New York Institute of Technology
            Department of Physician Assistant Studies
                                Sum...
Use of Technology:
All students must have access to a computer and an Internet Provider. Use of
the NYIT computer faciliti...
Schedule:

Session 1.    Lecture      History of Osteopathy Session

Session 2.    Lecture      Osteopathic Philosophy and...
New York Institute of Technology

  PHYSICIAN ASSISTANT
       PROGRAM


CLINICAL OSTEOPATHIC
   PRINCIPLES AND
    PRACTI...
INTRODUCTION

        This course is designed to help the Physician Assistant student
understand Osteopathic Medicine, wha...
Osteopathic Principles and Practice
                                   Lecture 1

                      HISTORY OF OSTEOPA...
III.   Other Aspects of Still’s Life
              A. Move to Kansas
                     1. Worked with father on a Shawn...
Osteopathic Principles and Practice
                                         Lecture 2

                                  ...
Osteopathic Principles and Practice
                         Lecture 3


           HISTORY OF MANIPULATION
              ...
VI   MANIPULATIVE TECHNIQUES
          A. Myofascial techniques
               1. Direct vs. Indirect
               2. Pa...
4. Low velocity – high amplitude ( articulatory
                       techniques)
                    5. Springing varian...
Osteopathic Principles and Practice
                                  Lecture 4

                       SOMATIC DYSFUNCTIO...
IV.   Vertebral Motion
             A. Vertebral unit: 2 vertebrae with disc between them; motion
                 of uppe...
VII. Etiology of Somatic Dysfunctions:

               A. Type I   Dysfunctions
                     1.    Muscle Spasm
  ...
Osteopathic Principles and Practice
                                   Lecture 5

                 POSTURE AND BODY SYMMET...
The musculoskeletal system is designed to support weight in specific
areas of the body – in the spine, the weight of the b...
b. Less often diagnosed
       2. Structural
              a. Less likely to be correctable
              b. May be geneti...
2. Flattening
            a. Bilateral psoas spasm
            b. Some paravertebral muscle spasms
            c. Associat...
Osteopathic Principles and Practice
                            Lecture 6

                          SCOLIOSIS




       ...
B. Short Leg Syndrome
      1. Fairly common
      2. ¼” or greater is significant to average person
      3. 1/16” can be...
C. Other functional scoliosis
            1. Long leg Syndrome – usually occurs with
                placement of a hip or...
Laboratory 2

                               LANDMARKS

I. Cranium

       A.    External Auditory Meatus
       B.    Ear...
V.     Pelvis/ Sacrum
               A. Innominates
                  1. Iliac crests
                  2. Anterior iliac ...
Osteopathic Principles and Practice

                     MIDTERM EXAMINATIONS

       The midterm written exam will consi...
Osteopathic Principles and Practice

                                 Laboratory 3

                           BODY SYMMET...
B. Trunk Rotation
      1. Direction of rotation
      2. Look at back for scapula to be visible and at front for
        ...
Osteopathic Principles and Practice
                                Laboratory 4

                      SOMATIC DYSFUNCTIO...
b. Edema of tissues – muscles feel “boggy”
                   c. May be tender or have “tender points” or “trigger
       ...
III.   RESTRICTION OF MOTION
            A. Methods of motion testing
                   1. Segmental motion testing - car...
Osteopathic Principles and Practice
                                  Lecture 7

       NEURO-MUSCLULAR PHYSIOLOGY AND SOM...
VI.     SPINAL CORD REFLEXES
        A. Somatovisceral reflexes
        B. Viscerosomatic reflexes
        C. Somatosomati...
Osteopathic Principles and Practice
                                  Lab 5

             PASSIVE MYOFASCIAL TREATMENT

  ...
C. Lumbar
      1. Perpendicular pull
      2. Perpendicular push
      3. Perpendicular push assisted with rotation of pe...
Osteopathic Principles and Practice
                                Lab 6

