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OPP exam

Opp Exam

by denise.lentz13, Feb. 2010

Subjects: at still

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194 Cards in this Set

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	forces acting on gait	gravity, muscle contraction, momentum
	normal gait	Pelvis rotates in an anterior & posterior Ilium anterior during swing phase Ilium posterior with stance leg
	base of normal gait	2-4"
	step length of normal gait	15"
	cadence	90 – 120steps/minute 100 calories/mile Decreases with advancing age fatigue pain muscle spam somatic dysfunction
	center of gravity normal gait	Center of gravity is 2” anterior to S2 The center of gravity oscillates vertically approximately 2 inches during gait. Flexing knee during push off minimizes vertical displacement Increased vertical motion may indicate pathology
	weight shift with normal gait	Pelvis & trunk shifts approximately 1 “ to the weight bearing side during gait to center weight over hip. Lateral shift increases with hip muscle weakness
	prerequisites for normal gait	Stability of the limb in stance phase Clearance of the limb in swing phase Effective shifts of the limb from stance to swing & from swing to stance Occurrence of these components in a fashion that promotes maximum efficiency of energy expenditures
	kinamatics	analysis of motion &resulting temporal & stride measurements
	analysis of muscle activity	Dynamic EMG
	kinetics	analysis of forces that produce motion
	stance phase	Heel strike Foot flat Midstance Push off
	double support	Occurs at the beginning & end of the stance phase when both feet are in contact with the floor
	swing phase	Acceleration Midswing Deceleration
	acceleration	Begins with lift-off of the foot from the floor & ends when the foot is aligned with the opposite foot
	midswing	Begins when the foot is aligned with the opposite foot & ends when the contralateral tibia is vertical
	deceleration	Begin when the tibia is vertical & ends when the foot contacts the ground(heel strike)
	heelstrike	Right ilium thrusts forward & rotates anteriorly & externally Initial contact before the weight transfers to foot Gastrocnemius longest Dorsiflexors shorten Hamstrings longest, breaking swing phase Fibular proximal head maximally anterior Contraction of quads locks knee in extension Right iliopsoas tight(shortest) Gluteal & piriformis longest & most relaxed
	foot flat	Weight transfers to right leg, force drives femur upward into right acetabulum, raising right acetabulum. Right ilium rotates posteriorly & superiorly Weight born laterally to counteract right leaning from transfer weight & balance lateral sway at base. Weight transfers anteriorly Dorsiflexors relax Gastrocnemius & plantar flexors contract as weight transfers Hamstrings contract, flexing knee Fibula slides posteriorly Quads relax after heel strike force transmitted to ileum via locked knee Gluteals & piriformis contract Iliopsoas relaxes & lengthens
	midstance	Ilium rises & left ilium begins to be carried anterior to the right ilium by swing phase in left lower extremity Foot pronates as weight transfer from lateral foot to ball of foot Fibular head slides posteriorly Hamstring shortens Quads tense to stabilize knee from internally rotating as foot enters pronation phase Gluteals & piriformis shorten Psoas begins to stretch as it relaxes, breaking thigh extension
	push off	Right ilium rotated maximally posterior Dorsiflexors relax Great toe pushes off & weight transfers Gastroc & plantar flexors shortest as toes push down Quads tightening to brake thigh extension & start swing contraction phase Hamstrings shorten Ilium rotated maximally posterior, Iliopsoas braking action switching to contractile shortening phase Gluteals & piriformis shortest in walking
	acceleration; musculoskeletal changes	Right ilium is @ maximal height, starts to descend & rotate anteriorly Gastroc starts to lengthen Fibular head starts to glide anteriorly Quads shorten Hamstrings begin to relax Iliopsoas start to shorten Gluteals & piriformi start to relax
	mid swing; musculoskeletal changes	Lower extremity carries the ilium anteriorly rotating the pelvis on the horizontal plane Dorsiflexors shorten so foot clears ground Gastrocs relax Quads start to extend leg & pulls fibula forward Hamstrings, Gluteals & piriformi relax & lengthen
	deceleration; musculoskeletal changes	Ilium till rotating forward maximally with the leg straightening so knee can lock to receive ground reaction force of heel strike. Dorsiflexors tight & ready for heel strike Fibula maximally anterior Hamstrings braking Gluteals & piriformi lengthen but are braking swing Quads tighten Iliopsoas shortening slowed
	Clearance Mechanism for Swing Phase	Specific coordinated event to achieve limb-length reduction Knee flexion:All of swing Coordinated hip & knee flexion :Early midswing Ankle dorsiflexion: Midswing Hip abductors: Control amount of pelvic drop in swing
	energy efficient movement	minimal movement of the body’s center of gravity in both the vertical & horizontal planes
	abnormal biomechanics	increases energy cost Compensatory decrease in walking speed A 10 degree loss of motion can be obstructive
	Most joint function depends on	small arcs of motion 15- 20 degrees.
	Pelvis & Sacrum R Step Forward	The COG shifts L lumbar spine SL,RR Locks L pole of upper sacrum @ L/S junction The sidebending of the lumbar spine to the L induces sacral rotation about its L axis Sacral rotation occurs on L on L axis Lumbar spine rotates to right
	Pelvis & Sacrum R Heel Strike	As COG moves forward R quad contracts to lift R thigh & foot forward Anterior rotation of R innominate about inferior transverse axis Forward motion of R innominate increases as R heel strikes & left leg begins to move forward COG is now forward & begins to shift R over the R femoral support R heel contacts the ground R hamstring tension increases Posterior rotation of R innominate on inferior transverse axis of sacrum
	Pelvis & Sacrum R Flat Foot	As COG shifts from over R femur to R margin of sacrum Lumbar spine S R,RL L foot is lifted L foot passes R foot R upper pole of SI joint is locked R oblique axis for sacral motion is established Sacral, innominate, & lumbar motions repeat themselves
	Toeing in	1 in 10 children (2 – 5 y/o) 80% spontaneously recover Caused by Rotation of pelvis Excessive femoral anteversion Internal tibial torsion Metatarsus adductus Equinovarus deformities Tight tibialis posterior
	toeing out	External rotation of femur (retroversion) Tight piriformis Tight iliopsoas Rotation of pelvis External tibial torsion Calcaneovalgus Pes planus Tarsal coalitions
	Pathologic Gait	Gait abnormalities can be categorized based on their timing with respect to the gait cycle Stance phase –abnormal base of support & limb instability may make walking unsteady & energy inefficient & possibility painful. Inadequate limb clearance & advancement during the swing phase will interfere with balance & energy efficiency.
	Limb Clearance and Advancement	Occurs during swing phase When limb clearance is inadequate limb advancement is compromised Most common causes Lack of adequate hip flexion Inadequate knee flexion &/or ankle dorsiflexion Stiff knee gait Early swing toe drag compensated by increased hip flexion, increasing contralateral limb length, or generating knee flexion
	Stiff knee gait	gait creates large moment of inertia which increase energy required to initiate swing phase. Lack of hip flexion caused by decreased psosas strength, Pt uses ipsilateral hip, trunk & contralateral limb compensatory motions Quad spasticity Stroke- activation of rectus femoris & vatus intermedius,
	Abnormal Base of Support	Ankle /foot posture critical in the interface with the walking surface during the stance phase. Ankle plantarflexion, inversion or eversion & toe flexion or extension can all interfere with normal gait. Inadequate base of support can result instability of the entire body.
