OMM midterm t1

Define spinal regional range of motion

–Evaluates patient’s ability to move through the various planes and axes of motion

–Assess a group of segments that make up a specific region of the spine

characteristics looked for during motion testing

–Motion Quality vs. Quantity

–Active vs. Passive motion

(ability to move normally vs abnormally)

Describe motion through the various planes and axes of the body

Motion occurs along the plane, around the axis (axis perpendicular to plane of motion)

Differentiate between active and passive motion testing.

–Active à Performed by Patient & Observed by Physician

–Motion caused by the patient’s muscle actions

–Passive à Performed by Physician on a Relaxed Patient

–Produces greater regional range as compared to active

–Motion caused by the physician’s force

Explain why motion testing is necessary as a diagnostic tool

Helps to narrow down to specific area → intersegmental motion testing to find specific segment(s) contributing to somatic dysfunction

also good to measure changes post-treatment changes

Differentiate the normal degrees of regional range of motion for cervical spinal regions.

flexion: 45-90

extension: 45-90

side-bending R/L: 30-45

rotation R/L: 70-90

Identify muscles that can affect regional range of motion in the cervical region

Trapezius

Splenius capitis

Semispinalis capitis

Sternocleidomastoid

Sagittal Plane Motion

–Around Transverse (Horizontal) Axis

–Forward & Backward Bending = Flexion (F) & Extension (E)

Coronal Plane Motion

–Around Anteroposterior (AP) Axis

–Sidebending R or L (S_R or S_L)

Transverse (Horizontal) Plane Motion

–Around Vertical Axis

–Rotation R or L (R_R or R_L)

Translatory motion = Along the axis

–Active

Performed by Patient & Observed by Physician

–Motion caused by the patient’s muscle actions

–Passive

Performed by Physician on a Relaxed Patient

–Produces greater regional range as compared to active

–Motion caused by the physician’s force

Identify muscles that can affect regional range of motion in the thoracic region

–Erector spinae group

–Semispinalis thoracis

–Rotatores

Identify muscles that can affect regional range of motion in the lumbar region

–Rectus Abdominus

–Erector spinae group (medial-lateral Semispinalis, Longissimus, Iliocostalis)

–Quadratus lumborum

–Iliopsoas

--obliques

Differentiate the normal degrees of regional range of motion for thoracic spinal region

sidebending R/L:

• T1-4: 5-25

• T5-8: 10-30

• T9-12: 20-40

rotation R/L: 30-45 in T9-12

Differentiate the normal degrees of regional range of motion for lumbar spinal regions.

flexion: 70-90

extension: 30-45

sidebending R/L: 25-30

tonus:

uThe slight continuous contraction of muscle

• aids in the maintenance of posture/the return of blood to the heart

hypertonicity:

• excessive tone of the skeletal muscles, can b size too

• increased resistance of muscle to passive stretching

contracture:

Shortening and/or development of tension in muscle

uIsotonic-length changes

• Concentric-muscle shortens

• eccentric (isolytic)-muscle lengthens

uIsometric-No change in length

spasm:

• sudden violent, involuntary contraction of a muscle or group of muscles

  • attended by pain and interference with function, producing involuntary movement and distortion

TART

Tenderness

Asymmetry

Restriction of motion

Tissue texture changes

Tenderness

as pain elicited by palpation, yes or no

Asymmetry

uStatic postural exam

uObserve Anatomic landmarks

uKnow mid-gravity lines and their components

uPalpation for alteration in tissues

uTest range of motion to detect asymmetry

Restriction of motion

• tested by active and passive ROM

• quality of motion and end feel and note loss of motion within normal range

Tissue texture changes

different feel depending on the:

