Flashcards in Lectures 8-15 Deck (269)
What part of the nervous system dominates the normal functioning of the lungs?
Persistent or unexpected coughing leads to what type of dysfx which complicates hemostasis?
Rib exhalation somatic rib dysfunctions
Pathophysiology of the pleura creates what structures?
What is dysfunctional about the receptors in the Hering-Breuer reflex?
They are unable to distinguish between fluid and air.
When the air sacs fill with fluid the Vagus. n sends a message to do what?
Decrease diaphragmatic excursion
What happens to the carotid body during this time?
It perceives the need for more O2 and sends signal to increase respiratory rate.
What is the ultimate result of the Hering-Breuer reflex?
Rapid, shallow breathing that can lead to loss of fluid.
What controls the sympathetics of the lungs?
T1-T6 (Parietal pleura may extend to T11)
What structures are stimulated by increased sympathetic tone and what does this lead to?
Stimulates bronchial glands, leading to increased numbers of Goblet cells and thick mucous secretions
Increased sympathetic tone does what to bronchiolar smooth muscle?
What happens with prolonged sympathicotonia?
Vasoconstriction and hypoperfusion of the lung
What causes a Chapman point?
Increased sympathetic tone causes lymphatic stasis that is palpable as a tender myofascial, rubbery nodule. A primary visceral afferent produces a secondary myofascial tender point.
Do Chapman points radiate?
How do you manipulate a Chapman point?
With mild-moderate pressure in small circles; do this until modularity and tenderness dissipates
Where is the anterior Chapman point for the Bronchus?
2nd intercostal space near the sternum
Where is the anterior Chapman point for the Upper Lung?
3rd intercostal space near the sternum
Where is the anterior Chapman point for the Lower Lung?
4th intercostal space near the sternum
Where is the posterior Chapman point for the Bronchus?
In the soft tissue between spinous process of T2 and transverse process of T2
Where is the posterior Chapman point for the Upper Lung?
In the soft tissue between spinous process of T3 and transverse process of T4
Where is the posterior Chapman point for the Lower Lung?
In the soft tissue between spinous process of T4 and transverse process of T5
What is the parasympathetic nerve of the lung?
Vagus (CN X)
What do CN IX/X, and the carotid body control?
BP, CO2, and O2 regulation
What effect do the parasympathetics have on the bronchial cells?
Inhibition of bronchial cells decreases the number of Goblet cells and leads thinning of mucous
How do parasympathetics effect the bronchiolar smooth muscle?
What can you evaluate to Dx parasympathetic function?
What occurs in an inhalation rib dysfunction?
Rib or group of ribs is “stuck up” and does not come down fully during exhalation. Rib space is narrow and wider below.
What is the key rib in an inhalation dysfunction?
Bottom rib (BITE)
What are the Sx of inhalation dysfunction?
Pain with exhalation and it may cause rapid, shallow breathing
What occurs in an exhalation dysfunction?
Rib or group of ribs is “stuck down” and unable to move up fully in inhalation. Rib spaces is wider, and narrower below.
What is the key rib of an exhalation dysfunction?
Top rib (BITE)
What are the Sx of an exhalation dysfunction?
Pain with inspiration
What comprises the functional thoracic inlet?
T1-4, ribs 1+2, manubrium, clavicles
Where is the drainage of the pleural sacs and lung tissues?
Pretracheal nodes——-> Right lymphatic duct
What is the innervation of the diaphragm?
C3,4,5 keep the diaphragm alive!
What creates negative intra-thoracic pressure?
What creates positive intra-thoracic pressure?
What structures pass through the diaphragm and where?
I 8 10 Eggs at Noon
IVC, T8; T10, Esophagus; Aorta T12
What structure opens in inhalation?
What structure closes in inhalation?
What muscles are you using when you treat with ME for the first rib?
Anterior + Middle scalenes
What muscles are you using when you treat with ME of the second rib?
What muscles are you using when you treat with ME Ribs 3-5?
What muscles are you using when you treat with ME Ribs 6-9?
What muscles are you using when you treat with ME Ribs 10-11?
What muscles are you using when you treat with ME Rib 12?
What muscles of respiration become overused in pulmonary disease, producing Sx in the neck and back?
What syndrome is associated with breathing with your neck?
