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135 Cards in this Set

  • Front
  • Back

1. What is a functional short leg?

Functional short leg:

Measure with patient supine
Compare malleoli

May be altered by:
-lumbar curve
-Innominate rotation
2. What is an anatomic short leg?
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
3. What is pelvic side shift? How do you test for it?
Definition:

Deviation of the pelvis to the right or left of the midline at a standing position

Test:
Stabilize shoulder, push pelvis laterally
4. What are the findings for a pelvic side shift right?
Side shift right:

Produces a curve (curve convex left)

Alters sacral position (sacral sidebending left and sacral rotation)
5. What is the typical short leg pattern? What are the symptoms of a typical short leg?
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
6. Can you change a primary thoracic curve with a heel lift?
You can’t change a primary thoracic curve with a heel lift
(you can balance the sacrum)
7. How does contraction of the psoas affect pelvic side shift?
“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


Or, psoas may balance a short leg, eliminating side shift

OR: psoas may compound the problem
8. What is lift therapy?
• 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
9. What are 5 general rules for lift therapy?
1. 1/8 inch increments at 2 week intervals
2. 1/4 inch is maximal starting dose
3. Lifts of > 3/8 inch require elevating sole
4. For long standing problems: 1/2 of the leg length shortening will balance the patient
5. For acute shortening (fractures, surgery), correct the difference immediately
10. What are some additional things to keep in mind w/lift therapy?
1. Not all patients have a typical pattern

2. Sometimes a lift is trial and error

3. If sciatica is present, do not lift the sciatic side

4. Patient must adopt to the lift
a. OMT to mobilize the spine
b. lazy persons exercise to stretch concavity of the curves
c. active exercises to mobilize and strengthen the spine
11. How do you know when you added the right or wrong amt 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)
12. What is Ferguson's lumbosacral angle? What is the CCOM Angle?
Has to do w/AP postural balance

Ferguson’s Lumbosacral Angle:
32 - 45 degrees measured against horizontal

CCOM Angle:
55 -65 degrees

Wire plumb bob produces a true vertical white line on film
13. How can you determine lumbosacral instability on a lateral xray?
1. Draw an ‘X” on L3 to locate center
2. Drop a vertical
3. Vertical should pass over sacral base
4. *If vertical is anterior to sacral base - this is x-ray evidence of lumbosacral instability
14. What is the pelvic index? What is designed to improve the pelvic index?
horizontal/vertical =
Pelvic Index = x/y

Levator orthotic is designed to improve the pelvic index
15. What is the rationale of postural xrays?
• 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.
16. What are 5 things that you need to do to obtain an accurate postural xray?
1. Normalize muscle contractions which have modified AP lumbar curve
2. Treat acute or persistent articular dysfunction which may distort weight-bearing performance
3. Be sure pelvis can side shift freely to each side with a patient in standing posture
4. Be sure patient can bear weight on each lower extremity equally
5. OMT before x-ray
17. What are the things to look at on a postural AP film?
• 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
18. An anatomic short lower extremity causes what dyfunctions?
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
19. What are 3 forces acting on gait?
1. Gravity
2. Muscle contraction
3. Momentum
20. What happens to the pelvis and sacrum on a right step forward?
Right Step Forward: Ilium anterior during swing phase (40°), Ilium posterior with stance leg.

The Center Of Gravity shifts Left (COG is 2 inches anterior to S2)

Pelvis & trunk shift approximately 1 inch to the weight bearing side during gait to center weight over hip.

