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184 Cards in this Set
- Front
- Back
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What are the major osteological components of the thorax?
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12 pairs of ribs
12 thoracic vertebrae Sternum Manubrium Xiphoid Process |
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What is the orientation of the superior thoracic spine facet?
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Posterior
Superior Lateral |
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What is the orientation of the inferior thoracic spine facet?
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Anterior
Inferior Medial |
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What are the relative ranges of motion in T1-T6 for Rotation, Sidebending, Flexion/Extension?
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Rotation > Sidebending > Flexion/Extension
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What are the relative ranges of motion in T7-T10 for Rotation, Sidebending, Flexion/Extension?
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Sidebending > Flexion/Extension > Rotation
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What are the relative ranges of motion in T11-T12 for Rotation, Sidebending, Flexion/Extension?
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Flexion/Extension > Sidebending > Rotation
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What organs have a close relationship with T1-T4?
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Head, neck, heart
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What organs have a close relationship with T2-T6?
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Lungs, esophagus
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What organs have a close relationship with T5-T9?
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Stomach, duodenum, liver, gallbladder, pancreas, spleen
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What organs have a close relationship with T10-T11?
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Jejunum, ileum, kidneys, ureters, gonads, ascending colon
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What organs have a close relationship with T12-L2?
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Descending colon, sigmoid colon, pelvic organs
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What parts of the body have a close relationship with T2-T8?
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Upper extremities
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What parts of the body have a close relationship with T10-L2?
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Lower extremities
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In which ribs is pump handle motion more dominant?
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Ribs 2-5
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In which ribs is bucket handle motion more dominant?
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Ribs 5-10
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What are the attachments for the thoracic diaphragm?
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Inferior costal border/ridge
Lumbar vertebrae (as low as L3) |
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What are the indications for HVLA in the thoracic region?
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Specific joint mobilization to treat motion restriction in somatic dysfunction, and when the benefits outweigh the risk
You must have an accurate diagnosis, understand the joint, experience the feeling of the restrictive barrier, understand appropriate thrust force for the specific joint |
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What are some contraindications and precautions for HVLA in the thoracic region?
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Bone spurs
Bone disease (osteogenesis imperfecta, Pacets', cancer, osteoporosis, spondyloarthropathy, lytic bone infections - TB) Fractures - traumatic, pathological Fresh surgery, fluoroquinolones XRAY or other studies first Patient does not want HVLA Patient unable to relax, unable to be passive enough for treatment Risks > Benefits Not the right technique |
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What are some safety guidelines for thoracic HVLA?
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Weigh risk vs benefit
Make sure patient agrees to the treatment Make an accurate diagnosis through thorough palpatory examination Determine if a restrictive barrier can be obtained - if not, select a different technique Concentrate on force vector and restrictive barrier end feel - not emphasis on force Be aware of the whole patient |
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What are some common errors when performing thoracic HVLA?
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Incorrect hand placement
Incorrect direction of force Inadequate localization, especially lack of sidebending Disengaging barrier prior to delivering thrust Inadequate fulcrum to deliver force (limp hand, loose fist) |
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What is correct hand placement for crossed arm thrust technique?
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Open hand - thenar eminence on posterior TP
Closed fist - thenar eminence on posterior TP, knuckles on contralateral TP, SPs in the groove created by the fist |
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Where is force directed in thoracic HVLA if patient is flexed?
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Patient lies supine
Thenar eminence on dysfunctional segment Elbows line up with dysfunctional segment Thrust vector through patient's elbows to chest perpendicular to the table |
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Where is force directed in thoracic HVLA if patient is extended?
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Patient lies supine
Thenar eminence on the TP below the dysfunctional segment Flex patient to the level below the dysfunctional segment Doctor positions self 45 degrees to table so patient's elbows line up with the dysfunctional segment |
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What is the procedure for double arm thrust thoracic HVLA (~11 steps, per Dr. Comfort)?
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1. Diagnose a segmental somatic dysfunction.
2. Lay patient supine with operator standing on the contralateral side of rotation. 3. Have patient lay arms across chest with contralateral arm on top. 4. Rotate patient toward operator by lifting contralateral shoulder and thorax. 5. Operator reaches across patient to places thenar eminence on patient’s Transverse Process. Flexion or Neutral dysfunction: thenar eminence placed at posterior TP of dysfunctional segment Extension dysfunction: thenar eminence placed at TP inferior to dysfunctional segment 6. Flex patient to fulcrum by supporting patient’s head, neck and shoulder with operator’s cephalad arm. 7. Sidebending can be localized by levering the upper thorax toward side of restriction. 8. Localize forces over fulcrum point by adjusting vector of force over patient’s elbows through operator’s epigastric contact. 9. Instruct patient to inhale and fully exhale as more localization of force is obtained during deep exhalation. - opportunity to help patient relax more while also assessing the level of passive compliance - distracters/diversions may also be helpful here 10. HVLA thrust applied through elbows to fulcrum. - Flexion or Neutral dysfunction: perpendicular to table - Extension dysfunction: 45 degrees to table 11. Re-evaluate: note effects of the manipulation and look for what remains to be treated. |
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What is the thrust vector in prone, cross-arm technique for thoracic HVLA?
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Patient lies prone
Thrust vector perpendicular to table Thrust through doctor’s arms, through thenar and hypothenar eminence, directed through dysfunctional segment “Twist” will occur with downward force |
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What is the direction of force on the ribs in thoracic HVLA?
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Thrust perpendicular to table
Thenar eminence on rib angles Align forces past midline so forces are directly over thenar eminence/fulcrum |
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What is the correct procedure for prone cross-arm thrust thoracic HVLA technique? (~7 steps, per Dr. Comfort)
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1. Diagnose a segmental somatic dysfunction.