• uspecific tissues involved

• uexact dysfunction

  uchronicity of the dysfunction

chronicity of a somatic dysfunction means that it has which attributes

uHistory: > 3 months

uPain: dull, achy, itching, crawling, gnawing, burning

uVasculature: vessels constricted due to hypersympathetic tone

uSkin: cool, pale due to chronic increase sympathetic vascular tone

uTissues: chronic congestion, stringy, ropy, fibrotic, contracture, thickened, increased resistance

uMusculature: decrease tone, ‘mushy’, limited range of motion due to contracture

uViscera: somato-visceral effects common

acute somatic dysfunction

uHistory: < 3 months

uPain: acute, severe, sharp

uVasculature: vessels injured, release of peptides (bradykinins) = chemical vasodilatation & inflammation

uSkin: warm, moist, red/inflamed via vascular & chemical changes

uTissues: edema, acute (boggy) congestion

uMusculature: increase in local tone leading to contraction, spasm, poor quality of motion

uViscera: minimal somato-visceral effects

physiologic barriers

uWhen a health joint is actively moved during normal activity, the end of motion is where this barrier occurs.

uThe limit of active range of motion (patient is moving themselves)

uCan be altered to increase range of active motion by warm-up activity, stretching, or myofascial release

anatomic barriers

• When the range of motion of a joint is tested passively during a physical examination, the end of the furthest motion is the _.

• determined by bone contour, soft tissues and ligaments.

This is the final limit to motion,  Tissue damage occurs with articulation beyond this barrier.

elastic barriers

“The range between the physiologic and anatomic barrier of motion in which passive ligamentous stretching occurs before tissue disruption.”

Determined by the capsules and ligaments around a joint.

Determines the passive range of motion of the joint.

restrictive barriers

A functional limit that abnormally diminishes the normal physiologic range.

• cause and sustain motion loss.

• the result of somatic dysfunction!!

• can be treated with osteopathic manipulative treatment (OMT)!!

You must know the cause of restriction to select the appropriate treatment.

pathologic barriers

• Compensatory strain secondary to the Pathological barrier can be helped with OMT though.

• causes and sustains motion loss, however

• not amenable to OMT.

• Decreased motion resulting from a pathologic alteration of tissue

Examples – osteophytes, contractures, fractures, congenital abnormalities

A more specific kind of a restrictive barrier

When a health joint is actively moved during normal activity, the end of motion occurs at the _.

Physiologic Barrier

When the range of motion of a joint is tested passively during a physical examination, the end of the furthest motion is the _

Anatomic Barrier.

The quantity of motion required to arrive at the _ is less than the amount required to reach the physiologic barrier.

restrictive barrier

Screen component from OSE

two parts:

• The initial general somatic examination to determine signs of somatic dysfunction in various regions of the body. 

• 1) Static Postural Examination Standing and Seated from Posterior, Lateral and   Anterior Views

  üAssessment of Body Symmetry/Asymmetry

  üAnalysis  of Spinal Curves

• 2) A Dynamic Examination

  •Regional Range of Motion Testing

  •Gait observation

Scan component from OSE

• An intermediate detailed examination of specific body regions that have been identified by findings emerging from the initial examination.

- Layer by layer palpation

• Differentiate tissue involved (Fascia, muscle, ligament, bone)

• Differentiate Acute versus Chronic issues

Segmental component of OSE

• The final stage of the spinal somatic examination in which the nature of the somatic dysfunction is detailed at a segmental level

very specific, gives you the actual three plane motion diagnosis for the dysfunctional segment

how OSE supports the diagnosis of somatic dysfunction, musculoskeletal conditions, and/or disease

• through differential diagnosis

• Gain information on visible defects, functional deficits, abnormalities of alignment, somatic dysfunction

• Key – determine whether these findings are related to the pathology being presented

Describe the clinical significance/implications of static asymmetry(s)

• Pain and dysfunction

• Muscle imbalances

• Scoliosis and spinal curvature

• Increased injury risk

• Impaired movement and function

• balance issues

•Use of your “dominant eye”

±Identify dominant eye

±Eye midline between structures to be compared 

Eyes should be level to the site being in order to evaluate asymmetries properly

•Describe the physiologic spinal curves - Primary versus Secondary

•Primary Curves

• Kyphotic (

• Thoracic/Sacral

•Secondary Curves

• Lordotic )