            ACTIVE MYOFASCIAL TREATMENT

A. MEC...
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PHAS 350 Osteopathic Principles

  1. 1. New York Institute of Technology Department of Physician Assistant Studies Summer 2001 Course: PHAS 350 Clinical Osteopathic Principles & Practice Course Instructor: Eileen L. DiGiovanna, D.O. Phone: (516) 686- 3777 Office Hours: As posted Office: NYCOM III Course description: This is an introductory course designed for Physician Assistant students. Students are made aware of historical and philosophical differences between osteopathic and allopathic physicians. They will gain an understanding of appropriate patterns of referral for osteopathic manipulative treatment. The integration of neurophysiological and biomechanical principles will be emphasized. The skill laboratory will assist the student in developing their palpatory skills and performing a structural evaluation of patients. Some basic techniques for the relief of muscle tension and pain will be taught. Prerequisite: Permission of PA Program Chair Objectives: The student will be able to: 1. Discuss the history and philosophy of Osteopathic Medicine 2. Utilize palpatory skills 3. Identify body landmarks. 4. Perform a structural evaluation 5. Identify the presence of Somatic Dysfunction 6. Develop a referral plan for Osteopathic Manipulative Treatment. 7. Perform Myofascial Techniques for the relief of muscle tension and pain. Required Text: None Suggested Reference Texts: 1. DiGiovanna, EL & Schiowitz, S, An Osteopathic Approach to Diagnosis and Treatment, 2nd Ed, 1997, Lippincott & Raven, Philadelphia, PA 2. Gevitz, Norman, The D.O.s, 1976, Univ of Chicago Press, Chicago, IL Professional Journals: Journal of the American Osteopathic Association Journal of the American Academy of Osteopathy
  2. 2. Use of Technology: All students must have access to a computer and an Internet Provider. Use of the NYIT computer facilities will meet this requirement for those without their own computers. Useful Websites: http://www.aoa-net.org • American Osteopathic Association http://www.aacom.org • American Association of Colleges of Osteopathic Medicine (AACOM) http://www.doctor- t.com/osteopathic_manipulation.htm • Osteopathic Manipulation Required Equipment: None Special Dress Requirements: Special dress is required only for skills laboratory sessions. Males and females are to wear shorts; females are to wear a halter top, bathing suit top, or sports bra. As a requirement of this course, students will be broken into pairs and will perform selected components of the examination and treatment on each other. Evaluation Methodology: Students will be evaluated on their class attendance, a midterm and final written multiple-choice examination, and a midterm and final practical examination. Course Requirements: 1. Class attendance and participation. One excused absence is acceptable. Further absences will result in a grade penalty. 2. A Midterm and Final Written examination 3. A Midterm and Final Practical examination Evaluation Criteria: Percent of Grade: 1. Class Attendance and participation 10% 2. Average of Midterm and Final Written Examinations 45% 3. Average of Midterm and Final Practical Examinations 45%
  3. 3. Schedule: Session 1. Lecture History of Osteopathy Session Session 2. Lecture Osteopathic Philosophy and Concepts Session 3. Lecture History of Manipulation and Osteopathic Manipulation Session 4. Lecture Somatic Dysfunction Session 5. Lab Palpation Session 6. Lecture Posture and Body Symmetry Session 7. Lecture Scoliosis Session 8. Lab Identifying Body Landmarks Session 9 Midterm Written and Practical Examinations Session 10. Lab Body Symmetry Session 11. Lab Identifying Somatic Dysfunction Session 12. Lecture Muscle Physiology and Somatic Dysfunction Session 13. Lab Passive Myofascial Techniques Session 14. Lab Active Myofascial Techniques Session 15. Final Written and Practical Examinations
  4. 4. New York Institute of Technology PHYSICIAN ASSISTANT PROGRAM CLINICAL OSTEOPATHIC PRINCIPLES AND PRACTICE FOR PHYSICIAN ASSISTANT STUDENTS Student Schedule and Information Spring, 2000
  5. 5. INTRODUCTION This course is designed to help the Physician Assistant student understand Osteopathic Medicine, what it is and what it is not, and to have a grasp of the history and philosophy behind the profession. The student will then be aided, through lectures and hands-on laboratories, to understand the musculoskeletal system, the concept of “Somatic Dysfunction”, and the Osteopathic structural examination. Besides diagnosis labs, two treatment sessions will be held to give the student an opportunity to begin the treatment of the patient using soft tissue techniques. The value to the Physician Assistant will be added skills in diagnosing and treating the musculoskeletal system as well as understanding the criteria for referring patients for Osteopathic Manipulative Treatment by an osteopathic physician. In addition, these skills will make the Physician Assistant more useful when working in conjunction with osteopathic physicians in private offices or in hospital settings. DRESS The dress for the laboratory sessions will be similar to that for Physical Diagnosis Sessions. Males should wear shorts; females shorts with halter tops, bathing suit tops or sports bras. Of course, you may have tee shirts or sweats to cover up with when it is cold and you are not the person being examined. Please do not wear jean shorts. The material is heavy and the seams block certain areas to be palpated. EVALUATION Evaluation will be based on class attendance and participation (10%), the average of a written (multiple-choice) midterm and final examination (45%), and the average of a practical midterm and final examination (45%). There will be only one excused absence for the semester; further absences will result in grade penalty. SUGGESTED TEXTS: 1. DiGiovanna, EL & Schiowitz, S, An Osteopathic Approach to Diagnosis and Treatment, 2nd Ed, 1997; Lippincott & Raven, Philadelphia, PA 2. Gevits, Norman, The D.O.s, 1976, Univ of Chicago Press, Chicago, IL