2. Lay patient prone with operator standing on the contralateral side of segmental rotation. 3. Doctor places thenar/hypothenar eminence of one hand on ipsilateral TP and the thenar/hypothenar eminence of the other hand on the contalateral TP (posterior TP). Type I: Cephalad hand on posterior TP, use thenar eminence. (Thumb pointed toward patient’s feet.) Caudad hand on ipsilateral TP. (Thumb pointed toward patient’s feet Type II: Caudad hand on posterior TP, use thenar eminence. (Thumb pointed toward patient’s head.) Cephalad hand on ipsilateral TP. (Thumb pointed toward patient’s feet.) 4. Doctor positions himself/herself 90 degrees to segmental dysfunction, placing equal weight on thenar and hypothenar eminences. 5. Patient is instructed to inhale and fully exhale while operator maintains contact tension following the thoracic cage through full exhalation. Continue to localize forces at barrier near posterior TP. IF patient IS RELAXED enough, then: 6. HVLA thrust is applied perpendicular to patient’s spine. 7. Re-evaluate: note effects of the manipulation and look for what remains to be treated. (*Note: This technique is for a flexion dysfunction.) |
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Describe the correct procedure for double arm thrust to the ribs for thoracic HVLA? (~11 steps, per Dr. Comfort)
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1. Diagnose dysfunctional Rib - Inhalation versus Exhalation somatic dysfunction (not for non-physiologic rib dysfunctions).
2. Patient is placed supine and doctor stands on the contralateral side of rib dysfunction. 3. Patient instructed to cross arms over chest. 4. Rotate patient by pulling contralateral shoulder toward doctor. 5. Using an open hand, physician places thenar eminence of caudad hand posterior to the dysfunctional rib. (Note: You treat the key rib with respect to the dysfunction.) 6. Patient rolled back over doctor’s thenar eminence and contact is made with operator’s chest or abdomen and patient’s elbows. 7. Pressure is directed through patient’s chest wall using elbows, localizing at the thenar eminence fulcrum. 8. Doctor flexes patient to fulcrum by supporting patient’s head, neck and shoulders with cephalad hand. 9. Patient is instructed to inhale and fully exhale. More localization is achieved during exhalation by sidebending toward (inhalation somatic dysfunction) or away (exhalation somatic dysfunction). IF patient IS RELAXED enough, then: 10. HVLA thrust is applied through patient’s crossed arms and chest wall to thenar eminence fulcrum. 11. Re-evaluate: note effects of the manipulation and look for what remains to be treated |
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What are some key points regarding rib HVLA?
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Make sure to roll patient over open hand past midline to direct force over rib angle
Remember to adequately sidebend the thorax to engage the barrier of the inhalation or exhalation dysfunction Remember to treat the key rib Due to the intrinsic recoil property, expect the rib to require significant expiratory excursion to fully reach the restrictive barrier |
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What were some of the research focuses of Dr. Korr?
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Axonal Transport
Trophic Function Electromyography Electrical Skin Resistance Sweat Gland Activity Thermography |
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What were Dr. Korr's findings for EMGs?
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He found the stronger the signal, the greater number of muscle fibers fire
He could predict EMG readings based on the severity of TART findings. Areas with TART have a lower threshold of excitement than areas with no SD |
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How did OMT affect EMG thresholds?
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OMT increased the threshold for areas previously with TART findings
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How did muscle relaxants affect EMG thresholds?
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Muscle relaxants are not specific to just the muscles with SD so the threshold for all muscles overall was raised - and relatively, the muscles with SD still had a lower threshold
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Are muscle relaxants a suitable substitute for OMT?
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No, because even at maximum therapeutic doses of muscle relaxants, the muscles with SD still have a lower threshold.
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What were Dr. Korr's finding about sympathetic tone and sweat gland activity?
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He found that sweat gland activity increases with increasing sympathetic tone - "cold sweat"
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What were Dr. Korr's findings with thermography studies?
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He correlated the areas of increased sympathetic tone (temperature, sweat, red reflex) to areas with facilitated segments
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What is ESR and how do the results correlate with TART findings?
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ESR is electrical skin resistance - the resistance between two electrodes placed on the skin surface.
Low resistance areas were correlated with increased sympathetic activity - hyperesthesia, TART. High resistance areas were correlated with sympathectomized areas |
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What was the difference in ESR between normal areas and hypersympathetic areas?
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200-fold difference in resistance
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What is the effect of sympatholytics on ESR?
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Sympatholytics increase resistance
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How was somatic dysfunction induced in ESR trials and what were the results?
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SD was induced with hypertonic saline injections
The result was lowered ESR at the level of injection and its referral pattern. |
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What are some conditions Dr. Korr researched for role of sympathetic hypertonus?
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ARDS
Peptic ulcer Pancreatitis Arterial disease Hepatotoxicity Cardiovascular/renal Uterus function Eye disease Correlation with disease at autopsy - sympathetic ganglia at level of diseased organs show morphological changes |
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Describe the mechanism for neuropathic pain syndromes such as reflex sympathetic dystrophy.
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Dysfunction anywhere along the sympathetic circuit induces increased sympathetic tone at a segment and at other structures on that segment's circuit and referral pattern.
Pattern becomes a permanent positive feedback loop. |
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What is caused by hypersympatheticotonia?
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Increased sweating, vasomotor changes, resorption of bone as well as pain in the involved area
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Describe axoplasmic transport.
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Axons deliver substances (nutrients, cytoskeleton, tubules, organelles) to the organs they innervate - also help cells differentiate.
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How did Dr. Korr study axoplasmic transport?
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He injected labels in the nerve cell which were delivered only to where that axon goes, and they travel in waves - hours, days, weeks, and a month later.
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How do nerves and their target organs affect one another in the case that one fails?