Lumbar spine SBl,Rr
Sacral rotation occurs on L on L axis
21. What is the base length, step length, and cadence for a normal gait?
Base
2-4 “

Step length
15 “

Cadence:
90 – 120steps/minute
100 calories/mile
22. What happens to the COG during a 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
23. What are 4 prerequisites of normal gait?
1. Stability of the limb in stance phase
2. Clearance of the limb in swing phase
3. Effective shifts of the limb from stance to swing & from swing to stance
4. Occurrence of these components in a fashion that promotes maximum efficiency of energy expenditures
24. What are 3 ways to qualitatively analyze gait?
1. Kinamatics (analysis of motion &resulting temporal & stride measurements)

2. Dynamic EMG (analysis of muscle activity)

3. Kinetics (analysis of forces that produce motion)
25. What are the two main phases of gait?
Stance phase (60%)
-foot contact on the ground

Swing phage (40%)
-foot is in the air for limb advancement
26. What are the 4 components of stance phase?
1. Heel strike
2. Foot flat
3. Midstance
4. Push off
27. About how much of the stance phase is in double support?
Double support is 25% of stance

This occurs at the beginning and end of the stance phase when both feet are in contact w/the floor
28. What occurs during a right heel strike?
The instant the right foot hits the ground:

***Right ilium thrusts forward & rotates anteriorly & externally***

• Initial contact before the weight transfers to right 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
29. What occurs during the right foot flat stage?
Foot flat: From flatfoot position until the opposite foot is ready for swing (Loading response).

***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
30. What occurs during midstance?
Midstance: From the time the opposite foot is lifted until the ipsilateral tibia is vertical.

• ***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
31. What occurs during push off from the right foot?
Push off: From heel rise until the opposite foot contacts the ground (contralateral heel strike).

***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
32. What are the points of stability throughout the stance phase?
Ankle dorsiflexion control:
Midstance

Knee extension:
Heel strike

Ankle plantar flexion:
Push off

Controlled trunk shift

Also, prevent excessive forward rotation of the tibia through the forces of the plantar flexion
33. What are the 3 components of the swing phase?
1. Acceleration
2. Midswing
3. Deceleration
34. What occurs in the acceleration part of swing phase for the right foot?
Acceleration: Begins with lift-off of the foot from the floor & ends when the foot is aligned with the opposite foot.

*Right ilium is @ maximal height, starts to descend & rotate anteriorly*

• Gastroc starts to lengthen
• Fibular head starts to glide anteriorly
• Quads shorten (contract)
• Hamstrings begin to relax
• Iliopsoas start to shorten
• Gluteals & piriformi start to relax
35. What occurs in the midswing part of swing phase for the right foot?
Midswing: Begins when the foot is aligned with the opposite foot & ends when the contralateral tibia is vertical

*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
36. What occurs in the deceleration part of swing phase for the right foot?
Deceleration: Begin when the tibia is vertical & ends when the foot contacts the ground (heel strike)

*Ilium still 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
37. What is the clearance mechanism for the swing phase?
This is a specific coordinated event to achieve limb-length reduction. It involves:

1. Knee flexion during all of swing
2. Coordinated hip and knee flexion during early midswing
3. Ankle dorsiflexion during midswing
4. Hip abductors control amt of pelvic drop in swing phase
38. How do abnormal biomechanics affect energy expenditure?
Energy efficiency is dependent on unrestricted joint mobility & the precise timing & intensity of muscle action

Most joint function depends on small arcs of motion 15- 20 degrees.

Abnormal biomechanics increases energy cost
-Compensatory decrease in walking speed
-A 10 degree loss of motion can be obstructive.

Energy efficient motion is characterized by minimal movement of the body’s center of gravity in both the vertical & horizontal planes
39. What is the avg total displacement on COG in a normal gait?
Average total displacement on cog is 5 cm in normal gait
40. Transverse sacral axes (superior, middle, transverse)
Superior: Respiratory and craniosacral motion at S2 body

Middle: Postural motion at S2 sacral segment

Inferior: Innominate rotation at S3
41. What happens to the pelvis and sacrum on a right step forward?
Right Step Forward: The COG shifts L

a. lumbar spine SL,RR
b. Locks L pole of upper sacrum @ L/S junction
c. The sidebending of the lumbar spine to the L induces sacral rotation about its L axis
d. Sacral rotation occurs on L on L axis
e. Lumbar spine rotates to right
42. What happens to the pelvis and sacrum on a right heel strike?
1. As COG moves forward R quad contracts to lift R thigh & foot forward
a. Anterior rotation of R innominate about inferior transverse axis
b. Forward motion of R innominate increases as R heel strikes & left leg begins to move forward

