PHAS 350 Osteopathic Principles

New York Institute of TechnologyDepartment of Physician Assistant Studies

Summer 2001

Course: PHAS 350 Clinical Osteopathic Principles & Practice Course Instructor: Eileen L. DiGiovanna, D.O.Phone: (516) 686- 3777Office Hours: As postedOffice: 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 Medicine2. 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, 2 nd 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 AssociationJournal of the American Academy of Osteopathy

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 Associationhttp://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 examination3. 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%

Schedule:

http://www.doctor-t.com/osteopathic_manipulation.htm

http://www.doctor-t.com/osteopathic_manipulation.htm

http://www.aacom.org/

http://www.aoa-net.org/

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

New York Institute of TechnologyNew York Institute of Technology

PHYSICIAN ASSISTANT PROGRAM

CLINICAL OSTEOPATHIC PRINCIPLES AND PRACTICE FOR

PHYSICIAN ASSISTANTSTUDENTS

Student Schedule and InformationStudent Schedule and InformationSpring, 2000Spring, 2000

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, 2 nd Ed , 1997; Lippincott & Raven, Philadelphia, PA

2. Gevits, Norman, The D.O.s, 1976, Univ of Chicago Press, Chicago, IL

Osteopathic Principles and PracticeLecture 1

HISTORY OF OSTEOPATHYOsteopathic 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, VAB. Parents

1. Father – Abram Still, M.D.a. Methodist minister – circuit riderb. Physicianc. Farmer

2. Mother – Martha Poague StillC. 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 medicine3. 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 OsteopathyA. Headaches as a childB. Hunting – the anatomy of the animals he skinned – he

developed a love of anatomyC. Religious upbringingD. Medicine as it was practiced on the frontier

1. Heavy metals2. Emetics and cathartics3. Narcotics4. Alcohol5. Magnetic medicine6. Spiritualists7. Bonesetters

E. Death of three children from meningitis

III. Other Aspects of Still’s LifeA. Move to Kansas

1. Worked with father on a Shawnee Indian reservation – studied human bones

2. AbolitionistB. Civil War – Major in Kansas MilitiaC. Legislator in Kansas TerritoryD. Business Man

1. Building of Waukarusa Mission2. Building of Baker University in Baldwin Kansas

IV. Move Back to MissouriA. KirksvilleB. Not accepted at first – quackC. “Miracle” curesD. Statue in courthouse yard – unveiled by grandson, Charles

Still, Jr.E. Death in 1917

V. Founding of First School

V. Founding of other Osteopathic Colleges1. Flexnor Report – 19102. Pharmacology began to be taught – 1929

VI D.O.s in the Military

VI. LicensingA. Vermont first – 1896B. Mississippi last – 1973

VII Other ContributorsA. J. Martin LittlejohnB. William Garner SutherlandC. Fred Mitchell, Sr. D.O.D. Lawrence Jones, D.O.E. Stanley Schiowitz, D.O.


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 worthyosteopath who realizes the great importance of this truth, andpractices 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)


HISTORY OF MANIPULATIONAND

OSTEOPATHIC MANIPULATION

I. HISTORY OF MANIPULATIONA. Dates back to Egyptian, Greek, and Roman medicineB. Used by HippocratesC. A part of Oriental medicine – Chinese & JapaneseD. Began as treatment for fractures and dislocationsE. Later began to be used for scoliosis, “lumbago”, and

systemic diseasesF. European “Bonesetters”

II. DEFINITIONSA. “The body, in normal structural relationship, and with

adequate nutrition, is capable of mounting its own defenses.” StillB. Osteopathic Manipulative TreatmentC. Osteopathic Manipulation vs. Other Forms of Manual

Therapy1. Physician (M.D.)2. Chiropractic3. Physical therapist4. Massage therapist

