OPP EXAM ONE

OMT

*Osteopathic Manipulative Treatment*

The therapeutic application of manually guided forces by a physician to improve physiological function and homeostasis that has been altered by somatic dysfunction.

\

OPP

*Osteopathic Principles and Practice*

Historic term relating to osteopathic philosophy and application.

Course at some colleges of osteopathic medicine.

OMM

*Osteopathic Manipulative Medicine*

The application of osteopathic philosophy, structural diagnosis, and use of osteopathic manipulative treatment (OMT) in the diagnosis and management of the patient.

NMM

*Neuromusculoskeletal Medicine*

Specialty that emphasizes the incorporation of osteopathic manual diagnosis and osteopathic manipulative treatment into the evaluation and treatment of the nervous, muscular, and skeletal systems in their relationships to other systems of the body as well as the whole person.

ONMN

*Osteopathic Neuromusculoskeletal Medicine*

A primary ACGME residency program disciplined in the neuromusculoskeletal system, its comprehensive relationship to other organ systems, and its dynamic function of locomotion.

The 4 Tenets of Osteopathic Medical Philosophy

•The body is a unit; the person is a unit of body, mind, and spirit.

\
•The body is capable of self-regulation, self-healing, and health maintenance.

\
•Structure and function are reciprocally interrelated.



•Rational treatment is based upon on these principles

Somatic Dysfunction

Impaired or altered function of related components of the somatic (body framework) system.

This may include skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.

What is the purpose of OMT?

1. Hands-on treatment aimed at:


1. Resolving primary and secondary somatic dysfunctions


1. Additional Goals:


1. Improving homeostatic mechanisms (e.g., respiratory, circulatory, immune, etc.)
2. Improving energy efficiency (e.g., reduction of the work of breathing or more efficient gait)
3. Reduction of inappropriate afferent neural stimuli

What are the goals of OMT?

1. Normalize structure
2. Increase functional movement
3. Remove impediments to nervous and arterial supply and venous/lymphatic return
4. Restore correct anatomical/functional relationships (correct somatic dysfunction)
5. Restore normal vascular supply (arterial)
6. Improve venous/lymphatic drainage (reduce stagnation, congestion)
7. Improve neurological function (reduce entrapments/balance ANS)
8. Remove viscerosomatic or somatovisceral reflexes and other impedances to homeostasis
9. Reduce or eliminate pain
10. Stimulate the immune system Prevent recurrences

The only indication for OMT is….

Somatic dysfunction

Who founded the osteopathic medical profession?

Andrew Taylor Still, MD, DO

What was the year that he said he discovered osteopathy?

1874

What was the name of the first osteopathic medical school? What year was it founded? Where was it founded?

American School of Osteopathy

1892

Kirksville, MO

If you had to express the osteopathic philosophy in about a five word sentence, what would it be?

Seek health in your patients

\

 What are the two most common presenting complaints which may indicate the need for OMT?

Pain & ROM

Name the two values/conditions in the muscles and bones which are generally set to pathological values in somatic dysfunction, and are the first gross values reset by OMT?

Muscle length and tension

Joint surface apposition

“The rule of the artery is: ______”

Supreme

The first state to license the practice of osteopathy was:

Vermont, 1896

The last state to license the practice of osteopathic medicine was:

Mississippi, 1973

What are the five models of somatic function and dysfunction?

Biomechanical, Respiratory-Circulatory, Neurological, Metabolic-energy

What is significant about 1971?

Arkansas granted Osteopathic Physicians the right to apply for unlimited licensure

What do we D.O.?

\
If we combine our knowledge of anatomy, physiology, and pathophysiology, we can develop safe, effective, and rational treatment methods for our patients.

**“________ are for situations we imagine.**



  **________ are for ones we don’t.”**

Techniques, Principles

Unconscious Incompetence

Does not necessarily recognize the deficit. May deny the usefulness of the skill. *Wrong Intuition.*

Conscious Incompetence

Recognizes the deficit and sees value in a new skill. Doesn’t yet know how to do the new skill. *Wrong analysis.*

Conscious Competence

Two Parts: Knowledge, Practice

Understands and knows how to do something. Heavy conscious involvement in executing the new skill. *Right Analysis.*

\

Unconscious Competence

The skill is “second nature” and can be performed easily. Can teach others. *Right Intuition.*

Posture

**is the shape and position of the body when under the effects of gravity.**

Optimal Posture

Reduces stress on the body due to gravity during exertion.



