OPP 3 Study Guide Written Exam 1 Fall 2024 PDF

OPP 3 Written Exam 1 Study Guide Fall 2024  Osteopathic Concepts For ANY disease state, the patient must be STABLE before performing OMT*** Cardiovascular, pulmonary, GI, GU, etc. The sicker/weaker/more injured a patient is, use gentler techniques New onset of chest pai...

OPP 3 Written Exam 1 Study Guide Fall 2024  Osteopathic Concepts For ANY disease state, the patient must be STABLE before performing OMT*** Cardiovascular, pulmonary, GI, GU, etc. The sicker/weaker/more injured a patient is, use gentler techniques New onset of chest pain or shortness of breath is not a time for OMT! Somatic dysfunction can occur anywhere in the body at Sympathetics levels Paraysmpathetic levels Soma (not autonomic related) Viscerosomatic reflexes occur at Sympathetics levels Parasympathetics levels Facilitated segments ONLY occur at Sympathetics Important Concepts Remember, sometimes muscle hypertonicity, contraction, spasm can be caused by direct irritation of the what is overlying the muscle: For example, if there is a renal lithiasis, it may cause the psoas to become hypertonic, and you would have a positive Thomas test For example, if there is appendicitis, it may cause the psoas to become hypertonic, and you would have a positive Thomas test For example, if there are inflamed lymph nodes, this may make the muscle they are touching to become hypertonic such as sternocleidomastoid After obtaining a history, you perform a physical exam: observation is one of the first things you do in a physical exam A reversible dextroscoliosis or levoscoliosis means there is NO SAGITTAL COMPONENT present (no flexion or extension component) so it follows Fryette Type 1 mechanics. A dextroscoliosis would have the convex side pointing to the right, therefore indicating a neutral side- bending left, rotating right pattern for the vertebrae. Therefore, for example, a dextroscoliosis from T4-T6 would have all of the vertebra being neutral, sidebent left, rotated right. A left lateral convexity means the vertebrae are sidebent right. A right lateral convexity means the vertebrae are side-bent left When treating a group dysfunction with OMT, go for the apex (middle) of the group curve. Example T10-T12, go for T11. Type II dysfunction would usually occur at the apex (middle) of the group curve. However, please see above regarding reversible dextro/levoscoliosis that DO NOT have a sagittal component and would not have Type II mechanics present. Translation to the right=left side-bending, translation to the left=right side-bending Piece together findings given to you in question with chapman points, autonomic reflexes as to what the diagnosis is. Know your sympathetic levels, parasympathetic levels. If sympathetic is not in your answer choices, see if a parasympathetic level to that organ is present (lot of people tend to forget about the parasympathetics). Remember a facilitated segment can only be sympathetic. Dysfunctional vertebrae tend to rotate towards the side of the dysfunctional organ, for example gallbladder issues will cause vertebrae to rotate to the right, gastritis will cause vertebrae to rotate to the left. Feather’s Edge represents the perceived quality of motion near the restrictive barrier Indication for HVLA is a distinct, solid barrier. Need a firm end-feel Most commonly used form of contraction in muscle energy is isometric contraction  Osteopathic Concepts Vertebral bodies usually rotated towards the side of dysfunction. For example: if you have left lower lobe pneumonia, the vertebra will rotate to the left. If you have gastritis, the vertebrae will rotate to the left If you have cholecystitis (gallstones), the vertebrae will rotate to the right: For example, patient may be passing flatus after eating meals and the verterbrae would rotate to the right in the area of the gallbladder  4 Principles of Osteopathic Medicine Principle 1: The body is a unit; the person is a unit of mind, body, and spirit (gastric ulcer causes thoracic tissue texture changes) Principle 2: The body is capable of self-regulation, self-healing, and health maintenance (healed fracture) Principle 3: Structure and function are reciprocally interrelated Principle 4: Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the inter-relationship of structure