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Nerves cut = nerve atrophies
Nerves cut = Organ atrophies Organ cut = Nerve dies |
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How does SNS affect recovery from injury?
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SNS will not allow healing or growth of tissue
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Remember the following important quote...
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There is a somatic component to every disease which is not only a manifestation of the disease, but an important contributing factor
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What are some principles derived from Dr. Korr's research?
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Induce a dysfunction in any structure, that dysfunction is distributed to every other structure on that vertebral segment
Induce a dysfunction on a structure, and any stimulus that even peripherally involves that structure will irritate it, even light stimulus |
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What is a common denominator in chronic degenerative illness, a common cause of death in the elderly population?
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Sympathetic hypertonus
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What are some of the papers that Dr. Zink wrote?
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"An Osteopathic Structural Exam and Functional Interpretation of the Soma"
"Respiratory-Circulatory Care: The Conceptual Model" |
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What is the CCP?
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Common Compensatory Pattern
Creates a framework for interpretation of the significance of asymptomatic somatic dysfunction.' Organizes a regional exam (first-pass) Identifies transitional zones, junctions, diaphragms. |
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What are the four transitional zones and corresponding junctions and transverse diaphragms of the CCP?
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Occipitoatlantal (OA) - transverse diaphragm: tentorium cerebelli; Craniocervical junction
Cervicothoracic (CT) - transverse diaphragm: thoracic outlets/inlets; Cervicothoracic junction Thoracolumbar (TL) - transverse diaphragm: respiratory diaphragm; Thoracocolumbar junction Lumbosacral (LS) - transverse diaphragm: pelvic diaphragm; Lumbosacral junction |
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What are some areas of important spinal transition in relation to CCP?
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Anterior-Posterior curves
Vertebral anatomy Facet orientation Spinal motion characteristics Areas of mechanical stress Horizontal diaphragms |
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Describe some characteristics of the craniocervical junction.
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Heavy head to mobile spine
Tonic neck reflexes influences postural tone Disruption causes hypertonicity of postural muscles, equilibrium and locomotor deficits CN IX, X, XI transverse functional diaphragm |
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Describe some characteristics of the cervicothoracic junction.
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Most mobile part of the spine connects to most restricted portion
Powerful muscles of upper extremity and shoulder girdle insert Lymphatic ducts, brachial plexus R/L, phrenic and vagal nerves Sibson's fascia Facets change from 45 degree to coronal |
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Describe some characteristics of the thoracolumbar junction.
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Less mobile to more mobile
Facets change from coronal to sagittal Abdominal diaphragm SD associated with hypertonus of iliopsoas, quadratus lumborum, thoracolumbar erector spinae, inhibition of the rectus abdominus Esophagus, thoracic duct, aorta, vena cava, azygous veins, vagus and phrenic nerves |
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Describe some characteristics of the lumbosacral junction.
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Base of spinal column
LE movement transmitted to spine Pelvic diaphragm Pelvic visceral support, sacral plexus Transmits thoracics, splanchnic and pudendal nerves, anal canal, urethra, and vagina |
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What are some hypotheses about the etiology of CCP?
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Response to gravity and postural stresses
Viscerosomatic reflexes In-utero torsions, birth forces "Coriolis effect" Western civilization - right-handed world |
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How did Zink determine the origin of patterns?
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Asked patients about their health - perceived level of wellness and health, ability to adapt to stressors, resistance to sickness, hospitalizations
Evaluated many patients Identified fascial patterns |
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Describe the respiratory-circulatory model.
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It focuses on fluid movement
Goal - increase efficiency of respiration, maximize pressure differentials between thorax and abdomen-pelvis Treatment - horizontal diaphragm, costal cage Treatment goals - decrease work of respiration, improve fluid movement, restore intrinsic elastic forces stored in the thorax |
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What are some symptoms of impaired respiratory
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Venous congestion
Lymphatic stasis Vague patient complaints Subclinical Lost feeling of well being |
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What are some characteristics of the circulatory system that maintain homeostasis?
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High pressure
Low pressure Structural aids Drainage sites |
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Describe low pressure systems in circulation.
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Dependent on pressure differentials
No assistance from muscles (peripheral pumps) Terminal lymphatic drainage also dependent on effective diaphragmatic respiration at rest. |
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What are the steps in the patient history component of the respiratory/circulatory evaluation?
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Vague sense of malaise
Sleep enough, but not rested Morning headache or backache that disappears with activity Lack of abnormal lab tests |
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What are some signs in the physical exam specific to the respiratory/circulatory evaluation?
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Increased lumbar lordosis
Shallow breathing with increased rate Excessive chest motion Decreased diaphragmatic amplitude Presence of "passive congestion" |
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What are some sites of passive congestion?
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Supraclavicular areas
Posterior axillary folds Epigastric area Inguinal regions Achilles tendons Popliteal spaces Suboccipital areas Cervical nodes Inguinal nodes Epitrochlear spaces Lateral thighs |
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Describe congestion.
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It is a sign of a problem with terminal lymphatic drainage
Most common site of congestion.. Sequence of treatment |
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What are some structural findings in patients with congestion?
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Supraclavicular edematous congestion
Tenderness and even thickening of tissues around the trapezius and supraspinous muscles Cervical lymphatic tissues may be enlarged Cervical tissues tender to the touch Cervical limited motion in the cervical area |
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What are the components of the shortened Zink fascial screening exam?
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Check medial malleolus for symmetry
Check iliac crest for symmetry, ASIS compression test and symmetry Pubic tubercle symmetry Check lumbar curve for lordosis (space between lumbar spine and table) Check translation of thoracolumbar junction (R and L) for symmetry Check pelvic rotation, and myofascial torsion over innominates for symmetry Check sternal deviation Check infraclavicular parasternal space for symmetry, resistance to posterior motion, tenderness Check 1st rib for symmetry Check upper cervical vertebral rotation for symmetry Check wrist rotation at radial styloid process |
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What are the different fascial patterns?