III. TERMS USEDA. Direct TechniquesB. Indirect TechniquesC. Passive TechniquesD. Active Techniques

IV. GOALS OF OSTEOPATHIC MANIPULATIONA. Achieve normal body mechanicsB. Achieve homeostasis – introduce change and allow body to

normalizeC. Treat somatic dysfunction

V. MANIPULTIVE MODELSA. PosturalB. Respiratory/circulatoryC. NeurologicD. BioenergeticE. Psychosocial

VI MANIPULATIVE TECHNIQUESA. Myofascial techniques

1. Direct vs. Indirect2. Passive vs. Active3. Goals

a. Relax hypertonic musclesb. Increase circulation to areas of ischemiac. Increase venous and lymphatic drainaged. Stimulatory effects on hypotonic muscles

B. Muscle Energy1. Active, direct technique2. Uses golgi tendon organ reflex to relax muscles3. Positions against motion barriers4. Uses isometric or isokinetic contractions (against

resistance)5. Relaxation between patient efforts6. Re-engagement of motion barriers7. Three contractions then passive stretch of muscle

C. Counterstrain1. Passive, indirect technique2. Diagnosis relies on “Jones’ tender points”3. Positional technique4. Changes abnormal muscle spindle firing

D. Facilitated Positional Release1. Passive, indirect technique2. Positioning

a. Flattening of spinal regionsb. Positions into ease of motion

3. Uses a facilitating force – compression, torque, or both

E. Fluid Motion1. Circulation2. Lymphatic flow

a. Thoracic pumpb. Pedal pumpc. Effleurage

3. Freeing Bronchial secretions4. Sinus drainage

F. Thrusting (Impulse) Techniques1. Passive, direct technique2. Uses an operator force to move through barriers to

motion3. High velocity – low amplitude

4. Low velocity – high amplitude ( articulatory techniques)

5. Springing variants6. Types of barriers7. Force used

G. Visceral Manipulation1. To have direct effects on viscera2. Uses

H. Osteopathy in the Cranial Field1. “Primary respiratory mechanism”, “cranial rhythmic

impulse”2. Direct or indirect, passive3. 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 FORCES1. Operator effort2. Gravity3. Additional aids

B. INTRINSIC FORCES1. Inherent body forces2. Respiration3. Patient muscle contraction

VII. PRACTICAL APPLICATIONS

A. Whiplash injuriesB. HeadachesC. Scoliosis – functional, idiopathicD. Thoracic Outlet SyndromeE. Lumbar pathologies (herniated disc, strains)F. CoccygodyniaG. DysmenorrheaH. ObstetricsI. Pulmonary Disease (Bronchitis, asthma, pneumonia)


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: TARTA. Tenderness (subjective)B. Asymmetry (static)C. Restriction of motion (active)D. Tissue texture changes (static)E. Acute vs. chronic

III. Factors involved in TARTA. Neurologic factors

1. Sudomotor changes2. Rigidity of tissues3. Skin temperature changes4. Muscle irritability5. Facilitated Segment

B. Vascular Factors1. Temperature changes2. Erythema3. Swelling – edema4. Tenderness – ischemia

C. Muscular Changes1. Increased tone2. Fibrosis/Edema3. Tenderness

D. Restriction of Motion1. Barrier concept2. Physiologic barrier3. Anatomic barrier4. Restrictive barrier5. Tethering

IV. Vertebral MotionA. Vertebral unit: 2 vertebrae with disc between them; motion

of upper on lowerB. Planes of motion

1. Sagittal: flexion/ extension2. Horizontal: rotation, right & left3. Coronal: sidebending (lateral flexion), right & left4. Direction of rotation or sidebending is named

relative to the frontof the body of the vertebra.

V. NamingSomatic 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 curves2. Spine is in neutral – no flexion or extension; easy

normal3. Sidebending and rotation occur in opposite

directions4. 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 vertebra2. Occurs when spine is hyperflexed or hyperextended3. Sidebending and rotation of one segment will be in

same direction4. 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.

