OPP II Sem 1

5 models of osteopathic care?

• biomechanical → structural

• resp-circ → venous, lymphatic

• neuro → control, coordination, integration

• metabolic → homeostasis, energy, immune/inflammation, digestion, waste removal, reproduction

• behavioral → psych/soc, habits, values/attitude/belief

soft tissue principles? CI?

• parallel/long., perp./lat., deep pressure/inhibition, effleurage, petrissage/skin rolling, tapotement

  • direct + passive

• relative → fracture, open wound, infection, abscess, DVT, coagulopathy, neoplasm

  • absolute → skin/tissue not intact, trauma, friable

MFR principles? CI?

• innate motion of myofascial structure (indirect/direct + passive)

• relative → fracture, open wound, infection, abscess, DVT, anticoagulation, neoplasm, post-op near, aortic aneurysm

articulatory principles? CI?

• gentile + repetitive motion → versatile, long lever

  • direct + passive

• relative → upper cervical (VA compromise)

  • absolute → fracture/dislocation/instable joint, local inflammation, neuro entrapment, vasc. compromise, local malignancy, bleeding disorder

ME principles? CI?

• direct + active (dec. gamma gain → dec. muscle spindle activity)

  • PIR (relaxation), joint mobilization, resp. assistance, oculocephalogyric, reciprocal inhibition (lengthen), crossed extensor, isokinetic strengthen, isolytic lengthen

• relative → infection/hematoma/muscle tear, fracture/dislocation, rheumatologic, joint swelling, vasc. compromised, severe osteoporosis, neoplastic

CS principles? CI?

• indirect + passive

  • tender points in muscle tissue

• relative → can’t relax/ill, upper cervical rotation/extension w/ VS disease or ligamentous instability, dens malformation, severe osteoporosis, rheumatological flare, apprehension

  • absolute → neuro/vasc. symptoms, life threatening symptoms (EKG, O2 drop)

HVLA principles? CI?

• direct + passive → articular SD, joint restriction w/ firm articular barrier

• relative → herniate NP, radiculopathy, whiplash/spasm/strain, osteopenia/porosis, spondylolisthesis, hypermobility, implants/joint replacement, Hx inflammatory arthritidies

  • absolute → upper cervical (RA, DS, AD, chiari), fracture/dislocation/joint instable, joint fusion, klippel-feil, vertebrobasilar, acute inflammatory arthritidies, joint infection, malignancy, spinal cord pathology

neutral thoracic supine HVLA (kirksville krunch)?

• stand on opp. side of rotation TP (place thenar eminence) + pt. cross arms (rotation side above)

• pt. elbows into sternum + forearm support upper thoracic → SB away

• thrust perpendicular w/ taking up slack

non-neutral thoracic supine HVLA (kirksville krunch)?

• flexed → extend thorax + SB toward (opp. of Dx), take up slack + cephalad force

• extended → flex thorax + SB towards (opp. of Dx), take up slack + caudad force

thoracic prone HVLA (texas twist)?

• flexed → stand opp. rotation w/ caudad thenar eminence on TP, take up slack w/ SB (turn opp. of rot/SB= towards me), thrust towards fingers + ant.

• neutral → stand same rotation w/ cephalad hypothenar on TP, take up slack w/ SB (same rot./SB = towards me)

• NOT on extended

lateral recumbent HVLA?

• rotation side down, monitor w/ cephalad hand

• use ankle to flex hip + knee (for flex/extend)

• hold top ankle + tell them to straighten bottom

• switch monitor hand

• inf. arm pull for rotation (opp. of SD)

  • type I (N) = pull inf.

  • type 2 (F/E) = pull sup.

• forearm against greater trochanter + ant. axilla → take up slack via twist → thrust towards table

cervical HVLA?

• stand on side of rotation w/ thumb on bone

• OA → 2nd MCP on occiput, slight traction + ant. extension (decompress), rotate opp. + SB opp., thrust towards eye

• AA → 2nd MCP on C1 AP, flex 45 + ant. pressure, rotate opp., thrust towards nose

• typical (rotational emphasis) → 2nd MCP on AP, ant. pressure, flex, rotate opp. + SB ease

tensegrity? FPR principles? physiological mechanism?