  6. 6. Osteopathic Principles and Practice Lecture 1 HISTORY OF OSTEOPATHY Osteopathic medicine has been around for over 125 years and has established itself as a fully licensed, fully accredited practice of medicine in the United States. Internationally, osteopaths practice only manipulation although in many countries, the practitioners are attempting to upgrade the education of their students so that they, too, may encompass the full practice of medicine. Osteopathic medicine allows a full range of diagnosis and treatment, which includes detailed evaluation of the neuromusculoskeletal system and treatment of somatic dysfunctions along with other types of pathologies. Balancing the autonomic nervous system and relieving any musculoskeletal impediments to the free circulation of blood and lymph as well as free transmission of nervous impulses assists treatment of systemic illness. I. Founder – Andrew Taylor Still, M.D. A. Birthplace – Jonesboro, Lee County, VA B. Parents 1. Father – Abram Still, M.D. a. Methodist minister – circuit rider b. Physician c. Farmer 2. Mother – Martha Poague Still C. Effects on Andrew 1. Religious upbringing – he believed that God is perfect and therefore created a perfect machine, the human body. 2. Father was his early preceptor in medicine 3. Father moved with the frontier – Andrew was influenced by the type of medicine practiced on the American frontier. Settled in Kirksville, Mo. II. Factors Influencing Still in the founding of Osteopathy A. Headaches as a child B. Hunting – the anatomy of the animals he skinned – he developed a love of anatomy C. Religious upbringing D. Medicine as it was practiced on the frontier 1. Heavy metals 2. Emetics and cathartics 3. Narcotics 4. Alcohol 5. Magnetic medicine 6. Spiritualists 7. Bonesetters E. Death of three children from meningitis
  7. 7. III. Other Aspects of Still’s Life A. Move to Kansas 1. Worked with father on a Shawnee Indian reservation – studied human bones 2. Abolitionist B. Civil War – Major in Kansas Militia C. Legislator in Kansas Territory D. Business Man 1. Building of Waukarusa Mission 2. Building of Baker University in Baldwin Kansas IV. Move Back to Missouri A. Kirksville B. Not accepted at first – quack C. “Miracle” cures D. Statue in courthouse yard – unveiled by grandson, Charles Still, Jr. E. Death in 1917 V. Founding of First School V. Founding of other Osteopathic Colleges 1. Flexnor Report – 1910 2. Pharmacology began to be taught – 1929 VI D.O.s in the Military VI. Licensing A. Vermont first – 1896 B. Mississippi last – 1973 VII Other Contributors A. J. Martin Littlejohn B. William Garner Sutherland C. Fred Mitchell, Sr. D.O. D. Lawrence Jones, D.O. E. Stanley Schiowitz, D.O.
  8. 8. Osteopathic Principles and Practice Lecture 2 Philosophy of Osteopathy “A school of medicine based upon the theory that the body is a vital mechanical organism whose structural and functional integrity are coordinate and that perversion of either is disease, while its therapeutic procedure is chiefly manipulative correction….” Tabers Medical Dictionary “A system of health care founded by Andrew Taylor Still (1828-1917) and based on the theory that the body is capable of making its own remedies against disease and other toxic conditions when it is in normal structural relationship and has favorable environmental conditions and adequate nutrition. It utilizes generally accepted physical, pharmacological, and surgical methods of diagnosis and therapy, while placing strong emphasis on the importance of body mechanics and manipulative methods to detect and correct faulty structure and function.” Glossary of Osteopathic Terminology I. Body as a unit Paracelsus – “The physician who wants to know man must look upon him as a whole…” Still – “Look upon the human body as an organized brotherhood of laborers. The business of the operator is to keep peace and harmony throughout the whole brotherhood. He is a worthy osteopath who realizes the great importance of this truth, and practices it.” A. The approach to the patient’s treatment should support all aspects of the patient’s condition: • Physical • Social • Psychological • Spiritual B. The body is not a series of autocratic compartments bagged together by the skin and the skeleton. C. The patient represents a total unit with intercommunicating components: • Glandular (hormones and enzymes • Neurological (brain, spinal cord, nerves, neurotransmitters, sensory organs) • Circulation (vascular, lymphatic)