• Cervical/Lumbar 

•Transition zones are anatomically defined & occur at:

•Occipital-cervical, cervicothoracic, thoracolumbar, and lumbosacral junctions

• OA, C7-T1, T12-L1, & L5-S1

• Includes arthrodial, skeletal, and myofascial anatomy

•The transition zones are areas commonly susceptible to somatic dysfunction

Describe the clinical significance/implications of static asymmetry(s)

• Pain and dysfunction

• Muscle imbalances

• Scoliosis and spinal curvature

• Increased injury risk

• Impaired movement and function

• Balance issues

•Cross-overs” occur when

• the postural line crosses the gravitational line

  • at the transition zones

• OMT restores proper mobility and reduce compensatory strain

What is the Goal of the Osteopathic Structural Evaluation ?

To determine:

• Whether somatic dysfunction is present

•Whether another musculoskeletal condition or disease is present

VINDICATE for differential diagnosis

Vascular

Infection/Inflammatory

Neoplastic/(Neurologic)

Degenerative

Iatrogenic

Autoimmune

Trauma

Endocrine

External Landmarks Determine

levelness

landmark @ C7

vertebra prominens

landmark @ T3

Spine of Scapula

landmark @ T7 Spinous process/ T8 transverse process

Inferior angle of scapula

landmark @ L4

iliac crest

landmark @ S2

posterior superior iliac spine

posterior mid gravity line landmarks

•Inion 

•Vertebral spinous processes C1-S5

•Inter-gluteal cleft

•Mid- heel point

•Coronal plane view for scoliosis, leg length discrepancy, extremity asymmetry

valgrus

knock-kneed

varus

bow-legged

 Sagittal Plane

midline (left and right half)

Coronal/Frontal Plane

•Vertical plane which goes through body midline left to right

•Divides the body anterior & posterior (front and back)

•Motion in coronal plane  around an anterior/posterior  axis = _

(sagittal axis) is Sidebending (Lateral Flexion)

•Motion in sagittal plane is _

forward bending (Flexion) and backward bending (Extension) around transverse axis

•Spinal curves in sagittal plane best viewed from the lateral body view

•Kyphosis

•Lordosis

Transverse Plane

•horizontal plane going through the body (top and bottom half superior/inferior)

•Motion in the transverse plane around a vertical axis is _

Rotation

Discuss three key historic events that led to Dr. Still’s development of  osteopathic principles.      

• Still lost his first wife (wife died of pneumonia),  two sons and two daughters during two waves of a meningitis epidemic that swept the US between 1859 & 1864. (1 wife 4 kids)

• witnessed failures of orthodox medicine as a surgical assistant during the Civil War

• loss of first wife secondary to complications in childbirth and total of 5 children; 3 to spinal meningitis and one to pneumonia. Lost another child to an accident later on. (2 more kids lost in second marriage)

Distinguish Still’s osteopathy from the “heroic” medicine of the 1800s.

•Most common American medical practice of middle 1800s = orthodox medicine, also known as allopathy or allopathic medicine

          Used by “regular” physicians, who criticized “irregulars”

•Not concerned with specific cause of disease, osteopathy is

•Much heroic medical theory was based on idea of loss of equilibrium of between the body and environment (different focus)

Therapeutic applications involved procedures to regulate “intake” and “outflow” and “depletion”

Treatments included therapeutic bleeding, sweating, blistering, and giving drugs to induce vomiting or diarrhea = “purging” (induced harm)

•A. T. Still bitterly decried the use of calomel while heroic medicine used it often

!! osteopathy doesn’t induce harm/pain unnecessarily, still detested calomel while heroic medicine used it often, still was concerned with cause of disease while heroic medicine was not, use of many drugs; he felt were more harmful than beneficial or at least ineffective, such as commonly used arsenic and opium

List and discuss three ideals embraced by Dr. Still that demonstrate that Dr. Still was well ahead of his time in philosophy and practices. 

• he was against:

  • Use of many drugs; he felt were more harmful than beneficial or at least ineffective, such as commonly used arsenic and opium.

