Opp2 Final Exam_Lectures + Nelson

Front 1

A 14 year old girl has had right leg pain for one week. The pain started while running in gym class and is now worse with walking. She has point tenderness on the right anterior tibia, right knee extension to -15 degrees, and slightly BLUE sclera.

Which diagnostic test would you order?

A) tibia x-ray
B) Venous doppler flow study
C) genetic testing
D) echocardiogram
E) anterior compartment pressure

Back 1

***A) tibia x-ray***

This is Osteogenesis Imperfecta
-blue sclera
-osteoporosis ** (get x-ray)

Front 2

A 14 year old girl has had right leg pain for one week. The pain started while running in gym class and is now worse with walking. She has point tenderness on the right anterior tibia, right knee extension to -15 degrees, and slightly BLUE sclera.

Which initial treatment for her leg pain is appropriate?

A) Knee Strengthening
B) Knee Prolotherapy
C) Splinting
D) Knee Articulatory
E) Ankle ME

Back 2

**Splinting**

This is Osteogenesis Imperfecta
-blue sclera
-osteoporosis ** (get x-ray)

Front 3

A 28 year old right-handed female with chronic back pain has restricted lumbar flexion, a right anterior innominate, and L5 ESRr . Joint motion testing reveals index finger extentsion 100 degrees, thumb contact with ventral forearm, elbow and knee extension 5 degrees.

What is the most appropriate initial treatment for her back pain?

A) posterior lumbar counterstrain
B) lumbar prolotherapy
C) back strengthening
D) sacrum ME
E) Lumbar thrust

Back 3

**E) Lumbar Thrust**

Yes, she has some hyper-mobile joints but not HYPERMOBILITY Syndrome. Even then, there is no mention of her L-spine being hypermobile.

Place her on her RIGHT SIDE (rotation side) and do the thrust...

Front 4

What Beighton non-dominant screening test values signify:

-Hypermobility likely, use caution with all direct treatments

Back 4

4/5 & 5/5

**Use counterstrain and indirect Tx only**

Front 5

A patient with stretchy skin presents with chronic low back pain. He says you did a lumbar thrust on his buddy and now his back is just fine. He was hoping you could do the same for him.

What do you say?

Back 5

**He may have Ehlers-Danlos Syndrome**

- Which has skin hyperextensibility and ligamentous laxity (joint hypermobility as well)
~~~~~~~~~~~~~~~~~~~~~~~

HVLA is contraindicated!!

**Use counterstrain and indirect Tx only**

Front 6

A tall patient with very long arms presents with chronic low back pain. He says you did a lumbar thrust (HVLA) on his buddy and now his back is just fine. He was hoping you could do the same for him.

What do you say?

Back 6

**He may have Marfans**

- Abnormal growth of cartilage and long bones. These patients have a wide arm span and aortic aneurism and they may have joint hypermobility (that is not universal)

~~~~~~~~~~~~~~~~~~~~~~~

HVLA is contraindicated if he is hypermobile!!

**Use counterstrain and indirect Tx only**

Front 7

Hypermobility syndrome may be treated with (4)

Back 7

Hypermobility syndrome may be treated with:

i. Counterstrain or indirect MFR to relieve pain

ii. Anti-inflammatory medications to relieve inflammation

iii. Joint strengthening to prevent recurrence

iv. Prolotherapy for selected symptomatic joints if strengthening is not tolerated

Front 8

A patient with a hyper-mobile elbow has been having pain in her elbow for months.

You have tried OMT and joint strengthening but those just haven't seemed to work.

What could you do next? MOA?

Back 8

**Prolotherapy**

-stimulation of ligament or tendon repair by injection

-glucose injection into LIGAMENT or tendon followed by home-excercise

Front 9

Give the screening areas for the Beighton non-dominant screening test. (5)

-What scores indicate hypermobility is unlikely?

-Hypermobility likely?

Back 9

i. Index finger extension > 90%

ii. Thumb flexion all the way to the forearm

iii. Elbow extension ≥-10ᵒ

iv. Knee extension ≥-10ᵒ

v. Standing flexion where hands lay flat on floor

4/5 - 5/5 = hypermobility syndrome LIKELY

0/5 - 3/5 hypermobility syndrome UNLIKELY

Front 10

bOutpatient visit charges are coded and billed using Evaluation and management codes (E/M codes).