	Equinovarus	One of most common abnormal lower limb postures seen in patients with neurologic disorders. Limited dorsiflexion can prevent forward progression of the tibia over the stationary resulting in knee hyperextension & loss of propulsive phase of gait. During swing phase this plantarflexed foot results in clearance difficulties Foot drop results in same clearance issues
	Trendelenburg Gait	Insufficient gluteus medius Mechanical deficiency of the hip joint caused by pain DJD Malalignment Nerve injury to gluteus medius During stance on affected side the pelvis drops on non-weight bearing side & the trunk follows. Lateral trunk exceeds normal 1”
	neurologic gait problems	Hemiplegic gait Dyplegic gait Ataxic gait Waddling gait Scissors gait Steppage gait Shuffling gait Hysterical gait
	musculoskeletal gait deformities	Antalgic gait Gluteus medius gait Gluteus maximus gait Leg length discrepancy Short stance leg Long stance leg
	functional short leg	measure with patient supine compare malleoli may be altered by lumbar curve Innominate rotation
	anatomic short leg	standing assessment - PSIS is best indicator sacral dimple, unlevel crest, belt line tilts ASIS to malleolus is unreliable postural x-ray is the gold standard
	pelvic side shift	deviation of the pelvis to the right or left of the midline at a standing position
	test for pelvic side shift	stabilize shoulder, push pelvis laterally
	ride pelvic shift	produces a curve (curve convex left) alters sacral position (sacral sidebending left and sacral rotation
	Typical Short Leg Pattern (left)	Anatomic short leg (left) Pelvic side shift and rotation (right) Anterior sacrum (left) Lumbar curve convex (left) Symptoms back pain from short leg is located at the “anterior sacrum” or deep, tender, painful sulcus pain increased from walking or running
	compensatory curves	“asymmetry requires compensatory asymmetry” primary curve is the larger curve secondary curve is the smaller curve you can’t change a primary thoracic curve with a heel lift (you can balance the sacrum)
	effect of the psoas	psoas muscles balance the lumbar spine and pelvis on the femur” contraction of right psoas causes side shift left contraction of left psoas causes side shift right psoas may balance a short leg, eliminating side shift OR: psoas may compound the problem
	leg lift general rules	Object is to level sacral base Dose is a function of flexibility of the patient Test - level sacral base by having patient stand on magazines - observe what happens to the curve 1/8 inch increments at 2 week intervals 1/4 inch is maximal starting dose lifts of > 3/8 inch require elevating sole long standing problems 1/2 of the leg length shortening will balance the patient acute shortening (fractures, surgery) correct the difference immediately
	leg lift process	not all patients have a typical pattern sometimes a lift is trial and error if sciatica is present, do not lift the sciatic side patient must adopt to the lift OMT to mobilize the spine lazy persons exercise to stretch concavity of the curves active exercises to mobilize and strengthen the spine
	how do you know how much leg lift to use	Right amount of lift X-ray evidence of sacral base unleveling improvement anterior sacrum on short leg side is improved or no longer presents a problem (if sacrum flips to other side, there is too much lift)
	furgusons angle	32 - 45 degrees measured against horizontal
	ccom angle	55 -65 degrees
	wire plumb bob	produces a true vertical white line on film
	Lumbosacral Instability	draw an ‘X” on L3 to locate center drop a vertical vertical should pass over sacral base if vertical is anterior to sacral base - this is x-ray evidence of lumbosacral instability
	Pelvic Index	horizontal/vertical = Pelvic Index = x/y Levator orthotic is designed to improve the pelvic index
	Postural X-ray	to evaluate postural inequities, especially short leg mechanics and sacral base unleveling 3 exposures - all standing AP thoracic spine AP pelvis and lumbar spine lateral pelvis not used to assess fine detail (blur)
	Postural x-rays - Rationale	Weight bearing goes throughout the lower extremity via the femoral heads to the pelvic girdle where the sacrum supports the weight of the spinal column and upper body. Importance - keep the sacrum level to support the spine ability to compensate is more important than actual leg length inequality
	Postural x-rays - Preparation	normalize muscle contractions which have modified AP lumbar curve treat acute or persistent articular dysfunction which may distort weight-bearing performance be sure pelvis can side shift freely to each side with a patient in standing posture be sure patient can bear weight on each lower extremity equally OMT before x-ray
	Postural x-rays: evaluation of AP films	femur heads, sacral base, illiac crest levels pelvic relation to midline lumbar convexity presence of lumbo-sacral anomaly lumbo-sacral arthrodials, sacralized 5th lumbars, lumbarized 1st sacral segments, lumbar bony modification from injury
	structural exam	stand erect , feet parallel to shoulders feet 6-8 inches apart observe for general symmetry observe and compare landmarks mastoids, A-C joint, inferior angle of the scapula, spinous process line, illiac crest, PSIS, greater trochanter, sacral dimple, planter longitudinal arch evaluate pelvic sideshift patient bends forward observe for asymmetry of muscle mass evaluate lumbar and sacroilliac motion along with tissue texture changes
	short lower extremity	anatomic short leg chronic anterior sacral dysfunction on the short leg side pelvic side shift to the long leg side “easy normal” lumbar convexity on the short leg side
	OMM goals during pregnancy	Restore anatomic structure and function. By doing so, blood flow and lymphatic drainage improves. Breathing becomes more coordinate and effective. Reduce pain and improve activities of daily living.
	secondary patient complaints during pregnancy	Heartburn Shortness of Breath Low Back Pain Numb Hands and Feet Neck and Upper Back Pain Nausea/vomiting
	GI changes during pregnancy	Stomach position is shifted by gravid uterus This changes the angle of the GE junction allowing GE reflux to occur in 45-70% of patients This results in heartburn and chest pain Pylorus is distorted upward and backward, slowing gastric emptying Placenta secretes hormone Gastrin which increase stomach acid production and volume which lowers ph.
	GI chapmans points during pregnancy	Review Chapmans points Esophagus T2 Left paraspinal, and T2-3 Parasternal costochondral junction bilaterally. Stomach acidity Left T5-6 costochondral junction anteriorly and Left T5 paraspinal Remember Chapman’s points are bilateral unless designated.
	physiological changes during pregnancy	Renal GFR increases 50% early , returns to normal This increases Creatinine Clearance and Bun runs 8-9 mg/dl and Creatinine levels run around 0.5 mg/dl. Hepatic changes Serum Alkaline Phosphatase is elevated from placental secretion CNS Changes Elevated Progesterone and B-endorphins
	respiratory changes during pregnancy	Chest circumference increases 5-7cm. Subcostal angle increases from 68-103 degrees Diaphragm is pushed superiorly by 4cm but excursion increases by 1-2 cm. This results in a 40% increase in Tidal Volume. This causes a 30-50% increase in minute ventilation, despite resp rate being unchanged Increased Progesterone is felt to be the cause
	tidal volume changes during pregnancy	Minute ventilation increases approx. 50% Due to increase in tidal volume 40% Respiratory rate remains the same FRC (functional residual capacity) is reduced by 20% FRC= Residual Vol. + End Exp Reserve Vol. This gives feeling of breathlessness
	effects of edema during pregnancy	Increase Progesterone leads to fluid retention and soft tissue edema. This contributes to airway swelling and “Stuffy Nose of Pregnancy” This fluid retention also contributes to carpal tunnel syndrome. Characteristically, it is bilateral, more common at night, resolves shortly after delivery, and occasionally requires splinting
	diaphragmatic changes during pregnancy	Late in pregnancy the expanding uterus can reduce diaphragmatic excursion. This in turn reduces venous return contributing to peripheral edema, backache, constipation, hemorrhoids, and varicosities of the vulva. Treating Diaphragmatic, Fascial and Thoracic Inlet Dysfunction is key to treating these complaints.
