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147 Cards in this Set
- Front
- Back
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Pediatric Somatic Dysfnx:
5 Major Reasons |
-Rapid Growth
-Intra-Uterine Positioning -Birth Trauma -Weight Bearing mMechanics -Additional Trauma |
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How many bones are in the head?
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23
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How many "soft spots" does a baby's head have?
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6 major fontanels:
-Anterior (Bregma) -Posterior (Lambda) -2x Sphenoidal (Pterion) -2x Mastoidal (Asterion) |
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Ossification Timeline of Cranial Synchrondroses
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Sphenoid & Temporal Bone <2yo
Occipital Bone: 8±1: formed from 4 bones SBS: 13 ±3 yrs |
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General Principles of Pediatric OMT
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1. Req' delicate touch
2. Dx & Tx w/o causing distress 3. Tx sequence determined by pt cooperation 4 they will respond to low doses No HVLA <6 yo Absolute contraindication to Cervical HVLA: DownSyndrome or RA: rupture odontoid ligament (aka, apical ligament of dens, ≠ superior longitudinal band of the cruciate ligament; [dens = odontoid process]) |
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APGAR
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Appearance
Pulse Grimace Activity Respiration 1 and 5 minutes after birth + 15 min if initial scores are low 7-10 are normal |
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Caput Succedenum vs. Cephalohematoma
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Caput Succcedenum: under skin, crosses midline
cephalohematoma: beneath peritoneum, does not cross midline |
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1 Month Dvlpt Milestones
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Verbal: Distinct Cries for Hunger vs Distress
Social/Mental: Comforted by voices, being held; [does not follow with eyes, does not recognize specific persons] Gross Motor: head flops backward if unsupported; jerky, quivering arm thrusts; brings hands within range of eyes and mouth, moves head from side to side while lying on stomach Fine motor: keeps hands in tight fists, Strong reflex mvmts |
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3 Month Dvlpt Milestones
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Verbal: Coos in response to human attention
Social/Mental: Follows moving objects with eyes, Social Smile Gross Motor: Lifts head and chest when lying on stomach, wiggles and kicks with arms and legs Fine motor: grasps rattle w/o thumb [does not reach for objects, does not shake rattle] |
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6 Month Milestones
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-Single Syllabule Words
-Sits up unsupported -Shakes a rattle -Rolls over -Reaches for objects |
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Mvmt Dvlpt
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3 mo: lifts shoulders when prone
~6 mo: sits unassisted Homolateral "alligator" Creeping → Cross Pattern Commando Creeping → Lifted Abdomen Crawl ~9 mo: pulls up to stand ~12 mo: "cruising" moving around room supporting self on furniture 18 mo: walks w/o assistance 24 mo: Runs, Walks up and down stairs alone 36 Mo: alternates feet with stair walking, jumps, walks on toes or hops Each step is important to dvlp integrated cerebral fnx |
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Learning to talk
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<2 mo: distinct cries for hunger vs. distress
~2 mo: vocal coos in response to human attention 6 mo: Single Syllables (Repetitive Babbling) 9 mo: Multiple Syllables 18 mo: 10 words, own name 2 yrs: 2 word phrases, 250 word vocabulary, including pronouns & own name 3 yrs: speaks in complete sentences |
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12 month milestones
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Verbal: Responds to own name, simple instructions, [has been using combining syllables since 9 mo, will know 10 words incl. own name by 18 mo]
Social/Mental: Object Permanence, Separation anxiety Gross Motor: Knocking 2 blocks together, Cruising: moving around furniture Fine Motor: Pincer grasp: uses thumb and index/forefingers to grab things, Drinking from a cup without help, Feeding self finger food |
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18 mo milestones
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Verbal: 10 word vocabulary incl. own name
Ment/Soc: Rapproachement Gross: walks without assistance, throws a ball [cruises at 9 mo, kicks ball at 2 yrs] Fine: stacks 3 blocks [pincer grasp w/' self feeding at 12 mo, fork & spoon at 2 yrs] |
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24 mo milestones
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Vocal: Combines two words, uses Pronouns
Social: Parallel play, "No!" Gross Motor: Runs/walks up and down stairs alone, kicks ball Fine Motor: stacks 6 blocks, uses spoon and fork |
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Age 3 milestones
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Vocal: Speaks in complete sentences, knows parts of own body, can drawl a self portrait, copies a circle
Social: Toilet Training, Gender Identity, Comfortably Spends Time Away from mother Gross Motor: Alternates feet w/ stair walking, jump on step, can walk on toes and hop 2x, rides a tricycle Fine motor: Stacks 9 blocks, uses scissors, partially dresses self [has been using fork and spoon as well as undressing since age 2] |
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Crawling function
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each step is essential in dvlpt of integrated coortdinated cerebral fnx
1. Crawling w/ abdoment on floor --Starts w/ "Alligator Crawl" Homo lateral arm leg motions --Advances to Cross patern movement 2. Lifts abdomen off floor 3. Pulls to stand 4. Cruising 5. Forward Walking 6 Skipping |
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Fetal Molding
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Δ(cranium shape)