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Physiologic (ideal)
Compensated - alternating patterns Uncompensated - body couldn't get into a compensation pattern |
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What are the two compensatory patterns?
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Common compensatory pattern - 80% - LRLR
Uncommon compensatory pattern - 20% - RLRL |
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What are some characteristics of congestion that can be seen in axillary lymphatic tissues?
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Enlarged, posterior axillary fold may be edematous
Chronically may become thicker and tender to the touch Anterior axillary fold may show same findings Inguinal lymphatic tissue may be affected Folds of edematous or fatty tissue may be on the lower lateral aspect of the leg above the knee. |
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What are some lymphatic signs of congestion?
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Decreased muscle tonus and tissue turgor on calf
Popliteal fossa may show edema Either side of Achilles tendon may show edema Edema above elbow Supratrochlear lymphatic nodes Tonus of forearm muscles, also turgor and edema |
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What position is the patient in during the CCP examination?
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Supine
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What is the ideal supine state?
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Gravity effect minimal
Major vessels horizontal Viscera tend to redome the diaphragm Level pelvis Spine has no lateral curvatures Lumbar spine flat on table Symmetrical costal cage Midline, symmetrical sternum |
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What are some ideal patient findings?
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Diaphragmatic breathing
Abdominal motion all the way to the pubes Slow respiratory rate Sternal angle evident No depression of the 1st ribs at medial third of clavicle Subclavicular fossae only at lateral aspects of the clavicle Rib cartilages not tender to light pressure Rib cartilages would yield, not be rigid Sternum in midline, equal and easy to move side to side Sternum level side to side (not A or P) Lower lateral thoracic cage resilient to compression Good abdominal wall tonus Lumbar spine flat against the table ASIS level and horizontal Iliac crests level Cephalolateral – caudadomedial motion of opposite hands symmetrical Inguinal ligaments without tension, ticklishness, or tenderness Pelvis rotation symmetrical Pubic symphysis level, horizontal, non-tender Leg length equal Angle formed by feet with table equal Patient comfortable with legs straight (uncrossed) Arm length stretched overhead equal at the radial styloid process Arms would contact the table without arching the lumbar spine Angles of arms with the forearms equal Good muscle tone and turgor |
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What are the 10 principles of CCP?
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Innominates
Sacrum Lumbosacral area Thoracolumbar junction Tenth rib FIfth rib Third thoracic vertebra First rib First thoracic vertebra Upper cervical complex |
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How are CCPs treated?
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Myofascial techniques
HVLA Muscle energy Counterstrain |
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What are the treatment goals in dealing with CCP?
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Restore patient to ideal
Each patient has his own peculiar pattern OMT can improve function within each person's pattern |
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How are treatments focused for CCP?
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Focus on the transitional areas of spine to straighten the spine
Improves thoracoabdominal pump by restoring diaphragmatic respiration of supine patient Release myofascial restrictions, ligamentous articular strains, and membranous articular strains Synchronized pelvic and thoracoabdominal diaphragms No set sequence |
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What are the principles for hydrodynamics?
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Treat central to distal
Treat site of terminal lymphatic drainage (thoracic inlet) first (aspiration by respiration) Then treat middle and lower thorax Often more effective to treat pelvis, low back, and then lower thorax to establish better tonus of abdominal wall and pelvis, redome diaphragm Occasions when good to start Tx at cranium Can Tx away from “hot” areas to decongest them Treat axial before appendicular |
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Why is the Zink screening useful?
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Efficient/quick systematic fascial evaluation
Identifies problems at transitional areas Identifies about 85% of axial SDs Allows treatment of subclinical SDs Effective Tx improves respiration and circulation, reduces congestion Improves general health |
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What are two approaches for toning down the S-ANS?
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Progressive exhalation - exhale maximally in short steps (exhale pause exhale pause) - inhale deeply, take some normal breaths, then repeat.
2:1 Breathing - Inhale for 2 seconds, exhale for 4 seconds. Note any internal changes, increase intervals if necessary (3 seconds and 6 seconds) |
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What are five concepts associated with the body and its dynamic processes, components, etc?
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Balance
Symmetry Tensegrity Unity Alignment |
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What is an osteopathic lesion, according to Wilbur Cole, D.O.?
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A physiological perversion which, by virtue of the irritations
produced, instigates and/or maintains functional disorders and is usually a reversible reaction The presence of an Osteopathic Lesion instigates a reflex which influences organs by producing significant physiological dysfunctions that vary according to the location and duration of the lesion. |
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How did Dr. Cole study osteopathic lesions?
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He induced “Osteopathic” lesions in laboratory animals & then euthanized them. These lesions were often produced using Burns’ method in which steady pressure was applied to a spinous process and repeated daily until paravertebral muscular rigidity was palpated in the region.
Studied gross and histological changes in the tissues Studied effects of lesions after 96 hours, 6 weeks, 6 months He then looked at the effects of the lesion on the CNS |
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What were Dr. Cole's findings for the induced osteopathic lesion at 96h after inducing lesion?
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Hyperthermic
Eyes protruded Autopsy - Paravertebral muscles were hyperemic, extending bilaterally, cephalad and caudal to lesion, no gross changes in viscera |
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What were Dr. Cole's findings for the induced osteopathic lesion at 6 weeks?
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Pulse erratic, rigid paravertebral musculature, tenderness to palpation
Autopsy - Minimal visceral changes, paravertebral muscles were hyperemic, extending bilaterally, cephalad and caudal to lesion |
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What were Dr. Cole's findings for the induced osteopathic lesion at 6 months?