    Unnecessary surgical procedures

    Lack of aseptic practices

    Other common medical treatments of that time which, today, are largely abandoned

• He believed in immunity and that the body had all the means to care for itself, including a natural pharmacy

Describe the time and state the year that A. T. Still “Flung the Banner of Osteopathy to the Breeze”.

1874

antiseptics issues in the military, death in the family, and recent innovations in antiseptics and disease transmission (pasteurization)

Describe the early American School of Osteopathy and state the year it was founded.

• 1892

• Early charter stated the goal of the ASO was

  “To improve our present system of surgery, obstetrics, and treatment of diseases generally, and to place the same on a more rational and scientific basis, and to impart information to the medical profession”

• most new students were former patients or family

• ASO grew quickly

Describe the history of the DO versus MD degree controversies of 1899 and 2008.

• 2008: a strong discussion arose in several medical schools about changing the DO degree to either an MD degree or a modified degree

MDO, DOM, OMD, DO-MD, MD-DO

example of history “rhyming”

• 1899: ASO saw debate over granting DO versus MD degree

  • J. Martin Littlejohn, then Dean at ASO, championed “Doctor of Medicine” degree. He and ASO faculty petitioned the Board of Trustees to change the degree to MD. Dismissed by Still, who still had authority with the school.

•This would be a recurring issue in the osteopathic profession, coming to a head 70 years later, in California

Describe what the Flexner Report was and consequences it had on organized medicine.

•AMA created the Council on Medical Education in 1904vto restructure American medical education.

• began in 1908; made education standards and increased admission standards

•Written by Abraham Flexner, published in 1910

•Found majority of MD schools to be lacking

•Virtually all the alternative medical schools listed in the Flexner Report closed along with many other schools

•osteopathic medical schools held to same standards as MD schools

•The AOA was able to help bring a number of osteopathic medical schools into compliance with Flexner’s recommendations including PCOM (est 1899)

Describe the events and outcome of the California Merger of 1962.

•1962 AMA accepted a California statewide merger between MDs and DOs

• DOs turned in their DO diplomas and received MD degrees for $65

• DO degree was no longer recognized in California

• The Los Angeles osteopathic college converted to an MD-granting institution (now the U of C, Irvine School of Medicine)

• Known as “little mds” and never well-accepted = NOT a good outcome

• DOs successfully pushed for full licensure in all states

Describe the unified pathway postgraduate medical training (ACGME).

•2014: AOA and AMA agreed to unify graduate medical education in 2020

•2020 Fully integrated single accreditation system for US graduate medical education

Describe the outcome of patient care given by osteopathic physicians in the Spanish influenza epidemic of 1916-1918.

•1916-18 Spanish Influenza epidemic; 110122 patients treated by DO’s.

    5% mortality with standard medical care

    0.25% mortality with osteopathic medical care

•1916-18 Secondary pneumonia in Spanish Flu epidemic

    35% mortality with standard medical care

    10% mortality with osteopathic medical care

definition of osteopathy

•Osteopathy is that science which consists of such exact, exhaustive, and verifiable knowledge of the structure and functions of the human mechanism, anatomical, physiological, psychological, including the physics of its known elements, within the body itself, by which nature under the scientific treatment peculiar to osteopathic practice, apart from all ordinary methods of extraneous, artificial, or medicinal stimulation, and in accord with its own mechanical principles, molecular activities, and metabolic processes, may recover from displacements, disorganizations, derangements, and consequent disease, and regain its normal equilibrium of form and function in health and strength.”

•Autobiography of Andrew T. Still, 1897

Discuss the Triune Nature of man as first described by Andrew Taylor Still.

• Body: material body

• Motion: the spiritual being

• Mind: a being of mind that is far superior to all vital motions and material forms, whose duty is to wisely manage this great engine of life.

Describe the tenets of osteopathic medicine currently approved by the AOA House of Delegates.

1.The body is a dynamic unit of function.

2.The body has the capacity for self healing, self regulation and maintaining homeostasis.

3.Structure and function are reciprocally interrelated.