Physiologic: Adaptation of the fetal cranium to the shape of the mother's pelvis, normally resolves w/in hours Pathologic: molding after the first day of life: bone deformation ± cranial base strain |
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Plagiocephaly:
Pathogenesis, SD, DDx, Tx, |
Functional plagiocephaly: distorted shape of infants skull due to molding of unfused sutures
↑ incidence since "Back to Sleep" anti-SIDS campaign Our role as Docs: --Rule out synostotic plagiocephaly: prematurely fused and mis-shapen, this will show up on a head circumference gorwth curve --Parental Reassurance, OMT, encouraging tummy time is most effective treatment Dysfnx patterns: OA &SBS --Lateral Strain: prallelgram towards flat side --OA rotation towards falt side Dr. Scott does not like helmets |
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Torticollis
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Malposition of the head and neck upon the torso
Cranial SD often occiput + temproal bones → CN XI dysfnx "Congenital Torticollis" ~5 wko (± 1) SCM, Trapezius ± Scalenes |
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Suckling
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Non nutritive: "pacifier suckling"
Nutritive: dvlps by end of week 2 first two weeks are not useful, extremely frustrating for moms: 2/3 give up in first 2 weeeks <32 wks gestation: predominantly non-nutritive pattern <36 wks gestation: ± immature suckling pattern Hypoglossal Foramen → CN12 tongue weakness Jugular Foramen → CN9, X, XI: muscle weakness in pharynx & neck Biomechanical SD of any ff: Extrinsic tongue muscles, Mandible, Hyoid, Superficial Thraot muscles, Shoulders, Clavicles Important to Address: Occipital Decompression, Jugular Foramen (Temporals) |
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OMTx: Gastroesophageal Reflux in Peds
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Address:
CNX in jugular foramen Thoracoabdominal diaphragm: esophagus motility & dysfnx |
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Infantile Colic & Conspitation:
DDx (4) & OMTx |
Rule out organic causes:
Congential megacolon, hypothyroidism,CF, Hirshsprungs Address lumbar & Pelvic Dysfnx |
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Condylar Decompressions for Peds
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Light touch!
pads of middle fingers on condyles hands are approximated with MFR technique |
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Craniofacial Somatic Dysfnx
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The shape of the eyeball is affected by the diameter of the orbital cavity
The EOM's originate from psphenoid, frontal and maxilla bones Shepnoid bones houses cavenous sinus & innervation of EOM's Sphenoid Compression: myopia, hyperopia, strabismus, lacrymal duct stenoisis |
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Important Anatomy of Pediatric Otitis Media
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ET from middle ear between petrous portion of temportal bone and basisphenoid.
sphenoid portion entirely cartilaginous: diameter of tube narrowest at osseus-cartilaginous jnx through petrosphenoid articulation At birth ET/EAC more horizontal, incidence of OM declines to age 6 as it slowly becomes more verticle Cranial strain patterns affect ET mechanics See page 31 for OMTx's |
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Galbreath Maneover
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Gentle traction on proximal mandible for about 30 seconds
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Sinus efflurage
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2-5 minutes of repetitive strokes:
thumbs across the forntal, amxillary from emdial to lateral ending near earlobe follow with milking anterior SCMon each side twoards heart |
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Ear Pull
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For Otitis Media
Gentle bilatearl ear pull to mobilize undelrying fascia and temproal bones wait for release Pinnae up & out ↑ External Rotation Pinnae down & in ↑ Internal Rotation child must be still |
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Most commoncauses of childhood pneumonia
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20% are bacterial, 80% viral
Viral: RSV, Influenza, PIV Bacterial: Strp Pneumo, M pneumo, Chalmydia pneumo, H influenza (not in vaccinated) SMCH = "Smooch" |
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OMT evaluation for pneumonia
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Upper thoracic vertebrae, ribs, and sternum
T1-T5 to address Lung SNS OA for PSNS Accessor muscles Throacic diaphragm (C3-5) Chapman's reflexes for lungs, sinuses Cranial Sacral mechanism,SBS compression |
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Most common cause of childhood ER visits
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Asthma
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OMT for Asthma
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Hyperactive Vagus, Diminshed SNS, Reduced Lymphatic Drainage
Rib Raising T2-6 & TL jnx to balance PSNS &SNS Diaphragm release OA Tx: Vagus T1-T6, T10-L2 SD Accessory muscle rebalancing Anterior cervical fascia Chapman's Reflexes: lungs, sinuses, adrneals Lymphatic pump: pedal, thoracic CV4 |
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OMT for Neurologic Disorders
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restore strx &balance esp to craniosacral
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Optimizing External Factors
for Infantile Dvlpt |
Tummy Time
Discourage walker use and extended time in stationary centers Discontinue pacifery by age 2 ≥1h exercise/day balanced diet OMT during pregancy |
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4 Most Significant Feature sof Pediatric Hx
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Birth Hx
Feeding Problems Sleep Problems Delayed Dvlptal Milestones |
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4 parts of visceral-somatic tx
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SNS (incl chapman's reflexes)
PSNS Lymphatics Facilitated Somatic Structures |
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SD: Baby with Hx Trouble Breathing
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[apneic, irregular, asymmetrical etc.]