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Pulse erratic, rigid paravertebral musculature, tenderness to palpation
Autopsy - External surface of female reproductive organs had extreme degree of congestion. Accumulations of sludged blood in the capillaries of the heart and erythrocytes between cardiac fibers. Congested vessels in lungs with perivascular cuffing and thickening of alveolar walls. Vasodilatation throughout GI tract with contraction bands in smooth muscle layer. Some liver sections exhibited fatty metamorphosis. Smaller vessels showed thrombi. |
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What is perivascular cuffing?
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A density of lymphocytes/plasma cells around vasculature indicating inflammation or immune processing
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How are parasympathetic effects induced via an osteopathic lesion?
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Hyperemia and contracture of cervical musculature are parasympathetic responses. Stimulation of striated muscle receptors feeds back to the spinal cord and activates the ANS and CNS --> hypothalamus --> dorsal vagus --> parasympathetic effect
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What CNS findings were there in Dr. Cole's research on osteopathic lesions?
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Alterations in vascular supply from the segment that extended into the spinal cord and brain stem. This includes congestion, small hemorrhages, and sludging throughout the CNS (including the meninges, medulla, pons, thalamus, and spinal cord), glial proliferation (but not neuronal liquefaction)
Signs of autonomic imbalance |
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What were Dr. Cole's findings about the end motor plate?
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The structural variation of the motor end plate due to physical and chemical stimulation such as carbon dioxide, electricity, trauma, the action of curarizing substances, alterations following muscle contraction, and the changes following fatigue have been reported. The results of these varying experiments indicate that the morphological variations observed were similar even though the modality producing these changes were different. Furthermore, these observations would indicate that the morphological changes noted in these experiments were similar to those exhibited by the motor end plate in the present investigation.
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What did Dr. Cole conclude about the role of the CNS in maintaining SD/Osteopathic lesions?
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If a neural mechanism were not involved in association with the lesioning process it would seem probable that the paravertebral muscles would return to normal after irritation has ceased by virtue of the natural reparative processes. Although sufficient time elapsed after lesioning to permit it, this did not happen. Hence, besides simple irritation, there must be a neural mechanism.
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What is the effect of an (induced) osteopathic lesion on the OA?
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Slowed pulse
Subnormal blood pressure |
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What is the effect of an (induced) osteopathic lesion on T2-T4?
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Irregular pulse
Cardiac pathology Increase in body fluids |
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What is the effect of an (induced) osteopathic lesion on T5?
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Gastric erosions (if present for 10+ months)
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What is the effect of an (induced) osteopathic lesion on the lumbar spine?
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Abnormal young
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What are characteristics of inflammation in histology slides of osteopathic lesions?
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Vasodilation
Vascular permeability Exudation Vascular stasis |
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What is a major cause of loss of integrated function (Patterson, Foundations of Osteopathic Medicine)?
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Improper fluid movement - primary and vital cause of loss of integrated function
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How do sympathetic nerves integrate with and affect the vasculature?
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Fibers follow tunica media of blood vessels
Secrete norepinephrine - vasoconstriction, increased prostaglandins |
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How do sensory fibers integrate with and affect the vasculature?
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Found in arterial walls
Secrete substance P when irritated - proinflammatory, vasodilatory neuropeptide - results in neurogenic inflammation and edema Send nociceptive inflammation and edema Can become sensitized |
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According to Dr. Cole, how does the ANS relate to osteopathic vertebral lesions?
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The theory best substantiated by experimental evidence is that the so-called osteopathic vertebral lesion is important in clinical syndromes due to its primary involvement of the autonomic nervous system. This imbalance results in a disturbance of blood supply of viscera roughly in a segmental pattern, and the cellular changes are secondary to the anoxemia due to the altered vascularization
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What did Dr. Patterson study/research? What were some findings/conclusions?
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Habituation and sensitization - established that the spinal cord actively processes incoming signals, not simply a conduit.
"The cord learns and has a memory" Also explained how prolonged somatic dysfunction will “burn a (dysfunction) memory pattern” into the spinal cord. This maintains/restores the dysfunction, even after the nociceptive input has been corrected |
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According to Dr. Korr, what is the role of a facilitated spinal segment?
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The facilitated segment acts as a neurologic lens, focusing activity onto the organs, both skeletal and visceral, innervated by neural outflow from the facilitated segment to the spinal cord
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What is a facilitated spinal segment?
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An asynchronous area of neural function exhibited through low-threshold spinal reflexes - probably due to some constant bombardment by input.
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What were two conclusions gained by understanding the relationship between facilitated segments, soma, and viscera?
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1. Palpatory Findings were proven to correlate with altered muscle excitability as relevant somatic dysfunction
2. Osteopathic Manipulation’s potential scope of influence was shown to range from the soma to the vital functioning of the viscera. Through the neural connection we interface with and affect both. |
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Define somato-somatic reflex.
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Localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures (ie patellar DTR)
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Define somato-visceral reflex.
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Localized somatic stimuli producing patterns of reflex response in segmentally related visceral structures (ie decreased urine output after repeated stimulation at T10)
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Define viscero-somatic reflex.
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Localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures (abdominal cramping after appendix rupture)
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Define viscero-visceral reflex.
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Localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures (decrease in HR after distension of carotid sinus)
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Who was John Stedman Denslow?
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Born in Hartford, Connecticut - 1906.
Graduated from Kirksville in 1929 Faculty at Chicago COM Professor and chairman of the department of osteopathy theory and methods at Kirksville. |
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What were some of the main topics of research performed by Dr. Denslow?
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Validation of the osteopathic lesion, correlation between muscle activity and palpation.