and function  5 Osteopathic Models Biomechanical (structural, postural) Anatomy of muscles, spine, extremities; posture, motion OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis Neurological Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions Respiratory/circulatory Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems Lymphatic techniques Metabolic/Nutritional Regulates through metabolic processes Behavioral (psychobehavioral) Focuses on mental, emotional, social and spiritual dimensions related to health and disease Reflexes somatosomatic reflex, localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures. For example, rib somatic dysfunction from an innominate dysfunction. somatovisceral reflex, localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures. For example, triggering an asthmatic attack when working on thoracic spine. viscerosomatic reflex, localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures. For example, gallbladder disease affecting musculature. viscerovisceral reflex, localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures. For example, myocardial infarction and vomiting. ***Remember, post ganglionic sympathetic fibers lead to tissue texture changes such as hypertonicity, moisture, erythema, etc. Dorsal horn of the spinal cord is where somatic and visceral afferent nerves synapse giving a viscerosomatic reflex  Sympathetic levels Head and Neck: T1 – T4 Appendix: T10 – T11 Heart: T1/T2 – T5/T6 Kidneys: T10 – T11 Respiratory: T1/T2 –T6/ T7 Adrenal Medulla: T10 Esophagus: T2 – T8 Upper Ureters: T10 – T11 Upper GI Tract: T5 – T9 Lower Ureters: T12 – L1 – Stomach, Liver, Gall Bladder, Spleen, Bladder: T12 – L2 Pancreas, Duodenum Gonads: T10 – T11 Uterus & Cervix: T10 – L2 Middle GI Tract: T10 – T11 Erectile tissue: T11 – L2 – Pancreas, Duodenum, Jejunum, Ileum, Prostate: T12 – L2 Ascending colon, Right Transverse Colon, Kidney, Upper Ureter, Gonads Arms: T2 – T8 Legs: T11 – L2 Lower GI Tract: T12 – L2 – Left Transverse Colon, Descending Colon, Sigmoid colon, Rectum, Prostate, Bladder, Lower Ureter Parasympathetic Levels Vagus Nerve (OA, AA, C2) Trachea, esophagus, heart, lungs, liver, gallbladder, stomach, pancreas, spleen, kidneys, proximal ureter, small intestine, ascending colon, and transverse colon up to the splenic flexure S2-S4 Distal to the splenic flexure of the transverse colon, descending colon, sigmoid colon, rectum, distal ureter, bladder, reproductive organs, and external genitalia. Variations: Ovaries & Testes Vagus Nerve S2-S4 Collateral Ganglia  Collateral Ganglia Sympathetic Pre-ganglionics - T5 through L2: Greater Splanchnic (T5-T9), Lesser Splanchnic (T10-11), Least Splanchnic (T12), Lumbar Splanchnic (L1-L2) nerves Celiac Ganglion (T5-T9) Post-ganglionic to: Distal Esophagus, Stomach (epigastric), Liver, Gallbladder (cholecystitis), Spleen, portions of Pancreas, proximal Duodenum (foregut) Superior Mesenteric Ganglion (T10-T11) Post-ganglionic to: Portions of Pancreas, Duodenum, Jejunum, Ileum, Ascending Colon, Proximal 2/3 of Transverse Colon. (midgut); Adrenals, Gonads, Kidneys, upper ½ Ureter Inferior Mesenteric Ganglion (T12-L2) Post-ganglionic to: Distal 1/3 Transverse Colon, Descending Colon, Sigmoid, Rectum (hindgut); lower ½ Ureter, Bladder, Prostate Genitalia Sympathetic Innervation Greater Splanchnic Nerve (T5-9) Synapses at the Celiac Ganglion Stomach, Liver, Gall Bladder, Pancreas, Parts of Duodenum Lesser Splanchnic Nerve (T10-11) Synapses at the Superior Mesenteric Ganglion Small Intestines and Right Colon (appendix is found here) Least Splanchnic Nerve (T12) and Lumbar Splanchnic Nerve (L1-2) Synapses at the Inferior Mesenteric Ganglia Innervates the Left Colon and Pelvic Organs Sympathetics Sympathetic nerve supply to the head and neck: T1 – T4 It forms the cervical ganglia (inferior, middle, and superior cervical ganglia), which affects the mid to lower cervical spine From there, it contributes to other collateral ganglion that govern the sympathetic innervation to the head Increased Sympathetic Activity Increased goblet cells Increased thick, sticky secretions Dries the mucous membranes Pupillary dilation Decreased lymphatic/circulatory drainage Impaired immune response Tinnitus Increased intraocular pressure  Chapman Reflex Points Liver Anterior: 5th intercostal