PRM dirves prope breathing in lungs, rib cage suggests Temproal bones are not working in integrated fashion |
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Baby with Hx Trouble Sucking
SD, Tx |
Compression of CN12 between nonfused condylar parts
Decompress condylar parts Teach Child to suck by having mother put figner on back of tingue wher eit tips backwards &then draw tongue forward. baby will learn to suck on finger then nipple |
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OMT: Baby vomiting after feeding
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despite conventional wisdom: NOT PHYSIOLOGIC
2* to compression of CNX Decompression of Condylar Parts &V Spread |
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Colic, IBS, Reblux, Constipation
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Address SD:
Occyptial Condyles Chapman's GI pts Celiac, Sup Mes, Inf Mes Lumbar, Pelvis, Sacrum Balance 4 diaphragms |
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OMT: Otitis media
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MFR hyoiid, sternum, ant C&T fascia, thoracic ducts
Temproal bone rocking:: lateral fluid fluctuation Galbreath Maneuver: teach parents Chapman's Point: Middle ear Ant: superior aspect medial clavicle where R1 dives under Post: posterior Occipital condyles Ear pull |
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Fulford's Recto-Respiratory Reflex
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Impairment as a cause of Otitis Media
During birth: sacrum becomes restricted —| PRM —| Respiration —| Lymphatic Drainage → OM |
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Coordinating the 4 diaphragms
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Abdominal/TLJ
CTJ necklace technique: D & I MFR Pelvic Diaphgram: prone-steering wheel thumbs under ischial tubes, inhale, exhale cough OA: Occipital decompression teach parents sympl lymphaetic pump, stretches, et all at home |
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Frequency of LBP
Cost, Incidence |
2nd most common presentation to 1° Care
[1/3 of all PC visits Musculosckeltal in nature] 80% lifetime incidence 5%/year incidence Leading cause of work related disability:1/3, major cause of lost income and governmental expenses 50-75 Billion USD |
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Epidemiology of Acute LBP
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Acute onset btw 20-50
occupation plasy major risk: --Nursing --Garbage Colelction --Warehouse --Airlines |
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Causes of Low back pain
by the %'s due dilligence to ... |
70% Somatic Disfunction
10% Osteoarthritis 4% Osteoporosis 4% Disc herniation w/ nerve entrapement 2% recurrent visceral disease 0.7% Symptom of Systemic Neoplastic Disease Always give due diligence to disc hernaition, neoplasm, organic diseases |
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Causes of Radicular Pain
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Intraspinous: Neurofibroma, Ependymoma, meningioma, Disc, Spinal Stenosis, AVM of cort, Spinal AV fistula
NB: Ependyma = CSF Producing Epithelium lining Ventricles Mn: StAV MEND Exstrapinous: piriformis, Vascular Disease, Nerve Root irritation, Neoplasms, Plexitis, Polyneuropathy, Neuropraxis 2° to Trauma, Shingles Mn: PirVIN PlePoNeuSh |
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Non-Radicular Pain
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Traumatic: SD,compression fx, transverse fx
Chronic/sub acute: muscle, SD DJD: Spondyloslisis w/ spondylysthesis, Fibromalgia Referrred Pain: AAA, pancrease, SD Infection: Bone, disc, epidurial UTI Neoplastic: metastatic: breast, prostatic, lung thyroid, RCC, myeloma, primary bone tumor Rheumatologic:HLAB27: Ankylosing spondylitis, Reithers' IBD, Psoriasis Misc.Paget's Osteopenia,Osteomalacia |
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6 Alarm Sx for LBP
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Age >50
Prior Hx CA Unexplained fevers/night sweat Unintentional weight loss Pain >1 mo, often intractible and unrelieved by rest No improvement following Conservative therapy |
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Straight Leg Raise
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between 20-60*
Sensitivity 80% Specificity 40% negative SLR makes herniated disc unlikely positive is a non-specific finding |
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Laboratory Workup of LBP
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CBC: Infx,Abscess, Lymphoma, Myelodysplastic Animea
ESR: Inflammation Ca2+ osteolytic mets PSA, AP Mammography and breast exam (1/8) X rays Bone scan if Multiple Myeloma suspected CT for stress fractures MRI for Soft Tissue problems |
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Acute onset LBP which is constant, shapr and shooting. Radiates dermatomally and unilaterally. Worse with cough, sneeze sitting, improved lying down.
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Discogenic Radicular Pain: activities which ↑ intrathecal pressure aggrevate
Most commong cause is irritationof nerve root will affect motor fnx and DTR's Sensory often affected before motor fnx Tpically exert presssure on nerve root below IV disc space Not always caused by classic herniated nucleus pulposus: → can be caused by SD |
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Risk Factors for Herniated Nucleus Pulposus
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Repetitive Lifting Activity
Prolonged Sitting Twisting Rotational movement Chronic Cough Prior SpinalInjury or Disc Disease Tobacco use Prolonged Exposure to vibratory forces |
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Herniated Nucleus Pulposus
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Most commonly in posterior lateral location because of small Posterior Longitudinal Ligament
Most Commonly L4-L5 > L5-S1: lordosis-kyphosis transition with high weight pain worse with increasing intrathecal pressure: coughing, sitting males more than females Dx: MRI, CT, myelogram Tx: Heat/Ice, OMT, Corticosteroids, NSAIDS, Opiods, Epidural Infx, Surgery if progressive TCA's &Gabapentin used for neruopathic pain unresponsive to opiods |
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Protruding Discs
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52% of protruding discs on MRI are aSx
herniated discs are different story |
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What is the most common location of a HNP?