	cardiovascular changes during pregnancy	Blood and Plasma volume increase 40% Cardiac Output increases 40%. CO = HR x SV Stroke Volume increases by 30% Heart Rate increases by 15% These increases can lead to innocent grade 1-2 systolic flow murmur which is transient.
	hematological changes during pregnancy	ALL clotting factors increase by at least 100% during pregnancy Pregnant patients are hyper coaguable Pregnant patients should be checked for venous thrombosis regularly All complaints of shortness of breath and chest pain should be taken seriously due to pulmonary embolism and cardiac events
	structural changes during pregnancy	Forward tilting of pelvis resulting in a compensatory increase in Lumbar Lordosis. Can stretch on Dura and result in cranio-sacral strain patterns with resulting headache and low back complaints. CV4 HOLD IS CONTRAINDICATED DURING PREGNANCY…UNLESS YOU ARE TRYING TO INDUCE LABOR!.. As the pregnancy continues and abdomen distends, the muscles begin to lose their ability to aid in this counter balancing act. Fast, et al, performed a study revealing 11% of non-pregnant patients and 86% of pregnant patients could not perform a single sit up.
	transition zone change during pregnancy	Spine is designed to resist gravity through 3 transition zones (curves) in the spine. Major transition zone is L5-S1 Minor transition zones are C7-T1 and T12-L1 Spinal curves allow for spine to resists 10x more weight than “Stay and Mast” arrangement. Transition Zones act like springs and transfer forces longitudinally. These transition zones serve as fulcrums for upward and downward forces. Somatic Dysfunction therefore is much more common in these areas. These are the areas where Type II dysfunction occurs.
	illopsoas changes during the pregnancy	Paraspinal muscles shorten while abdominal muscles stretch and weaken Iliopsoas is the “Mainstay” in the mast system. Transition zones with their curves reduce the efficiency of iliopsoas. Iliopsoas also acts as anchoring mechanism for Crura and aids in respiration. Iliopsoas also stabilizes the lumbar spine during sitting, standing, and walking. Thomas Test could be modified to lateral position with physician monitoring the extended leg during contralateral hip flexion in later stages of pregnancy. IIiopsoas weakness,( or laxity), is a major contributing factor to the low back pain of pregnancy. It contributes to increased lordotic curve with increased shear forces across facet joints and intervertebral discs. Forward pelvic rotation also occurs as a result of this.
	pregnancy and exercise	all pregnant patients who are not high risk should participate in a sensible exercise program. Many hospitals offer pre-natal supervised exercise classes. Otherwise, daily walks should be encouraged and sensible weight gain, (30 lbs or less), should be encouraged.
	pregnancy and scoliosis	Controversy regarding pregnancy and idiopathic scoliosis. Berman et al found pregnancy may cause pre-existing scoliosis to progress. However, only 8 patients in study, and 3 had progressing scoliosis. Betz, et al did retrospective study of 355 patients with no progression of scoliosis during pregnancy. Consensus is most scoliosis progresses into adulthood but is not exacerbated by pregnancy.
	Supine Maternal Hypotension Syndrome	Occurs after 20 weeks gestation Enlarged uterus compresses aorta and vena cava while in supine position leading to maternal hypotension. Symptoms include light headedness, nausea and vomiting Treatment=Prevention When patients are symptomatic, place pregnant patient in supine position Elevate right buttocks 10-15 cm with a sheet or blanket. Or…manually distract uterus to the left You don’t want to clean up your exam room after the patient vomits Maternal hypotension often results in undiagnosed fetal bradycardia due to placental hypo-perfusion and fetal asphyxia.
	pregnancy and CPR	CPR IS TOTALLY INEFFECTIVE IF YOU DO NOT PERFORM LEFT UTERINE DISPLACEMENT WHILE PERFORMING CPR. UTERO-CAVAL COMPRESSION PREVENTS ANY BLOOD FROM RETURNING TO THE HEART THEREFORE NO CARDIAC OUTPUT!!!
	low back pain and pregnancy	Facet pain: From increased Lordosis Herniated lumbar disc: 1:10,000 Posterior Joint Pain: Pain over PSIS, non - radiating, felt to be from hormonal relaxation of the SI joints. Posterior Pelvic Pain: Pain distal and lateral to lumbosacral junction and may radiate down to or below the knee. No muscle weakness or sensory deficit.
	factors increasing low back pain during pregnancy	Manual Labor Smoking?? Parity Age Previous Low Back Pain with pregnancy
	factors NOT affecting low back pain during pregnancy	Race Occupation Weight gain or pre-pregnant weight Exercise Habits Sleep posture or mattress Shoe Heel Height Previous Epidural Analgesia
	contraindications of OMM during pregnancy	Undiagnosed vaginal bleeding Threatened or incomplete abortion Ectopic pregnancy Placenta Previa Placental Abruption Premature rupture of membranes Pre-term Labor (relative contraindication) Prolapsed umbilical cord Severe preeclampsia or eclampsia Other medical or surgical emergencies
	hypertension in pregnancy	Systolic BP > 140mmhg or 30 mmhg increase over baseline Diastolic BP > 90 mmhg or 15mmhg rise over baseline. Preeclampsia, triad of hypertension, proteinuria, and edema. Eclampsia, all the components of preeclampsia and including a tonic clonic seizure. Chronic hypertension is persistent or pre-existing hypertension before 20th week. Gestational hypertension is hypertension not accompanied by proteinuria or generalized edema.
	somatic dysfunction: definition	Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements. Somatic dysfunction is treated using OMT. Glossary of Osteopathic Terminology, Foundations for Osteopathic Medicine 2nd Edition So . . . evaluate bones, joints, muscle, fascia, pulses, nodes / swelling, neurologic exam
	Goals of outpatient OMT	Restore anatomical/functional relationships Restore normal blood flow (O2, nutrients) INTO an area Restore normal blood flow OUT OF an area (improve venous drainage) Restore normal lymphatic drainage Improve nervous system function by reducing or eliminating compression Reduce abnormal autonomic reflexes (viscerosomatic/somatovisceral) Stimulate or balance the immune system Prevent recurrences of pain, organ or somatic dysfunction Decrease Pain Restore mind-body-spirit balance RESTORE HOMEOSTASIS!!!
	osteopathic medicine: definition	A complete system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery, and obstetrics, that emphasizes the interrelationship between structure and function and that has an appreciation of the body’s ability to heal itself
	introducing an unfamiliar patient to OMT	Look at the definitions and give a basic description appropriate to the patients level of understanding
	COMMON PRESENTATIONS for PCP’s	Back Pain Headaches Neck Pain Sports Injuries / Joint Pain Sprain, Strain, Ligamentous injuries, Fractures Infectious Bronchitis, Pneumonia, Otitis media, Pharyngitis, UTI Hypertension, Diabetes, Heart Disease, COPD
	How to Treat - “rules”	Guided by patient’s response Use safest & most effective techniques Treat until clinical conclusion What was the objective? Ex. Correct a somatic dysfunction Did I meet the objective? How do I know? Recheck, Recheck – Recheck – Recheck – Recheck!!!!!!!!! Risk-benefit ratio. Safe and effective. Modify techniques as needed. Ex. Seated or Supine
	OMT modalities	Soft tissue Articulatory HVLA (thrust) Muscle energy Counterstrain Indirect Fascial release Cranial Inhibitory pressure Lymphatic Pump Trigger points Visceral
	Selection & Sequencing of Techniques	Different opinions Part of the “art” of medicine Personal style Patient preferences and tolerances
	Thoughts on Selecting Sequencing Techniques	Treat : Axial skeleton before extremities Proximal before distal dysfunction Promotes lymphatic drainage. Acute changes last Facilitating dysfunction before primary dysfunction. Any somatic dysfunction is significant until determined otherwise. Upper cervicals and sacrum are related. Treatment of one may correct the other.