  9. 9. Osteopathic Principles and Practice Lecture 3 HISTORY OF MANIPULATION AND OSTEOPATHIC MANIPULATION I. HISTORY OF MANIPULATION A. Dates back to Egyptian, Greek, and Roman medicine B. Used by Hippocrates C. A part of Oriental medicine – Chinese & Japanese D. Began as treatment for fractures and dislocations E. Later began to be used for scoliosis, “lumbago”, and systemic diseases F. European “Bonesetters” II. DEFINITIONS A. “The body, in normal structural relationship, and with adequate nutrition, is capable of mounting its own defenses.” Still B. Osteopathic Manipulative Treatment C. Osteopathic Manipulation vs. Other Forms of Manual Therapy 1. Physician (M.D.) 2. Chiropractic 3. Physical therapist 4. Massage therapist III. TERMS USED A. Direct Techniques B. Indirect Techniques C. Passive Techniques D. Active Techniques IV. GOALS OF OSTEOPATHIC MANIPULATION A. Achieve normal body mechanics B. Achieve homeostasis – introduce change and allow body to normalize C. Treat somatic dysfunction V. MANIPULTIVE MODELS A. Postural B. Respiratory/circulatory C. Neurologic D. Bioenergetic E. Psychosocial
  10. 10. VI MANIPULATIVE TECHNIQUES A. Myofascial techniques 1. Direct vs. Indirect 2. Passive vs. Active 3. Goals a. Relax hypertonic muscles b. Increase circulation to areas of ischemia c. Increase venous and lymphatic drainage d. Stimulatory effects on hypotonic muscles B. Muscle Energy 1. Active, direct technique 2. Uses golgi tendon organ reflex to relax muscles 3. Positions against motion barriers 4. Uses isometric or isokinetic contractions (against resistance) 5. Relaxation between patient efforts 6. Re-engagement of motion barriers 7. Three contractions then passive stretch of muscle C. Counterstrain 1. Passive, indirect technique 2. Diagnosis relies on “Jones’ tender points” 3. Positional technique 4. Changes abnormal muscle spindle firing D. Facilitated Positional Release 1. Passive, indirect technique 2. Positioning a. Flattening of spinal regions b. Positions into ease of motion 3. Uses a facilitating force – compression, torque, or both E. Fluid Motion 1. Circulation 2. Lymphatic flow a. Thoracic pump b. Pedal pump c. Effleurage 3. Freeing Bronchial secretions 4. Sinus drainage F. Thrusting (Impulse) Techniques 1. Passive, direct technique 2. Uses an operator force to move through barriers to motion 3. High velocity – low amplitude
  11. 11. 4. Low velocity – high amplitude ( articulatory techniques) 5. Springing variants 6. Types of barriers 7. Force used G. Visceral Manipulation 1. To have direct effects on viscera 2. Uses H. Osteopathy in the Cranial Field 1. “Primary respiratory mechanism”, “cranial rhythmic impulse” 2. Direct or indirect, passive 3. Goals: to restore normal motion to cranial bones and balance to reciprocal tension membranes (falx cerebelli, falx cerebri, and tentorium cerebelli) VI. USE OF ACTIVATING FORCES A. EXTRINSIC FORCES 1. Operator effort 2. Gravity 3. Additional aids B. INTRINSIC FORCES 1. Inherent body forces 2. Respiration 3. Patient muscle contraction VII. PRACTICAL APPLICATIONS A. Whiplash injuries B. Headaches C. Scoliosis – functional, idiopathic D. Thoracic Outlet Syndrome E. Lumbar pathologies (herniated disc, strains) F. Coccygodynia G. Dysmenorrhea H. Obstetrics I. Pulmonary Disease (Bronchitis, asthma, pneumonia)
  12. 12. Osteopathic Principles and Practice Lecture 4 SOMATIC DYSFUNCTION I. Definition of Somatic Dysfunction “An altered or impaired function of components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic and neural elements.” Glossary of Osteopathic Terminology II. Diagnostic Criteria: TART A. Tenderness (subjective) B. Asymmetry (static) C. Restriction of motion (active) D. Tissue texture changes (static) E. Acute vs. chronic III. Factors involved in TART A. Neurologic factors 1. Sudomotor changes 2. Rigidity of tissues 3. Skin temperature changes 4. Muscle irritability 5. Facilitated Segment B. Vascular Factors 1. Temperature changes 2. Erythema 3. Swelling – edema 4. Tenderness – ischemia C. Muscular Changes 1. Increased tone 2. Fibrosis/Edema 3. Tenderness D. Restriction of Motion 1. Barrier concept 2. Physiologic barrier 3. Anatomic barrier 4. Restrictive barrier 5. Tethering
  13. 13. IV. Vertebral Motion A. Vertebral unit: 2 vertebrae with disc between them; motion of upper on lower B. Planes of motion 1. Sagittal: flexion/ extension 2. Horizontal: rotation, right & left 3. Coronal: sidebending (lateral flexion), right & left 4. Direction of rotation or sidebending is named relative to the front of the body of the vertebra. V. Naming Somatic dysfunctions are always named for their freedoms of motion. This is due to the fact that the joint is asymmetrically positioned into the ease of its motion and thus is palpated as being in the position for which it is named. VI. Laws of Physiologic Motion (Fryette’s Laws) A. First Law: When the spine is in a neutral position, sidebending will occur in the direction opposite rotation. 1. Applies to groups of vertebrae – group curves 2. Spine is in neutral – no flexion or extension; easy normal 3. Sidebending and rotation occur in opposite directions 4. Creates Type I somatic dysfunctions B. Second Law: When the spine is flexed or extended (close- pack position), one segment must rotate in the same direction as sidebending. 1. Affects a single vertebra 2. Occurs when spine is hyperflexed or hyperextended 3. Sidebending and rotation of one segment will be in same direction 4. Creates Type II somatic dysfunctions - usually the most problematic. C. Third Law: When a change occurs in one plane of motion the other planes will be affected D. These laws or rules apply only to the Thoracic and Lumbar vertebrae. They do not apply to the cervical vertebrae. Cervical vertebrae have Joints of Lushka on the bodies, which guides them into rotation and sidebending in the same direction. If a cervical has probably been a trauma to the area.