Optimal __posture__ is a perfect distribution of the body mass around the center of gravity.



•This is achieved when postural muscles are at resting tone with no additional energy beyond basal level needed for upright posture.

Gait

Posture in Motion

Optimal Gait

is the maximization of energy transformation into motion.

This is achieved when the three distinct oscillatory motions of gait summate with minimal interference, maximizing energy transformation into motion.

Kyphosis

is the primary curve of the vertebral column at birth.

When do the cervical and lumbar lordosis develop?

Cervical lordosis accentuates around 4-7 months.



Lumbar lordosis develops after 12 months

When does a child typically take its first steps?

12mo

How do we analyze posture?

a.External Auditory Meatus



b.Lateral Humeral Head



c.Body of L3



d.Anterior 1/3 of sacrum



e.Greater Trochanter



f.Lateral Femoral Condyle



g.Anterior lateral Malleolus

Wolff’s law

bone remodels due to stress

What is a moment arm?

A moment arm is the length between a joint axis and the line of force acting on that joint. The longer the moment arm, the more load will be applied to the joint axis through leverage.

Shopping Cart Sign

Lumbar spinal stenosis can cause a person to lean forward in order to open the lumbar facets and take pressure off the nerves.

Scoliosis: *Definition, Screening Test, Mechanics, Obtaining Definitive Diagnosis.*

Curvature of the spine in the coronal plane.



Screen with Adams forward bending test.



Vertebrae tend to side bend in one direction and rotate in the opposite direction (this is also known as Type 1 Mechanics).



Rib problems common given the rib interface with 2 vertebral segments.



Definitive diagnosis by radiograph and measurement of Cobb angle.

What can we use to name and describe scoliosis?

S-curve or C-curve?

Region?

Convexity?

to the right = dextroscoliosis

to the left = levoscoliosis

Cobb angle? (from radiograph)

Apex?

Adam’s Forward Bending Test

1\.Perform Adam’s forward bending test.

*A prominence of the rib cage (rib humping) on one side of the spine indicates a positive screen for scoliosis.*

2\.Next, have patient side-bend towards side of rib humping.

*If the rib humping reduces it is considered a* __***Functional Scoliosis***__*. Functional Scoliosis is reversible with treatment.*

*If rib humping remains fixed with positional changes the scoliosis is* __***Structural***__*. Structural Scoliosis is irreversible without surgery.*

Gait Cycle

One gait cycle is heel contact from one foot through heel contact of the SAME foot.



Swing Phase accounts for 40% of gait cycle



Stance Phase (single and double) accounts for 60% of gait cycle



Double Stance occurs in 20% of gait cycle



The vulnerable phases of gait are:

Heel strike to loading response

Midstance

Weight shifts to side of _____ leg.

planted

**Sacral And Innominate Motion**

•Sacrum moves in a forward torsional pattern on an oblique axis ipsilateral to the side of the planted leg.



•During leg swing the lumbar spine sidebends towards the planted leg and rotates toward the side of the swinging foot.



•The Innominate of the swinging leg rotates posteriorly and flares inward (i.e. rotates to side of planted leg on a vertical axis)

Pronation is a combination of

eversion, abduction, and dorsiflexion of the foot

Primary motion/function of pronation during gait

Eversion (subtalar joint)



Eccentric deceleration and shock absorption.

Supination is commonly described as a combination of

inversion, adduction, and plantarflexion of the foot

Primary Motion/Function

**Inversion (subtalar joint)**



**Concentric acceleration and initiation of propulsion**

What are the three main events of energy conservation and gait?