	Dosage of Treatment	Key areas first Allow time for treatment response Chronic disease requires chronic treatment Can’t fix it in one app. Acute cases have a shorter interval between treatment As they respond, interval is increased. The sicker the patient, the less the dose
	Osteopathic Clinical Template	History Physical Osteopathic Principles Musculoskeletal Autonomics Viscerosomatic Key lesion/Area(s) of Greatest Restriction (AGR) Whole Person Effective Treatment Plan
	chapmanns points for esophagus	Between 2nd & 3rd Ribs lateral to sternum B/L
	chapmanns points for stomach	Acid: Between 5th & 6th Ribs lateral to sternum on left Peristalsis: Between 6th & 7th Ribs lateral to sternum on left
	celiac ganglion release	Divide area between xyphoid & umbilicus into 3 parts Palpate top third for tension & tenderness Apply inhibitory pressure to area to relieve
	TREPHINING	the boring of holes into the skull to release evil spirits or toxins was used during Neolithic times.
	precolumbian surgery	astringents made from vegetable oils and bird eggs. They also covered wounds with feathers and bandages made of skin.
	infection	most common cause of surgery related death in history
	19th century surgery	Therapies included: Diet Exercise Baths Bloodletting Scarification Blistering Sweating Emetics Purges & Laxatives Enemas Fumigation Heavy mercurials Cautery for STD’s
	problems with 19th century surgery	Few plants or minerals were available and empirical evidence for their efficacy was lacking. Heavy metals and mercurials were used to treat venereal disease. Most physicians let disease run its course. Homeopathy: “Cure worse than Disease” The advent of anesthesia in the 1840’s allowed surgical procedures grow in complexity. The benefits of anesthesia and surgery were soon neutralized by deadly post operative infections. The discoveries of Lister in the 1860’s and the advent of modern germ theory and antiseptic technique allowed for a more safe entry into the human body cavity.
	anesthesiology	Coca leaf wrapped with guano and lime used to release alkaloid cocaine used for trephining. 1842 Dr. Crawford Long first to use ether to provide anesthesia for surgery, but not witnessed. Multiple accounts exist as to whom may have been the first to use ether. 1844 Horace Wells used Nitrous Oxide for dental anesthesia. 1846 Willaim Morton first public use of ether 1853 Chloroform used by Simpson for Queen Victoria during the birth of Prince Leopold. Removed stigma of pain during childbirth.
	AT Still and surgery	A.T. Still, D.O. was a proponent of surgical training for osteopathic students. (Sic.) Advocating skill in setting dislocations, adjusting fractured ribs, bandaging the body while bones unite, explore dislocations of the spine, and how to adjust them. He should be taught how to amputate a toe, foot, or leg. How to relieve watery collections in the abdomen and chest,…to remove external growths from the body. To administer anesthetics and proceed in treating gunshot, knife, and saw wounds., and to the use of instruments in the practice of obstetrics
	20th century surgery	On Jan. 26, 1927, the American College of Osteopathic Surgeons was incorporated. This body provides and maintains practice standards to this day for the practice of surgery in osteopathic training programs. The application of osteopathic principles to the surgical patient requires the understanding of anatomy, lymphatics, pathology, and psychosocial components.
	Abdominal PainAutonomic Nervous System Review	Although pain is perceived via both somatic, (peripheral) and visceral, (autonomic) nervous systems, abdominal pain is primarily transmitted through autonomic system. Noxious stimuli perceived are stretch, distention, inflammation, and ischemia. Cutting and burning are imperceptible
	parasympathetic/sympathetic synergy	Remember sympathetics and parasympathetics act in opposition to each other to balance each other out. Visceral Afferents refer to fibers which receive nocioceptive impulses and transfer them to the brain. Their course is very similar to that of sympathetics, but are not specifically indentified as sympathetic or parasympathetic
	sympathetics	Arise in lateral horn segments T1-L2 Form paravertebral chain ganglia These axons converge to form Greater Splanchnic Nerve T5-9 Celiac Ganglia Lesser Splanchnic Nerve T10-11 Sup. Mesenteric Least Splanchnic Nerve T12 Inf. Mesenteric Ganglia Then proceed to respective target organs
	parasympathetics	Represented by PAIRED vagus nerves arising in the brainstem Represented by sacral splanchnic nerves arising from S2-4
	enteric nervous system	Network of sympathetic and parasympathetic nervous system within the bowel wall. Auerbach’s Plexus (outer) layer. Controls motility Meisner’s Plexus (inner) layer. Controls GI secretions and blood flow. Therefore, noxious stimuli can affect bowel function. E.g., Peritonitis can result in an ileus.
	ileus	diminished or absent bowel function. Schwartz, Principles of Surgery: Divided into 3 groups Adynamic or inhibition ileus: diminished or absent motolity secondary to inhibition of neuromuscular apparatus. Ex. Peritonitis . Spastic Ileus: Contracted bowel musculature inhibits propulsive motility. Ileus of vascular occlusion: Dead or ischemic
	Spastic Ileus	Rare. Usually secondary to organophosphates, heavy metal poisoning, porphyria, and occasionally uremia
	Adynamic or inhibition Ileus	: Most common. Usually secondary to peritonitis, appendicitis, surgical manipulation, anastomotic leakage, pancreatitis, retroperitoneal disease such as ureteral stones, sepsis, electrolyte imbalance and opiods.
	origin/treatment of ileus	Spastic Ileus from increased parasympathetic tone. Best example is organophosphate (insecticide), poisoning. Vascular Ileus is from ischemic bowel. Modulating sympathetic tone is a key osteopathic principle in treating ileus. Rib raising temporarily. increases, then decreases sympathetic tone.
	Abdominal Pain Redux	Bowel dilates 1st order nerves,(symp afferents) stim Enter dorsal horn 2nd order nerve to contralateral spinothalamic tract & spinoreticular Ascend to Pons/Medulla Thalmus 3rd order n. to cortex Conscious perception of pain,(spinothalamic) Limbic Stimulation, (spinoreticular) AVERSE RESPONSE
	Abd. Pain Redux X2	Many fewer visceral afferents than somatic afferents. Therefore pain is not sharp. 3 midline areas: embryologic formation of the gut which develops in midline and brings neurovasc. bundle along with it.
	Epigastric Pain:Foregut	T5-9. Celiac Ganglia. Distal esophagus, stomach, prox. duodenum, liver, pancreas.
	Peri-umbilical Pain	Midgut: T8-11. Sup. Mesenteric Ganglia. Small intestine,appendix, ascending colon.
	Hypogastric Pain	: T11-L1. Inf. Mesenteric Ganglia. Distal third transverse colon, and recto-sigmoid.