space near sternum on R Stomach (Acid) Anterior: 5th intercostal space near sternum on L Stomach Acid (think ulcers/NSAID use/Steroid use) Liver, Gallbladder (think Cholecystitis) Anterior: 6th intercostal space near sternum on R Stomach (Peristalsis) Anterior: 6th intercostal space near sternum on L Stomach Peristalsis (think of emptying time) Pancreas (think of Amylase/Lipase/Blood glucose) Anterior: 7th intercostal space near sternum on R Spleen Anterior: 7th intercostal space near sternum on L Appendix Anterior: Tip of the right 12th rib  Sympathetic Innervation: Chapman’s Reflexes (Ganglioform nodules/tissues) 5th IC space Right: Liver Left: Stomach Acid (Gastritis)(may raise red flag to NSAID use) 6th IC space Right: Liver, Gallbladder (Cholecystitis) Left: Stomach Peristalsis (may have delayed stomach emptying time, food may not pass quickly through system) 7th IC space Right: Pancreas (glucose, amylase, lipase) Left: Spleen Jugular Foramen Formed by Temporal Bone and Occiput, which make the occipitomastoid suture CN IX, X, and XI exit from the jugular foramen CN XI (the spinal accessory nerve) is involved with torticollis. There is usually compression at the occipitomastoid suture/jugular foramen CN X is involved with nausea/vomiting Indications and Contraindications Remember indications and contraindications for techniques For example if a patient is too young or is not able to follow commands, you can not do techniques such as muscle energy If a patient has lax ligaments such as Rheumatoid Arthritis or Trisomy 21, you do not want to do HVLA, or ANY type of articulatory techniques in the upper cervical spine. Remember Still Technique is an articulatory technique. Jugular Foramen Formed by Temporal Bone and Occiput, which make the occipitomastoid suture CN IX, X, and XI exit from the jugular foramen CN XI (the spinal accessory nerve) is involved with torticollis. There is usually compression at the occipitomastoid suture/jugular foramen CN X is involved with nausea/vomiting Sample Question A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. What is the most likely level of facilitation due to a viscerosomatic reflex in this patient? A. OA B. L2 *C. T3 D. T8 E. T11 In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because facilitation occurs only at the sympathetic level! Sample Question A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to viscero-somatic reflex relating to her presentation? *A. OA B. L2 *C. T3 D. T8 E. T11 In this case, both A and C would be correct answers, because both the parasympathetic and sympathetic nervous system would have viscerosomatic reflexes present in this patient’s clinical scenario! Sample Question A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a sympathetic viscero-somatic reflex relating to her presentation? A. OA B. L2 *C. T3 D. T8 E. T11 In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because the question asks for the sympathetic level! Sample Question A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a parasympathetic viscero-somatic reflex relating to her presentation? *A. OA B. L2 C. T3 D. T8 E. T11 In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose A, because the question asks for the parasympathetic level! Palpating Somatic Dysfunction ACUTE CHRONIC Recent history (injury) Long-standing Sharp or severe localized pain Dull, achy diffuse pain Warm, moist, sweaty skin Cool, smooth, dry skin Boggy, edematous tissue Possible atrophy Erythematous Fibrotic, ropy feeling tissue Local increase in muscle tone, Pale/skin pallor contraction, spasm, increased muscle spindle firing Decreased muscle tone, contracted muscles, sometimes flaccid Normal or sluggish ROM Restricted ROM May be minimal or no somatovisceral effects Somatovisceral effects more often present “Old is cold, hot is not” ***Remember, post ganglionic sympathetic fibers lead to tissue texture changes such as hypertonicity, moisture, erythema, etc. Dorsal horn of the spinal cord is where somatic and visceral afferent nerves synapse giving a viscerosomatic reflex  5 Osteopathic Models Biomechanical (structural, postural) Anatomy of muscles, spine, extremities; posture, motion OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis Neurological Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions Respiratory/circulatory Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems Lymphatic techniques Metabolic/Nutritional Regulates through metabolic processes Behavioral (psychobehavioral) Focuses on mental, emotional, social and spiritual dimensions related to health and disease  Orientation of Orientation of Superior Facets Inferior Facets Region Facet Orientation Mnemonic Region Facet Orientation Mnemonic Cervical Backward, BUM Cervical Anterior, Inferior, AIL Upward, Medial Lateral Thoracic Backward, BUL Thoracic Anterior, Inferior, AIM Upward, Lateral Medial Lumbar Backward, BM /BUM Lumbar Anterior, Lateral AL /AIL Medial Anterior, Inferior, Backward, Lateral Upward, Medial  Fryette Law 1 ¡ When side-bending is attempted from N neutral (anatomical) position, rotation of vertebral bodies follows to the opposite direction. ¡ Typically applies to a group of vertebrae (more than two) ¡ Occurs in a neutral spine (no extreme flexion or extension) NO SAGITTAL COMPONENT ¡ Side-bending and rotation occur to opposite T2-6 RRSL sides ¡ Side-bending precedes rotation ¡ Side-bending occurs towards the concavity T2-6 N RRSL of the curve ¡ Rotation occurs towards the convexity of the curve ¡ Diagnosed as a Type I dysfunction T2-6 N SLRR Fryette Law 2 ¡ When side-bending is attempted from non- F neutral (hyperflexed or hyperextended) position, rotation must precede side-bending to the same side. E ¡ Typically applies to a single vertebra ¡ Occurs in a non-neutral spine (flexion or extension of spine present) SAGITTAL COMPONENT ¡ Side-bending and rotation occur to same sides ¡ Rotation precedes side-bending T4 E RLSL ¡ Rotation of the vertebra occurs into the concavity of the curve ¡ Diagnosed as a Type II dysfunction T4 E SLRL ¡ May be described as traumatic injury T4 E SRL 28  Tri-positional Diagnosis Determine which transverse process of the vertebra is posterior: this is the side of rotation (should test with rotational component) Keep the side of rotation/posterior transverse process in your mind as you move to the next step  Tri-positional Diagnosis Monitor the posterior transverse process. Then, have the patient flex and extend to see if the posterior transverse process moves more anteriorly (in other words: evens out, improves, becomes more symmetrical, gets better) with either flexion or extension If a posteriorly rotated process moves anteriorly with flexion: it is F Rx Sx If a posteriorly rotated process moves anteriorly with extension: it is E Rx Sx If rotational component does not change with either maneuver (or gets worse with flexion and extension), it is neutral: N Sx Ry  Translational Motion Translation If a segment translates to the right, this induces left side-bending If a segment translates to the left, this induces right side-bending L R This segment is translating to the left, which is inducing right side-bending  Tri-Positional Diagnosis Screen the region. Identify a transverse process that feels posterior. (Posterior TP = X) Have patient flex and extend his/her spine. evaluate if the asymmetry improves Improves In No Improves In Flexion Improvement Extension FRSX NSYRX ERSX Neutral (Type I) Non Neutral (Type II)  Spinous process deviation If a spinous process is deviated to the left = right rotation If a spinous process is deviated to the right = left rotation Neutral Rotated Right Rotated Left  Cervical Spine OA (occipitoatlantal joint) side-bends to one side and rotates to opposite. Also Flexes and Extends in a rocking motion (Type I like) AA (atlantoaxial joint) primarily rotational C2-C7 rotate and side-bend to same side (“typical vertebrae”) (Type II like) Cervical superior facets: BUM (Backwards, Upwards, Medial) Can be also described as Posterior, Superior, Medial Cervical spine follows Fryetteʼs III principle; does not follow Fryetteʼs I or II principles Indirect and Direct treatment If INDIRECT treatment used: exaggerate/augment the dysfunction Take the dysfunction the way it likes to go If DIRECT treatment used: engage the barrier/reverse the dysfunction Take the dysfunction the way it does not like to go Indirect Technique Somatic dysfunction is exaggerated or augmented Somatic dysfunction is taken the way it likes to go Restrictive barrier is disengaged Dysfunction is taken into position of injury Uses inherent forces Uses a