VII. Etiology of Somatic Dysfunctions:

A. Type I Dysfunctions1. Muscle Spasm2. Short leg syndrome3. Sacral/pelvic imbalances

C. Type II Dysfunctions1. Trauma2. Neuromuscular reflex abnormalities3. Posture4. Viscero-somatic reflexes ( organ pathology)

VII. Diagnostic and Therapeutic Significance of Somatic Dysfunctions

A. Diagnosis1. Viscerosomatic reflexes point to organ pathology at

related autonomic innervation areas2. Somato-somatic reflexes help identify areas of

somatic problems (e.g. Arthritis)3. Identification of source of pain/discomfort4. Identification of source of motion restrictions

B. Treatment1. Relieve pain2. Relieve motor restriction3. 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 dysfunction1. Involving muscle spindle2. Muscle tensions / strains

B. Loss of normal joint play in accessory motions of the jointC. Facet menisci

1. Meniscal entrapment2. Meniscal extrapment


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 gaitB. SeatedC. Supine – lying on backD. Prone – lying on abdomenE. Postures during sleepF. Modifications

1. Position of arms & legs2. Position of head

CHARACTERISTICS OF POSTUREActive Posture: Postures that occur during various motions including

gait, sports activities, use of upper extremitiesSleeping postures: Postures that occur during sleepAutomatic 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 CURVESThe 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.

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. Fractures2. Injury to growth plates in bones3. Congenital abnormalities4. Neurologic problems5. 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. Functionala. Usually correctable

b. Less often diagnosed2. Structural

a. Less likely to be correctableb. May be geneticc. Structure of bone or ligaments abnormal

CERVICAL SPINE

The cervical spine may exhibit either flattening or an increase in lordosis.

1. Flatteninga. Muscle spasmb. Whiplash injuryc. Ankylosing Spondylitisd. Some arthritides

2. Lordosisa. Associated with increased kyphosis in thoracic spineb. Posterior muscle spasm or contracture

3. Reversed Curvea. Trauma/ severe whiplashb. Parkinson’s disease

THORACIC SPINE

1. Kyphosisa. Postural – habitual, occupationalb. Osteoporosis – “Dowager’s hump”c. Juvenile – may be associated with “Schmorles nodes”,

genetic2. Flattening

a. Posturalb. Muscle tensionc. May have visceral significance

LUMBAR SPINE

1. Lordosisa. Genetic – often seen in blacksb. Wearing high heelsc. Obesityd. Pregnancye. Pelvic rotationsf. Associated with increased thoracic kyphosisg. Some muscle spasms

2. Flatteninga. Bilateral psoas spasmb. Some paravertebral muscle spasmsc. Associated with other spinal flatteningd. Ankylosing Spondylitis

PELVIC/SACRAL IMBALANCES

1. Lateral Tilt of Pelvisa. Short legb. Long legc. Muscle imbalance

2. Rotation of pelvis in horizontal plane3. Unequal size of innominates4. Rotation of one or both innominates in sagittal plane5. Sacral somatic dysfunction

a. Sacral rotation – rotates around diagonal axisb. Sacral torsion ( L5 is rotated in opposite direction)

i. Forward – rotates forward on a diagonal axis ii. Backward – rotates backward on a diagonal axis

c. Sacral shear (unilateral sacral flexion) – slides down the articulation and side-bends.


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. FUNCTIONALA. 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 dysfunction3. Pelvic/Sacral Imbalance

II. STRUCTURALA. Side-bending toward the convexity will not

straighten the curveB. Not generally correctable, goal is to prevent

progression and/or deformity.C. Causes:

1. Generally genetic2. 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 Evaluation1. Test side-bending2. Evaluate for rotary component3. Evaluate leg length4. Evaluate for pronation of one foot greater

than other.5. Evaluate for pelvic disproportion.