• integral balance of tensile + compressive force

• direct + passive by Stanley Schiowitz

• dec. muscle spindle (y-motor) activation in neutral position, lower afferent excitatory (Ia + II) input, dec. reflex a-MN act. → put into ease w/ facilitating force

  • 3-5 seconds

FPR indications + CI?

• myofascial or articular somatic dysfxn → dec. hypertonicity

• relative (not tolerated, severe osteoporosis, malignancy, joint instability, spinal stenosis/impingment)

• absolute (unstable fracture, neuro symptoms, life threatening)

  • EKG change, O2 drop

OA Dx? AA Dx? typical cervical Dx?

• SB + rotation opposite (can F+E)

  • translation ease = SB opposite

• rotation only w/ 45 flexion

• SB + rotation same w/ F or E

  • translation ease = SB opposite

OA FPR? AA FPR?

• pt. supine, physician at head

• passive flexion → flatten

• compression/distraction → position into freedoms

• hold for 3-5 sec → return to neutral

• reassess

FPR seated thoracic + lumbar?

• stand on rotation side, monitor TP w/ hand opp. to rotation

• forearm on R. trap w/ hand on neck

• pt. sit up straight (neutral)

• compression (1lb) + freedom (SB + rotation) 3-5 sec

• neutral → reassess

FPR prone thoracic?

• stand opp of SB/R

• monitor TP of same side of SB/R w/ opp hand

• grasp same shoulder → pull up (neutral) + toward feet (compression that = SB + E)

• hold 3-5 sec → neutral

• BETTER FOR EXTENDED

FPR prone lumbar?

• sit on same side of dysfxn w/ thighs parallel

• pillow under pelvis (neutral)

• monitor same side TP w/ opp hand

• grasp knee + flex hip/knee → place leg on your thighs

• localize via movie leg sup. (roll closer to head)

• lat. knee push into pt. popliteal fossa (raise + lat = traction)

• non monitoring hand pushes leg to floor until motion felt → hold 3-5 sec → neutral

BLT principles? CI?

• minimize peri-articular tissue load via balanced tension in all planes → Tx ligamentous articular strains, indirect + passive

  • disengage → exaggerate → balance

• relative → fracture, open wound, infection/abscess, DCT, anticoagulation, neoplasm, post. op, aortic aneurysm

  • absolute → fracture, neuro/life threatening symptoms

BLT steps?

• Dx SD → compressive/traction (disengage)

• engage ligaments + fascia to move towards ease in all planes

• max. ease (balance pt.) → hold tissue

  • any additional movement = tension

• feel pulsation/unwinding → release

• return to original position

BLT prone lumbar?

• place same side thumb over dysfxn TP + index/3rd over opposite TP

• other hand same position on lower vertebra

• compressive/traction + extend/flex

• SB + rotate into ease

• use respiration → return to neutral + reassess

BLT OA? typical?

• OA = hypothenar eminence + medial palms hold occiput → palpate C1 TP w/ 2nd + 3rd fingers → ant. + cephalad force (extend C1) → use palms to move occiput indirectly to ease

• typical = hypothenar eminence hold occiput → palpate AP w/ 2nd + 3rd fingers → compress/traction to disengage → towards position of ease via E/F, SB, rot.

  • approach balance → press ant. on opp. AP to further rotate (disengage = balance, tension = not balance)

still technique principles? CI?

• direct + indirect → indirect via axial force (compression, traction, torsion) then carry region through restrictive barrier

• relative → loss of intersegmental motion (2ndary to spondylosis, osteoarthritis, RA), joint instability, acute sprain/strain

visceral manipulation? chapman reflexes? CI?

• direct palpation of viscera + supporting structure (abnormal motion test/creates SD)

  • relative → aortic aneurysm, splenomegaly, GI obstruction, post surg, hernia, diastisis recti, complicated pregnancy, GI infection, ischemic bowel

• rotatory motion address ST dysfxn (TTA = visceral pathology)

  • relative → skin/ST not intact, trauma, friable

  • absolute → fracture, open wound, infection/abscess, DVT, coagulopathy, neoplasm, over operation

lumbar facet? disc and nerve relation? ligament function?

• lumbar facet → smaller IV foramen w/ extension (noci, mechano, proprioceptors)

• bulging disc → nerve root pain

  • lumbar nerve exits sup. to vertebral disk → ruptured disc affects nerve root exiting below (L5 nerve root irritated via L4/5 disk rupture)

• ligament fxn → bone to bone, proprioception, sensory, resist abnormal movement, tissue/joint injury feedback

types of LBP?