Thoracic OUTLET syndrome
What Sx can occur with breathing with your back?
Pneumonia is highly associated with what kind of surgery?
What do you treat Pre-Op to prevent pneumonia?
C3-5 (aka Phrenic n.)
What do you treat Post-Op to prevent pneumonia?
Also C3-5 + rib raising
What are some situations in which HVLA may not be well tolerated?
Toxic tissues, viscerosomatic dysfunctions
What are the atypical ribs?
Anything with a 1 or 2: so, Rib 1, Rib 2, Rib 10, Ribs 11 + 12
Typical ribs contain 2 ______ articulations at the ________ joints.
Typical ribs have _____ articulation with the transverse process but have ______ articulation(s) some the same vertebrae
What makes Rib 1 atypical?
It articulates only with T1 and has no rib angle.
What makes Rib 2 atypical?
Large tuberosity attaching to Serratus anterior
What makes Rib 10 atypical?
Not always considered to be atypical, but attaches only to T10
What makes Ribs 11 + 12 atypical?
Articulate only with the corresponding vertebra (i.e. Floating ribs)
What are the True Ribs?
Where do the true ribs attach?
Directly or through chondral masses to the sternum
What are the False Ribs?
Do the false ribs attach directly to the sternum?
What are the Floating Ribs?
Ribs 11 + 12
“The sympathetic nervous system is diffuse in distribution the and is the sole enervator of both the musculoskeletal and vasomotor systems. Therefore somatic dysfunction could impact on reflex patterns between both the musculoskeletal and autonomic nervous systems through the sympathetic intermediary, as well as the vasomotor system and could also become a common denominator in a wide variety of disease entities. The only way to alter sympathetic activity is osteopathic manipulative treatment.”
Who said this?
What is the primary motion of Rib 1?
50% Pump Handle Motion + 50% Bucket Handle Motion
What is the primary motion of Ribs 2-5?
What ribs display primarily Bucket Handle Motion?
What ribs display Caliper motion?
11 + 12
Pump Handle Motion of Ribs 1-5 increases what?
AP Chest diameter
What happens to Pump Handle ribs during inhalation?
Posterior angles moves inferiorly and anterior ends move superiorly around the transverse axis.
Where is Pump Handle Motion best palpated?
The axis of rotation is closer to what plane in pump handle motion?
What muscles lift the chest for pump handle motion?
Ribs 3/4/5: Lifted by pec minor
Rib 2: Lifted by pec major
Posterior Scalene m
Bucket Handle motion increases what diameter and occurs around what axis?
Increases transverse chest diameter occurring around the AP axis
What occurs with bucket handle motion during inhalation?
Intercostal space widens and the rib moves laterally and superiorly.
What occurs with bucket handle motion during exhalation?
Intercostal space narrow and rib moves medially and inferiorly
Where is Bucket Handle Motion best palpated?
Mid- axillary line
The axis of rotation is closer to what plane in bucket handle motion?
What muscle lifts the chest in Bucket Handle motion?
How do Ribs 11 + 12 move during caliper motion?
Both move posteriorly and laterally
Rib 11 moves slightly superior and Rib 12 moves slightly inferior
How do Ribs 11 + 12 move during exhalation?
Anterior and medially
What muscles attach cervical vertebrae to the 1st rib?
Anterior and middle scalenes
What structure emerges between the anterior and middle scalenes?
The brachial plexus
What structure attaches the 1st rib to the clavicle?
What are the attachments of the diaphragm?
Anterolateral surface f T12-L3
What is the origin of the serratus anterior?
Anterior surface of the medial border of the scapula
What is the insertion of the serratus anterior?
Superior lateral surface of Ribs 2-8
What is the action of the serratus anterior?
Protracts the scapula and holds it against the thoracic wall
What is the innervation of the serratus anterior?
Long thoracic nerve (C5-C7)
What are the muscles of Forced Inhalation?
SCM, Scalenes, Serratus anterior m.
What innervates the SCM?
CN XI (Spinal Accessory n.)
What part of the chest does the SCM move?
Manubrium of the sternum/ Lateral 1/3 of clavicle
What innervates the scalenes?
Ventral rami of C3-C8
What is the main muscle of forced expiration?
What is the innervation of the rectus abdominus?