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L4-L5 > L5-S1: lordosis-kyphosis transition with high weight
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Cauda Equina Syndrome
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Inpringement of cauda equina
0.0004% of all LBP pts 50% 2* to tumor Sx: bilateral extremity sensory loss, loss of rectal sphincter tone, loss of bowel, bladder fnx, saddle numbnesss with severe LE motor weakness Tx: Emergent Surgical decomression |
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Spinal Stenossis
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CT & Bone overgrowth reducin gsize of vertebral foramen
main cause is degeneration and remodelling caused by normal aging processs, ± accelerated by arthritis mostly >60, chornic progressive often bilateral, poorly localized, raidating to buttocks, thighs legs >>worsened with extension (standing walking, improves with flexion<< stopping ambulation may not improve sx, unlike vascular claudication |
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PVD Claudication & LBP
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Peripheral Vascular Disease Claudication
Chronically progressive, poorly localized ±bilateral pain which increases with any LE exertion & improves with rest risk factors: moking, DM, hyperlipidemia, FmHx PE reveals diminished pulses, poor capillary refill and cyanotic, cool extremities |
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Osteoarthritis and LBP
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degenerative disease of the psinal column leading to fusion and of the vertebral bones
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Spondylolyis:
Define, Pt, Exacerbation, Dx |
stress fracture of the pars interarticularis of he intervertebral arch
associated with hyperextension, esp seen in football lineman and gymnasts pain is worse with extension &compressive loads Dx'd with an oblique view lumbar XR (45*) |
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Spondylolithesis:
Define, Sx, Tx |
slippage of one vertebral body onto the next
Grade I: 0-25% displacement 25% displacment/grade Grave 3 & 4 are surgical Grade 1 & 2 req monitoring no always assoc w/ LBP |
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Facet joint syndrome
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osteoarthritis of the facet joints (?)
pain in lower back, in facet region w/o radiation below knee paravertebral tenderness & signs of spasm at segmental level pain esp with extension, normal neurologic exam pain in morning, lessens with physical activities |
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facet trophism
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dislocated facet joint
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Hip or Knee Pathology as cause of LBP
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Ostoarthritis
Gradula onset w/ normal neruo exam pain mostly loclaized to joint &aggrevated by joint ROM |
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Myofascial pain causing LBP
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worsens with rest
relieved by warmth stiffness, tenderness, limited ROM |
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Compression Fractures & LBP
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Usually acute onset ± event, ± segmental radiation
aggreated by flexion/sitting probably hx: old, osteoporotic, steroids or CA |
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SD & LBP
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70% of LBP
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5 Usual segmental an dLigamentous dysnfx of LBP
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L5
SI joint, esp sacral torsions short leg stretch of iliolumbar ligament myofascial injury |
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Greenmans' principles of tonic and phasic muscles for LBP
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page 74
also "major muscles involved in chronic LBP" not making cards |
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Muscle Str Testing & DTR's of the LE
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Muscle Str
L1, L2: Psoas L3: Quads L4: Dorsiflexion L5: Big toe up S1: Gastrocnemius DTR's Patella = L4 Achilles = S1 |
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Grading Muscle Str
Grading DTR's |
Muscles
0- Nothing 1- Muscle Flexes no mvt 2- can move but not against gravity 3: can move vs gravity 4: movement vs resistance, but not strongly 5: strong motion against resistance DTR's 0- no response 1- minimal 2- normal 3- hyperactive, (consider hypocalcemia) 4- clonus |
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Dermatomes of the LE
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.
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Provocative Tests for LBP
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Straight leg Raise: Pain Below 60* indicates nerve root irritation
Patrick's test: indicates hip pathology or Si pathology Thomas test: tight hip flexor |
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Tx: Innominate Rotation
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Anterior: ME engaging hamstrings & pulling down on the posterior ilac spine
Posterior: ME engaging quads (looks more like psoas) OMM Srping p 85 |
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Tx: Innominate Shear
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Supeiror Sheer: Pt Supine, Doc grasps foot proximal to ankle, ABducts 15* to loose pack position, internally rottes to close pack position. Doc pulls traction while pt performs 3 deep breaths. During last exhalation pt coughs, doc tugs.