The three key components of an E/M service code are:

Back 10

History
physical examination
medical decision making (MDM)

Front 11

4. Discuss the concept of medical insurance bundling

Back 11

**Medical insurance bundling**

- the process by which payers group separates identifiable charges, as defined by CPT, and then pay for the “bundled” group at a lower rate than the sum of the individual charges.

Front 12

3. Describe the use of a modifier 25 in E/M coding

Back 12

a25 modifier is an attachment to the E/M code.

-It signifies that a separate identifiable service has been performed on the same day for which you should be paid in addition to the E/M

- shows that E&M and procedures are **separate and distinct clinical activities**.

- Proper billing prevents them from being lumped together (bundled) when it comes to reimbursement

Front 13

5. List the additional components necessary for the addition of OMT to a SOAP note

Back 13

OBJECTIVE:
**Osteopathic Structural Exam**
- The physical examination must document any somatic dysfunction found, thus establishing the indication and creating the medical necessity for OMT.

ASSESMENT:
**Osteopathic somatic dysfunction**
– somatic dysfunction ICD-9 codes for each region found in OSE

PLAN:
**Procedure of OMT**
- region treated
– what modality??

-response to treatment (i.e. T5 FSBRr – ME – good response), include any adverse or miraculous responses

Front 14

Medical decision making (MDM), is a ncessary component of the evaluation and management (E/M) service code. What is it exactly?

Back 14

Medical decision making (MDM) evaluates the number of diagnoses the amount of data to be reviewed and the level of risk involved depending on the type of problems medical and/or therapeutic intervention needed

Front 15

A young mother brings her 2-week old son in to you for evaluation. She claims, "He just doesn't look right".

You note that he has a flattened occiput and his right eye seems more anterior than his left.

Dx?
Strain?
Tx (3)?

Back 15

**Plagiocephaly**

- Right Lateral SBS Strain

Treatment:
-TUMMY TIME**
-OMT**
-HELMET**

Front 16

What is the mechanism of how OMT can help Amblyopia (lazy eye)?


**clicker**

Back 16

reduces pressure on CN 6

Front 17

What 2 treatments can you teach a parent to do at home for a child with recurrent otitis media?


**clicker**

Back 17

-MFR of thoracic outlet

-Mandibular Drainage (Galbreath)

Front 18

Which scoliosis can you treat with OMT conservatively?

A) 30 deg. Right Lumbar
B) 60 deg. Left thoracic
C) 15 deg. Right Thoracic

**clicker**

Back 18

C) 15 deg. Right Thoracic

OMT is good for Cobb Angles 0-20 deg

20-45 deg = refer for opinion

>50 deg = surgery

Front 19

In kids, allergies, structural or somatic dysfunction (cranial base strains ) can lead to otitis media...

Why?

Back 19

Eustachian tube is at a flatter angle.. Fluid can easily get caught in there..

(Note: adults have a more flexed cranium which allows the tube to drain better)

Front 20

How does colic present? What is thought to be the cause?

Back 20

Rules of 3:

cry 3 hours/day,

at least 3day/week

around 3PM

~~~~~~~~~~~~~~~~~~~~~~~

Entrapment neuropathy of CN IX, X and XII from cranial base strains

Front 21

OMT for a child with colic? (2)

Back 21

– occipital decompression (CN IX, X, XII)

- MFR of abdominal valves and plexi.

Front 22

What is the proposed cause of Feeding Disorders and GERD in infants?

What is the treatment? (2)

Back 22

entrapment neuropathy of CN IX, X, XII from cranial base strains

**Tx:**
– occipital decompression (CN IX, X, XII)

- MFR of abdominal valves and plexi.

(same tx as colic)

Front 23

OMT for Amblyopia (lazy eye)?

1. Compression of CN VI (abducens) under petrosphenoidal ligament from cranial somatic dysfunction

Back 23

Osteopathy in the Cranial Field

Front 24

OMT can be used to treat Headaches in kids... What is the proposed mechanism?

Back 24

- tension on dura, innervated by CN V and tension in suboccipital and cervical areas

-Use cranial OMT

Front 25

Know OMT can treat ADHD in children...

Back 25

Suurrreeeee it can.....

Front 26

OMT can e used to treat kids with asthma. Generally you don't want to use it in acute cases.

OMT can help the body heal after an acute case and help cut down on more attacks.

What type of treatment should you AVOID?

What 3 target areas of treatment are very helpful?

Back 26

AVOID--> techniques that increase inhalation (such as classic lymphatic pump)

**TARGET**
-vagal tone
- muscles of respiration
- pulmonary lymphatics

Front 27

A 15 year old girl presents with low back pain after gymnastics practice. What is diagnoses that you need to rule out?

Back 27

**Sponylolisthesis**

-common in female gymnasts

-Add OMT to treatment:
(ME, MFR)

Front 28

What types of treatment do you want to do when adding OMT as standard of care to adolescents with Spondylolisthesis or Scoliosis?

Back 28

ME, MFR

Front 29

What is the first thing you have to do when an adolescent patient presents with a sports injury?

Back 29

Rule out Structural Derangement
(epiphyseal injuries)

Front 30

OMT can be used to treat soliosis if the Cobb angle is < ___?

Back 30

less than 20 degrees

Front 31

What is the normal Ferguson angle?

What does an increased Ferguson angle mean?

Decreased Ferguson Angle?

Back 31

Normal = 40ᵒ +/- 2ᵒ

Increased = angle >42ᵒ may result in excessive strain on ligamentous structures and shearing forces on intervertebral discs

Decreased = angle<38ᵒ may result in flattening lumbar lordosis or compressive forces on articular facets

Front 32

1/3 of all children under 11 presenting with a scoliosis have an underlying _____ _____

Back 32

neurological defect

-get an MRI if neuro exam is abnormal

- May have: Arnold chiari I malformation, tethered cord with spina bifida, syrinx (fluid filled sac formed around spinal cord)

Front 33

**Uterus/Cervix**

Sympathetics?

Parasympathetics?

Back 33

Sympathetics = T10-L2

Para = S2-S4

Front 34

Parasympathetic Stimulation of the Uterus causes what?

Back 34

Uterine Relaxation
(cervix constricts)

Front 35

Sacral Inhibition would cause what in the uterus/cervix in a patient with dysmenorrhea?

Back 35

↑ Parasympathetics

- Uterus --> RELAXES

- Cervix--> CONSTRICTS

Front 36

Sympathetic Stimulation of the uterus/cervix causes what?

Back 36

- Uterus --> CONTRACTS

- Cervix --> RELAXES

Front 37

A fetus is in the breached position and you want to try and get the uterus to relax to allow for repositioning. What should you do?

Back 37

Sacral Inhibition = ↑ Parasympathetics

- Uterus --> RELAXES

Front 38

Know that you can do OMT during the bi-manual pelvic exam...

Back 38

It should be myofascial release or
balanced ligamentous tension

(MUST communicate with pt.)

Front 39

Dysmenorrhea can be caused by lymphatic congestion (it's called secondary dysmenorrhea).

What diaphragms should you treat?

Back 39

cervico-thoracic diaphragm

abdominal diaphragm

pelvic diaphragm

Front 40

How does Parasympathetic stimulation of the Vagus Nerve at the OA affect the ovaries?

Back 40

Increased Blood Flow

Front 41

Sympathetic stimulation of the ovaries causes _________

Back 41

Decreased Blood flow

Front 42

Is chronic pain normal or abnormal?

Back 42

abnormal

Front 43

What is allodynia?

Back 43

When noxious stimulation of the muscle afferent C-fibers is prolonged and persistent, the PNS and CNS neurons become hyperexcitable or facilitated. *****

This enlarges the peripheral pain receptor field and allows for ***non-noxious*** sensations to be experienced as painful

Front 44

What is the significance of "facilitation"?

Back 44

Facilitated segments have a lower threshold of stimulation to produce PAIN

Front 45

What is Hyperalgesia ?

Back 45

noxious stimulation of the muscle afferent C-fibers is prolonged and persistent, the PNS and CNS neurons become hyperexcitable or facilitated.***

This enlarges the peripheral pain receptor field and allows for ***noxious sensations*** to be experienced as more painful