Lower 6 thoracic and first lumbar segmental nerves
What is Plagiocephaly?
Asymmetrical and twisted condition of the head, resulting from irregular closure of the cranial sutures
What is the anterior fontanelle?
It is the junction of the frontal + parietal bones at the intersection of the metopic, coronal, and sagittal sutures
When does the anterior fontanelle close?
@ 20 months
What is the posterior fontanelle?
The junction of the lambdoid and sagittal sutures
When does the posterior fontanelle close?
@ 3 months
What is Craniosynostosis?
Premature closure of the fontanelles
Increased venous congestions leads to what condition?
85% of the venous drainage of the head is via the ___________ veins located in the ________ foramina between the occipital and temporal bones.
Dilated pupils, photophobia, and narrow angle glaucoma are all condition that are related to increased sympathetic tone where?
A constricted pupil is due to what nerve?
CN III, parasympathetic response
Where does CN III synapse?
Ciliary ganglion; (goes to ciliary muscle)
What are some of the causes of nystagmus?
Can be congenital, secondary to vision loss, medication, MS, etc.
What nerves are compressed to elicit nystagmus?
CN III, IV, VI near tentorium
Is conjunctivitis usually bacterial or viral?
Conductive hearing loss can be secondary to what dysfunction?
Dysfunction of the Eustachian tube
What is the sympathetic innervation of the lungs?
What is the parasympathetic innervation of the lungs?
Increased sympathetic tone will do what to nasal secretions?
What is the first sign of lymphatic congestion?
A “Plugged Ear” is secondary to what type of infection?
What are the Sx of Sphenopalatine syndrome (aka Pterygopalatine syndrome)?
Red, engorged mucous membranes, photophobia, tearing and pain behind the eye, nose, neck, ear, and temple
What the is cause of Sphenopalatine syndrome?
Irritation/somatic dysfunction of the sphenopalatine ganglion.
What is the route of parasympathetic innervation to the lacrimal gland + nasopharyngeal mucosa?
Innervation travels via CN VII, synapses in the sphenopalatine ganglion
How do you Tx somatic dysfunction of the sphenopalatine ganglion and what is the result of Tx?
Stimulation of the Sphenopalatine ganglion; results in tearing and thinning of secretion
What are some of the clinical effects of autonomic dysfunction?
Vasomotor congestion, secretions, nutritive functions, immune response, visual disturbances, hearing disturbances, vertigo, dizziness, light-headedness, and pain
What are some of the Sx associated with increased sympathetic activity?
Thick secretions with cough/irritation; dilation of pupils and photophobia; clouding of the lens; vasoconstriction; dry and cracked mucous membranes (pharyngitis); and secondary infections
What are some of the Sx of increased parasympathetic activity?
Increased clear, thin, watery secretions of glands; irritation of tissues; pupillary constriction and vision disturbance
What anatomical changes can affect autonomic output?
Cranial nerve entrapments + TMJ syndrome
What nerves are affected in cranial nerve entrapment?
CN III, IV, VI
What do these nerves pass under?
Petrosphenoidal ligament formed by the tentorum cerebelli
Entrapment of nerves in the petrasphenoidal ligament leads to what?
Increased dural strain
What are the SX of Cranial Nerve Entrapment?
Blurred vision, diplopia, nystagmus, eye fatigue, headache
What nerve is closest to the dura and is most likely affected?
If CN IV is affected, what is the result?
What is the first step of the general treatment plan for HEENT?
Treat the thoracic inlet (1st ribs and stellate ganglion, cervicothoracic)
Treatment of what region of the thoracics is most effective for HEENT?
What is the main goal of rib raising?
To normalize the sympathetic ganglia
What is the main goal of treating rib dysfunction?
To improve respiration and enhance drainage
What is the result of releasing the diaphragm?
When you treat L1 + L2, what are you really treating?
The diaphragmatic attachments
Frank Chapman initially described his points (in the 1920s) as _________ __________ that blocks lymphatic drainage.
Who wrote “An Endocrine Interpretation of Chapman’s reflexes” in 1937?
Charles Owens DO and Ada Chapman DO
What syndrome did Owens coin?
PTAS: Pelvis-Thyroid-Adrenal Syndrome
What is the official Hendryx definition of a Chapman reflex?
