segment into the barrier (opposite from the somatic dysfunction) to “lock it out”.
* Apply a SHORT (amplitude=distance), quick (velocity) thrust. The accuracy is dependent on the “lock”. The physician should not bounce or back off, after the barrier is engaged. Occasionally the joint will move with just the appropriate set up/lock and no thrust is required.
* Re-assess the joint. The patient should have immediate improved range of motion.
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sudden distraction of joint surfaces produces
nitrogen bubble, along with the noise and increased freedom of motion
noise may indicate a successful treatment, it could be from an unrelated joint and the altered joint would remain restricted
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Most frequent of the severe complications of HVLA
neurovascular accidents to the upper cervical spine
Occipitobasilar strokes (Wallenburg syndrome),
* vertebral artery compression with thrombosis, arterial dissections and cerebellar infarcts
vascular compromise due to cervical rotation of head extended on neck
* occlusion of vertebral A occurs opp of rotation
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Routine screening of scolosis begins:
10-15 y/o : puberty - rapid growth
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Scoliosis Characterized by
•Lateral curvature and Vertebral rotation
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Structural Scoliosis
idiopathic : condition not well understood
* often genetic predispostion
•characterized by a curve that fails to correct on side bending.
* C- curved or S- Curved
•Early loss of flexibility in the spine is the first sign of structural scoliosis
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Functional Scoliosis
* Correctible condition: postural or biomechanical factors
* Crucial to diagnose and treat while it is still flexible, otherwise it can grow into a structural issue.
1. Muscle Hypertonicity
2. Short Leg Syndrome
3. Compensation
4. Weak Musculature
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Functional Scoliosis: Muscle Hypertonicity
* Caused by Type I SD
* One side of the spine has hypertonic muscle, thus creating bowstring effect on spine
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Functional Scoliosis: •Short Leg Syndrome
* one leg is shorter than the other
* sacrum and pelvis tilt towards lower side.
* causes spine to curve back as it attempts to keep head and eyes level.
* Measure from ASIS to the medial malleolus of each leg
* Standing postural x-ray of iliac crests, sacral base, femoral heads is most accurate.
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Functional Scoliosis: Compensation
* The area of the spine next to the scoliotic curve will often curve in the opposite direction
* i.e. thoracic spine may curve to compensate for a curve in lumbar spine.
* May also see cranial side-bending dysfunction
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Functional Scoliosis: •Weak Musculature
* One side of the paravertebral muscles are weaker than the other
* The stronger muscle will create a bowstring effect on the spine.
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Screening for Scoliosis
Look at levelness of horizontal planes:
* Occipital plane
* Shoulder plane
* Scapular plane
* Iliac crest plane
* PSIS plane
* Greater trochanteric plane
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Clinical Evaluation of scoliosis
1) Evaluate trunk alignment with plumb line from occiput
2) Look for levelness of horizontal plane
3) Assess pelvis for rotation
4) Measure leg length
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what is this showinG?
Adam’s Forward Bend Test
* Stand behind patient
* Observe a “rib hump” as patient slowly bends forward.
* Run fingers along spinous process from top to bottom
* Ask patient to sidebend towards the high rib to see if levelness can be restored.
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Classification of Scoliosis
1. Reversibility
2. Severity
3. Location
4. Etiology
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Classification of Scoliosis: Reversibility
•Functional scoliotic curves go away with side bending, rotation or forward bending.
structural never reduces
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Classification of Scoliosis: severity
•Measured from taking postural x- rays and using Cobb method
The location of a structural curve is defined by the location of the apical vertebra.
* –Mild (5-15)
* –Moderate (20-45)
* –Severe( \>50)
•Compare x rays taken within a 5 month period
* •Is there a \> 5 degree increase in curvature?
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Classification of Scoliosis: etiology
1.Idiopathic
* •accounts for 70-90% of scoliotic curves
* •no known reason for occurrence
* •compensatory patterns
2. Congenital
* 75% progressive
3. Acquired
* Osteomalacia, Inflammation, Sciatic irritability, Psoas syndrome, healed leg fracture, hip prosthesis, short leg syndrome
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Levoscoliosis
Spine side-bends to the right and thus convex on the left.
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Dextroscoliosis
Spine side-bends toward left and thus convex on the right.
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Most common scolosis curve pattern in idiopathic scoliosis
Right thoracic Curve Pattern
## Footnote
\*severe vertebral rotation, ribs on convex side become badly deformed
\*Results in severe cosmetic defect, impairment of cardiopulmonary function when curve \> 60 degrees
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Double Major Scoliosis
S shape = double curve with convexity changing from one direction to another. this is less deforming because it looks like the patient is standing up straight.
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WHAT MAY AFFECT RIBS
ØVisceral organs are suspended from the bones through ligaments and fascia. Any restriction of the bone can affect the organ, and vice versa.
Any surgery, even abdominal or pelvic - destab rib cage
Muscle spasm of any origin.
Postural compensation
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pectus carinatum
the sternum projects forward and downward (congenital).