Inferior Shear: Pt on side, dysfnx side up. Doc supports LE, one hand from ischial tuberosities to PSIS, other hand from ischial tuberosity to inferior pubic ramus. Lift innominate towarrds ceiling &presses cephelad. Pt takes 3 breaths. |
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Tx: Pubic Shear
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Shotgun Pubes
Pt supine, knees bent. Doc holds pts knees together, resits 3 ME efforts of abduction. Place forarms between knee & resist 3 ME efforts of adduction |
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Tx: Innominate Flares
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Inflare: Pt supine, Knee in FABERE, Doc's cephalad hands holds opposite Iliac Down, caudal hand holds Knee in FABERE as Pt ME's into Internal Rotation
Outflare: Pt supine, Doc's cephalad hand pulling posterior ilac outwards, caudal hand holds Knee in adduction while Pt ME's external rotation |
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Tx: Sacral Torsion
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Forward: Axis side down; rotate pts torso rotated forwards towards table, flex knees & hips. ME pt tries to rotate trunk towards floor & ankles toward ceiling. Engages bottom piriformis
--alternate position: axis side up, has benefit of doc not pushing legs into table Backward: Axis side down, lower leg extended, upper leg flexed & hanging off table. Torwo rotated backwards toward table. ME: Trunk → and raising upper leg → ceiling. Engages top piriformis. |
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Tx: Sacral Flexion, Extension
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Unilateral Flexion: Pt prone, abduct dsyfnx side leg to maximum relaxation of SI joint. monitor dysfnx sulcus. Spring dsyfnx ILA to find angle that produces greatest spring at sulcus. use heel of hand to induce cephalad &anterior force to ILA as pt inhales deeply. ME 3-5x
Unilateral Extension: Pt prone: abduct dysnfx leg to maximum relaxion of SI joint. Spring dysfnx side base while monitoring ILA to find angle of greatest spring. Pt comes into sphinx position. Use heel to induce caudad & anterior force at dysfnx sacral base as pts exhales deeply. ME 3-5x Bilateral Flexion: Abudct both legs to rleax both joints. moitor both sulci, spring over ILA's to find angle which causes best spring. Use heel of hand to push cephalad & anterior over ILA while Pt inhales. ME 3-5x Bilateral Extension: Abduct both legs to relax both SI joints. Monitor ILA's. Spring sacral base to find angle which causes greatest spring at ILA's. Use heel to press caudad & anterior over sacral base as pt exhales. ME 3-5x. |
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UPL5
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Upper Pole 5th Lumbar = Multifidus, Rotatores, SI ligaments
TP: superior medial surface of PSIS, pressing inferiorly & laterally S/CS: Prone, extend hip & support leg on doc's thigh. slight adduction & mild external rotation. 1° mvmt is extension. |
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TP: superior medial surface of PSIS, pressing inferiorly & laterally
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Upper Pole 5th Lumbar = Multifidus, Rotatores, SI ligaments
S/CS: Prone, extend hip & support leg on doc's thigh. slight adduction & mild external rotation. 1° mvmt is extension. |
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S/CS: Prone, extend hip & support leg on doc's thigh. slight adduction & mild external rotation.
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Upper Pole 5th Lumbar = Multifidus, Rotatores, SI ligaments
TP: superior medial surface of PSIS, pressing inferiorly & laterally S/CS: 1° mvmt is extension. |
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LPL5
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Lower Pole 5th Lumbar: Iliospoas,SI ligaments
TP: inferior aspect of PSIS, pressure applied anteriorly S/CS:Prone, dysfnx leg dropped off edge of table, hip flexed to 90*, slight adduction; opposite iliuim maybe retracted slightly to fine tune. Alternate posit'n: doc stand son opposite side and grasps dysfnx ilium, retracts & rotates ilium towards tenderpoint (looks horrible) |
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TP: inferior aspect of PSIS, pressure applied anteriorly
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Lower Pole 5th Lumbar: Iliospoas,SI ligaments
S/CS:Prone, dysfnx leg dropped off edge of table, hip flexed to 90*, slight adduction; opposite iliuim maybe retracted slightly to fine tune. Alternate posit'n: doc stand son opposite side and grasps dysfnx ilium, retracts & rotates ilium towards tenderpoint (looks horrible) |
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S/CS: Prone, dysfnx leg dropped off edge of table, hip flexed to 90*, slight adduction
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Lower Pole 5th Lumbar: Iliospoas,SI ligaments
TP: inferior aspect of PSIS, pressure applied anteriorly C/CS: opposite iliuim maybe retracted slightly to fine tune. Alternate posit'n: doc stand son opposite side and grasps dysfnx ilium, retracts & rotates ilium towards tenderpoint (looks horrible) |
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SSI
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Superior Sacroiliac:Gluteus Medius
TP: 3cm lateral to PSIS, pressure applied anteriorly and then medially S/CS: Pt prone, pts thigh extended, moderatelly abducted. Doc supports LE on Doc's Leg (foot on table). |
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TP: 3cm lateral to PSIS, pressure applied anteriorly and then medially
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Superior Sacroiliac:Gluteus Medius
S/CS: Pt prone, pts thigh extended, moderatelly abducted. Doc supports LE on Doc's Leg (foot on table). |
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S/CS: Pt prone, pts thigh extended, moderatelly abducted.
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Superior Sacroiliac:Gluteus Medius
TP: 3cm lateral to PSIS, pressure applied anteriorly and then medially S/CS: Doc supports LE on Doc's Leg (foot on table). |
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ISI
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Inferior Sacroiliac: Coccygeus, Sacrotuberous Ligament
TP: along Sacrotuberous ligament from the ischial tuberosity to sacral ILA S/CS: Pt prone, Doc opposite. extend, ADDUCT, and externally rotate across univolved leg. |
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TP: along Sacrotuberous ligament
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Inferior Sacroiliac: Coccygeus, Sacrotuberous Ligament
TP: from the ischial tuberosity to sacral ILA S/CS: Pt prone, Doc opposite. extend, ADDUCT, and externally rotate across univolved leg. |
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S/CS: pt prone. extend, ADDUCT, and externally rotate across univolved leg.