• mechanical → arise form spinal or MSK (localized, radicular or non)

  • w/o radiation below knee → nonspecific, SD, DDD (xray, MRI), fracture/spondylolysis (xray, CT)

  • w/ radiation (MRI) → radiculopathy (dermatome), SS (numb/tingle), CES (urine/bowel)

• non mechanical → systemic or structural (infection, neoplasm, inflammatory,

• referred → visceral/retroperitoneal (GI, renal, gynecologic, vascular, psychological)

risk factors for low back pain? red flags?

• excess weight, weak core, lack of exercise, smoking, poor posture; heavy lifting, repetitive motion, vibration, desk job; age, mental health, genetics

• red flags: night sweats, weight loss, saddle anesthesia, gait disturbance, urinary retention, sphincter tone loss, recent prostate cancer Dx, corticosteroids, HIV

muscular condition causing LBP clinical patterns? ligaments?

• psoas syndrome → prolonged flexed waist = inc. lumbar lordosis + SI joint compression

  • upper lumbar SD (R + SB towards psoas), ipsilateral post. pelvic tilt, ER distal LE

• iliolumbar lig. syndrome → repetitive rotation + hips shifted lat. = ipsilateral SI joint pain

  • tender pt. sup. med. iliac crest

• pelvic outlet/piriformis syndrome → buttock radiates to post thigh via trauma, use, sitting

  • LE ER supine, reproduce w/ resisted ER/AB

joint conditions causing LBP clinical patterns? spinal cord?

• DDD + joint disease → injury/age in lumbar/cervical = osteophytes, spondylosis (ache + stiff, if compressed rad.)

  • L4/5, L5/S1 most common in radiculopathy via narrow PLL

• SI joint pain → gaenslen, FABER, compression, thigh/sacral thrust

• cauda equina syndrome (urgent) → compressed lumbosacral nerve root = severe LBP, urinary retention, lose anal sphincter tone, LE weak, saddle anesthesia

dirty ½ dozen (main types of SD)?

• muscular imbalance of trunk + LE

• non-neutral (T2) lumbar SD

• dysfunction of symphysis pubis (pubic shear)

• short leg + pelvic tilt/sacral base unlevel

• restricted flex (nutation) of sacral base (post. sacral base or backward torsion)

• innominate shear

low back pain physical exam tests?

• forward bend (adam’s test) → scoliosis via palpate PV hump (if SB restores = functional)

• facet loading (kemp’s test) → sit/stand, hand on shoulder + spine (extend, SB, rotate lumbar spine via compress shoulder) = pain

• pelvic side shift → hold iliac crest + opp. shoulder, translate pelvis, note motion (+ = freer/name that side)

• stork test → pt. flex hip + knee, extend lumbar spine (pars/stress fracture or spondylosis)

• hip drop test → flex knee = opp. hip drops + lumbar spine SB away from wt bearing (+ = no drop w/ lumbar SB towards wt bearing → trouble bending opp. of + test)

• trendelenburg test → pt. lifts leg (+ = tilt towards unaffected hip via weak gluteus medius on opp. leg)

• standing flexion → PSIS motion

thomas test? straight leg raise? FABER/patrick test?

• pt. supine at end of table w/ both legs flexed at knee + hip → 1 leg extend off table holding opp. knee → tests iliopsoas muscle tone (+ = contralateral raises off table)

• passive raise pt. leg w/ knee extend → tests sciatic nerve (+ = pain @ 30-60)

  • bragards → lower leg below pain + ankle DF (+ = pain below knee)

• flex, abduct, ER, extension → test SI joint

muscles contributing to pelvic SD?

• iliolumbar ligament → prevents L5 ant. slide, blends w/ ant. SI for smooth symmetry, common SD cause

• piriformis syndrome → sciatica compression (S1/2), gluteal ache, inc. pain sitting, paresthesia down post. thigh, w/ contralateral psoas syndrome

• psoas syndrome → sudden lengthen (via sitting, bending, gardening then stand), overuse (sit-ups, hurdles), back/buttock pain, short/ER leg, ant. rot. innominate, hypertonic CL piriformis, flexed L1 or L2 SD rot. + SB ipsilateral

sacral axes? motions?