	Abdominal PainSomatic Origin	There can be a somatic component of abdominal pain. Appendicitis can cause inflammation of parietal peritoneum. A-delta fibers then transmit this into right lower quadrant pain. This is why early appendicitis presents with periumbilical pain, then later localizes to right lower quadrant because of peritoneal irritation
	What Happens During Surgery?	NPO Anesthesia, Local, Regional, General Cardiovascular Effects: Decreased BP, Decr. Contractility, vasodilatation. Positive press ventilation instead of normal negative press ventilation causing decr. Venous return. Treatment?? Usually IV fluids, occ. vasopressors
	what happens to muscles during surgery?	Muscle relaxation: Tracheal intubation, surgical relaxation. Problems with muscle relaxation? DECREASE LUMBAR LORDOTIC CURVE Common cause of low back pain? EXT.SACRUM!! Urinary retention Secondary to drugs and sympathectomy from anesthetics. IV Fluid volume to fill dilated blood vessels and augment cardiac filling. What happens when anesthetic effects wear off? Transient fluid overload can occur. Resulting edema and CHF. Remember to check bladder for distention if patients post op are hypertensive or complain of abdominal pain. Swelling from surgical trauma. Resolves in 24-48 hrs.
	what happens to respiration durign surgery?	Tracheal Intubation: Hoarseness, dislocated arytenoid, vocal cord granuloma, shortness of breath from paralyzed cord. Dislocated Hyoid. Atelectasis: A total or partial collapse of the lung. Can be entire lobe or microscopic alveolar collapse. Secondary to hypoventilation from modest tidal volumes during surgery, sedatives or splinting from pain post op. Airway collapse causes inflammation and believed to contribute to post op temp. increase
	what happens pharmalogically during surgery?	Drugs Opioids.. Cause sluggish bowel motility, urinary sphincter spasm, delerium. Cholinergic muscle relaxant reversal agents can cause contraction ileus and urinary retention secondary to increased parasympathetic tone
	what happens to sympathetics after surgery?	Emergence from anesthesia. Excitement stage. Opioids reset CO2 receptor and apneic threshold. Hypercarbia from opioids and anesthetics can cause catecholamine release. This is felt to contribute to post op low grade fever and increased sympathetic tone
	what happens after surgery?	Back Pain: Usually extended sacrum. Can also be facet pain, SI pain, or hip pain. Parasthesias from positioning and lying in a normally uncomfortable position. Ileus: As previously described. Urinary retention and distended bladder: Most common cause of hypertension Post Op in the absence of pain.
	OMT and surgery	More recent study by Sleszynski in 1993 suggested that Thoracic Lymphatic Pump, (TLP), was used, patients had earlier return to pre-op values for both FEV1 and Forced Vital Capacity, (FVC) 21 patients in each group. TLP vs Incentive Spirometry. Post-op cholycystectomy. 5%,(2) patients in each group developed atelectasis. TLP group returned to baseline sooner.
	Hemodynamic Effects of OMM	What did they do? The measured reproducible hemodynamic parameters before and after OMT in patients immediately post op CABG surgery. They measured Thoracic Impedance,( gross measure of intrathoracic central fluid volume), Cardiac Index, and Mixed Venous Oxygenation, (SvO2%) They measured Thoracic Imp., C.I. and SvO2 in anesthetized, intubated patients at 1hr and 2 hrs after surgery in 10 study patients. 19 control patients were studied in the same except for Thoracic Imp. This was excluded. Measurements in study group taken 5-10 min before and 5-10 min after OMT OMM Techniques Used: BLT to thoracic spine Indirect Myofascial Release of the Sternum Indirect Release of Respiratory Diaphragm Occipital Release Rib Raising Sibsons Fascia Release
	OMT proticol in pregnancy study	ME, Soft Tissue, Myofascial Release, ROM Mobilization Regions examined and treated included cervical, thoracic outlet, clavicles, ribcage, diaphragm, pelvis and sacrum. HVLA “Prohibited” because increased ligamentous laxity MAY pose a THEORETICAL RISK during such maneuvers They never mention the possible “Risks”
	Back Pain in Pregnancy (study)	Back disability over time was improved the most in the OMT group, less in SUT group and Increased in UOBC group and were significantly different statistically. Study was small and limited in power by sample size, but if reproducible, larger studies would be warranted.
	primary dysmenorrhea	Functional Dysmenorrhea. Painful menses in the absence of organic disease. DiGiovanna. Diagnosis of exclusion
	secondary dysmenorrhea	Acquired. Painful menses associated with pathology. Uterine fibroids, polyps, IUD’s, pelvic congestion assoc. with retroverted uterus,PID, ovarian cysts, ectopic pregnancy, etc..
	PMS	Symptoms occur around 7-10 days prior to menses. Headache, bloating, abd. Swelling, irritability, food cravings, anxiety/depression in severe forms. Treatment is balance sympathetics, thoracic inlet and diaphragm release to enhance lymphatic flow, uterine inhibition from sacral rocking to relieve cramping. Occasionally anti-depressants are required.
	Atelectasis and Fluid OverloadOsteopathic Treratment	Lymphatic Drainage and Rib Raising are KEY treatments REMEMBER, ALWAYS TO TREAT THORACIC INLET FIRST! 1ST RIB ROTATIONAL COMPONENT OF T1 SIBSONS FASCIA THEN TLP, PEDAL PUMP, DOME DIAPHRAGM
	evaluate a hospitalized patient	Make sure patient is stable for treatment: Review chart Review vital signs Visually observe patients breathing Find out if the patient has hand any new symptoms Observe where the patient is connected to machines, tubes, I.V.’s, Wires etc.
	Review chart for red flags	Past medical history (i.e. Caner, Osteoporosis, Disc herniation, Hypercoagulable states, PE , DVT) New Chest pain undiagnosed New Orders to rule out DVT, PE, MI Abnormalities on Telemetry monitoring over night Fluctuation in vital signs Radiologic tests, EKG’s and Labs
	question patient on new symptoms	Chest pain Swelling in extremities Shortness of Breath Neurologic changes Loss of conciseness
	most common hospitalized patient complaints	Pneumonia (2) COPD (3) Asthma (4) Bronchitis (5) GI Motility (6) ileus (7) Constipation (8) LBP (9) Neck Pain (10) Swelling
	disk x+1 rule	Herniation at disc X affects nerve root X+1 Nerve root X will have already exited the foramina and will be unaffected
	Light touch, pin, vibration	128 Hz
	Spurling test	Tests for narrowing of neural foramina Sidebend and backward bend head; add compression Positive if pain radiates to ipsilateral arm
	underburg test	Test for vertebral artery insufficiency Supine, backward bend, rotate, WAIT 30 seconds Positive with dizziness, nausea, lightheadedness
	Kenneth E. Graham, DO	Different approach similar to old fashioned time-honored approach -If OMM is to survive in the hospital and out patient practices -DO students will continue their OMM skills in the 3-4 yr and into their practices
	PRIMARY GOALS AND GUIDELINES Hospitalized patient	)* PREVENTION of many of the common problems and complications of hospitalization and surgery (pneumonia, atelectasis, ileus, etc) (2) RETURN TO FUNTION- to their pre-surgery, pre-hospitalization, and pre-trauma (quickly get them back on their feet to prior health baseline (3) Guidelines are not designed to address a lifetime of somatic dysfunction, but to provide help to beginning students/practitioners to learn how to begin their approach to common clinical problems found in the hospital setting
	CRITERIA FOR SUCCESS IN HOSPTAL SETTING	Must therapeutically benefit the patient -clinical efficacy of OMM in the hospital setting has long been established. (2) Must save the hospital money -guidelines designed to reduce common complications (ICU, surgical, bedfast patient) (3) Must be simple, efficient, time sensitive (so large numbers of patients can be treated)
	OMM services	do save money - do help patients - are time consuming at times - may be difficult to perform - only a small number of patients can be treated
	Dr.Grahm's guidelines	designed to be done in 10-12 min -hospitals with OMM residencies can treat many pts -hospitals without OMM residencies(few pts get treated)
	dose treatments	healthy/robust (more vigorous) -Debilitated/fatigued (more gentle approach) omit parts fewer repetitions (3-5 gentle slow rib raises) cancel prn
	situations to avoid OMM	Cerebralvascular Bleeding Unstable pt -CVA/TIA Uncooperative pt -DVT/PE MI -Unresponsive pt Cancer/ METS -Spinal fx”s
	always make an attempt in a hospitalized patient to at least perform	O/A/CB release (OA Cranial Base Decompression and Release
	post surgery patient	after surgery many body systems functioning at below normal levels - GI tract slowed down - Decreased bladder tone - Kidneys slowed down - Pulmonary function is down *Be aware, the challenge is not to treat a lifetime of somatic dysfunction, but to “wake up” all the shut down organ systems, so they can get back to work Use OMT to quickly and efficiently return poor functioning organ systems to optimal functioning.