2. COG is now forward & begins to shift R over the R femoral support
a. R heel contacts the ground
b. R hamstring tension increases
c. Posterior rotation of R innominate on inferior transverse axis of sacrum
43. What happens to the pelvis and sacrum on a right foot flat?
As COG shifts from over R femur to R margin of sacrum
a. Lumbar spine S R,RL
b. L foot is lifted
c. L foot passes R foot
d. R upper pole of SI joint is locked
e. R oblique axis for sacral motion is established
f. Sacral, innominate, & lumbar motions repeat themselves
44. What is toeing in?
Toeing in:
i. 1 in 10 children (2 – 5 y/o)
ii. 80% spontaneously recover

Caused by:
1. Rotation of pelvis
2. Excessive femoral anteversion
3. Internal tibial torsion
4. Metatarsus adductus
5. Equinovarus deformities
6. Tight tibialis posterior
45. What is toeing out?
Toeing out

Caused by:
• External rotation of femur (retroversion)
• Tight piriformis
• Tight iliopsoas
• Rotation of pelvis
• External tibial torsion
• Calcaneovalgus
• Pes planus
• Tarsal coalitions
46. What is genu varum?
There is physiologic genu varum but this is generally when there is bow legging of the tibia

Positive 12-20 degrees tibiofemoral angle*
47. What is genu valgum?
There is also physiologic genu valgum but this is generally when there is knee knocking. Should resolve by 7 years of age.

Negative tibiofemoral angle*
48. What is the Foot Progression Angle?
A positive FPA means that the foot is turning out.

A negative FPA means that the foot is turning in.

Normal is slightly positive (about 5 degrees) but a person who is between -10 and + 15 is considered within normal limits (WNL).

*The first thing you should look at in a patient is the FPA!
49. What is the Thigh Foot Angle?
Eyeball measurement of how much torsion there is in the tibia.

Examined with the patient prone, hip in extension.

The thigh foot angle is usually positive, but a patient between -5 and + 30 is WNL.
50. What is the Tibiofemoral Angle (TQ)?
Angle created by the long axis of the femur to the tibia and is measured from an AP view

Little Kids: should be bow legged (+ 20 to + 12 degrees)
Should straighten out from 18 mos-2 years (pathologic if they don’t)

From about 2 – 3 ½ years – knees go into excessive valgus (knock knees)

By the time the child is about 6 or 7, should get the adult tibiofemoral angle which is about – 7 degrees.
51. What are the most common causes of an inadequate limb clearance and advancement?
Occurs during swing phase

When limb clearance is inadequate limb advancement is compromised

Most common causes:
1. Lack of adequate hip flexion
2. Inadequate knee flexion &/or ankle dorsiflexion
3. Stiff knee gait
-Early swing toe drag compensated by increased hip flexion, increasing contralateral limb length, or generating knee flexion
52. What is an abnormal support base? Why is it important?
1. Ankle /foot posture critical in the interface with the walking surface during the stance phase.
2. Ankle plantarflexion, inversion or eversion & toe flexion or extension can all interfere with normal gait.
3. Inadequate base of support can result instability of the entire body.
53. What is one of the most common abnormal lower limb postures seen in pts with neurologic disorders?
Equinovarus: Toe walker; looks really painful. The pt does not have heel strike or flat foot stages.
54. Explain equinovarus again...?
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
55. What can cause abnormal limb stability?
Knee flexion or hyperextension during early stance caused by ligamentous instability, degenerative joint disease, muscle weakness or flaccidity can result in instability & increased risk of falling

Transfemoral amputee
Knee hyperextension
i. ankle plantar flexors
ii. Knee extensors, plantar flexion contracture
iii. Quadriceps weakness
iv. Knee hyperextension prevents normal forward advancement of the tibia during stance and restricts contralateral limb advancement.