Laid a foundation for Dr. Korr's work on the facilitated segment. Called for standardization of postural X-Ray procedure. |
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What motivated Dr. Denslow to start postural studies with relation to X-Rays?
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He studied it while in Chicago, was interested in vertebral mechanics, neuromuscular reflexes involved in posture.
As he studied more, he decided that postural X-Ray studies needed to be standardized. |
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What are important factors for postural X-Ray studies?
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Placement of equipment and the patient
Magnification and Distortion Reliability and stability of radiological findings in the weight bearing position |
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Why are proper methods for taking postural X-Ray studies so important?
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Important for...
Acquiring measurable, accurate data which can be reproducible Integration of research findings and clinical experiences Describing the relationship between structural problems and functional abnormalities Use as a tool to correlate with the osteopathic palpatory structural exam |
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What were Denslow's interests and questions about osteopathic lesions?
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He was interested in describing the basic mechanism underlying the osteopathic lesion
Establishing scientific validation Correlating palpation abnormality in tissue texture Examining abnormality due to reflex muscle contraction Studying the relationship between the characteristics of muscle activity and palpatory diagnosis. |
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Describe Denslow's use of EMG studies in his research.
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He used EMG studies to determine how reflex muscle contractions in normal areas compare to those in lesioned areas
Selected lesioned and normal regions by palpation Recorded the number of action potentials in each region |
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What were the four different conditions in the EMG studies (ABCD) performed by Dr. Denslow?
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A - patient is voluntarily contracting both areas - control to make sure electrodes are in contact with the muscle
B - patient lying quietly - no contraction is normal, spontaneous single motor unit contraction in the lesioned area C - patient relaxed by using pillows in a way to relax the lesioned area - no contraction in the normal or lesioned area D - Stimulated both areas, then recorded - normal stays relaxed, lesioned area shows contraction |
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What were the results of the EMG studies done by Dr. Denslow?
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Areas with TART reacted differently than normal areas, with and without stimulation
Established the existence of an osteopathic lesion Laid a foundation for studies on facilitated segments Also proved palpation is an effective way for detecting areas with osteopathic lesions EMG studies demonstrated that the "lesioned" areas were facilitated segments on the spinal cord - not present in the normal areas. |
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What were some things investigated in Dr. Korr's studies?
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Reflex threshold
Palpation of tissue Pain upon palpation Susceptibility to minor trauma |
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What was the background of Dr. Elliot Hix?
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WWII veteran
Got PhD in Physiology from Kansas State University and instructed there Joined Kirksville as a physiology instructor Chairperson and professor of Pharmacology Director of the neurobiology lab in 1978 until he retired in 1990 |
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What did Dr. Elliot Hix study?
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Neurobiology of Reflexes
Renal function - new methodology, reflex mechanisms |
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What were Dr. Hix's main research ideas?
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He was interested in the neural aspect of renal function
Research: Use the same subject for both the control and experiment. Answer the questions: How do we measure the quantity and quality of each kidney separately in order to compare? What happens if we disconnect a ureter from the bladder and have it drain from the abdominal wall instead (exteriorize it)? What does catheterizing the ureters do? |
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For Dr. Hix, what were his findings regarding...
...if the ureter drains out the abdominal wall ...the effects of catheterizing ureters |
If ureter drains out the abdominal wall, it causes irritation, excoriation, and when severe enough can lead to reflex renal functional disturbances. Not a clean model.
Catheterizing ureters causes a decrease in output from the ipsilateral kidney. Prevents the acquisition of accurate measurements and data collection. |
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What was Dr. Hix's new model for studying renal function?
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He separated one ureter from the bladder and externalized it using a skin flap
The other ureter was still connected to the bladder It allowed measurement of the quality and quantity of each kidney without effects of the catheter or skin irritation, infection. |
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How would a stress, such as catheterization, affect kidney function?
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Results in lowered volume output, GFR, RPF - altered kidney function
No significant difference between the control ureter and the rubber nipple collection of the exteriorized ureter. |
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How did Dr. Hix test his new model and whether it had any reflex alterations?
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Under anesthesia, reflex alterations are halted, so he compared the urine output, GFR, and RPF while under anesthesia and while not under anesthesia.
Results: no significant change |
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How did Dr. Hix control for reflex alterations in kidney function?
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Blocking the autonomic ganglions with hexamethonium chloride
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What type of reflex is occurring when catheterization of the ureters results in altered kidney function?
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Viscero-visceral reflex
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What did Dr. Hix study with regard to the effects of emotional and chronic physical stress?
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The renal responses to unilateral uretal irritation with emotional stress
the long term effects of mild chronic ureteral irritation |
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How did Dr. Hix conduct the experiment for emotional and chronic physical stress?
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He induced ureter irritation by catheterizing the exteriorized ureter thus creating a 'facilitated' segment
Then introduced an emotional stressor like firing an air pistol, etc. |
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What were the results of Dr. Hix's experiments on kidneys to see the effects of emotional and chronic physical stress?
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Compared to the control kidney...
ERPF decreases 20% when a catheter is introduced, creating a facilitation An emotional stressor decreases ERPF even more |
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What were the results on kidney function of introducing a catheter into one of two exteriorized ureters?
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20 days later - catheterized kidney had decreased creatine clearance
36 days later - catheterized kidney had markedly decreased creatine clearance and Cpah |
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What were the results of de-innervating the kidneys so as to prevent reflex response?
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74 days post-de-innervation the ipsilateral kidney was practically nonfunctional
Morphologically - atophic, ischemic with cortical nephron necrosis, fibrosis. |
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What somato-visceral reflex was observed by Dr. Hix in his kidney studies?
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Stimulating the paravertebral muscle at the same dermatome as the kidney caused decreasd urine output from the ipsilateral kidney.
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What viscero-somatic reflex was observed by Dr. Hix in his kidney studies?