B. Short Leg Syndrome1. Fairly common2. ¼” or greater is significant to average person3. 1/16” can be significant to someone requiring good balance e.g. dancers4. 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 heightSBU = Sacral base unlevelingD = Duration of short leg

<10 years = 110-20 years = 2>20 years = 3

C = CompensationSide-bending w/ no rotation = 1Rotation to convexity = 2Wedging or facet changes = 3

8. Heel Lifta. 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.

C. Other functional scoliosis1. 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 Evaluation1. Evaluate rotary component during forward

bending - “rib hump”.2. Evaluate with side bending – curve will not

straighten.B. X-ray Evaluation - Cobb Angle MeasurementC. Type of Curve

1. C-shaped2. S-shaped ( may be structural or may be

accommodation)3. Right thoracic – most common, always a

major curve; cosmetic problems4. 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 measurement2. Frequent during adolescence3. May occur during pregnancy4. Rapidly progressing curves should be

referred for specialist care.

E. School Screening for scoliosis

F. Treatment1. Braces2. Casts3. TENS unit4. Surgical – Harrington rod5. OMT6. Exercise

Osteopathic Principles and Practice

Laboratory 2

LANDMARKS

I. Cranium

A. External Auditory MeatusB. Ear lobesC. Mastoid ProcessesD. InionE. Nuchal Line

II. Cervical SpineA. Occipital SulcusB. Vertebra Promenens (C7)C. Articular Pillars

III. ThoraxA. Spinous processesB. RibsC. Scapula

1. Acromion2. Corocoid process3. Inferior Angle4. Spine of scapula

D. Anterior Chest Wall1. Sternal notch2. Angle of Louis3. Xiphoid Process4. Clavicles

a. Sternoclavicular jointb. Acromioclavicular jointc. Mid-clavicular line

5. Axillaa. Anterior axillary lineb. Mid-axillary linec. Posterior axillary line

IV. Lumbar Region1. Iliac crests mark L4 level2. Waist creases3. Umbilicus – L34. Lumbo-sacral junction

V. Pelvis/ SacrumA. Innominates

1. Iliac crests2. Anterior iliac spines (ASIS)3. Posterior iliac spines (PSIS)

B. Sacrum1. Hiatus2. Inferior lateral angles (ILAs)3. Base4. Apex

C. Gluteal creases

VI. ExtremitiesA. Greater trochanterB. PatellaeC. Tibial tubersitiesD. Popliteal creaseE. Medial MalleoliF. Lateral MalleoliG. Medial arches

VII. MusclesA. Erector spinaeB. Sternocleidomastoid (SCM)C. TrapeziusD. Latissimus dorsiE. SupraspinatusF. InfraspinatusG. QuadricepsH. Hamstrings


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.


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 VIEWA. Ear lobes levelB. Shoulders levelC. Tip of scapula levelD. Waist CreasesE. Iliac Crests levelF. PSIS levelG. Gluteal Creases levelH. Popliteal Creases levelI. Malleoli levelJ. Medial arches of feet heightK. Spine – any evidence of scoliosis?

II. ANTERIOR VIEWA. Ear lobes levelB. Head tiltC. Shoulders levelD. Nipple line in malesE. Finger tipsF. ASIS levelG. Knees

1. Genu valgus2. Genu varus

III. LATERAL VIEWA. Head

1. Forward carriage2. Backward carriage

B. Trunk Rotation1. Direction of rotation2. Look at back for scapula to be visible and at front for

opposite chest wall to be visible.

C. Anterior and Posterior Curves of spine1. Cervical2. Thoracic3. Lumbar

D. Lower Extremities1. Genu recurvatum2. Flexion deformity of knee

Osteopathic Principles and PracticeLaboratory 4

SOMATIC DYSFUNCTION

Somatic dysfunction is diagnosed by using the following criteria:T – TendernessA – Asymmetry of positionR – Restriction of motionT – 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. Skin1. Temperature changes

a. Increase in heat or a coolness in a small area near a vertebra may indicate somatic dysfunction.

i. Increase in temperature – acuteii. Decrease in temperature - chronic

b. Palpate with back or side of hand

2. Color changesa. Erythema testb. Redness which persists indicates acute somatic

dysfunctionc. Blanching which persists indicates chronic somatic

dysfunctiond. Hyper-pigmentation may indicate long-standing

dysfunction3. Skin Drag

Indicates increase in moisture in small area – acute dysfunction

B. Connective TissueMost connective tissue changes occur in the fascia and are palpated as an increase in tension in the fascia.