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Inferior Sacroiliac: Coccygeus, Sacrotuberous Ligament
TP: along Sacrotuberous ligament from the ischial tuberosity to sacral ILA S/CS: Doc opposite. |
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PS1
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Posterior First Sacral: Levator Ani (LA also tx'd by PS5)
TP: in sacral sulcus, medial and slightly inferior t PSIS, pressure applied anteriorly S/CS: anterior pressure on opposite ILA to rotate around oblique axis |
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TP: in sacral sulcus
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Posterior First Sacral: Levator Ani (LA also tx'd by PS5)
TP: medial and slightly inferior t PSIS, pressure applied anteriorly S/CS: anterior pressure on opposite ILA to rotate around oblique axis |
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S/CS: anterior pressure on ILA
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Posterior First Sacral: Levator Ani (LA also tx'd by PS5)
TP: in sacral sulcus, medial and slightly inferior t PSIS, pressure applied anteriorly S/CS: anterior pressure on opposite ILA to rotate around oblique axis |
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PS5
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Posterior Fifth Sacral: Levator Ani (LA also tx'd by PS1)
TP: 1 cm superior & medial to ILA, pressure applied anteriorly S/CS: pt prone, anterior pressure on sacral base opposite TP to rotate around oblique axis |
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TP: 1 cm superior & medial to ILA, pressure applied anteriorly
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Posterior Fifth Sacral: Levator Ani (LA also tx'd by PS1)
S/CS: pt prone, anterior pressure on sacral base opposite TP to rotate around oblique axis |
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S/CS: pt prone, anterior pressure on sacral base to rotate sacrum about oblique axis
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Posterior Fifth Sacral: Levator Ani (LA also tx'd by PS1)
TP: 1 cm superior & medial to ILA, pressure applied anteriorly S/CS: pt prone, anterior pressure on sacral base opposite TP to rotate around oblique axis |
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G5 P4105
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G-P:TPAL
Gravity 5 Parity 4 Term: 4 Preterm: 1 Abortions: 0 Living: 5 |
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Naegle's Rule
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EDC Estimate date of "confinement" (ie delivery) = FDLMP (first day of last menstrual period) minus three months plus one week
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Determining Gestational Age w/ Fundal Height
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12 weeks: symphysis pubis
16 weeks: 1/2 way btw SP &umbilicus 20 weeks: Umbilicus 1 week / cm above umbilicus up to 36 weeks --not accurate after 36 weeks 36 weeks: at breastbone does not apply to twins |
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Determining Fetal Age with US
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First Trimester: Acurate ± 7 days by measuring crown to rump
2nd Trimester: accurate ± 7 days by measuring femur length All parameters ± 3 weeks in 3rd trimester |
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Timing of Delivery
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Lost <20 wks: spontaneous abortion
≤36 wks preterm 37-42 wks term ≥ 43 wks post term |
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Fetal Movements
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"quickening" is first momvements, occurs by 20, as early as 15 in multigravid
fetal mvmts should occur 10x /12h |
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Prenatal Screening frequency
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1-28 wks: monthly (1st 4 mo)
28-36 wks: every 2 weeks (5th to 9th mo) 36-40 wks: weekly (10th mo) |
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Average weight gain during pregnancy
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30 lbs ± 5
less for obese pts |
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Fetal Development:
CNS Heart Sex |
CNS formation begins at 2 weeks (importance of folic acid)
Heart forms during week 3, visible via US ~wk 6: detectable heart extremely positive Px factor vs. spontaneous abortion sex visible ~wk 17 |
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3 Major osteopathic considerations of pregnancy
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Δ weight Δ fluid Δ hormones
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Physiologic Cardiovascular Changes of Pregnancy
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CO increases by ~40% btw wks 6-24. Remains near peak until wk 30
CO ↓ slightly from wk 30 to labor during labor CO ↑ another 30% ↑ uteroplacental circulation to ~1L/min, 20% of all CO at term. Imagine the hemorrhage! HR ↑ up to 90 bpm Stroke Volume ↑ Total Blood Volume ↑ Hg ↓ from 13 to 12 g/dL from fluid dilution |
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Physiologic Renal Changes of Pregnancy
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Roughly prallel ↑ in Cardiac Output
↑ GFR ~40% peaking wks 16-24, but remains up nearly to term ↓ BUN & Cr |
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Physiologic Respiratory Changes of Pregnancy
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↑ progesterone: ↑ uterus: interferes with lung expansion
↑ progesterone: signal sbrain to lower CO2 levels ↑ tidal, minute volume & RR → respiratory alkalosis ↑ 20% O2 consumption increases ↑ 10cm thoracic circumference hyperemia & edema of respiatory tract (incl nasal stuffiness) mild dyspnea-on-exertion |
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Physiologic Endocrine Changes of Pregnancy
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placental βHCG maintains corpus luteum during trimester