Hypertonic hamstrings
56. What is a Trendelenburg gait, and what causes it?
1. Insufficient gluteus medius

2. Mechanical deficiency of the hip joint caused by:
a. pain
b. DJD
c. Malalignment
d. Nerve injury to gluteus medius

3. During stance on affected side the pelvis drops on non-weight bearing side & the trunk follows.

4. Lateral trunk exceeds normal 1”
57. What is an antalgic gait?
Antalgic Gait – PAINFUL (use cane on opposite side)

The painful leg has:
Short stance phase
Pelvis shifts away
Trunk is rotated away
58. What is a scissor gait?
Scissor Gait – Neurologic gait where the knees cross

Knees can cross b/c either:
i.Adductors are tight (surgeon would cut adductor)
ii. Femurs are anteverted (surgeon would cut femur and rotate)

Negative foot progression angle is likely, toes pointed in > -10’
59. What is an ataxic gait?
Wide based

Stiff motion – very little motion of joints -
60. What is a crouch gait?
Crouch Gait:

Tight Hamstrings

Swing or externally rotate foot to gain clearance

Toe extensors are also recruited to dorsiflex foot to help w/ clearance
61. People with quadriceps insufficiency have a big problem in....?
People with quadriceps insufficiency have a big problem in maintaining gait in heel strike.
62. The fibular head is anterior/posterior all through swing phase?
Fibular head is anterior all through swing phase
63. What are 4 goals of OMM during pregnancy?
1. Restore anatomic structure and function.
2. By doing so, blood flow and lymphatic drainage improves.
3. Breathing becomes more coordinate and effective.
4. Reduce pain and improve activities of daily living.
64. What are some secondary patient complaints during pregnancy?
Heartburn
Shortness of Breath
Low Back Pain
Numb Hands and Feet
Neck and Upper Back Pain
Nausea/vomiting
65. What are 5 GI changes during pregnancy?
1. Stomach position is shifted by gravid uterus
2. This changes the angle of the GE junction allowing GE reflux to occur in 45-70% of patients
3. This results in heartburn and chest pain
4. Pylorus is distorted upward and backward, slowing gastric emptying
5. Placenta secretes hormone Gastrin which increase stomach acid production and volume which lowers ph.
66. What are the Chapman's points for the GI?
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.
67. What are 4 hepatorenal changes during pregnancy?
1. Renal GFR increases 50% early, returns to normal
2. This increases Creatinine Clearance and Bun runs 8-9 mg/dl and Creatinine levels run around 0.5 mg/dl.
3. Hepatic changes Serum Alkaline Phosphatase is elevated from placental secretion
4. CNS Changes Elevated Progesterone and B-endorphins
68. What are 6 respiratory changes during pregnancy?
1. Chest circumference increases 5-7cm.
2. Subcostal angle increases from 68-103 degrees
3. Diaphragm is pushed superiorly by 4cm but excursion increases by 1-2 cm.
4. This results in a 40% increase in Tidal Volume.
5. This causes a 30-50% increase in minute ventilation, despite resp rate being unchanged
6. ***Increased Progesterone is felt to be the cause***
69. How do the physiologic respiratory parameters change 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%

This gives feeling of breathlessness
70. What is the equation for FRC?
FRC= Residual Vol. + End Exp Reserve Vol.
71. How does increased progesterone cause airway swelling and stuffy nose 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.
72. Late in the pregnancy, how does the diaphragmatic excursion change?
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.
73. What are 5 changes in cardiovascular parameters during pregnancy?
1. Blood and Plasma volume increase 40%
2. Cardiac Output increases 40%. (CO = HR x SV)
3. Stroke Volume increases by 30%
4. Heart Rate increases by 15%
5. These increases can lead to innocent grade 1-2 systolic flow murmur which is transient.
74. What are the changes in hematologic parameters 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
75. What causes the compensatory increase in lumbar lordosis 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.