compressive, tractional, or torsional component Direct Technique Somatic dysfunction is taken the way it does not like to go Restrictive barrier is engaged Uses external forces  Examples of Direct Techniques Myofascial Release (May also be indirect) Soft tissue Articulatory Muscle Energy High velocity, low amplitude (HVLA) Springing Cranial (may also be indirect) Still Technique (combined indirect and direct) Initial positioning of Still Technique set up is indirect Ending positioning of Still Technique is direct  Muscle Energy Technique Postisometric Relaxation Reciprocal Inhibition Procedure Procedure - Dysfunctional Structure Positioned at Feather Edge of Direct - Dysfunctional Structure Positioned at Feather Edge of Barrier Direct Barrier (Positioning is in All Three Planes of Motion) (Positioning is in All Three Planes of Motion) - Physician Continuously Monitors Dysfunction - Physician Continuously Monitors Dysfunction - Patient is Instructed to GENTLY Push AWAY From the Barrier - Patient is Instructed to GENTLY Push TOWARD the Barrier - Physician Resists Patient’s Effort for 3 - 5 Seconds - Physician Resists Patient’s Effort for 3 - 5 Seconds - Patient is Instructed to Relax - Patient is Instructed to Relax - Physician Repositions Patient to Feather Edge of New Barrier - Physician Repositions Patient to Feather Edge of New Barrier - Repeat 3 - 5 Times or until Maximum Improvement - Repeat 3 - 5 Times or until Maximum Improvement - Passively Reposition to Neutral After Last Effort - Passively Reposition to Neutral After Last Effort - Recheck Area of Dysfunction for Change - Recheck Area of Dysfunction for Change Soft Tissue Examples Stretching – a longitudinal or parallel traction technique in which the origin and insertion of the myofascial structures being treated are longitudinally separated. Kneading – a perpendicular traction technique in which a rhythmic, lateral stretching of a myofascial structure, where the origin and insertion are held stationary and the central portion of the structure is stretched like a bowstring. Inhibition – a deep inhibitory pressure, which is a sustained deep pressure over a hypertonic myofascial structure. Effleurage – Gentle stroking of congested tissue used to encourage lymphatic flow Petrissage – Involves pinching or tweaking one layer and lifting it or twisting it away from deeper areas Tapotement – striking the belly of a muscle with the hypothenar edge of the open hand in rapid succession in order to increase itʼs tone and arterial perfusion. A hammering, chopping percussion of tissues to break adhesions and/or encourage bronchial secretions  Examples of Indirect Techniques Counterstrain Facilitated Positional Release (FPR) Balanced Ligamentous Tension Technique (BLT) Functional Technique Myofascial Release (may also be direct) Cranial (may also be direct) Still Technique (combined indirect and direct) Initial positioning of Still Technique set up is indirect Ending positioning of Still Technique is direct Counterstrain: Steps of Treatment Assess the “this is a 10” pain level Maintain finger contact at all times (NOT PRESSING FIRM constantly, only monitoring!)(***continuous monitoring) this is to monitor tension, not to treat Find the position of comfort Retest by pressing with contact finger This is a passive treatment Hold it for 90 seconds (that’s the time for ALL counterstrain points, including ribs) monitor tension and response Return patient to neutral position SLOWLY!! Recheck pain level should be a 3 or less The only time you press firmly is when finding the point, repositioning the point. All other times you are keeping you contact finger on point to just monitor location. Anterior Cervical CS Points Tender Point Location Treatment Position Acronym Anterior Cervical 1 Mandible=Posterior aspect Markedly rotated away RA of the ascending ramus of the mandible at the level of the earlobe Transverse process=Lateral aspect of the transverse process of C1 Anterior Cervical 2-6 On the anterolateral Flexed, side-bent away, F SARA aspect of the rotated away corresponding anterior tubercle of the transverse process Anterior Cervical 7 On the clavicular Flexed, side-bent toward, F STRA attachment of the SCM rotated away Anterior Cervical 8 At the sternal attachment Flexed, side-bent away, F SARA of the SCM on the