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pectus excavatum
the sternum pushed posteriorly by an overgrowth of the ribs (congenital).
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the sternum projects forward and upward, anteroposterior diameter is increased (pathological conditions, such as emphysema, COPD).
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KYPHOTIC DEFORMITIES
* Round back – pelvic inclination 20 degrees.
* Hump back (gibbus) anterior wedging of the body of one or two vertebrae, pelvic inclination is usually normal – 30 degrees.
* Dowager’s hump – results from postmenopausal osteoporosis, anterior wedge fractures, along with scoliosis.
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Adolescent Kyphosis
wedging shape of the vertebrae
5 degrees or more, constitutes Scheuermann’s disease.
* Postural roundback - deformity goes away when lying down
* Scheuermanns - need 2-3 pillows at night to stay comfy since deformity remains
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Func of ribs and sternum
–1. Protection of vital organs
–2. Respiration
–3. Pump for venous and lymphatic return
–4. Platform for upper extremities
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CLASSIFICATION
of the RIBS
* Ribs 1 through 7 articulate with the sternum directly and are classified as TRUE ribs.
* Ribs 8 through 10 join directly with the costocartilage and are classified as FALSE ribs (also vertebrochondral).
* Ribs 11 and 12 are classified as FLOATING ribs because they articulate only with the bodies of the T11 and T12.
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head of the rib articulates with
the vertebral body of its own vertebra and the vertebra above it.
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Atypical
ribs
1,11,12
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Anterior Articulations
* Rib 1: non-synovial synchondrosis with manubrium
* Rib 2: synovial with Angle of Louis
* 3-7 synovial with body of sternum
* 8-10 merge with cartilagenous mass
* 11-12 none and only have costovertebral articulation.
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Two types of posterior articulations
–costotransverse- tubercle of rib and transverse process of the vertebrae - absent in ribs 11& 12
–costovertebral- rib head and demifacets of vertebral body
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1st rib: landmark
•attached to the manubrium under the clavicle anteriorly
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2nd rib : landmark
•articulates with the sternum at the angle of Louis (body and manubrium).
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3rd rib : landmark
posteriorly = spine of scapula
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7th rib : landmark
anteriorly - sternal body and xiphoid
posteriorly - tip of inferior angle of scapula
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10th rib: landmark
cartilage can be palapted at mid-calvicular line at lowest point of rib cage
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12th rib : landmark
posteriorly will be the first bony structure palpated above the iliac crests and almost parallel to them.
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rib CLASSIFICATION by Motion
1-5: pump handle
* anterior elevates, posterior fixed, increase A/P diameter
6-10: bucket handle
* lateral elevates, A/P fixed, increase txverse diameter
11,12: caliper action
* increase both A/P and txverse diameter
* stab diagphragm
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INHALATION motion of ribs
1-5 = pump
6-10= bucket
11,12 = caliper (posterior and lateral)
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EXHALATION mvmt of ribs
1-10 = caudad
11,12 = anterior, medial
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Angle of Louis
what type of joint?
•(synchondrosis) where second rib articulates
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a landmark for several counterstrain tender points
Manubriosternal or jugular notch
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FIRST RIB
* Broad, flat, most curved and the shortest and strongest, has single articular facet on the head.
* It is the lateral border of the thoracic inlet. Articulates with only T1, no angle.
* Muscle Attachments ( MASS )
* Middle + Anterior scalenes (from the neck);
* •Subclavius + Serratus anterior (from anterior chest wall)
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THORACIC OUTLET SYNDROME
subclavian artery and the brachial plexus
* compression passing over 1st rib b/w tubercles and attachments of anterior and middle scale M
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costo-clavicular syndrome
entrapment of the brachial plexus and/or subclavian artery and vein between the first rib and the clavicle.
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third type of thoracic outlet syndrome
compression of the neuromuscular bundle happens along the border of the pectoralis minor near its attachment to the coracoid process and the rib cage.
not related to 1st rib
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Accessory muscles: forced inspiration
A.Sternomastoid
B.Scalenes (3 pair) – Anterior, Medius, Posterior.
C.Pectoralis major and minor.
D.Serratus anterior (inferior fibers).
E.Latissimus dorsi. (Lower 3 or 4 ribs)
F.Serratus posterior superior.
G.Iliocostalis (superior fibers).
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Anterior, Medial & Posterior Scalenes
* Origin: transverse processes of cervicals
* insertion:
–ant. & med- rib 1
–post. - rib 2
•action - elevate ribs 1 & 2
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Ribs 3, 4, 5 moved by
Pectoralis Minor
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RIBS 9,10,11,12 moved by
serratus posterior inferior
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Quadratus lumborum
* Origin: iliolumbar ligament, iliac crest
* Insertion: rib 12
Action: moves rib 12 - inhalation
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Thoracostomy (chest) tube is usually placed
fourth intercostal space just above the fifth rib.