  14. 14. VII. Etiology of Somatic Dysfunctions: A. Type I Dysfunctions 1. Muscle Spasm 2. Short leg syndrome 3. Sacral/pelvic imbalances C. Type II Dysfunctions 1. Trauma 2. Neuromuscular reflex abnormalities 3. Posture 4. Viscero-somatic reflexes ( organ pathology) VII. Diagnostic and Therapeutic Significance of Somatic Dysfunctions A. Diagnosis 1. Viscerosomatic reflexes point to organ pathology at related autonomic innervation areas 2. Somato-somatic reflexes help identify areas of somatic problems (e.g. Arthritis) 3. Identification of source of pain/discomfort 4. Identification of source of motion restrictions B. Treatment 1. Relieve pain 2. Relieve motor restriction 3. Relieve sensory abnormalities (e.g. paresthesias, numbness) 4. Balance autonomic input to organs to assist the body in healing organ pathologies VIII. Theories of Causation A. Neuromuscular dysfunction 1. Involving muscle spindle 2. Muscle tensions / strains B. Loss of normal joint play in accessory motions of the joint C. Facet menisci 1. Meniscal entrapment 2. Meniscal extrapment
  15. 15. Osteopathic Principles and Practice Lecture 5 POSTURE AND BODY SYMMETRY POSTURE: The relationship of the body to the ground and the relationship of the body parts to each other. TYPES OF POSTURE: A. Upright - both standing and during gait B. Seated C. Supine – lying on back D. Prone – lying on abdomen E. Postures during sleep F. Modifications 1. Position of arms & legs 2. Position of head CHARACTERISTICS OF POSTURE Active Posture: Postures that occur during various motions including gait, sports activities, use of upper extremities Sleeping postures: Postures that occur during sleep Automatic Posture: Postures that the body assumes automatically to maintain balance. Influenced by proprioceptors in joints, the nervous system “righting mechanism”, and the inner ear. Habitual postures: Those postures, which become habitual and therefore are somewhat automatic. May be influenced by occupation, furniture in which one sits, mental attitude, “laziness” of muscles. SPINAL CURVES The human spine has several curves in the antero-posterior plane, which develop gradually during the early years. An infant has a C-shaped spine (kyphotic). As the child begins to lift its head as it lies on its abdomen, a lordotic curve begins to develop in the cervical spine. When the child stands and begins to walk, a lordotic curve develops in the lumbar spine. Thus the adult normally has a cervical lordosis (curves in an anterior direction), the thoracic spine has a kyphosis (curves posteriorly), and the lumbar spine has a lordosis. The sacrum is slightly kyphotic. CENTER OF GRAVITY The body’s center of gravity is normally located just anterior to the second sacral segment. Proper body alignment will maintain the center of gravity in this position when standing. Changes, of course, occur with movement, use of extremities or other postures such as sitting or lying down.
  16. 16. The musculoskeletal system is designed to support weight in specific areas of the body – in the spine, the weight of the body is supported on specific vertebrae, which are designed to support that weight. Poor posture shifts the center of gravity and, thus, the weight of the body shifts onto vertebrae not designed to support the weight. Poor posture also puts abnormal strains on muscles, tendons, and ligaments. The center of gravity may actually shift outside the body in certain activities, e.g. ski jump with sharply forward-bent body or high-jumping in which the body is thrown backward over a bar. These are obviously very strained postures and the body performing them must be very fit to tolerate it. CONDITIONS THAT LEAD TO POSTURAL DYSFUNCTIONS 1. Fractures 2. Injury to growth plates in bones 3. Congenital abnormalities 4. Neurologic problems 5. Disease processes, including mental (e.g. depression). 6. Muscle spasms or abnormal tensions KYPHOSIS Kyphosis is most commonly found in the thoracic spine. It may be purely the result of poor posture, in which case the patient must be made aware of the problem and started on proper exercise to strengthen postural muscles. Kyphosis may be genetic, generally a juvenile type. Kyphosis is commonly found in more severe cases of osteoporosis where there are micro- fractures of the anterior body of the vertebrae in the thoracic spine causing the typical posture of “Dowager’s Hump”. There is frequently an increase in the lordosis or the cervical and lumbar spines when the thoracic spine is kyphotic. Kyphosis may or may not be correctable. If it is postural, it will be correctable with work on the patient’s part; if structural, it will not be correctable. LORDOSIS The term lordosis is also used for an abnormal A-P curve, usually found in the cervical or lumbar spine. The anterior curvature is exaggerated. LATERAL CURVES Lateral curves in the spine are always abnormal. These are called scoliosis or rotoscoliosis (indicating an element of rotation with the lateral sidebending). Occasionally scoliosis may be associated with an A-P curve such as kyphosis (kyphoscoliosis). 1. Functional a. Usually correctable