1. Propulsion during push off


1. Propelling the center of mass (COM) up and forward
2. Controlling forward movement


1. COM “falls” forward
2. Deceleration at the end of the cycle
3. Shock absorption at heel strike

**Energy is conserved when the COM is**

**minimally displaced during gait.**



**(e.g. vertical, medio-lateral, and antero-posterior)**

**The most common ankle sprain is an**

**inversion ankle sprain.**

Midstance

one foot is bearing all the weight and in a neutral position. Knee ligaments are more vulnerable without the myofascial forces associated with pronation and supination of the foot.

\

Vulnerable phases of gait

Heel strike to loading response phase, the talus is loose from slight plantar flexion and vulnerable to inversion.

Antalgic Gait

(gait to avoid pain) A limp is adopted to avoid pain on weight bearing structures (hip, knee, ankle). Typically, the stance phase is shortened relative to the swing phase on the affected side (e.g. knee pain on the right decreases the stance phase of the right leg)

Ataxic Gait

An unsteady, uncoordinated walk, a wide base of support. Often due to cerebellar problem (e.g. intoxication, stroke). Can also be due to sensory ataxia (e.g. peripheral neuropathy)

\

Fenestrating Gait

short, accelerating steps are used to move forward, often seen in patients with Parkinson’s Disease \*\* (i.e. Shuffling Gait)

Hemiplegic Gait

involves unilateral flexion and circumduction of the hip due to weak extensors. Will se ipsilateral upper extremity flexion. Common post stroke.

\

Spastic Gait (Diplegic)

walk in which legs are held close together and move in a stiff manner, bilaterally. (e.g. scissor gait in patients with cerebral palsy)

\

Trendelenburg Gait

an abnormal gait caused by weakness of the abductor muscles of the lower limb (gluteus medius and gluteus minimus)

\

Steppage Gait (Foot Drop Gait)

gait in which the advancing foot is lifted higher than usual so that it can clear the ground (decreased/absent dorsiflexion). Seen in L5 and fibular neuropathies leading to weakened dorsiflexion.

At each visit, healthcare providers should ask at risk patients and patients >65 years of age:

\

Do they feel unsteady or worry about falling when standing or walking? Have they fallen in the past year ?

What are the **cardinal findings of somatic dysfunction?**

Tissue Texture Abnormalities

Asymmetry

Restriction of Motion

Tenderness

\

How many TARTs are required to diagnose somatic dysfunction?

Two

What are some manifestations of somatic dysfunction?

Altered muscle length and tension (imbalance/spasm). **Often chronic conditions.**

Altered connective tissue tensions (fascia/ligaments).

Joint surface malposition.

\
*Important to have a history when diagnosing*

What is muscular Imbalance? How might this occur?

Occurs when the length and tensions of related muscles are unequal.

\
* Gravitational strain (posture related)
* Trauma
* Over-use (microtrauma)
* Compensation from any of the above

\

What are some effects of muscle imbalance on function?

* Affect dynamic function
* Alter proprioception
* Arthrodial instability due to imbalanced loads on joint surfaces
* Change joint structure
* Impede neurovascular function

Proprioception

is the subconscious mechanism involved in the self-regulation of posture and movement.

\
\
Large A-alpha fibers offer afferent input into the system from stimuli originating in receptors imbedded in every joint, tendon, and muscle and combine with information from the vestibular system to interpret the position and change in position of the soma.

How does somatic dysfunction alter the interpretation of Stimuli?

This leads to a maladaptive, feedforward, allostatic cascade (i.e. “vicious cycle”) which can affect pain interpretation, inflammatory cascades, and protective reflexes.

\

Tensegrity

“the property of skeletal structures that employ continuous tension members and discontinuous compression members in such a way that each member operates with the maximum efficiency and economy.”

\
The way in which bony tension elements are held together by connecting elastic elements (ligaments and antigravity muscles), which helps create/maintain the balance between stability and strength

\
Fascial and musculoligamentous tensions take on primary importance as connecting elements within the system.

\
Imbalance within the system can lead to dysfunction of the system.

\
Nothing happens in isolation.

\


The predictable total structural response to tension change anywhere in the body

Regional Interdependence

Describes the clinical observations related to the relationship purported to exist between regions of the body, specifically with respect to the management of musculoskeletal disorders.