medial rotated away end of the clavicle  Posterior Cervical CS Points Tender Point Location Treatment Position Acronym PC1 inion On the inferior nuchal line, lateral Marked Flexion F St Ra to the inion Fine tune with side-bending toward, rotating away PC1 occiput On the inferior nuchal line at the Extended E Sa Ra splenius capitis (midway between Slight side-bending and rotation the inion and mastoid) away as needed PC2 occiput On the inferior nuchal line at the Extended E Sa Ra attachment of semispinalis capitis Slight side-bending and rotation away as needed PC2 midline spinous process On the superior or superior lateral Extended, side-bent away, rotated E SARA aspect/tip of the spinous process away of C2 PC3 midline spinous process On the inferior or inferolateral Flexed, side-bent away, rotated F SARA aspect/tip of the spinous process away of C2 PC4-PC8 midline spinous process On the inferior or inferolateral Extended, side-bent away, rotated E SARA aspect of the tip of the spinous away process. Remainder of tender points follow this pattern. PC3-PC7 lateral On the posterolateral aspect of the Extended, side-bent away, rotated E SARA articular process associated with away the dysfunctional segment  Anterior Thoracic CS Points Tender Point: Location Classic Treatment Acronym Anterior Position Midline or just lateral to the jugular F AT1 (suprasternal) notch Flexion to dysfunctional level Midline or just lateral to the Flexion to dysfunctional level F AT2 junction of manubrium and sternum (angle of Louis) Midline (or with some degree of Flexion to dysfunctional level F AT3-AT5 sidedness) at level of corresponding rib; Midline (or with some degree of AT6 sidedness) xiphoid–sternal junction FPR Body part in NEUTRAL position (flatten curve) COMPRESSION applied to shorten muscle/muscle fibers (some cases may have TRACTION instead) Place area into EASE of motion (INDIRECT) for 3-5 seconds Return body part to neutral THIS TECHNIQUE IS INDIRECT!!!!  FPR For example, if C2 is extended, rotated right, side-bent right, you would: Place neck in a neutral position (flatten curve) Add a compressive force Then take C2 into extension, right rotation and right side-bending Hold for 3-5 seconds Return to neutral position and release compressive force Still Technique Tissue/joint placed in EASE of motion position (augments the somatic dysfunction) Compression (or traction) vector force added Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!! Still Technique For example, if C2 is extended, rotated right, side-bent right, you would: Beginning of Still Technique: C2 E RR SR End of Still Technique: C2 F RL SL There are many ways to ask how to diagnose C2 and once you figure out the diagnosis you can answer the treatment questions, for example: C2 does not translate well to the right and becomes more symmetrical in extension C2 translates easier to the left and becomes more asymmetrical in flexion Both of these give you the diagnosis of C2 E RR SR  Neurological Exam of Upper Extremity Root Sensation Motor Reflex C4 Shoulder None None C5 Lateral Elbow Biceps Biceps C6 Thumb, Index Finger Wrist Extensors Brachioradialis C7 Mid Finger Triceps Triceps C8 Ring Finger, Pinky Wrist Flexors None T1 Medial Elbow Interossi None Indications and Contraindications to OMT Remember indications and contraindications for techniques For example, if a patient is too young or is not able to follow commands, you can not do techniques such as muscle energy If a patient has lax ligaments such as Rheumatoid Arthritis or Trisomy 21, you do not want to do HVLA, or ANY type of articulatory techniques in the upper cervical spine. Remember Still Technique is an articulatory technique.  