Alterations in our normal ligamentous and spinal disc posture lead to a compensatory increase in muscle activity to aid in counterbalance and the fight against gravity (erector spinae, quadratus lumborum and iliopsoas muscles)

As the pregnancy continues and abdomen distends, the muscles begin to lose their ability to aid in this counter balancing act. (Pregnant women could not perform a single sit up).
76. What are the major and minor transition zones of the spine?
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

Transition Zones act like springs and transfer forces longitudinally.
77. What is the significance of these transition zones?
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.
78. What are the structural changes in the paraspinal muscles (specifically the iliopsoas) during 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.
79. How can one assess iliopsoas function in a pregnant woman?
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.*
80. Does pregnancy worsen scoliosis?
Consensus is most scoliosis progresses into adulthood but is not exacerbated by pregnancy.
81. What is 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

When patients are symptomatic, place pregnant patient in supine position and elevate right buttocks 10-15 cm with a sheet or blanket.

Or…manually distract uterus to the left
82. What are some possible symptomatic problems caused by supine maternal hypotension syndrome?
Maternal hypotension often results in undiagnosed fetal bradycardia due to placental hypo-perfusion and fetal asphyxia.

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!!!
83. What causes low back pain during 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.
84. What are 5 factors that increase risk of back pain while pregnant?
1. Manual Labor
2. Smoking??
3. Parity
4. Age
5. Previous Low Back Pain with pregnancy
85. What are 7 factors that DO NOT increase risk of back pain while pregnant?
1. Race
2. Occupation
3. Weight gain or pre-pregnant weight
4. Exercise Habits
5. Sleep posture or mattress
6. Shoe Heel Height
7. Previous Epidural Analgesia
86. What are 10 contraindications for OMM during pregnancy?
1. Undiagnosed vaginal bleeding
2. Threatened or incomplete abortion
3. Ectopic pregnancy
4. Placenta Previa
5. Placental Abruption
6. Premature rupture of membranes
7. Pre-term Labor (relative contraindication)
8. Prolapsed umbilical cord
9. Severe preeclampsia or eclampsia
10. Other medical or surgical emergencies
87. What is pregnancy induced hypertension?
Definition of 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.
88. What is gestational hypertension?
Gestational hypertension is hypertension not accompanied by proteinuria or generalized edema.
89. What is the definition of somatic dysfunction?
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.
90. How do you introduce OMT to a patient who is unfamiliar?
OMT is 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

OR:

“I am an Osteopathic Physician, in addition to the types of treatment you have had in the past, I use my hands evaluate your muscles and bones and can use manipulation as part of your treatment plan. It will help you feel better sooner. We can start treatment now."
91. What are the rules on sequencing treatments?
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
92. What are 6 RED FLAG's you should look for on a hospital pt's chart?
1. Past medical history (i.e. Cancer, Osteoporosis, Disc herniation, Hypercoagulable states, PE , DVT)
2. New Chest pain undiagnosed
3. New Orders to rule out DVT, PE, MI
4. Abnormalities on Telemetry monitoring over night
5. Fluctuation in vital signs
6. Radiologic tests, EKG’s and Labs
93. What are the 10 most common hospital consults?
(1) Pneumonia
(2) COPD
(3) Asthma
(4) Bronchitis
(5) GI Motility
(6) ileus
(7) Constipation
(8) LBP
(9) Neck Pain
(10) Swelling
94. What is Spurling's test?
Tests for narrowing of neural foramina

Sidebend and backward bend head; add compression

*Positive if pain radiates to ipsilateral arm*
95. What is Underburg's test?
Test for vertebral artery insufficiency

Supine, backward bend, rotate, WAIT 30 seconds

*Positive with dizziness, nausea, lightheadedness*
96. What are Dr. Graham's goals for OMM?
(1)* 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
97. What are Dr. Graham's 3 criteria for OMM success in hospital settings?
(1) 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)
98. Summary of 3 guidelines (have no idea what's going on)
(1) 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 processes that might arise with hospitalization
99. Celiac gangion innervates...?
Stomach, Liver, Gallbladder, Spleen, portions of Pancreas and Duodenum (foregut)
100. Superior mesenteric ganglion innervates?
Portions of Pancreas, Duodenum, Jejunum, Ileum, Asc. Colon, Prox. 2/3 of Transverse Colon. (midgut)
101. Inferior mesenteric ganglion innervates?
Distal 1/3 Transverse Colon, Desc. Colon, Sigmoid, Rectum (hindgut)
102. T12-L2 viscerosomatic levels correspond to what organs?
T12-L2:

Left Colon
Bladder
Prostate
Lower Extremity
103. What are the 4 OMM technique guidelines for the ICU, Critically Ill, or Bedfast Patient?
1. Perform an O/A/CB Decompression and Release
2. Perform Rib Raising to the Thorax
3. Perform Lumbosacral Pelvic(L/S/P) Soft -Tissue and Articulation and/or Lumbosacral Pelvic Decompression and Release
4. Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release
104. What is the 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 urine flow and removal of dead cells, inflammation, and congestion by direct mechanical stimulation, and increase venous and lymphatic drainage and circulation to the area.
105. What can cause failure of extubation, and how can OMM techniques help?
Failure of extubation often occurs when thoracic diaphragm has become atrophied and “lazy” (ventilator has taken over responsibility for breathing)

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

OMM is designed to stimulate the diaphragm to resume its pumping action

Techniques should be performed throughout intubation period, immediately before and after extubation, then at routine intervals after extubation
106. What are the 4 OMM technique guidelines for Ventilator Extubation of the ICU Patient?
1. Perform O/A/CB Decompression and Release
2. Treat any Cervical Dysfunction with Articular Muscle Energy, Counterstrain, or Myofacial Release
3. Perform Rib Raising
4. Perform Rib Walking to the Anterior Thorax
5. Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release
107. Which step is often the key to stimulating the diaphragm to return to a more normal level of functioning?
Thoracic Diaphragm Soft-Tissue and Myofascial Release
108. What are the 5 OMM technique guidelines for Improving Lower Respiratory Tract Functions in Patients Presenting with Asthma, Atelectasis, Poor Respiratory Effort, Pneumonia, and Bronchitis?
1. Perform O/A/CB Decompression and Release
2. Perform Rib Raising and Rib Walking
3. Perform Thoracic Diaphragm Soft- Tissue and Myofascial Release
4. Perform Lymphatic Pump Procedures
5. Perform Muscle Energy, Myofascial, Counterstrain, and/or HVLA Technique to the Cervical and Thoracic Spine, Thoracic Outlet and Diaphragm and Ribs
109. What is the single most important thing you can do to improve a pt's lower respiratory function?
Perform Thoracic Diaphragm Soft- Tissue and Myofascial Release

*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*
110. What are the 5 OMM technique guidelines for Improving Lower Respiratory Function in Patients Presenting with COPD?
1. Perform an O/A/CB Decompression and Release
2. Perform Rib Raising to the Thorax
3. Perform Rib Walking to the Anterior Thorax
4. Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release
5. Perform Muscle Energy, Myofascial, Counterstrain, and/or HVLA Technique to the Cervical and Thoracic Spine, Thoracic Outlet and Diaphragm, and Ribs
111. Work of breathing assoc with lung disease, increases total body energy by how much?
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 output to only 6 %
112. 5 techniques for the post-surgical pt?
1. Perform an O/A/CB Decompression and Release:
2. Perform Rib Raising for the Thorax
3. Perform Lumbosacral Pelvic (L/S/P) Soft-Tissue and Articulation and/or Lumbosacral Pelvic Decompression and Release
4. Perform Thoracic Diaphragm Soft-Tissue and Myofascial Release
5. Perform a Pedal Fascial Pump Procedure
113. Guidelines recommended to address problems of GI tract?
1. Perform an O/A/CB Decompression and Release
2. Treatment of any Somatic Dysfunction found in the Thoracic Spine, Thoracic Diaphragm, Lumbar Spine, and/or Pelvis
3. Perform Lumbosacral Pelvic(L/S/P) Soft Tissue and Articulation and/or Lumbosacral Pelvic Decompression (lumbar roll)
114. Relaxation of the upper cervical muscle spasm and myofascial tension through O/A/CB Decompression and Release will do what?
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 GI system
115. Parasympathetics Pelvic Splanchnic Nerve (S2, S3, S4) supply parasympathetics to...?
Lower ureter and bladder