A system of reflex points that present as predictable anterior and posterior fascial tissue texture abnormalities (plaque-like changes or stringiness of the involved tissues) assumed to be reflections of visceral dysfunctions or pathology. Used by Chapman and described by Owens
Where are Chapman points located?
Located deep to skin, subcutaneous tissue in deep fascia or on periosteum
We know that Chapman points are paired on both the anterior and posterior surfaces. Which points are usually more tender?
Describe a Chapman point.
Nodular: small (2-3 mm), smooth, firm, discrete, and move slightly
Does the pain radiate in a Chapman point?
Where are the VS Reflexes of the Upper Respiratory Tract (i.e. Head, Neck and Bronchi) located?
Where are the Cardiopulmonary (i.e. Heart, Lungs, Trachea, and Bronchi) VS reflexes located?
What are the VS Reflexes T5-T9 on the Left?
Stomach (L) and Duodenum
What are the VS Reflexes T5-T9 on the right?
Liver and Gallbladder
What are the VS Reflexes T7 on the Right and on the Left?
Where are the VS Reflexes for the Right side of the colon located?
Where are the VS Reflexes for the left side of the colon located?
Where is the VS Reflex for the appendix?
What is the first step in treatment using Chapman points?
Normalize the pelvis
How long do you typically treat a Chapman point?
What treatment methods seem to correlate with the meridian acupuncture points?
Chapman points (60%)
Travell Trigger Points (70%)
Jones Counterstrain (80%)
How many tender points must a fibromyalgia pt experience in order to make a definitive Dx?
11/18 or more
What is the definition of a primary Key Lesion?
The somatic dysfunction that maintains a total pattern of dysfunction, including other secondary dysfunctions
What are some examples of those other secondary dysfunctions?
They can be somatic, visceral, mental, emotional, spiritual, or energetic
What is the definition of a secondary Key Lesion?
Somatic dysfunction arising either from mechanical or neurophysiologic responses subsequent to or as a consequence of other physiologies
What are 3 ways to find Key Lesions?
Through H + P; listening/observing; appropriate evaluation
What are the 3 headache classifications?
Migraine (with or without aura); Tension-type, Cluster
What is the most important factor in Dx of a headache etiology?
Take a good H + P
Name some other types of headache etiologies:
Idiopathic cranial HTN
Spinal low pressure
Chronic daily headache
What is the most prevalent type of primary headache in the general population?
Tension-Type Headache, mostly the infrequent episodic subtype (less than once/month)
What plays a critical role in the pathogenesis of TTH?
Heightened sensitivity of the pain pathways in the CNS and PNS
What type of condition is associated with the intensity and frequency of TTH attacks?
Pericranial muscle tenderness
How do you Tx a TTH?
Pharmacologic (NSAIDS, m. relaxants, antidepressants)
What is the theories regarding the pathophysiology of Cluster headaches?
PNS and SNS dys fyx
How do you Tx Cluster headache?
What OMT can you perform for a cluster headache?
Same as for Migraine:
Cranial, C1-C3, Upper thoracics, 1st rib, lymph + thoracic inlet
ALSO: SPG release
Define Bell palsy.
A unilateral lower motor neuron facial paralysis resulting from dysfx of CN VII
What is the etiology of Bell palsy?
Possibly viral infection or cold air exposure, psychological distress
What is the natural history of Bell palsy?
What are some Tx options for Bell palsy?
Protect the eye
Prednisone +/- antivirals
Inflammation of CN VII at the location of the ______ _______ is responsible for Bell palsy.
What type of cranial somatic dysfunction is typically seen with Bell palsy?
Internally rotated temporal bone
How can you correct somatic dysfunction in Bell palsy?
Using indirect or direct action cranial techniques
What Sx do you see with TMJ Dysfunction?
Pain over TMJ radiating to the ear; clicking, popping, locking of jaw when opening/closing; deviation of jaw to one side with opening
What structures make up the TMJ?
It is formed by the head of the mandible + mandibular fossa of the temporal bone as well as the fibrous capsule and ligaments
What occurs when the mouth opens?
The head of the mandible + articular disc move anteriorly relative to the temporal bone. The opposite occurs when the mouth closes.