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Irritation of the ureters and kidneys produced muscle spasms in the paravertebral muscles sharing the same nerve supply.
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What vertebrae deliver sympathetic innervation to..
the kidneys? the upper ureter? the lower ureter? |
Kidneys - T10-T11
Upper Ureter - T10-T11 Lower Ureter - T12-L1 |
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What were the contributions of Dr. Henslow?
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Validated the osteopathic lesion
Described methods for standardized postural X-ray studies Laid a foundation for Dr. Korr's work on the facilitated segment |
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What were the contributions of Dr. Hix?
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Developed new methods for renal physiology research
Described and applied the viserco-visceral, somato-visceral, and viscero-somatic reflex mechanisms. |
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List some of the properties of Wolff's Law.
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Bone will remodel according to weight bearing force lines
Bone will resorb if no load bearing Muscle tendon and ligament have their own corollaries Even more significant while actively growing. |
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How is treating children different from adults?
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You have the chance to shape the physiology and anatomy in ways that you cannot in later years
Can affect growth Intervene before somatoneurological reflex pathways become set |
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About how many infants hat Sutherland cranial strain patterns?
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~88%
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What are indications for an exam on an infant?
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The child has pulse and respirations, not in acute distress
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What are some indications for treatment in an infant?
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Any restriction, asymmetry, pain or poor functioning
Alterations of physiology - something doesn't work well, constipation Structural or functional asymmetry/inefficiencies (preference of asymmetric position) Examine child on well and sick visits Illness Trauma - examine even if no apparent effects Pain - baby cries, or is avoidant |
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What are some exam and treatment indications (red flags)?
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Pre/postmaturity
Long/difficult labor Multiple birth Breech, transverse Illness Oxytocin, forceps, vacuum Meconium Child had any neonatal distress Precipitous delivery |
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What are some visceral complaints for infants/children?
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Seizures
Nursing-eating difficulties, speech pathology Gastric motility - emesis, constipation, gastroenteritis, post op ileus Respiratory distress - wet lung, meconium, asthma, infection Urinary tract infection "growing pains" Hypoglycemia Jaundice |
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What are some postural and structural deviations in infants/children?
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Torticollis, plagiocephaly
Positional preference Scoliosis Asymmetric gait/limb (dysplasia, weak limb, turns foot in/out) Tone problems (high, low) Bowed legs Visual convergence problems Dental malocclusion |
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What are some more subjective problems in infants/children
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Otitis media
headaches - 2.5% of school age, 15% of midteens Back pain (fairly common) Behavioral problems Failure to thrive/developmental delay Syndromes Failure to make milestones Sleep problems |
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What are some contraindications in infants/children?
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Same as adults, plus...
Lack of parental consent Cranial specific extreme conditions: prematurity (< 32 weeks), meningitis, meconium aspiration, mechanical ventilation (increased risk of brain bleed), craniotomy Modalities - depend on cooperative ability, primitive reflexes, tissue maturity/fragility, growth plates |
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What do you do when parents are hesitant to let you do OMM on their child?
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Examine the child
Formulate what OMM could help If child not in imminent danger without immediate intervention, need to present options to parents with risks and benefits of having and not having treatment |
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What is the optimal time to treat a child/infant?
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Start before 3 months of age, some ossifications really start progressing then.
Remember: Changes can always be made, sooner the better. |
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What are some "common" things in infants that can/should be treated?
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Pediatric hypertension
Pediatric hypercholesterolemia Pediatric obesity |
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What cues may indicate that an infant/child has a problem being overlooked?
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"All babies do that" "they'll grow out of it" "that's fine"
Turned/twisted position Has preference for different positions Something works more slowly |
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What is "normal" by higher, osteopathic standards for infants/children?
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Symmetry for head trunk and pelvis, preferably midline
All four limbs move symmetrically, prefer anatomic position Baby can lie flat and be placed in sitting position with smooth primary C-curve, without distress, and with all parts equally participating Organ function smooth, regular Symmetry of rest and motion Lack of fussiness or irritability Enthusiastically engages the world Development on time |
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Describe interosseous restrictions and how it relates to growth and osteopathy.
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Future single adult bones are in several parts in children - able to develop strains that will become permanent in the future adults
Can be treated as an adult, but it takes longer and is not as complete a resolution Some critical bones ossify early, treatment is easier if begun before 3 months of age. |
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What were some of the findings/contributions of Dr. Arbuckle, D.O.?
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Identified scoliosis capitis (crooked head) as a precursor for scoliosis corporis (crooked body)
Explain why braces and scoliosis are concurrent age-wise Head is crooked, affects teeth growth Thoracic scoliosis associated with plagiocephaly, torticollis Lumbar scoliosis associated with leg length discrepancy, or sacral or pelvic unleveling Postural instability may contribute to learning and behavioral problems |
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What are the typical interpretation of normal feeding in infants?
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Kid gains weight
8-10 wet diapers Falls asleep after eating |
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What is the osteopathic interpretation of normal feeding in an infant
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Breast feeding should be good on both sides (CN XI)
Shouldn't spit up - CN X Burps easily Strips the breast quickly Baby draws finger in, as far as cruciate suture, can pull glove off finger Good air seal No gag reflex No chewing, tongue thrust, or fasciculation |
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What are some vestibular effects from temporal bone dysfunction?
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Vision
Suck/swallow Language development Balance Cerebellar function State of consciousness Gross motor function Developmental delay Learning disabilities Reading/writing Sensory integration Others: TMJ, Dental malocclusion, headaches, tinnitus, cough, other cranial dysfunction, hearing, eustachian tube dysfunction (ear infections, pressure changes) |
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What are some problems that are considered "normal" that have been found in students with neurological problems?