• sup. (high S2) → resp. + cranial motion

• middle (low S2) → SI axis (post. nutation/flexion + counternutation/extension)

• inf. (S3) → IS axis (innominate ant./post. rotation)

• central horizontal (flexion/extension), left oblique (L/L, R/L sacral torsion), right oblique (R/R, L/R sacral torsion)

innominate evaluation? sacral? L5 mechanics

• standing flexion test or ASIS compression, ASIS, ASIS midline, pubic ramus, PSIS

• seated flexion test or ASIS compression, sacral base, ILAs, L5, spring (+= stiff), sphinx (+ = no improvement)

  • L5 = rotates opp. sacrum + SB same as axis (ROSSA), forward torsion w/ N L5

• non-physiologic (trauma) = shears + backward sacral torsion

sacrum Dx?

gait cycle relation to innominate? sacrum?

• leg post. = ipsilateral innominate ant.

• weigh bearing leg → sacrum engages ipsilateral oblique axis (forward torsion)

  • L5 (ROSSA)

innominate PIR MET anterior rotation? posterior?

• pt. supine → flex, ER, ABduct knee (pull ischial tuberosity ant.), push knee into shoulder

• pt. supine → stabilize opp. ASIS, leg + ischium off table (extend leg), pt. push thigh up

innominate PIR MET superior shear? inferior shear?

• slight raise, abduct + IR (gap SI joint), lean back (traction = engage SI joint) → pt. hike hip up

  • OR → stabilize ASIS + leg off table (ischial tuberosity on), push thigh up

• slight raise, abduct + IR, compress hip (engage SI joint) → pt. push heel down

  • OR → flex, ADduct hip w/ ischial tuberosity ant.

innominate PIR MET inflare? outflare?

• flex affected hip + knee (cross over opp. knee) → stabilize opp. ASIS + ABduct hip → pt. push knee into hand

• flex affected hip + knee w/ foot on table → monitor PSIS + ADduct hip → pt. push into hand

innominate PIR MET pubic compression? gapping?

• flex hips + knees

  • ABduct pt. knee w/ forearm btwn → pt. ADduct knees

  • ABduct knees ~18 in. (w/ knee closer against abdomen), hold other knee w/ both hands → pt. ABduct knees

indirect sacral MFR w/ respiratory assist?

• pt. prone, abduct legs 20-30 degree

• place hands on sacrum w/ bottom pointing cephalad

• downward pressure on whole sacrum (press toward table to gap SI joint)

• encourage unwinding

indirect sacrum BLT?

• pt. supine w/ knees bent

• caudad hand contacts sacrum (2nd-4th finger contact base) + cephalad hand contact ilia to disengage (2nd-4th finger contact ASIS)

  • disengage via bring ASIS closer (lat. traction force @ SI joint)

  • move sacrum into SD

SI joint BLT?

• sit on side of SI restriction

• contact pelvis at SI joint w/ finger pads + place other hand on ASIS

• bring innominate into ease (ant. pressure to sacrum)

unilateral sacral flexion MET? extension?

• abduct leg 15 deg. for SI joint + IR hip

  • place caudad hand on ILA (reinforce w/ cephalad hand) → inhale = push (encourage extension) + exhale = resist

• sphinx, abduct leg 15 deg. for SI joint + IR hip

  • place cephalad hypothenar on sacral sulcus (reinforce w/ caudad hand) → exhale = push (encourage flexion) + inhale = resist

bilateral sacral flexion MET? extension?

• place caudad hand on ILAs (fingers up) → downward pressure (inhale = push/extend) (exhale = resist)

• contact sacral sulci → downward pressure (exhale = push/flex) (inhale = resist)

forward torsion? backward torsion?

• down on axis, hug table, monitor sacral base w/ hips flexed >90, push down on feet

• down on axis, monitor sacral base, draw shoulder to face up, flex hips <90, push down on knees

OMM geriatrics, theories/physiology aging

• stressor compensation dec. efficiency + stressors inc. = frailty

• hospital readmission, prevent high risk disease, fall prevention, manage multiple chronic conditions

age related postural change? gait change?

• cervical lordosis (altered esophagus/trachea), thoracic kyphosis, lumbar lordosis (compensates upper back + pelvic tilt)

• mandible protrusion (mastication strain), scapula retraction, ribcage depression (dec. AP), post. rot. pelvis, sacral counternutation (ext), iliopsoas short, knee flexion, DF ankle, altered vestibular

• via osteoporosis/osteopenia, IV disk, sarcopenia, body fat, compensation, cumulative injury, ankylosing spondylitis, SD/VSR

• dec. gait velocity, step/stride length, clearance; inc. initial contact, widened stance

evaluation and treatment of geriatric patients?

