New York Institute of Technology
Department of Physician Assistant Studies
Summer 2001
Course:
Course Instructor:
Phone:
Office Hours:
Office:
PHAS 350 Clinical Osteopathic Principles & Practice
Eileen L. DiGiovanna, D.O.
(516) 686- 3777
As posted
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.
2.
3.
4.
5.
6.
7.
Discuss the history and philosophy of Osteopathic Medicine
Utilize palpatory skills
Identify body landmarks.
Perform a structural evaluation
Identify the presence of Somatic Dysfunction
Develop a referral plan for Osteopathic Manipulative Treatment.
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
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:
Required Equipment:
http://www.aoa-net.org
 American Osteopathic Association
http://www.aacom.org
 American Association of Colleges of
Osteopathic Medicine (AACOM)
http://www.doctort.com/osteopathic_manipulation.htm
 Osteopathic Manipulation
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%
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
New York Institute of Technology
Student Schedule and Information
Spring, 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, 2nd Ed, 1997; Lippincott & Raven,
Philadelphia, PA
2. Gevits, Norman, The D.O.s, 1976, Univ of Chicago Press, Chicago,
IL
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
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.
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)
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
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
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.
B.
C.
D.
E.
F.
G.
H.
I.
Whiplash injuries
Headaches
Scoliosis – functional, idiopathic
Thoracic Outlet Syndrome
Lumbar pathologies (herniated disc, strains)
Coccygodynia
Dysmenorrhea
Obstetrics
Pulmonary Disease (Bronchitis, asthma, pneumonia)
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
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 (closepack 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.
VII. Etiology of Somatic Dysfunctions:
A. Type I
1.
2.
3.
Dysfunctions
Muscle Spasm
Short leg syndrome
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
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.
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.
2.
3.
4.
5.
6.
Fractures
Injury to growth plates in bones
Congenital abnormalities
Neurologic problems
Disease processes, including mental (e.g. depression).
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 microfractures 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
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
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. Backward – rotates backward on a diagonal axis
c. Sacral shear (unilateral sacral flexion) – slides down the
articulation and side-bends.
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.
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.
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
Laboratory 2
LANDMARKS
I. Cranium
A.
B.
C.
D.
E.
External Auditory Meatus
Ear lobes
Mastoid Processes
Inion
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
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.
B.
C.
D.
E.
F.
G.
H.
Erector spinae
Sternocleidomastoid (SCM)
Trapezius
Latissimus dorsi
Supraspinatus
Infraspinatus
Quadriceps
Hamstrings
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.
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
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
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
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 nonreversible
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?
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.
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
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
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
C. Lumbar
1. Perpendicular pull
2. Perpendicular push
3. Perpendicular push assisted with rotation of pelvis
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.