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73% had a history of neonatal trauma - especially illness in mom, prematurity, difficult labor, C-section
Measured mobility, visual, auditory, and tactile development Treatment goal - restoration of unrestricted movement |
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What are some constraints on OMM research?
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Limited funding for manual medical research
Limited access to ill patients Limited models - placebo treatment Widely variable skills and experience among practitioners Widely variable findings among patients Protocols vs "ad lib" techniques Physicians vs students as surrogate DOs |
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In Dodd's studies of in vitro biophysical strain model, how did he structure the experiment?
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Used human dermal fibroblast cultures
Flexible, collagen coated wells Distorted by applying suction to outside Analysis of cell shape, viability, and secreted inflammatory cytokines |
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At low strain magnitudes (10% strain for 12 hours) - what findings were there for the in vitro cells?
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Mild cellular rounding
Truncated pseudopods IL-6 doubled NO tripled Hyperplasia (ds DNA) Altered alignment (to align with strain vector) |
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At high strain magnitudes (30% strain for 12 hours) - what findings were there for in vitro cells?
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Pseudopods gone
Membranes ruptured in 75% of cells Double stranded DNA (hyperplasia) decreased |
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What were the contributions of Dodd's studies of in vitro biophysical strain?
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Detailed observations of cellular responses to acyclic strain
Correlation between strain and damage Opens the door to further inquiry - what does OMT do? |
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How was OMT's effect on a repetitive motion strain tested?
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Cyclic strain was introduced to model repetitive motion strain
OMT model was introduced Fibroblast proliferation and interleukins tracked |
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What were some scenarios that were tested regarding OMT and repetitive motion strains?
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Baseline - cells on pre-strain (10%) membranes
RMS: Baseline 10%, then 8hrs of cyclic pulses (18% strain every 1.6 sec), then sampled 24RMS: RMS, but sampled 24 hrs later 24IOMT: Baseline, then strain off for 1 minute, restored Baseline strain, sampled 24 hrs later 24RMS + IOMT: RMS, 3hrs Baseline, IOMT, sampled 24 hrs later |
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What did Dodd's research of in vitro biophysical strain add?
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In vitro cell cultures can be strained and treated
OMM reduces the inflammatory response and reverses effects of inflammation Beneficial effects of OMM persisted after the strain was restored, even at 24 hours OMM not only reduced inflammation but enhanced fibroblast proliferation (fights disease, promotes health) |
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How was increased lymphatic flow in the thoracic duct during OMT tested?
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5 dogs were fitted with flow transducers to check their thoracic duct, ascending aorta, and the descending aorta was catheterized for BP
Measurements were made during treadmill exercise and two lymphatic pump techniques. |
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What are the three main lymphatic pump techniques?
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Thoracic pump - increases the thoracic suction on venous and lymphatic fluid
Abdominal pump - pushes lymph from the Cysterna chyli into the thorax Pedal pump - pushes fluid out of the legs Pedal pump |
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What were the results of the thoracic/lymphatic research with the dogs?
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OMT increased TDF without increasing cardiac measurements
After OMT concluded, increased TDF reverted to normal Physical activity tended to move more lymph than the abdominal pump, better than thoracic pump |
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What did the dog study for lymphatics show?
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First direct measurement of lymph movement obtained by OMM
Increased lymph flow was independent of cardiac variables Increased flow was dependent on OMM - increase in flow stopped when the OMM stopped |
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How was the study on cannabimimetic effects of OMT conducted?
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31 subjects, half OMT and half sham treatment
Gave a Drug Reaction Scale questionnaire Checked serum levels of endocannabinoids - Anandamide (AEA), 2-arachidonoylglycerol (2-AG), Oleylethanolamide (OEA) |
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What were the findings of direct OMT compared to placebo?
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Anandamide increased 168%, 17% with sham treatment
Oleylethanolamide increased 27% with OMT, no increase in sham There were subjective qualifiers |
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What discussion was there on the results of the cannabimimetic effects?
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Increases Anandamide (AEA) levels
May explain the use of OMT in schizophrenics, anorexia, releases OMT |
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How was the OMT prenatal care study structured?
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160 women treated, 4 different cities
Multiple outcomes tracked Case-matched to 161 from same cities - without OMT - to control for placebo effect |
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What are some statistics about prenatal care OMT and the benefits?
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1911 Labor time reduced 50%
1918 Reduced labor time 40% 1932 - reduced mortality rate with OMM - 2.2 per thousand compared to 6.8 per thousand. USC LA county medical center - too few maternal complications to train obstetrical residents. |
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In the more recent prenatal OMT studies, which outcomes were tracked?
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MSAF - meconium-stained amniotic fluid
PTD - pre-term delivery UCP - umbilical cord prolapse Use of forceps - vacuum extractor not studied CSD - Cesarean section delivery |
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What kind of OMT was performed in the prenatal OMT studies?
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No protocols, no students, no placebo treatments, number of treatments 2.8-5.0 overall
Typically older |
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What were the outcomes of the prenatal OMT studies?
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OMT strongly reduced MSAF and PTD
Mildly reduced forceps use Benefits older gravidas Benefits seen even with few treatments |
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What were some challenges with the prenatal OMT study?
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OMT more prevalent in higher socioeconomic brackets so are better obstretical outcomes
One author abstains from forceps use and that center had higher CSD incidence One center's data abstracted from another study for OMT in LBP during pregnancy. |
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What was the OMT recurrent AOM study?
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57 patients, 6 months - 6y, 25 treated
OMT by four physicians All 57 received standard pediatric care by physicians blinded to the study group Improvements - fewer AOM episodes, fewer surgeries, better tympanograms OMT was given by physicians, applied as needed not by protocol, 15-25 minute treatments, entire body not just head/neck, no HVLA |