Front 46

Acute Pain is a ______

Back 46

symptom

-often associated with
objective physical signs of increased heart rate, increased blood pressure, increased pupil diameter, decreased gut motility, decreased salivary flow, decreased superficial capillary flow, striated muscle tension, fear and/or anxiety and release of glycogen adrenaline and noradrenaline (stress response)

FIGHT OR FLIGHT!!!!

Front 47

Chronic pain is a _______

Back 47

Disease

Front 48

Acute Vs. Chronic Pain:

- Cortical thinning and cell loss in the anterior cingulated cortex and anterior insula,

-differences in the density of thalamic and prefrontal gray matter and altered sensitivity to stimulation with sensitization in pain-related neural activity

Back 48

Chronic Pain

Front 49

What 4 systems respond to tissue injury?

Back 49

nervous system

endocrine system

immune system

musculoskeletal system

Front 50

What are the "essential features" of an adaptive system?

Back 50

*** Connectivity ***
- The interactions that produce patterns and self-regulation feedback.

- Consequently, the **connectivity of a system is more important than the system components themselves** – this is so that each system can talk to each other and ensures there are appropriate feedback loops in place.

***Irritability***
- System dynamically responds to disturbances

***Plasticity***
- Capable of change, may be non-linear

***Unpredictability***

Front 51

What do we call our body's response to stress?

Back 51

allostasis

Front 52

Stress Response:

-What are the steps of the allosteric stress response that is working correctly to control pain?

Back 52

Alarm, resistance, RECOVERY

Front 53

Stress Response:

-What are the steps of the allosteric stress response that is ABNORMAL and leads to CHRONIC PAIN?

Back 53

Alarm, resistance, EXHAUSTION

Front 54

Parts of the MINE supersystem?

Back 54

(M)uscoluskeltal

(I)mmune

(N)ervous

(E)ndocrine

Front 55

Discuss the importance of the musculoskeletal system in the MINE supersystem.

Back 55

The MINE supersystem states that the (I), (N), (E) supersystem is nested within the musculoskeletal system (M).

The connectivity is expanded to include the **connective tissue and fascial system **

Front 56

Know that cranial OMT can ↓ dizziness in Parkinson's Patients

Back 56

That is all...

Front 57

You might want to look at Beatty's nervous system lecture...

Back 57

I'm not gonna cover it...

Front 58

A patient presents with RIGHT sided sciatica symptoms. Pain is increased with straight leg test (+)

MRI confirms a right posterior herniation of the L5 disc. How should you set the patient up for Lumbar Sidebending ME?

Back 58

Patient must be laying on right side... Lift legs and have them try to push them back to the table

Front 59

1. List what psychiatric diagnoses are likely to involve somatization focused on the musculoskeletal system

Back 59

Personality Disorders – cluster B

Affective disorders – major depressive disorder, dysthymia, and minor depression

Schizophrenia – especially paranoid type

Anxiety Disorders – panic disorders, generalized anxiety disorder, OCD

Front 60

What is a psychosomatic (psychophysiologic) disorder?

Back 60

- this group of illnesses presents primarily as physical conditions that are affected by emotional factors.

They typically involve a single organ system and are usually associated with ***increased activity of the autonomic nervous system***

Symptoms result from physiologic changes that normally accompany certain emotional states, but these changes are more intense and sustained than normal.

Front 61

Describe the Psychosomatic pathway

Back 61

-ability of the segmental facilitation, found in association with spinal somatic dysfunction, to focus descending neurological impulses from increased cortical activity.

This produces segmental hypersensitivity to nociceptive stimuli, which in turn results in increased cortical awareness of structures, somatic and/or visceral, innervated by the facilitated segment.

It also explains how emotional distress, acting through descending pathways, can be directed by the facilitated segment to result in gastrointestinal hypermobility or bonchospasm, depending upon the anatomic level of the spinal cord facilitated.

Front 62

What is somatization?

Back 62

a defense mechanism, an automatic psychologic process that protects the individual from anxiety and the awareness of internal/external stressors or danger.

It is characterized by a physical complaint, not fully explained by an existent medical condition but severe enough to result in medical treatment or alteration in lifestyle.

Front 63

What symptoms must a patient display in order to be considered to have a somatization disorder?

Back 63

constellation of pain and GI, sexual, and pseudonerologic symptoms before age 30, and the condition must have been present for years.

Front 64