When the mouth opens, the head of the mandible rotates about a ______________ axis on the inferior surface of the articular disc.
What occurs when the jaw protrudes?
Head of mandible glide anteriorly and articular discs move posteriorly. The opposite occurs with retraction of the jaw.
When the mouth closes, the head of the mandible rotates _________ direction on the transverse axis.
Who is the father of cranial osteopathy?
William Garner Sutherland, DO
“Beveled, like the gills of a fish, and indicating an articular mobile mechanism for respiration”
_______ ________ ________
William Garner Sutherland
What are the 5 tenants that comprise the Primary Respiratory Mechanism?
Inherent mobility of the brain and spinal cord
Fluctuation of the CSF
Mobility of the intracranial and intraspinal membrane (reciprocal membrane tension)
Articular mobility of the cranial bones
Involuntary mobility of the sacrum between the ilia
What does PRM maintain?
Maintains an inherent, rhythmic, automatic, involuntary “life and motion” cycle of mobility and motility expressed by every cell and all the fluids in the body
Brain and spinal cord have a subtle, inherent slow pulse-wave like motion described as having ________ ________, which ma have a rhythmic nature
What happens in the flexion phase?
CNS shortens and thickens
What happens in the extension phase?
CNS lengthens and thins
What causes fluctuation of the CSF?
Pressure gradients produced by production and release of the CSF into the cranial cavity by the choroid plexus in the ventricles, and drainage of CSF into the venous system and lymphatics
Inherent motility of the brain and spinal cord will cause movement of the ______ ______.
What is the “Sutherland “fulcrum”
Junction of the falx and tentorum at the common origin: Straight sinus
A balancing point or fulcrum located along the straight sinus where falx cerebri joins tentorium cerebelli
Provides balancing point from which membranes can shift in response to motion induced by primary respiratory mechanism
Cranial and spinal nerves may be affected by what changes?
Changes in dural tension
What is the Reciprocal Tension Membrane?
It is the core link between the cranium and sacrum
What is a suture?
Sutures are joints that allow for a minimal amount of motion while still providing protection for the brain
Cranial dura is continuous with spinal dura which has a firm attachment where?
To the posterior superior aspect of the second sacral segment
The sacrum rocks between the ilia on the __________ ________ _______ through the articular pillar of the second sacral segment.
superior transverse axis
What is the movement of the sacrum in flexion?
Posterior and superior
What is the movement of the sacrum in extension?
Anterior and inferior
What is the keystone of all cranial movement?
SBS: Sphenobasilar synchodrosis. The angle of the SBS defines the Flexion and Extension phases.
The basiocciput and basisphenoid move ___________ during flexion.
How many cycles/minute is typical motion?
What are some things that will diminish the amplitude of a flexion/extension cycle?
Age, stress, psychiatric illness, infection, chronic poisoning
What are some things that will increase the amplitude of a flexion/extension cycle?
Exercise, fever, OMT
__________ bones flex and extend as defined by the SBS
What is the motion of paired bones?
Internal and external rotation
Do the sacrum and occiput move in the same or different direction(s) due to RTM?
Temporal motion is driven by what?
Facial bone motion is driven by what?
What bones are considered midline structures?
Occiput + sphenoid; ethmoid + vomer; sacrum
What bones are considered paired structures?
Parietals, temporals, frontal (yeah, I know, I don’t like it either); most facial bones, innominates, UE + LE
In flexion, there is an increase in _______ diameter and a decrease in _________ diameter.
In flexion, rotation of the sphenoid is __________.
How does the basiocciput move during flexion?
How does the foramen magnum move during flexion?
How does the sacral base move during flexion?
Posteriorly and superiorly
An “Ernie” head is in what?
A “Burt” head is in what?
What are the 4 physiological strains?
Flexion, extension, torsion, sidebending rotation
What are the three pathological strains?
Superior + Inferior Vertical, Right and Left Lateral, SBS compression
What is the goal of cranial osteopathy?
To balance membranous tension
Who benefits from indirect action (aka exaggeration) techniques?
Ages 5 through adult
What is a contraindication to the indirect action technique?
Who benefits from direct action (aka disengagement) techniques?
When is it appropriate to use a disengagement technique?
In cases of trauma or overriding sutures
What are the 2 absolute contraindications to treatment with cranial osteopathic techniques?