corpus luteum produces progesterone to maintain pregnant state also secretes relaxin: ↑ SI & pubic symphysis mobility, [relaxin] ≈ LBP placental produces progesterone directly starting 2nd trimester fetal adrenal cortisol prodnx → lung surfactant prodxn placenta produces HPL human placental lactogen to maintain fetal glucose levesl → gestational diabetes: tested wk 26-28; risks include obesity, FHxDM 4% of women Prolactin from anterior pituitary stim's milk release once estrogens fall |
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Physiologic Biomechanical Changes of Pregnancy
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SI joint pain
Center of gravity moved anterior Pelvis tilted atnerior Lumbar hyperlordosis Thoracic hyperkyphosis Paraspinal muscles shortened Abdominals stretched increased circulation to pelvic organs increased chest circumference External rotation of innominates |
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Risk Factors for LBP in pregnancy
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[relaxin] ≈ LBP
Multiparity Advanced maternal age Previous Hx LBP or trauma [NOTassoc: race, occupation, fetal weight/size, pre-pregnancy weight, previous epidural, exercise habits, sleep position, mattress type, heel height, weight gain] |
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Body Fluid Changes of Pregnancy
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Inferior vena cava compressed by uterus → LE venous stasis & edema
Fluids in the body increase approx 6.5 L (or 8.5 according to ICMD) Pts with carpal tunnel syndrome often manifest now (edema) put pt at risk for pre-explampisa,exlampsia, renal failure, htn may manifest as: CNS malase ↑ tidal volume (decreased blood flow) conspitation, liver, pancreas congestion hemorrhoids, varicosities, ↓ nutrition leg cramps, varicosities LBP from venous pelxus congestion |
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Pre-Ecpampsia
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New onset HTN >140/90 after 20wks w/ proteinuria >300 mg/24hrs & significant non-dependent edema
"Severe" defined as >160/110 measured 2x 6h apart or proteinuria >500 mg/24h Risk factors: nulliparity, chronic HTN, Hx preexpampsia, obesity, gestational DM, IR, and thrombophilias Sx: HA, visual disturbance, chest/epigastric pain, RUQ pain/tenderness, hyperactive DTR's clonus, edema in hands and legs |
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Pregnancy Induced HTN
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BP >140/90
usually develops near term ~20% progress to pre-eclampsia |
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Contraindications to OMT in Pregnant Pts
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VDAB-P-PED
V: Unstable matenral vital signs D: Untx'd DVT A: Placental abruption B: UnDx'd vaginal bleeding P: ↑ maternal BP P: Preterm Labor E: Ectopic pregnancy D: Fetal distress |
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Viscerosomatic Reflexes of Female GU tract
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T9-T10: Ovary & Fallopian Tubes
T10-L1: Uterus & Urinary Bladder PSNS:S2-S4 |
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Dysmenorrhea:
SD, OMTx |
Cramping pain assoc w/ menstruation
SNS: uterine contraxon PSNS: Uterine relaxon OMT to throacolumbar SD will improve homeostasis Pressure applied over the sacrum of a prone pt reduces the secverity of menstrual cramps: teach a family member (sacral inhibitor pressure) |
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Review Chapman's Points
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page 118
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Chapman's points of morning sickness
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C2, T5-9
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Sacral Inhibition
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Great For: Dysmenorrhea
Press down on sacrum, one hand over the other in line with vertical axis Pt 1/2 breath in and hold when they breath out you follow down steady presssure 1-2 minutes repeat prn |
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Ischial Tuberosity Spread
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Great for: Urinary Incontinence, Hemorrhoids, Pelvic Pain
Pt prone, upper body on elbows Knees flexed, heels turned out. Operator places thumbs meidal to ischial tuberosities and engages ts. Pt inhales & during exhalation doc pressses laterally. Space should be noted to open up in area of tx. |
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Visceral Tx of Bladder
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Great for: generalized bladder dysnfx after ruling out organic causes
Pt supine, doc alongside & facing pt at level of pelvis place palm of caudad hand over suprapubic region. place other hand on top of first hand. Upper hand listens. as lower hand "sinks" through ts . Test restrictions and tx |
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Thoracolumbar stimulation
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Greate for: improving quality of contractions as in uterine dystocia or prolonged labor
Rapid percussion with fists or thumbs T12-L2 for 1 minute every 15 minutes as tolerated |
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Pregnant Roll
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Pt supine, fingers interlaced behind neck.
Doc opposite dysfnx side T.P., caudad hand reaches across to stabalize ASIS. Cephalad hand grasps opposite shouler & rolls pt to doc upon pt exhale. Roll down to level of dysnfx No HVLA in pregnants. |
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Frogleg Sacral Rocking
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Pt supine, hips & knees flexed, feet together, knees falling toside.
Doc contacts sacrum. W/ respiraotry assistance take sacrum to ligamentous tension balance. pt hold breat & straightens out legs to rotate innominates. Rassesss. page 125 |
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Sacroiliac Articulartion
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Pt supine, Doc flexes pt knee & hip. Doc moves LE from extenral rotation to internal rotation followed by extension. Flex again and move from internal rotation to extenral rotation end with extension. repeat.