4.Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function.

Describe some of the physiologic basis of body-mind interaction, including some of the key CNS structures involved, as well as the activity and effects of the sympathetic nervous system.

•Conscious mind can affect pain perception

• Medial prefrontal cortex

• Dorsolateral prefrontal cortex

•Signals in the brain may be amplified by emotions

• Activating sympathetic system = Increasing pain levels

• Affecting structures that process both pain and emotion, such as amygdala, thalamus, and other structures

• These in turn can amplify nociceptive input or even misinterpret other sensory input as pain

• This can activate the “pain matrix” of CNS structures

Describe how the body-mind-spirit approach applies to patient care and to physicians themselves.

•Think of each person you work with and each patient you encounter as consisting of body-mind-spirit triune human, makes encounters more meaningful

•also referred to as “acknowledging the Health”

•being a friend can be accomplished while still maintaining personal and professional boundaries.

•be genuine by still keeping a more subtle, healthy boundary of professionalism.

•No one is perfect, however, we can all try to do our best.

•This is a career-long and life-long endeavor

Extrinsic muscles attaching to scapula or humerus.

  -considered “limb” muscles due to actions
  -innervation by _ of spinal nerves

ventral rami

sup: Trapezius

origin: EOP, superior nuchal line, nuchal ligament, C7-T12 spinous processes

insertion: scapular spine, acromion, clavicle (lateral 1/3)

action:

• (1) Superior: elevate scapula

  (2) Middle: retract scapula (+ w/ sup and inf)

  (3) Inferior: depress scapula
  

  (1 & 3) rotate glenoid superiorly

innervation: CN XI – Accessory n. + C3-C4

sup: Latissimus Dorsi

origin: T7-T12 spinous processes, thoracolumbar fascia, iliac crest, 3-4 inferiormost ribs

insertion: Floor of the intertubercular sulcus (humerus)

action:

• Extends, adducts, and medially rotate humerus;

  Alt: Pulls body toward arms during climbing

innervation: Thoracodorsal n.

sup: Levator scapulae

origin: Transverse processes of C1–C4 vertebrae

insertion: Superior part of the medial border of the scapula

action:

• Elevate scapula; rotate glenoid cavity inferiorly

innervation: Dorsal Scapular n.

sup: Rhomboid major and minor

origin:

• Minor: C7-T1

• Major: T2-T5

insertion:

• Minor: medial border above scapular spine

• Major: medial border below scapular spine

action:

• Retract scapula; rotate glenoid inferiorly

innervation: Dorsal Scapular n.

extra: Serratus anterior

origin: ribs 1-9

insertion: medial scapular border

action:

• protract scapula;

    rotate scapula upwards

innervation: Long Thoracic n.

extra: Deltoid

origin: scapular spine, acromion, & lateral clavicle

insertion: deltoid tuberosity

action:

• (1) Anterior: flex + medially rotates arm

  (2) Middle: abducts arm (up to 90 degrees)

  (3) Posterior: extend + laterally rotates arm

innervation: Axillary n. (C5, C6)

Thoracodorsal nerve injury would cause

Weakend arm extension and medial rotation

What muscle is antagonistic to the scapular rotation produced by the Rhomboids?

Trapezius

Dorsal scapular artery

  -follows same path as the nerve

  -branch of the Thyrocervical Trunk

  -var. transverse cervical a.

extra: Quadratus lumborum

origin: iliac crest

insertion: rib 12, L1-L4 vertebrae

action:

• Unilateral: flex trunk to same side

  Bilateral: stabilizes 12^th rib;   bearing down & expiration

innervation:

• Subcostal n. (T12)

• (+ L1-L4 spinal nn.)

external occipital protuberance (Inion)

back of head

c7

last moving joint, T1 is stationary

scapular spine is in line with

T3

inferior angle is in line with

T7

Iliac crest is at

L4

a bit lower than PSIS is

S2

how many cervicals

7

how many thoracic

12

how many lumbar

5

sacral (fused)

5

coccyx (fused)

3 - 4