  17. 17. b. Less often diagnosed 2. Structural a. Less likely to be correctable b. May be genetic c. Structure of bone or ligaments abnormal CERVICAL SPINE The cervical spine may exhibit either flattening or an increase in lordosis. 1. Flattening a. Muscle spasm b. Whiplash injury c. Ankylosing Spondylitis d. Some arthritides 2. Lordosis a. Associated with increased kyphosis in thoracic spine b. Posterior muscle spasm or contracture 3. Reversed Curve a. Trauma/ severe whiplash b. Parkinson’s disease THORACIC SPINE 1. Kyphosis a. Postural – habitual, occupational b. Osteoporosis – “Dowager’s hump” c. Juvenile – may be associated with “Schmorles nodes”, genetic 2. Flattening a. Postural b. Muscle tension c. May have visceral significance LUMBAR SPINE 1. Lordosis a. Genetic – often seen in blacks b. Wearing high heels c. Obesity d. Pregnancy e. Pelvic rotations f. Associated with increased thoracic kyphosis g. Some muscle spasms
  18. 18. 2. Flattening a. Bilateral psoas spasm b. Some paravertebral muscle spasms c. Associated with other spinal flattening d. Ankylosing Spondylitis PELVIC/SACRAL IMBALANCES 1. Lateral Tilt of Pelvis a. Short leg b. Long leg c. Muscle imbalance 2. Rotation of pelvis in horizontal plane 3. Unequal size of innominates 4. Rotation of one or both innominates in sagittal plane 5. Sacral somatic dysfunction a. Sacral rotation – rotates around diagonal axis b. Sacral torsion ( L5 is rotated in opposite direction) i. Forward – rotates forward on a diagonal axis ii ii. Backward – rotates backward on a diagonal axis c. Sacral shear (unilateral sacral flexion) – slides down the articulation and side-bends.
  19. 19. Osteopathic Principles and Practice Lecture 6 SCOLIOSIS Scoliosis is a lateral curvature of the spine, most commonly seen in the thoracic and lumbar regions, which is never normal curve. The line of gravity passing through the vertebrae does not pass through the center of the bodies so that the weight distribution is abnormal and stress is placed on the spine and on the intervertebral discs. There are two types of scoliosis, functional and structural. I. FUNCTIONAL A. When patient side-bends toward the side of the convexity, the curve will straighten. B. Usually correctable when cause is treated. C. Causes: 1. Tight muscles (bowstring effect) 2. Type I somatic dysfunction 3. Pelvic/Sacral Imbalance II. STRUCTURAL A. Side-bending toward the convexity will not straighten the curve B. Not generally correctable, goal is to prevent progression and/or deformity. C. Causes: 1. Generally genetic 2. Structural change in bone and/or ligament D. Affects women more than men. E. Generally diagnosed in late childhood/early adolescence. School screening is important. III. EVALUATING FUNCTIONAL SCOLIOSIS A. Structural Evaluation 1. Test side-bending 2. Evaluate for rotary component 3. Evaluate leg length 4. Evaluate for pronation of one foot greater than other. 5. Evaluate for pelvic disproportion.
  20. 20. B. Short Leg Syndrome 1. Fairly common 2. ¼” or greater is significant to average person 3. 1/16” can be significant to someone requiring good balance e.g. dancers 4. Best evaluated with “Postural x-ray”. Taken standing, feet 6” apart, weight equally distributed on each leg, knees straight, on level floor. Usually uses an x-ray film with grids. Measure femoral head heights, iliac crest heights, and sacral alae heights(the latter is the significant measurement.) 5. Convexity of curve of lumbar spine should be to the short leg side. 6. If the lumbar spine is straight or if the convexity is to the side of the long leg, no heel lift should be used. 7. Treat with Heel Lift The starting height of the heel lift is calculated with the Heilig formula: L= SBU D+C L = Lift height SBU = Sacral base unleveling D = Duration of short leg <10 years = 1 10-20 years = 2 >20 years = 3 C = Compensation Side-bending w/ no rotation = 1 Rotation to convexity = 2 Wedging or facet changes = 3 8. Heel Lift a. Height of lift is started using above formula and increased every 2-4 weeks until lumbar spine is straightened. b. Firm material (not foam rubber) such as cork or leather c. Must wear at all times when on feet except on sand. d. Cannot correct a short leg if the convexity is not to short leg side. e. If lift is greater than ¼” it must be put on outside of shoe, otherwise may be worn in shoe. f. If lift on heel is greater than ½”, then half that amount must be added to the sole of the shoe to avoid stressing foot.
  21. 21. C. Other functional scoliosis 1. Long leg Syndrome – usually occurs with placement of a hip or knee prosthesis. Heel lift may be used in heel of shorter leg as with a short leg syndrome. 2. Type I somatic Dysfunction or Tight muscles – Manipulation may used to treat these. IV. EVALUATING STRUCTURAL SCOLIOSIS A. Structural Evaluation 1. Evaluate rotary component during forward bending - “rib hump”. 2. Evaluate with side bending – curve will not straighten. B. X-ray Evaluation - Cobb Angle Measurement C. Type of Curve 1. C-shaped 2. S-shaped ( may be structural or may be accommodation) 3. Right thoracic – most common, always a major curve; cosmetic problems 4. Thoraco-lumbar – fairly common, either right or left, less deforming, may have compensatory curves 5. Double major curves – if curves are equal if may be hard to identify, not deforming 6. Lumbar major curve – Usually to left, thoracic spine remains flexible, frequently leads to arthritis in later life. D. Progression 1. Follow with Cobb measurement 2. Frequent during adolescence 3. May occur during pregnancy 4. Rapidly progressing curves should be referred for specialist care. E. School Screening for scoliosis F. Treatment 1. Braces 2. Casts 3. TENS unit 4. Surgical – Harrington rod 5. OMT 6. Exercise Osteopathic Principles and Practice