\
*“Dysfunction in any unit of the system will cause delivery of abnormal stresses to other segments of the system with the development of a subsequent dysfunction here as well.”*

Tissue Texture Abnormalities

Temperature, Moisture (skin drag), Red reflex, Bogginess, Ropiness, stringiness

\
\


•May be present in many ways



•May not cause the dysfunction



•Can be as a result of the dysfunction



•May be remote from the dysfunction



•May be the dysfunction



•Tissue may be – edematous, tender, fibrosed, rigid, atrophied (thin), hypertonic or many other things



•Doesn’t feel normal.  You have to know what normal feels like

Asymmetry of Tissues

Static (no active or passive motion)

Regional Examination

Segmental Examination

\

Restriction of Motion

Superficial fascia

Muscles

Deep fascia

Joints

\

Physiologic Barrier

A point at which a patient can actively move any given joint. For example, a person may actively rotate his head 80 degrees to either side



Limit of __**Active**__ Range of motion

Elastic Barrier

the range between the physiologic and anatomic barrier of motion in which passive stretching (induced by the physician) occurs before tissue disruption.



Range between the physiologic and anatomic barrier of motion   in which passive ligamentous stretching occurs before tissue   disruption.  Usually a very short distance. Ex. From physician

Anatomic Barrier

A point at which if any movement occurs past this point it will result in disruption of tissue (muscle, ligament, tendon, bone).

\


Limit of motion imposed by an anatomic structure; the limit of   __**passive**__ range of motion.

Restrictive Barrier

A functional limit that abnormally diminishes the normal physiologic range. Ex. somatic dysfunction

\
Barrier lies before the physiologic barrier, and prevents full range of motion of that joint

\
A functional limit within the anatomic range of motion, which will diminish the normal physiology range

\
***For Example***, head can rotate 80 degrees left/right – restrictive barrier only lets the head rotate 60 degrees to the left and 80 degrees to the right. There may be some tenderness at the restrictive barrier.

\

Pathologic Barrier

Restriction of joint motion associated with pathologic change of tissues (think of arthritis or a fracture)

Motion loss is a result of and maintained by a __________.

restrictive barrier

The restrictive barrier is a result of:

\

somatic dysfunction

Tenderness

Discomfort or pain elicited by the practitioner through palpation. A state of unusual sensitivity to touch or pressure (Dorland’s).

Pain

an unpleasant sensation induced by noxious stimuli and generally received by specialized nerve endings

Hypertonic Muscle

difficulty relaxing, enlarged, tense

\

Hypotonic Muscle

weakened contraction and neurtrophism

\

Ropiness of muscle

isolated contracted fibers, cord/string like

Trigger Points

small discrete hypersensitive areas within myofascial structures - palpation causes referred pain away from site

Fibrotic Muscle

dehydrated, poss. course and contracted

\

Dense Muscle

usually tight, restrictive and thickened

\

Spastic Muscle

Severely restrictive (chronic)

\

Boggy muscle

Non-edematous but increased fluid with decreased turgor, freq. viscero-somatic

How much pressure should you use?

Blanching of thumbnail or fingernail occurs typically between 1 and 4 kg of pressure

\
Tenderness may be reported at levels of 8 kg of pressure with no discernable dysfunction

Tender Point

small discrete hypersensitive areas within myofascial structures that result in localized pain

\

Chapman’s Point

small discrete nodular area located deep to the subcutaneous tissues, most often in the deep fascia or periosteum of the bone

Describe an example of acute vs chronic TART findings.

\

Somatic Dysfunction is named

for the way they like to go

*IF* a vertebrae rotates freely to the left but is restricted to the right then the dysfunction rotates left

*IF* the elbow will flex but not extend then the dysfunction is flexed

\

Primary vs. Secondary Somatic Dysfunction

*Primary*: the somatic dysfunction(s) that maintains a total pattern of dysfunction, including other secondary dysfunctions.

\
*Secondary*: somatic dysfunction arising either from mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies.

\

Always start your exam with

observation

True or False. You document that the patient is presenting to the clinic for OMT.

False

Exmaple of Physical Exam