	debilitated patients	dose carefully -treatment can make them tired temporarily -explain treatment can make them sore -most patients respond positively -*our chalenge is not to treat a lifetime of somatic dysfunction
	3) Goals	Improve the overall functional ability and capacity of the hospitalized patient to respond to the compromised condition that resulted in their hospitalization by improving the functional ability of their ANS, arterial, venous, lymphatic, nervous, fascial, myofascial, musculoskeletal, and visceral systems. (2) Treat functional visceral and musculoskeletal conditions that may result in hospitalization (3) Prevent and treat complications of other functional pathophysiologic proccesses that might arise with hospitalization
	normal GI	Bowel motility result of complex interaction: enteric nervous system, CNS, Hormones and Local factors affecting smooth-muscle activity. Autonomic Nervous System: Parasympathetics stimulate increase GI motility Sympathetics stimulate decrease GI motility
	Sympathetic Pre-ganglionics to:	Greater Splanchnic(T5-9) Lesser Splanchnic (T10-11) Least Splanchnic (T12-L2
	Celiac G. post-ganglionic	to: Stomach, Liver, Gallbladder, Spleen, portions of Pancreas and Duodenum (foregut)
	Superior Mesenteric G.	Portions of Pancreas, Duodenum, Jejunum, Ileum, Asc. Colon, Prox. 2/3 of Transverse Colon. (midgut
	Inferior Mesenteric G	Distal 1/3 Transverse Colon, Desc. Colon, Sigmoid, Rectum (hindgut
	T12-L2	Left Colon Bladder Prostate Lower Extremity
	OMM Techniques for the ICU, Critically Ill, or Bedfast	General: Designed to - Improve overall anatomic and physiologic functioning of patients -Helpful in prevention and treatment of complications of problems commonly seen -Hasten patient’s early discharge from hospital -Facilitate to normal functioning -Techniques designed to be a starting point for an OMM
	OMM Guidelines for the ICU, Critically Ill, or Bedfast Patient: 1st in sequence	1st: Perform an O/A/CB Decompression and Release (somatic dysfunction can cause the following problems) (1) Direct muscular pressure and myofascial tension on CN X (2) Compression of jugular vein as it exits the jugular foramen putting direct venous back pressure on cranial nerve (3) Through cranial venous sinus’s and vertebral veins back-pressure can also extend into the lower brainstem area, where the vegetative brain centers for the GI tract, heart, and respiration are located are located. This can result in decreased arterial circulation to the brainstem, and put direct venous compression to the brainstem proper (4) Compression of CN X can facilitate excessive sensory input to vomiting center, which can cause N & V These problems can combine to compromise normal physiologic function in the heart, Resp System, and GI Alteration of peristaltic tone, etc, Resp-bronchorestriction, increased mucous production, etc) (6) Removal of Somatic Dysfunction on cervical muscles by O/A/CB Decompression will remove facilitation and stress on the vagus and brainstem
	OMM Guidelines for the ICU, critically ill, or bedfast patient: 2nd in sequence	2nd: Perform Rib Raising to the Thorax (1) Enhance and encourage the “toilet” expectorant function of the lungs (2) Facilitate and encourage venous and lymphatic circulation and drainage in the lungs and abdomen (3) Encourage mucous drainage from the lungs (4) Increase rib cage mobility, which encourages chest and diaphragm excursion (5) Decrease pulmonary inflammation and congestion (6) 1-5 plus gentle ballottement of lung tissue, secondary to rib raising motion, can decrease the incidence of atelectasis and pneumonia Directly stimulate increased ANS tone, thru a pumping action on the SANS chain ganglia, resulting in bronchodilation (8) Rib raising on lower 6 ribs can encourage diaphragm motion (9) Improved SANS function, chest cage mobility, diaphragm motion, and venous and lymphatic drainage can all combine to imporve arterial and venous/lymphatic circulation within the lungs and other areas, which can decrease pulmonary congestion and inflammation, maximize tissue levels of oxygen and adaptive immunity( macrophages, IG’s, T-cells etc), improving delivery of antibiotics and other meds to lungs and body tissues (10) Gentle rocking motion produced by rib raising can stimulate and encourage return to normal peristaltic activity( ileus, nausea). (11) Rib raising motion can also stimulated other internal organs to recover from organ stasis and return to normal functioning
	kidney pump	When this pumping action is performed in the area of ribs 10-12 it can help restore normal physiologic functioning to the kidney. In cases of acute renal failure(hypovolemic shock, drug toxicity, etc) involving acute tubular necrosis, the kidney becomes inflamed and congested with damaged cells and fluid in response to the damage. This pumping/milking action promotes uring flow and removal od dead cells, inflammation, and congestion by direct mechanical stimulation, and increase venous and lymphatic drainage and circulation to the area.
	OMM Techniques for the ICU, critically ill, or bedfast: 3rd in sequence	3rd: Perform Lumbosacral Pelvic(L/S/P) Soft -Tissue and Articulation and/or Lumbosacral Pelvic Decompression and Release (Somatic Dysfunction can result in:) (1) Facilitation of the SANS supply to the pelvic viscera from sympathetic chain ganglia located at the tips of the lumbar TP’s (2) Facilitation of PANS supply to the pelvic viscera from the pelvic splanchnics emerging from sacral cord segments S2-4 (3) These problems can combine to compromise normal physiologis function of both the SANS and PANS tone to all the pelvic viscera. Compromise can cause: distal colon stasis, excessive gas, constipation, urinary retention, decreased kidney and adrenal fxn
	OMM techniques for the ICU, critically ill, and bedfast 4th in sequence	4th: Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release (important in experiencing respiratory distress, or who is on a ventilator) (1) Increase diaphragm tone -if too relaxed ( on ventilator ) (2) Decrease diaphragm tone - if in contracture( as COPD ) (3) Encourage diaphragm to return to normal physiologic function (4) Promote venous and lymphatic drainage (Important in Bedfast and post-op patients) (5) Encourage overall ventilatory effectiveness and efficiency Improve Oxygen and Carbon Dioxide Exchange (7) Techniques to stimulate the diaphragm ( in addition to rib raising, freeing diaphragm attachment sites, and treating mid-cervical somatic dysfunction(phrenic nerve) - soft tissue stretching -inhibition along costal margin -myofascial release of the diaphragm (8) All the above help increase diaphragm motion, increase arterial and lymphatic circulation within the lungs, decrease pulmonary congestion and inflammation, andmaximize oxygen levels
	OMM Guidelines for Ventilator Extubation of the ICU Patient	General Description: Technigues designed for successful weaning and extubation of the ICU patient - failure of extubation often occurs when thoracic diaphagm has become atrophied and “lazy” (ventilator has taken over responsibility for breathing) - designed to stimulate the diaphragm to resume its pumping action - technigues should be performed throughout intubation period, immediately before and after extubation, then at routine intervals after extubation If patient has CHF, Pneumonia, or is in end-stage COPD, extubation becomes more of a process than an event. Be patient, but assertive with this process
	Guidelines for Ventilator Extubation: 1st in sequence	1st: Perform O/A/CB Decompression and Release Spasms of upper cervical muscles collapse the veins exiting the cranium and spinal cord.causing venous back pressure to extend into the brainstem area leading to abnormal fuctioning of the vegetative centers.