  22. 22. Laboratory 2 LANDMARKS I. Cranium A. External Auditory Meatus B. Ear lobes C. Mastoid Processes D. Inion E. Nuchal Line II. Cervical Spine A. Occipital Sulcus B. Vertebra Promenens (C7) C. Articular Pillars III. Thorax A. Spinous processes B. Ribs C. Scapula 1. Acromion 2. Corocoid process 3. Inferior Angle 4. Spine of scapula D. Anterior Chest Wall 1. Sternal notch 2. Angle of Louis 3. Xiphoid Process 4. Clavicles a. Sternoclavicular joint b. Acromioclavicular joint c. Mid-clavicular line 5. Axilla a. Anterior axillary line b. Mid-axillary line c. Posterior axillary line IV. Lumbar Region 1. Iliac crests mark L4 level 2. Waist creases 3. Umbilicus – L3 4. Lumbo-sacral junction
  23. 23. V. Pelvis/ Sacrum A. Innominates 1. Iliac crests 2. Anterior iliac spines (ASIS) 3. Posterior iliac spines (PSIS) B. Sacrum 1. Hiatus 2. Inferior lateral angles (ILAs) 3. Base 4. Apex C. Gluteal creases VI. Extremities A. Greater trochanter B. Patellae C. Tibial tubersities D. Popliteal crease E. Medial Malleoli F. Lateral Malleoli G. Medial arches VII. Muscles A. Erector spinae B. Sternocleidomastoid (SCM) C. Trapezius D. Latissimus dorsi E. Supraspinatus F. Infraspinatus G. Quadriceps H. Hamstrings
  24. 24. Osteopathic Principles and Practice MIDTERM EXAMINATIONS The midterm written exam will consist of multiple choice questions based on lecture material and syllabus. Any assigned readings may be included as well. This examination will count as 25% of your grade in this course. The midterm practical examination will be a practical examination of laboratory material in the lab setting. You will be paired with a partner and will demonstrate your skills as a pair to an instructor. This examination will count as 25% of your grade. To participate in this examination you will be expected to dress in the same manner as required for laboratory sessions. Failure to do so will result in you being dismissed from the exam and receiving a “0” for that exam.
  25. 25. Osteopathic Principles and Practice Laboratory 3 BODY SYMMETRY It is important to evaluate body symmetry in the evaluation of the total person. The body’s posture is significant to the individual’s well-being. Variations in posture can cause the center of gravity to be deviated from the structures that are best designed to support the weight. They can create stress on muscles, ligaments and tendons. Evaluation of the symmetry of various body landmarks is useful in determining overall body posture. The patient should be dressed in such a manner that the body landmarks can be visualized. S/he should be standing with the feet about 6” apart with weight equally on both lower extremities. The physician’s assistant should view the patient from the back, the front, and each side. I. POSTERIOR VIEW A. Ear lobes level B. Shoulders level C. Tip of scapula level D. Waist Creases E. Iliac Crests level F. PSIS level G. Gluteal Creases level H. Popliteal Creases level I. Malleoli level J. Medial arches of feet height K. Spine – any evidence of scoliosis? II. ANTERIOR VIEW A. Ear lobes level B. Head tilt C. Shoulders level D. Nipple line in males E. Finger tips F. ASIS level G. Knees 1. Genu valgus 2. Genu varus III. LATERAL VIEW A. Head 1. Forward carriage 2. Backward carriage
  26. 26. B. Trunk Rotation 1. Direction of rotation 2. Look at back for scapula to be visible and at front for opposite chest wall to be visible. C. Anterior and Posterior Curves of spine 1. Cervical 2. Thoracic 3. Lumbar D. Lower Extremities 1. Genu recurvatum 2. Flexion deformity of knee
  27. 27. Osteopathic Principles and Practice Laboratory 4 SOMATIC DYSFUNCTION Somatic dysfunction is diagnosed by using the following criteria: T – Tenderness A – Asymmetry of position R – Restriction of motion T – Tissue Texture Changes Tenderness is a subjective finding based on patient perception. However, it is found during palpation of an area when a patient reports that the area hurts or is sore when pressure is applied. Asymmetry, restriction of motion and tissue texture changes are objective findings that are all diagnosed through the use of palpation. I. TISSUE TEXTURE CHANGES A. Skin 1. Temperature changes a. Increase in heat or a coolness in a small area near a vertebra may indicate somatic dysfunction. i. Increase in temperature – acute ii. Decrease in temperature - chronic b. Palpate with back or side of hand 2. Color changes a. Erythema test b. Redness which persists indicates acute somatic dysfunction c. Blanching which persists indicates chronic somatic dysfunction d. Hyper-pigmentation may indicate long-standing dysfunction 3. Skin Drag Indicates increase in moisture in small area – acute dysfunction B. Connective Tissue Most connective tissue changes occur in the fascia and are palpated as an increase in tension in the fascia. C. Muscle Changes 1. Acute changes with dysfunction a. Hypertonicity – a feeling of tension in the muscle, increased tone