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Intercostal Vascular & Nerve Supply
superior to inferior: VAN - vein, A, N
begween intercostalis intimus and interus
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Sympathetic ganglia and location on ribs
anterior to the head of each rib .
Somatic Dysfunction of the thoracic vertebrae and or ribs
can irritate a thoracic sympathetic nerve.
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INHALATION SOMATIC DYSFUNCTION
ribs stay up during exhale (classified as elevated)
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EXHALATION SOMATIC DYSFUNCTION
ribs stay down during inhale (classified as depressed)
exhalation dysfunction = inhalation restriction
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Which Rib to Treat for inhalation/exhalation SD
* B ottom
* I nhalation SD
* T op
* E xhalation SD
* In inhalation SD key rib to be treated is the lowest rib.
* In exhalation SD key rib to be treated is the top rib.
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Viscero-somatic Reflex
•Localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures
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VISCERAL AFFERENTS
•Contain Naked nerve endings (Peripheral Afferent Nociceptors = PAN’s)
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•PAN’s respond to 3 forms of potentially damaging stimuli:
–Thermal
–Mechanical
–Chemical (inflamm mediators)
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Where do visceral afferents synapse?
A.In the dorsal horn of the spinal cord
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ongoing afferent stimulation eventually leads to that segment of spinal cord becoming
•“facilitated” or “sensitized.”
given input level, the output exceeds appropriate response
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hypersensitive’ interneurons synapse with both
–The neurons in the lateral horn: the sympathetic system in the thorax and upper lumbar segments
–The motor neurons in the ventral horn
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Facilitation in the thoracic and upper lumbar segments of the spinal cord results in
1. “Sympathicotonia” or increased sympathetic tone…
2. Increased efferent activity to segmentally related musculature
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Chronic Segmental Facilitation
CHRONICALLY FACILITATED SEGMENT
* Thickened skin
* Increased muscle tone (“ropey muscles-dry”)
* Hypersensitive muscles
* Stiff joints with a firm end-feel
* Rapidly fading red reflex
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ACUTELY FACILITATED SEGMENT
* Increased temperature
* Increased skin moisture and skin drag
* Boggy muscles (“swollen”)
* Prolonged red reflex
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Sympathetic Memorization : T1 – T4
•Sympathetics to head and neck.
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Sympathetic Memorization : T1 – 6
•Heart + lungs. (Heart tends to display Left sided findings)
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Sympathetic Memorization : T5 – T9
•Upper abdominal viscera (celiac plexus)
–Right: Liver, GB, duodenum, head of the pancreas
–Left: Stomach, spleen, tail of the pancreas
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Sympathetic Memorization : T10 – T11
• (Superior mesenteric plexus)
–Remainder of small intestines, kidney, upper part of the ureters, gonads (ovaries and testes)
–Right: Appendix, cecum, and ascending colon
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Sympathetic Memorization : T12- L2
•(Inferior mesenteric and hypogastric plexi)
–Descending, sigmoid colon, lower part of ureter and pelvic organs (bladder, uterus, prostate).
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Palpated reflexes are of diagnostic value because
consistent anatomic relationship between the involved organ and the paraspinal soft tissues.
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“The possibility of recognition of abnormal viscerosomatic reflexes as an aid in diagnosis is inferred.”
Louisa Burns, 1907
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Vagus is _____ % afferent
* Up to 90% Afferent.
* Connections to spinal cord at C1 and C2
on to nucleur solitarius
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Nociception is mostly carried by
•VISCERAL afferents traveling with sympathetics
–Nociception is a strong drive for facilitation
282
PNS usually more conceerned with....
physio function
portion is nociceptive but not much - sympathetics = MORE nociceptive!
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is SC is facilitated and there is a loop of increased sympathetics from increased visceral input causing more visceral input by vasoconstriction, what to do about OMT?
try to do inhibitory, slower and steadier tx
OMT can be helpful by reducing afferent drive into facilitated seg of SC
1. reduce visceral nocicptive input
2. reduce somatic nociceptive input
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Sympathetic Outflow and ribs
to treat the ganglion, you need to treat both the rib and the thoracic vertebrae.
costotransverse seg
•Somatic dysfunction of a thoracic vertebra and/or rib can irritate or inhibit a thoracic sympathetic nerve.
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Chapman Reflexes or ‘Points’
found nodules correlated with visceral pathology
## Footnote
•“pea” or “BB” – 2-3 mm in diameter
–Smooth, Firm
–Discretely Palpable
–Usually tender to the patient
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where are Chapman “Point” usually located
•located beneath Sub-Q tissue on the deep fascia
* anterior: in between ribs near sternum
* posterior: gutter between TP and SP
* colon : found on lateral thigh
* Chronic : Points coalesce = bigger
* Tender point is muscle = different
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Chapman points physiology
•ganglioform contraction that blocks lymphatic drainage
visceral-somatic thinking
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tx of Chapman points
* firm, circular motion
* Dr. Chapman stated that one would treat the anterior points and use the posterior points for diagnosis