Intracranial bleed or increased intracranial pressure
What type of motion does the serrate (sawtooth) suture have?
What type of motion does the squamous (scale-like) suture have?
What type of motion does the harmonic (edge to edge) suture allow?
This suture allows for a combination motion.
Cranial Rhythmic Impulse: A palpable rhythmic fluctuation believed to be synchronous with PRM
Where is CRI palpated?
Cranium and sacrum
What type of axis is the craniosacral axis?
Superior transverse axis through S2 segment
What is the motion of the sacrum?
Flexion + Extension
What do the paired bones do during flexion?
Externally rotate (Ernie head, and Ernie is an extrovert)
What do the paired bones do during extension?
Internally rotate (Burt head and he’s an introvert)
What is the axis of a torsion?
Do the sphenoid and occiput rotate in the SAME or OPPOSITE directions in a torsion?
How do you name a torsion?
Named for the side of the higher great wing of the sphenoid (either a L or R torsion)
What are the axes for sidebending/rotation?
Two parallel vertical and one AP
Sphenoid and occiput rotate ___________ directions about the vertical axes and ________ direction about the side of the AP axis.
How do you name side-bending/rotation?
Named for the side of the convexity
What are the axes of a lateral strain?
2 parallel ; one through the sphenoid and one through the foramen magnum
In a lateral strain, sphenoid and occiput rotate in the _______ direction.
How do you name a lateral strain?
Named according to the location of the base of the sphenoid
What are the axes of a vertical strain/shear?
2 parallel transverse axes
In a shear, sphenoid and occiput rotate in the ______ direction.
What cranial impingement disorders arise from a dysfunction of CN X?
GI, respiratory, cardiac arrhythmias, colic, nausea/vomiting
What cranial impingement disorders arise from a dysfunction of CN IX,X?
Torticollis (SCM dysfxn), upper trap spasm, weakness (XI)
What cranial impingement disorders arise from a dysfunction of CN IX, X, XII?
Sucking/swallowing problems in infants
Name the 4 parts of the occiput at birth.
Base, squama, 2 condylar parts
At what age do the occipital part ossify?
What is the Tx for failure to suckle?
Condylar decompression and release temporal
List the full Sx of Bell palsy.
Facial m. paralysis (CN VII), chorda tympani dysfx leads to loss of taste on anterior 2/3 of tongue, hyperacusis due to paralyzed stapedius m.
How do you Tx Bell palsy with OMT?
Tx temporal, sphenoid, occipital bones, and stylomastoid foramen somatic dysfunctions
Compression of what nerve will cause tinnitus?
What is the OMT Tx for tinnitus?
Tx of temporal, sphenoid, occipital bone and SCM
What are the sympathetic pre-ganglionic collateral ganglia?
T12: Least Splanchnic
L1-L2: Lumbar splanchnic
The celiac ganglion sends post-ganglionic fibers to what structures?
Distal esophagus, stomach, liver, gallbladder, spleen, some pancreas, proximal duodenum (aka Foregut)
The superior mesenteric ganglion sends post-ganglionic fibers to what structures?
Some pancreas, duodenum, jejunum, ileum, ascending colon, proximal 2/3 of transverse colon (aka midgut) ; adrenals, gonads, kidneys upper 1/2 of ureters
The inferior mesenteric ganglion sends post-ganglionic fibers to what structures?
Distal 1/3 transverse colon, descending colon, sigmoid colon, rectum (Hindgut) lower 1/2 of ureter, bladder, genitalia
The thoracic duct pierces what structure two times?
What is the order of ventricular flow?
1. Lateral ventricle
2. Foramen of Monroe
3. 3rd ventricle
4. Cerebral aqueduct of sylvius
5. 4th ventricle
6. Foramen of Magendie
What major structure of the brain regulated respiration and where is it located?
Medulla; located in the fourth ventricle
What is a big, bad contraindication to Tx with CV-4?
Pregnancy: Stimulation of ptosin can induce early labor
Also acute CVA, malignant HTN, skull fracture, and aneurysm
What ages is otitis media common?
occurs in 20% of infants between 6 mo- 6 years
Why are ear infections more common in children?
Eustachian tube is narrower, shorter, and more horizontal, making the movement of fluid and air difficult