  28. 28. b. Edema of tissues – muscles feel “boggy” c. May be tender or have “tender points” or “trigger points” in them. d. Muscles may be in spasm – muscle contraction beyond the physiologic need 2. Chronic changes with dysfunction a. Hyper-tonicity or hypo-tonicity may be present. Either too much or too little tone b. Fibrous changes in muscle – muscles feel “ropy” or “stringy” c. Muscles may become contractured – a fixed shortening of the muscle which may be non- reversible d. In more extreme cases where there has been nerve impingement the muscle may become atrophic – lose its nutrition to the point where muscle mass decreases. II. ASYMMETRY OF POSITION Vertebrae are palpated for symmetry. The position of spinous processes and transverse processes (articular pillars in the neck) are palpated. A. Cervical Spine 1. Palpate articular pillars 2. Does one feel more prominent than another? If one is more prominent, it may be rotated toward that side. If it is rotated toward that side, it will be sidebent toward that side. 3. Palpate the spinous processes 4. Does the space between them feel equal? A change in space means that there is flexion or extension of one of the vertebrae. B. Thoracic Spine 1. Palpate the transverse processes looking for a prominence of one indicating a rotation. 2. Palpate the spinous processes looking for a change in spacing (remember that the spinous processes slope down from T4 to T10) C. Lumbar Spine 1. Palpate transverse process for symmetry 2. Palpate spinous processes for symmetry D. Do the asymmetry changes you have found correspond to the tissue texture changes you found?
  29. 29. III. RESTRICTION OF MOTION A. Methods of motion testing 1. Segmental motion testing - carrying the vertebra through each of its ranges of motion and feeling for a resistance 2. Translatory testing in the cervical spine – moving vertebra laterally to test sidebending 3. Rotoscoliosis testing – testing for asymmetry in neutral, flexion, and extension. 4. Barrier testing – moving vertebra into flexion and extension and palpating changes in the rotational component. B. Test the motion in any segment where you have found tissue texture changes and/or asymmetry of position. 1. Is there a correspondence of the three criteria? If you have two or more it is most likely a somatic dysfunction. C. Naming the dysfunction: always for the freedoms of motion not the restrictions. Write out the name of the dysfunctions you have diagnosed. D. Have faculty confirm your diagnoses.
  30. 30. Osteopathic Principles and Practice Lecture 7 NEURO-MUSCLULAR PHYSIOLOGY AND SOMATIC DYSFUNCTION A large percentage of somatic dysfunctions are created or maintained by abnormal muscle pull on the bones of the joints, not allowing normal motion within that joint. An understanding of basic muscle physiology and its relationship to somatic dysfunction is useful. The nervous system plays a major role in the physiology of the muscle as well as in the effects somatic dysfunction has on the body systems. Many nervous system reflexes interact between the body framework and the viscera. An understanding of these factors will assist you in diagnosing and treating patients with problems in these areas. I. BASIC TERMINOLOGY A. Afferent/Efferent Nerves B. Ventral/Dorsal Horn C. Contraction D. Contracture E. Agonist/Antagonist II. AUTONOMIC NERVOUS SYSTEM A. Sympathetic Nervous System B. Parasympathetic Nervous System IV. PROPRIOCEPTION V. SKELETAL MUSCLE SYSTEM A. Classification of Muscles 1. Striated a. Skeletal b. Cardiac 2. Smooth B. Typical spinal nerves C. Neuromuscular reflexes 1. Muscle spindle reflex 2. Golgi tendon reflex 3. Crossed Extensor reflex VII. SEGMENTALIZATION
  31. 31. VI. SPINAL CORD REFLEXES A. Somatovisceral reflexes B. Viscerosomatic reflexes C. Somatosomatic reflexes D. Viscerovisceral reflexes VIII. FACILITATION IX. NOCICEPTION A. Factors Involved B. Causes of Muscle Pain X. PRACTICAL APPLICATIONS OF NEUROPHYSIOLOGY IN OSTEOPATHIC DIAGNOSIS AND TREATMENT A. Palpation of Muscle Changes B. Maintenance of Somatic Dysfunction C. Manipulation 1. Myofascial/ Muscle Techniques a. Stretch Reflex b. Use of Heat c. Servo-assist function of Muscle spindle d. Golgi tendon organ reflex e. Reciprocal innervation f. Crossed extensor reflex 2. Inhibition/Stimulation Techniques
  32. 32. Osteopathic Principles and Practice Lab 5 PASSIVE MYOFASCIAL TREATMENT Treats the Soft Tissues of the body. 1. Muscle 2. Tendons 3. Fascia 4. Ligaments PASSIVE: Done by the physician assistant alone PURPOSE: A. Relieve Pain 1. Relax muscle 2. Reduce ischemia 3. Remove catabolites 4. Stretch contractured muscles and tense fascia C. Prepare tissues for treatment by D.O. D. Improve muscle tone - stimulatory E. Improve circulation F. Improve venous and lymphatic drainage HOW IT’S DONE: A. Manual Traction 1. Either end of muscle 2. Both ends of muscle 3. Push perpendicularly 4. Pull perpendicularly B. Deep Inhibition C. Effleurage – assist in removing fluids from tissues REGIONS A. Cervical 1. Suboccipital 2. Linear Stretch 3. Perpendicular Stretch 4. Bilateral Stretch to both ends of muscle 5. Unilateral Stretch to both ends of muscle B. Thoracic 1. Perpendicular stretch 2. Trapezius 3. Subscapular muscle 4. Parallel stretch
  33. 33. C. Lumbar 1. Perpendicular pull 2. Perpendicular push 3. Perpendicular push assisted with rotation of pelvis
  34. 34. Osteopathic Principles and Practice Lab 6 ACTIVE MYOFASCIAL TREATMENT A. MECHANISMS UTILIZED 1. Golgi Tendon Organ 2. Reciprocal Inhibition B. TYPES 1. Direct – having patient contract muscle involved against isometric resistance – golgi tendon organ 2. Indirect – having patient contract antagonist muscle against isokinetic resistance C.DIRECT TECHNIQUES 1. Cervical a. Suboccipital b. Paravertebral 2. Thoracic a. Arm to floor b. Arm to ceiling 3. Lumbar a. Legs to floor b. Legs to ceiling D. INDIRECT TECHNIQUES 1. Cervical Anterior or posterior cervical muscles with crossed extensor reflex. 2. Thoracic Pull arm across chest while supine 3. Lumbar Push legs up or down against isokinetic resistance. Treating opposite muscles.

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