C. Muscle Changes1. Acute changes with dysfunction

a. Hypertonicity – a feeling of tension in the muscle, increased tone

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 need2. 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 Spine1. Palpate articular pillars2. 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 processes4. 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 Spine1. 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 Spine1. Palpate transverse process for symmetry2. Palpate spinous processes for symmetry

D. Do the asymmetry changes you have found correspond to the tissue texture changes you found?

III. RESTRICTION OF MOTIONA. 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.


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 TERMINOLOGYA. Afferent/Efferent NervesB. Ventral/Dorsal HornC. ContractionD. ContractureE. Agonist/Antagonist

II. AUTONOMIC NERVOUS SYSTEMA. Sympathetic Nervous SystemB. Parasympathetic Nervous System

IV. PROPRIOCEPTION

V. SKELETAL MUSCLE SYSTEMA. Classification of Muscles

1. Striateda. Skeletalb. Cardiac

2. Smooth B. Typical spinal nervesC. Neuromuscular reflexes

1. Muscle spindle reflex2. Golgi tendon reflex3. Crossed Extensor reflex

VII. SEGMENTALIZATION

VI. SPINAL CORD REFLEXESA. Somatovisceral reflexesB. Viscerosomatic reflexesC. Somatosomatic reflexesD. Viscerovisceral reflexes

VIII. FACILITATION

IX. NOCICEPTIONA. Factors InvolvedB. Causes of Muscle Pain

X. PRACTICAL APPLICATIONS OF NEUROPHYSIOLOGY IN OSTEOPATHIC DIAGNOSIS AND TREATMENT

A. Palpation of Muscle ChangesB. Maintenance of Somatic DysfunctionC. Manipulation

1. Myofascial/ Muscle Techniquesa. Stretch Reflexb. Use of Heatc. Servo-assist function of Muscle spindled. Golgi tendon organ reflexe. Reciprocal innervationf. Crossed extensor reflex

2. Inhibition/Stimulation Techniques

Osteopathic Principles and PracticeLab 5

PASSIVE MYOFASCIAL TREATMENT

Treats the Soft Tissues of the body.1. Muscle2. Tendons3. Fascia4. Ligaments

PASSIVE: Done by the physician assistant alone

PURPOSE: A. Relieve Pain1. Relax muscle2. Reduce ischemia3. Remove catabolites4. Stretch contractured muscles and tense fascia

C. Prepare tissues for treatment by D.O.D. Improve muscle tone - stimulatoryE. Improve circulationF. Improve venous and lymphatic drainage

HOW IT’S DONE:A. Manual Traction

1. Either end of muscle2. Both ends of muscle3. Push perpendicularly4. Pull perpendicularly

B. Deep InhibitionC. Effleurage – assist in removing fluids from tissues

REGIONSA. Cervical

1. Suboccipital2. Linear Stretch3. Perpendicular Stretch4. Bilateral Stretch to both ends of muscle5. Unilateral Stretch to both ends of muscle

B. Thoracic1. Perpendicular stretch2. Trapezius3. Subscapular muscle4. Parallel stretch

C. Lumbar1. Perpendicular pull2. Perpendicular push3. Perpendicular push assisted with rotation of pelvis

Osteopathic Principles and PracticeLab 6

ACTIVE MYOFASCIAL TREATMENT

A. MECHANISMS UTILIZED

1. Golgi Tendon Organ2. 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. Cervicala. Suboccipitalb. Paravertebral

2. Thoracica. Arm to floorb. Arm to ceiling

3. Lumbara. Legs to floorb. Legs to ceiling

D. INDIRECT TECHNIQUES

1. CervicalAnterior or posterior cervical muscles with crossed extensor reflex.

2. ThoracicPull arm across chest while supine

3. Lumbar

Push legs up or down against isokinetic resistance. Treating opposite muscles.

Documents

PHAS 350 Osteopathic Principles