Cardiac Autonomics Sympathetics Heart: T1-6 with synapses in upper thoracic and cervical chain ganglia. When considering arrhythmias: Right and left-sided distributions Right- sinoatrial (SA) node and right deep cardiac plexus– predisposes to supraventricular tachyarrhythmias. Left-atrioventricular (AV) node and left deep cardiac plexus- predisposes to ectopic PVCs and V fib and V tach Asymmetries in sympathetic tone may play a role in the generation of serious arrhythmias. Sympathetic Effects: Cardiac Increases contractility Increases force of contractility Increases conduction velocity Increases vasoconstriction Increases peripheral vascular resistance Increases arrhythmias (tachy-arrhythmias) Decreases lymphatic drainage Decreases development of collateral circulation  Peripheral Sympathetic Supply In addition to the direct effects on the organs, the sympathetic innervation also controls the vascular tone. Sympathetic Supply to Upper Extremity Vasculature T2 to T8 levels Sympathetic Supply to Lower Extremity Vasculature T11 to L2 levels  Chapman Reflex Points Myocardium, Thyroid, Esophagus, Bronchus Anterior: 2nd intercostal space near sternum Posterior: Midway between the spinous process and tips of the transverse process at T2 Upper Lung Anterior: 3rd intercostal space near sternum Posterior: Midway between the spinous processes and tips of the transverse processes of T3 and T4 Lower Lung Anterior: 4th intercostal space near sternum Posterior: Midway between the spinous processes and tips of the transverse processes of T4 and T5 Liver Anterior: 5th intercostal space near sternum on R Stomach (Acid) Anterior: 5th intercostal space near sternum on L Stomach Acid (think ulcers/NSAID use/Steroid use) Liver, Gallbladder (think Cholecystitis) Anterior: 6th intercostal space near sternum on R Stomach (Peristalsis) Anterior: 6th intercostal space near sternum on L Stomach Peristalsis (think of emptying time) Pancreas (think of Amylase/Lipase/Blood glucose) Anterior: 7th intercostal space near sternum on R Spleen Anterior: 7th intercostal space near sternum on L  Chapman Reflex Points Adrenal Glands Anterior: 1” Lateral and 2” Superior to Umbilicus Ipsilaterally Posterior: Intertransverse Spaces of T11 and T12 Ipsilaterally Midway Between Spinous and Transverse Processes Kidneys Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1 Urinary Bladder Anterior: Umbilical Area (Periumbilical) Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2 Appendix Anterior: Tip of the right 12th rib Posterior: At the transverse process of T11  Cardiac Autonomics Parasympathetics Heart: CN X (Vagus nerve): OA, C1, C2 somatic dysfunction can affect CN X When considering arrhythmias: Right vagus-via SA node and hyperactivity predisposes to sinus bradyarrhythmias. Left vagus- via AV node where hyperactivity predisposes to AV blocks. Vagus nerves have fibers course to them from the C-1 & C-2 nerve roots. Heart may be reflexively slowed by other organ visceral afferents. Pulmonary branches have strongest influence. Parasympathetics to the Heart Parasympathetic Innervation to the Heart Cranial Nerve X (Vagus) Jugular foramen, Occipitomastoid (OM) suture, OA, AA, C2 Right and Left sided distribution Right side= SA node Left side= AV node (PS: minimal and isolated peripheral arteriolar innervation) Parasympathetic Effects: Cardiac Decreases contractility Decreases conduction velocity Increases arrhythmias (brady-arrhythmias)  Osteopathic Concepts Vagus nerve originates in the brainstem and exits through the jugular foramen. The jugular foramen is formed from the occipitomastoid suture, which is made up from the temporal bone and the occiput. So dysfunction affecting the vagus nerve could come from occipitomastoid suture compression. Think what organs that might affect: If it comes from the right side of left side. For example, how may it affect heart rhythms What happens to Vagus nerve in heart transplant patient? Which techniques would not be effective due to this following the surgery? Suboccipital Release because Vagus nerve is cut****  Important Highlights First rib elevation causes T1 to follow Type II mechanics to the opposite side Example, if left rib is elevated, T1 would be RRSR Feather’s Edge refers to feeling at Restrictive Barrier After a History, you must do a Physical (for example observation, palpation, etc.). Once these are done, along with any other diagnostic workup) then you can make an assessment and treatment plan. Important Highlights Congestive Heart Failure (decompensated), Acute Myocardial Infarction Do not use lymphatic pump techniques on patients Congestive Heart Failure, COPD Do not treat in supine position Avoid trendelenburg The sicker the patient is, the weaker the patient is, the more frail the patient is: Use gentle techniques, for example rib raising, soft tissue inhibition, myofascial release, counterstrain, etc. Do not use techniques like muscle energy