• less tolerant to direct technique (use indirect)

  • form adhesions from chronic strain/SD

• home exercise, loosen muscles, walk/aquatic, prevent fall risk

• impaired homeostasis (dec. height, body mass, water, fat; thin/fragile hair, wrinkle skin, sweat gland atrophy; dec. lens elasticity (presbyopia), inc. lens density (cataract), glaucoma, dec. color; dec. lingual papilla, taste, smell, receding gums; dec. hearing + balance)

fall injury risks for geriatric patients?

• tolerance to fall dec. w/ age (via dec. bone density/flexibility)

• via dec. vision, balance, cerebral blood flow (syncope); inc. cognitive impairment, delirium

  • exercise = strength, stamina, balance, metabolic syndrome (high BP + fasting glucose, abdominal obesity, high TG, low HDL)

• most common fatal + nonfatal injury

• = 20-30% mortality w/in 1 yr; 70% never fully recover

indications for geriatric patients? contraindications?

• chronic pain, dec. ROM, arthritis, postural imbalance, resp. support, lymph./circ. mobilization, autonomic balance, prevent 2ndary complication

• unstable joints, acute bone injury, malignancy, severe infection, spinal abnormalities

  • relative → osteoporosis, joint inflammation, degenerative joint, anticoagulation therapy, vasc. disease, post. surg. joint, mental/psych dependence, herpes zoster

elements of ADLs?

• basic → self-care for personal health/independence (bathe, groom, toilet, mobility/transfer, continence, feeding)

• instrumental → complex for independent living in community (manage meds, finances, meals, housekeep/security, shop, transport/communication device)

treating neck pain in geriatric patients? back pain?

• quick → OA release, ST cervical paraspinals

  • extended → FPR/BLT/MFR, thoracic ME, pec minor/levator scapulae/trapezius CS

• quick → ST thoracic/lumbar paraspinal, piriformis CS, psoas major/QL ME

  • extended → lumbar, innominate, sacrum ME

pec minor CS? levator scapulae CS? trapezius CS?

• @ coracoid, F ADD (stand on opp. side of SD + grab scapula)

• @ sup. med. scapula, F ADD elevate scapula, pt. head can be turned towards (stand on same side of SD + compress up from elbow)

• @ neck/shoulder jxn , F AB (stand on same side of SD + SB neck toward w/ R away, F/AB w/ traction via pulling)

piriformis CS? psoas major ME? QL ME?

• @ midpt ILA sacrum + greater trochanter (F ABD ER prone)

  • supine (support pt leg on shoulder), lat. recumbent (leg off table on thigh)

• supine, drop treatment side off table (AB + E) → push down on knee + stabilize opp. ASIS

• supine, SB legs away from QL treated, CL arm in treatment side axilla → torso SB away via grasp axilla hand underback

lateral recumbent ME?

• dysfxn side down w/ shoulders + hips perp. to table

• monitor segment (caudad hand) → rotate towards DO/into barrier → cephalad (extension) or caudad (flexion)

• switch monitoring hand (cephalad hand) → grasp ankles to move leg + pelvis (post. = E; ant. = flexion) **not needed for neutral

• pt. legs lifted up (nonneutral) or dropped (neutral) for SB → pt. pushes down

SOAP note components?

• subjective = CC, HPI, pain

• objective = specific Dx/tenderness + OMT procedure note (consent, region manipulated, technique, pt. response)

  • use ICD-10 (regional) + CPT OMT billing

• assessment = SD

• plan = medication, OMT, therapy (PT, OT, massage), human/holistic/lifestyle (education e.g posture), exercise, referral

humeroulnar joint dysfunction diagnosis? treatment? MIDTERM

• restricted lat. glide of prox. ulna during adduction = abducted ulna w/ medial glide (inc. carrying angle)

• restricted medial glide of prox. ulna during abduction = adducted ulna w/ lat. glide (dec. carrying angle)

• Tx via MET (twist olecranon + push wrist into barrier) or HVLA (twist olecranon, push wrist + extend arm to feather’e edge → thrust = further extension of arm)