	ventilator extubation: 2nd in sequence	2nd: Treat any Cervical Dysfunction with Articular Muscle Energy, Counterstrain, or Myofacial Release - The innervation to the diaphragm is via the left and right phrenic nerve arising from C3-5, primarily C-4. - Any dysfunction in this area, can through facilitation, inhibit the normal physiologic functioning of the phrenic nerve (compromising its function to move air )
	ventilator extubation 3rd in sequence	3rd: Perform Rib Raising -Done to the lower 6 ribs, can stimulate the diaphram to “wake up” and go to work -Diaphragm is attached posteriorly to lower 6 ribs, and lumbars(via the diaphragm crura), and myofascial extension into pelvis and lower extremity via the iliopsoas muscles
	diaphragm	Innervation: Phrenic nerve (C3-C5) Contraction causes cyclic pressure gradient changes. Negative intra-thoracic pressure: Inhalation Positive intra-thoracic pressure: Exhalation Attachments Xiphoid/Sternum Ribs 6-12 Anterolateral surface of T12-L3 Apertures: Aorta Lymphatics/Cisterna chyli Inferior vena cava Opens in inhalation Esophagus (Hiatal hernia) Closes in inhalation
	ventilator extubation: 4th in sequence	4th: Perform Rib Walking to the Anterior Thorax -will help as follows (a) Facilitate and encourage venous and lymphatic drainage and circulation within the thorax (b) Increase rib cage and spinal mobility ,which will (1) encourage thoracic motion (2) encourage diaphragm excursion (3) encourage general ventilation effectiveness and efficiency
	ventilator extubation: 5th in sequence	5th: Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release -This technique is often the key to stimulate the diaphragm to return to a more normal level of functioning*
	OMM Guidelines for Improving Lower Respiratory Tract Functions in Patients Presenting with Asthma, Atelectasis, Poor Respiratory Effort, Pneumonia, and Bronchitis: 1st in sequence	1st : Perform and O/A/CB Decompression and Release (1) Review origins of somatic dysfunctions for which O/A/CB D&R benefits ( in ICU Section ) (2) Normal physiologic function of the vagus can be compromised. Excessive vagal tone to lungs can cause bronchoconstriction and increased mucous production in the bronchial tree 3) Treatment of upper cervical muscle spasm and myofascial tension thru O/A/CB Decompression and Release (a) Can remove facilitation and stress on the vagus nerve (b) Can improve the functional ability and capacity of the body’s intrinsic regulatory mechanisms to respond appropriately to pathophysiological challenges
	OMM Guidelines for Improving Lower Respiratory Tract Functions in Patients Presenting with Asthma, Atelectasis, Poor Respiratory Effort, Pneumonia, and Bronchitis: 2nd in sequence	2nd : Perform Rib Raising and Rib Walking *REVIEW beneficial affects in Rib Raising (1) thru (9) in ICU section May be too tiring or strenuous for severely ill patients (may need to be temporarily omitted
	lower respiratory tract, 3rd in sequence	3rd : Perform Thoracic Diaphragm Soft- Tissue and Myofascial Release ** SINGLE most important thing you can do to improve the patient’s Lower Respiratory Function in the following manner: (1) Soft tissue stretching and inhibitory pressure both have the effect of stretching the annulospiral system causing reflex inhibition (relaxation) of the myofibrils and fascicular bundles resulting in decreased contracture and relation of the diaphragm 2) Increase diaphragm tone if too relaxed(on ventilator) or decrease diaphragm tone if in contracture(COPD) (3) Encourage diaphragm to return to normal functioning (4) Promote venous and lymphatic drainage (5) Encourage overall ventilatory effectiveness and efficiency (6) Improve oxygen and carbon dioxide exchange 7) In addition to rib raising, freeing up diaphragm attachment sites, and addressing phrenic nerve dysfunction, 3 additional technigues aid in stimulating the diaphragm: (a) soft tissue stretching (b) inhibition along the costal margin (c) myofascial release of the diaphragm (8) Assists in enhancing diaphragm motion, arterial , venous, and lymphatic ciculation
	Lower respiratory tract 4th in sequence	4th : Perform Lymphatic Pump Procedures (1) Encourage and facilitate lymphatic circulation and drainage (2) Improve the “toilet” expectorant function within the lungs (3) Encourage mucous drainage within the bronchial tree (4) Encourage overall respiratory motion of the chest cage (5) All of the above can decrease swelling, inflammation, and congestion in the bronchi and bronchioles (6) Increased lymphatic drainage and circulation promotes healing and improves natural and adaptive immunity
	Lower respiratory tract 5th in sequence	5th : Perform Muscle Energy , Myofascial, Counterstrain, and/o HVLA Technique to the Cervical and Thoracic Spine, Thoracic Outlet and Diaphragm and Ribs (often this section is omitted if patient is severely ill) (helps LRT functioning in the following way) (1) Will remove facilitation, myofascial tension on the vagus nerve as it exits the cranium (2) Increase spinal and chest cage ROM greatly improving the movement of air (3) Improve diaphragm motion by (a) treating mid-cervicals (phrenic), (b) freeing attachment sites(crura), (c) direct diaphragm treatment techniques (4) Remove upper spinal facilitation that may be inhibiting SANS tone to the bronchial tree( increased tone increases brochodilitation) (5) Alll the above assist in: (a) improve oxygen and carbon dioxide exchange, (b) improve venous and lymphatic circulation and drainage, (c) decrease pulm- onary inflammation and drainage (6) Pay special attn to cerv. and upper t-spine, thoracic outlet and ribs due to special relationship with ANS
	OMM Guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD	This approach can be helpful in the prevention and treatment of patients presenting with complications associated with COPD (pneumonia, resp failure, SOB, etc) 1st : Perform an O/A/CB Decompression and Release *Review origins of Somatic Dysfunction for which O/A/CB D&R benefits in the ICU Section - Compromise of normal physiologic function of Vagus Nerve by excessive vagal tone causes brochoconstriction and increased mucous production
	OMM Guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD: 2nd step	2nd : Perform Rib Raising to the Thorax
	OMM Guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD: 3rd step	3rd : Perform Rib Walking to the Anterior Thorax (1) Enhance and encourage the “toilet” expectorant function (2) Facilitate and encourage venous and lymphatic circulation and drainage within the thorax (3) Encourage mucous drainage from the lungs (4) Increase rib cage and spinal mobility which encourages chest cage and diaphragm excursion and ventilatory efficiency
	OMM Guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD: 4th step	4th : Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release
	OMM Guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD: 5th step	5th : Perform Muscle Energy, Myofascial, Counterstrain, and/or HVLA Technique to the Cervical and Thoracic Spine, Thoracic Outlet and Diaphragm, and Ribs (1) Increase spinal and chest cage ROM, improving movement of air (2) Improve diaphragm motion by: (a) treating mid cervicals (phrenic), (b) freeing attachments(crura), (c) direct diaphragm treatment techniques (3) Remove upper thoracic spinal facilitation that may be inhibiting SANS tone to the bronchial tree (Increased SANS tone increases bronchodilation) (4) All the above combine to: - improve oxygen and carbon dioxide exchange - improve venous and lymphatic drainage and circulation - decrease pulmonary inflammation and congestion Work of breathing assoc with lung disease, increases total body energy 3 to 33%. (can breath yourself to death) Heavy exercise, increases total body energy outpu t to only 6 %
	OMM in the post surgical patient	Designed to improve overall anatomic and physiologic function in patient’s recovering from surgery, while at the same time trying to prevent any complications and at the same time trying to hasten the patient’s discharge from the hospital and to return to optimal health as soon as possible.