which can wear out the patient. Do not use HVLA  Lymphatics Heart and lungs drain predominantly to the right lymphatic duct Treating Lymphatics ***(Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment) *** Another way of saying this is that you have to open myofascial pathways at the transition zones Examples include: Anterior cervical fascia release Thoracic inlet myofascial release Pectoral Traction Myocardial Infarction – “MI” Somatic diagnosis Viscerosomatic reflexes T1-T6 Chapman reflex Myocardium: anteriorly: 2nd intercostal space near sternum posteriorly: between T2 and T3 Palpable changes left upper thoracic spine and ribs Specific Anterior infarct- T2-3 L Inferior wall- T3-5L, C2 Right pectoralis major trigger point 5th intercostal space (ICS) associated with supraventricular tachyarrhythmia due to sympathetic nervous system  Hypertension Hypertension: a statistically significant correlation has been demonstrated between hypertension and C6,T2,T6 somatic dysfunction pattern. A cause-effect relationship has not been established *Johnson WL, Keslo AL, Babcock HB: Changes in presence of a segmental dysfunction pattern associated with hypertension: Part 1. A short-term longitudinal study. JAOA 1995;95:243-255. *Johnson WL, Keslo AL: Changes in presence of a segmental dysfunction pattern associated with hypertension: Part 2. A long- term longitudinal study. JAOA 1995;95:315-318. Hypertension: Common Functional Elements Vascular and cardiac hypersensitivity to sympathetic stimuli Prolonged sympathetic stimuli to the kidneys (T10-T11): THIS IS WHERE ACE INHIBITORS WOULD WORK Causes functional salt and water retention and increasing arterial pressure Venoconstriction causing increased cardiac output with normal peripheral resistance Eventual increase in peripheral resistance to reduce cardiac output Prolonged HTN causes baroreceptors in the carotid sinus to reset and maintain the increased arterial pressure Acute anterior wall MI with ST elevations and Q waves in V1– V4 and aVL reciprocal inferior ST depressions  Sinus tachycardia rate 140 Thoracic vertebrae should be rotated to the right  Atrial fibrillation HR ~150 to 110 (varies) Thoracic vertebrae should be rotated to the right  3rd degree AV block Cervical vertebrae should be rotated to the left  Sinus bradycardia Cervical vertebrae should be rotated to the right  1st degree AV block Cervical vertebrae should be rotated to the left Rib Raising Timing Rib raising done for a short period of time (less than 2 minutes) will usually stimulate the sympathetic effects. For example, bronchodilation Rib raising done for a longer period of time (greater than 2 minutes) will usually lessen the sympathetic effects. CHF/Acute MI What are you concerned about with OMT? Fatiguing the patient, too rough treatments. What lymphatic techniques should be utilized, and which ones should not and why? You can open up the thoracic inlet, transitional zone restrictions, but do not use “pump” techniques What treatment position is best avoided and why? Supine and Trendelenburg position.  Good luck!!!! For ANY clarifications, please refer back to the lecture/lab/reading material All concepts since Day 1 of OPP when you started ACOM through now are cumulative All concepts are cumulative: for example, Fryette principles, direct/indirect technique set up, principles of mechanisms, theories, set up, indications/contraindications, etc. etc. Please look over indications/contraindications for indirect and direct techniques: For example, if a patient is unable to follow commands (ie: due to language barriers, dementia(confusion), delirium (confusion) they can not participate in M.E. because they can not follow commands to push against resistance, etc. Please also review: Sacral mechanics with L5 Diagnosing C/T/L somatic dysfunctions Muscle energy/HVLA/FPR/Still/CS for thoracic/lumbar somatic dysfunctions Muscle energy/HVLA/FPR/Still/CS for cervical somatic dysfunctions know which form of muscle energy is being used, what the patient’s activating force is, what the physician’s resistive force is. In ME, know which form of muscle energy is being used, what the patient’s activating force is, what the physician’s resistive force is, etc. It will be different for post-isometric muscle energy versus reciprocal inhibition muscle energy