Uterus, prostate and genitals

Descending colon, sigmoid and rectum
116. 4 OMM Guidelines for Improving Overall Anatomic and Physiologic Functioning of the ICU, Critically Ill or Bedfast Patient:
1. Perform O/A/CB decompression
2. Perform rib raising
3. Perform L/S/P soft-tissue and articulation, X’s 2 and/or L/S/P Decompression and Release
4. Perform thoracic diaphragm soft-tissue and myofascial release
117. Diaphragm (innervation, insertion, attachment, functions)
Innervation: Phrenic nerve (C3-C5)

Contraction causes cyclic pressure gradient changes.
o Negative intra-thoracic pressure: Inhalation
o Positive intra-thoracic pressure: Exhalation

Attachments
o Xiphoid/Sternum
o Ribs 6-12
o Anterolateral surface of T12-L3

Apertures:
o Aorta
o Lymphatics/Cisterna chyli
o Inferior vena cava
-Opens in inhalation
o Esophagus (Hiatal hernia)
-Closes in inhalation
118. What is trephining?
TREPHINING, the boring of holes into the skull to release evil spirits or toxins was used during Neolithic times.

Coca leaf wrapped with guano and lime used to release alkaloid cocaine used for trephining.
119. What causes abdominal pain?
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.

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 identified as sympathetic or parasympathetic.
120. What makes up the 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.
121. What is ileus, and what are the 3 groups of ileus?
Ileus: diminished or absent bowel function.

1. Adynamic or inhibition ileus: diminished or absent motility secondary to inhibition of neuromuscular apparatus. Ex. Peritonitis.
2. Spastic Ileus: Contracted bowel musculature inhibits propulsive motility.
3. Ileus of vascular occlusion: Dead or ischemic.
122. What are the most and least freq forms of ileus?
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 opioids.
123. What is the course/order of abdominal pain?
1. Bowel dilates
2. 1st order nerves,(symp afferents) stim
3. Enter dorsal horn
4. 2nd order nerve to contralateral spinothalamic tract & spinoreticular
5. Ascend to Pons/Medulla Thalamus
6. 3rd order n. to cortex
7. Conscious perception of pain,(spinothalamic)
8. Limbic Stimulation, (spinoreticular)
9. AVERSE RESPONSE
124. Why is abdominal pain mostly vague and dull?
Many fewer visceral afferents than somatic afferents. Therefore pain is not sharp.
125. How does appendicitis cause pain?
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.
126. What happens during surgery?
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

Muscle relaxation: Tracheal intubation, surgical relaxation. DECREASE LUMBAR LORDOTIC CURVE
127. Symptoms of tracheal intubation?
Tracheal Intubation: Hoarseness, dislocated arytenoid, vocal cord granuloma, shortness of breath from paralyzed cord. Dislocated Hyoid.
128. Symptoms of 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.
129. What happens to the cardiovascular system when the anesthetic effects wear off?
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.
130. What happens to the respiratory system when the anesthetic effects wear off?
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.
131. What does the study by Walter J. McConathy,Phd. , et. al on the Hemodynamic Effects of OMM measure?
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%)
132. What does Dr. Seifert like about the study by Walter J. McConathy,Phd. , et. al?
One of few studies to measure physiologic effects of OMT and surgical patients

One of FEWER studies to suggest OMT improves measurable changes in physiology

Performing OMT on sedated patients removes any “Hands On” Placebo effect.

A GREAT spring board for further investigation
133. What does Dr. Seifert NOT like about the study by Walter J. McConathy,Phd. , et. al?
Small sample size

Did not randomize control with OMT patients

Did not know pre op C.I. or E.F.

Treatment was not standardized, it varied

Did not mention filling pressures, PaP, CVP, or measure SVR.
134. What is dysmenorrhea?
Painful menses in the absence of organic disease. Diagnosis of exclusion.

Secondary: Acquired. Painful menses associated with pathology. Uterine fibroids, polyps, IUD’s, pelvic congestion assoc. with retroverted uterus,PID, ovarian cysts, ectopic pregnancy, etc..
135. What are the symptoms/treatment of 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.