	OMM in the post surgical patient sequence	1st : Perform an O/A/CB Decompression and Release: 2nd : Perform Rib Raising for the Thorax 3rd : Perform Lumbosacral Pelvic (L/S/P) Soft-Tissue and Articulation and/or Lumbosacral Pelvic Decompression and Release (somatic dysfunction can result in the following) (1) Facilitation of SANS supply to pelvic viscera from SANS ganglia, located at the tips of the lumbar TP’s (2) Facilitation of the PANS supply to the pelvic viscera from the pelvic splanchnics emerging from the sacral cord segments S2-4 (3) These problems can combine to compromise normal function of both SANS and PANS tone to all pelvic viscera. This is especially important as it applies to the kidney, bladder, and distal colon in the post-op patient L/S/P soft tissue and articulation has the ability to decrease facilitation, myofascial tension, and strain to both the SANS and PANS supply to pelvic viscera 4th : Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release 5th : Perform a Pedal Fascial Pump Procedure (OMT can be helpful in the following manner) (1) Provides a gentle ballottement of all organs in the thoracic and abdominal cavities(stimulate normal fxn, overcome organ stasis, and DVT) (2) Lymphatic Pump ability to move fluids, tendency of body to retain fluids in extravascular space s/p surgery (3) All of the above can combine to decrease the incidence of pneumonia, ileus, constipation, gas, venous and lymphatic pooling, DVT, and general organ stasis
	OMM Guidelines for Improving Gastrointestinal Function in Patients Presenting with Nausea and Vomiting. Irritable Bowel Syndrome, Constipation, Diarrhea, Spastic Colon, Esophageal Spasm and Reflux, Hiatal Hernia, Peptic and Gastric Ulcers, Gastritis and Ileus	General Description: (1) Improve general anatomic and physiologic functioning of the GI Tract (GIT) , when it has become impaired (2) Normalize GI function by addresing excessive or inefficient ANS tone (3) Promote venous and lymphatic drainage (4) This approach is useful in prevention and treatment of patients presenting with GI tract (GIT) issues
	OMM Guidelines for Improving Gastrointestinal Function in Patients Presenting with Nausea and Vomiting. Irritable Bowel Syndrome, Constipation, Diarrhea, Spastic Colon, Esophageal Spasm and Reflux, Hiatal Hernia, Peptic and Gastric Ulcers, Gastritis and Ileus 1st step	1st : Perform an O/A/CB Decompression and Release (somatic dysfunction puts direct pressure on CN X) (1)Excessive PANS tone to the small intestine, right colon, and transverse colon, may result in increased: (a)motility, (b) spasticity, and diarrhea (2) Excessive PANS tone to the esophagus may result in: (a) excessive and inappropriate spasticity of the esophagus (b) relaxation of the lower esophageal sphincter promoting GERD (3) Inhibit PANS tone to entire GIT resulting in: (a) constriction of esophageal sphincter (b) decreased motility from esophagus to splenic flexure causing : (1) distention, (2) constipation, (3) gas retention, (4) N&V (4) Stimulate excessive PANS tone to the gastric and duodenal mucosa resulting in excessive gastric acid secretion (5) Compression of Vagus may facilitate excessive sensory input to the vomit center, which can result in N&V (6) Vagal stimulation of Occipital nerves C1 and C2 may also facilitate increased sensitivity to pain in the occipital region of the head increasing the possibility of headache often found in association with GIT disturbances.
	Relaxation of the upper cervical muscle spasm and myofascial tension through O/A/CB Decompression and Release	will remove facilitation and stress on the vagus nerve - allowing PANS tone to return to normal functioning in entire GIT
	OMM Guidelines for Improving Gastrointestinal Function in Patients Presenting with Nausea and Vomiting. Irritable Bowel Syndrome, Constipation, Diarrhea, Spastic Colon, Esophageal Spasm and Reflux, Hiatal Hernia, Peptic and Gastric Ulcers, Gastritis and Ileus 2nd step	2nd : Treatment of any Somatic Dysfunction found in the Thoracic Spine, Thoracic Diaphragm, Lumbar Spine, and/or Pelvis (somatic dysfunction(SD) can result in): (1) Lumbosacral SD may imbalance tone to lower GIT via pelvic splanchnics originating from S2-4 and innervating the left colon, sigmoid colon, and rectum - excessive PANS tone may increase motility and spasticity causing diarrhea -inhibited PANS tone may decrease motility resulting in constipation (6) In middle, lower thoracic, and upper lumbar areas SD may inhibit SANS tone to GIT(PANS tone would dominate), resulting in increased (a) motility, (b) spasticity, and (c) diarrhea (7) In the mid-thoracics, SD may facilitate excessive SANS tone to the gastric vessels resulting in (a) vasoconstriction, and (b) decreased production of mucous and associated buffers causing decreased ability of gastric mucosa to protect itself from hyperacidity (8) In upper and middle thoracics, SD may inhibit or stimulate SANS tone to the esophagus, resulting in SD of the esophageal sphincters (9) A combination of poor diaphragm function, impeded ANS function, pelvic diaphragm function and venous and lymphatic drainage can combine to diminish adequate arterial lymphatic and venous circulation that will in turn inhibit adequate tissue levels of oxygen natural and adaptive immunity, as well as antibiotic delivery
	OMM Guidelines for Improving Gastrointestinal Function in Patients Presenting with Nausea and Vomiting. Irritable Bowel Syndrome, Constipation, Diarrhea, Spastic Colon, Esophageal Spasm and Reflux, Hiatal Hernia, Peptic and Gastric Ulcers, Gastritis and Ileus 3rd step	3rd : Perform Lumbosacral Pelvic(L/S/P) Soft Tissue and Articulation and/or Lumbosacral Pelvic Decompression ( Somatic dysfunction of Lumbar and Sacrum can result in ) (1) Excessive SANS tone from sympathetic chain ganglia at tips of lumbar TP’s to distal GIT result in decreased peristalsis with resulting constipation (2) Excessive PANS tone to distal colon and rectum from pelvic splanchnics emerging from sacral cord segments S2-4 can result in increased motility, spasticity, and diarrhea (3) These problems can combine to compromise the normal function of both the SANS and PANS tone of the GIT. Lumbosacral Techniques have ability to decrease facilitation, myofascial tension, and strain to both the SANS and PANS allowing nl fxn
	Parasympathetics Pelvic Splanchnic Nerve (S2, S3, S4)	Supplies Parasympathetic to: Lower ureter and bladder Uterus, prostate and genitals Descending colon, sigmoid and rectum
	OMM Guidelines for Improving	1st: Perform O/A/CB decompression (Fig. 1) 2nd: Perform rib raising, X’s 2 (Fig. 2) 3rd: Perform L/S/P soft-tissue and articulation, X’s 2 (Fig. 11) and/or L/S/P Decompression and Release (Fig. 3)

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