"Spencer's technique of the LE" |
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Pelvic Diaphragm Release
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?
page 127 |
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Inguinal Ligament Tenderpoint
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TP: On lateral surface of the pubic bone, near attachment of the inguinal ligament
S/CS: Pt supine. Doc opposite TP, foot on table. LE flexed. "Good over evil" at the knee. Slight ADdxn of femur, w/ internal rotation on side of TP. |
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Iliacus Tenderpoint
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TP: anterior and deep throughout iliac fossa
S/CS: Pt supine. Doc on same side as TP, foot on table. Marked flexion & external rotation of hips. Knees separated, cross LE's at ankles induces flexion & external rotation at hips. fine tune with rotation of pelvis |
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AL5
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Anterior 5th Lumbar: Rectus Abdominus
TP: Anterior Pubic bone 1 cm lateral to symphysis S/CS: Pt supine, Doc same side as TP, foot on table. Flexion rotation of knees towards. Pts thighs flexed ≥90*. Pts knees rotated slightly rotated towards side of TP, torso slightly sidebent away |
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AL2
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Anterior Second Lumbar: External Abdominal Oblique
TP: Medial inferior surface of ASIS S/CS: Pt supine. Doc opposite TP, foot on table. Hips flexed ≥90*, rotate knees away form TP, Sidebend trunk slightly away from TP by pushign lower legs toward floor |
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AL3
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Anterior Third & Fourth Lumbar: Iliopsoas
TP: AL3 on lateral surface of AIIS AL4 inferior to AIIS S/CS: Pts upine, Doc opposite TP. Flex hip, sidepend trunk maredly away from TP by pulling feet warod doc while keeping knees midline. rotate slightly to fine tune. |
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AL4
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Anterior Third & Fourth Lumbar: Iliopsoas
TP: AL3 on lateral surface of AIIS AL4 inferior to AIIS S/CS: Pts upine, Doc opposite TP. Flex hip, sidepend trunk maredly away from TP by pulling feet warod doc while keeping knees midline. rotate slightly to fine tune. |
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TP: On lateral surface of the pubic bone
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Inguinal Ligament Tenderpoint
TP: On lateral surface of the pubic bone, near attachment of the inguinal ligament S/CS: Pt supine. Doc opposite TP, foot on table. LE flexed. "Good over evil" at the knee. Slight ADdxn of femur, w/ internal rotation on side of TP. |
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TP: Anterior Pubic bone 1 cm lateral to symphysis
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AL5 Anterior 5th Lumbar: Rectus Abdominus
S/CS: Pt supine, Doc same side as TP, foot on table. Flexion rotation of knees towards. Pts thighs flexed ≥90*. Pts knees rotated slightly rotated towards side of TP, torso slightly sidebent away |
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TP: Medial inferior surface of ASIS
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AL2: Anterior Second Lumbar: External Abdominal Oblique
S/CS: Pt supine. Doc opposite TP, foot on table. Hips flexed ≥90*, rotate knees away form TP, Sidebend trunk slightly away from TP by pushign lower legs toward floor |
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TP: lateral surface of AIIS
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AL3-4: Anterior Third & Fourth Lumbar: Iliopsoas
TP: AL3 on lateral surface of AIIS AL4 inferior to AIIS S/CS: Pts upine, Doc opposite TP. Flex hip, sidepend trunk maredly away from TP by pulling feet warod doc while keeping knees midline. rotate slightly to fine tune. |
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TP: Inferior to AIIS
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AL3-4: Anterior Third & Fourth Lumbar: Iliopsoas
TP: AL3 on lateral surface of AIIS AL4 inferior to AIIS S/CS: Pts upine, Doc opposite TP. Flex hip, sidepend trunk maredly away from TP by pulling feet warod doc while keeping knees midline. rotate slightly to fine tune. |
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S/CS: Pt supine. Doc opposite TP, foot on table. LE flexed. Dysfnx side kneee under other knee. Slight ADdxn of femur, w/ internal rotation on side of TP.
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Inguinal Ligament Tenderpoint
TP: On lateral surface of the pubic bone, near attachment of the inguinal ligament S/CS: Pt supine. Doc opposite TP, foot on table. LE flexed. "Good over evil" at the knee. Slight ADdxn of femur, w/ internal rotation on side of TP. |
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S/CS: Pt supine. Doc on same side as TP, foot on table. Marked flexion & external rotation of hips. Knees separated, cross LE's at ankle. fine tune with rotation of pelvis
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Iliacus Tenderpoint
TP: anterior and deep throughout iliac fossa S/CS: Pt supine. Doc on same side as TP, foot on table. Marked flexion & external rotation of hips. Knees separated, cross LE's at ankles induces flexion & external rotation at hips. fine tune with rotation of pelvis |
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S/CS: Pt supine, Doc same side as TP, foot on table. Flexion rotation of knees towards. Pts thighs flexed ≥90*. Pts knees rotated slightly rotated towards side of TP, torso slightly sidebent away
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AL5 Anterior 5th Lumbar: Rectus Abdominus
TP: Anterior Pubic bone 1 cm lateral to symphysis |
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S/CS: Pt supine. Doc opposite TP, foot on table. Hips flexed ≥90*, rotate knees away form TP, Sidebend trunk slightly away from TP by pushign lower legs toward floor
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AL2: Anterior Second Lumbar: External Abdominal Oblique
TP: Medial inferior surface of ASIS |
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S/CS: Pts upine, Doc opposite TP. Flex hip, sidepend trunk maredly away from TP by pulling feet warod doc while keeping knees midline. rotate slightly to fine tune.
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AL3-4: Anterior Third & Fourth Lumbar: Iliopsoas
TP: AL3 on lateral surface of AIIS AL4 inferior to AIIS |