Special considerations when treating psychiatric patients with OMT?

Back 64

- HVLA should be avoided under most circumstances

- treatment should begin in the least painful areas

start with soft tissue and avoiding forceful procedures.

Front 65

What is a contraindication to OMT treatment in the psychiatric patient?

Back 65

OMT is contraindicated if the patient does not wish to be touched, or feels that the intervention is too uncomfortable.

Front 66

What is the connection with tension, OMT and psychiatric patients?

Back 66

tension (↑ stress) can make psychopathology worse

-OMT can release this tension

Front 67

As the physician proceeds with the intervention, the **emotional component** will eventually be released

-the patient may suddenly feel sad, angry or frightened or begin to cry, bringing repressed emotions into the present moment where they can be dealt with

Back 67

Awwww....

Front 68

In a pregnant patient, where does the center of gravity shift?

Back 68

COG shifts anteriorly

Front 69

What happens to lumbar lordosis and thoracic kyphosis during pregnancy?

Back 69

Both INCREASE

Front 70

Which thoracic segments become the area of transition between thoracic kyphosis and lumbar lordosis in the pregnant patient?

Back 70

T8-T11

Front 71

During pregnancy, what causes swelling of extremities and carpal tunnel syndrome?

Back 71

Increased Body Water

Front 72

Why does Pulmonary respiratory efficiency increase during pregnancy?

Back 72

Expanding uterus limits the excursion of the diaphragm

Pulmonary respiratory efficiency increases during pregnancy in compensation for the mechanical compromise of respiration.

Front 73

Sympathetics for Uterus? Parasympathetics?

Back 73

SNS: T10-11

PNS: S2-S4

Front 74

Sympathetics for Ovaries? Parasympathetics?

Back 74

SNS: T9-10

PNS: S2-S4

Front 75

TMJ Dysfunction:

What is Myofascial Pain Dysfunction (MPD)?

Back 75

i. Psychophysiologic disease primarily involving the muscles of mastication and frequently provoked by somatic dysfunctions elsewhere in the body***.

ii. This is the most common cause of TMJ pain.******

iii. The etiologic basis of the symptoms are ** muscular hyperactivity and dysfunction**

Front 76

Most common cause of TMJ Pain?

Back 76

Myofascial Pain Dysfunction (MPD)

Front 77

TMJ Dysfunction:

What is Internal Derangement Injury (ID) ?

Back 77

i. Abnormal relationship between the articular disc and the mandibular condyle.

ii. Caused by biomechanical problems within the TMJ. Mandibular muscle spasm is observed as a response to the dysfunction.

**Anterior disc displacement is the most common cause of ID**

Front 78

What is the most common cause of Internal Derangement Injury of the TMJ?

Back 78

Anterior disc displacement

Front 79

TMJ Dysfunction:

What is Degenerative Joint Disease (DJD)?

Back 79

i. Organic degeneration of the articular surfaces within the TMJ

ii. This is often secondary to microtrauma or macrotrauma of the disc, mandibular condyle or surrounding connective tissue.

Front 80

Patient presents with facial pain that is periauricular and worsened by chewing. They have jaw range of motion (ROM) restriction, jaw locking, jaw noise (clicking or popping), and headaches or neck pain. Ear-ache is also present.

Back 80

TMJ Problems

Front 81

Why is the TMJ described as the most complicated joint in the body?

Back 81

not only acts as a hinge joint but it also permits gliding movement, in which the condyle of the mandible slides along the squamous portion of the temporal bone.

Front 82

lateral deviation of the mandible, muscle hypertrophy, malocclusion of teeth and abnormal dental wear.

Back 82

TMJ Dysfunction

(Fun Fact: mandible will deviate on side of TMJ dysfunction)

Front 83

What is the imaging study of choice if articular or meniscal pathology is suspected in the TMJ?

Back 83

MRI

Front 84

Trigger points in what 3 muscles refer pain to the TMJ?

Back 84

lateral pterygoid
medial pterygoid
masseter muscles

Front 85

Where is the best place to feel for lateral deviation of the TMJ?

Back 85

TMJ is best palpated directly below the zygomatic arch, 1-2 cm anterior to the tragus.

The posterior aspect can be palpated through the external auditory canal.

Front 86

differential diagnoses for a patient with TMJ syndrome?

(just read)

Back 86

Dental infections
mandibular fractures
gout
pseudogout
rheumatoid arthritis
tension headaches
migraine headaches
otitis media
sinusitis
temporal arteritis
trigeminal neuralgia, postherpetic neuralgia

Front 87

What type of OMT does TMJ respond to in patients with trauma?

Back 87

soft tissue massage
MFR, ME,
counterstrain
osteopathy in the cranial field

Front 88

Treatment for Acute TMJ pain caused by clenched muscles?

Back 88

relieved by slightly stretching the joint capsule, which promotes relaxation of hypertonic muscles.

Front 89

What are some osteopathic considerations for Chronic TMJ Pain?

Back 89

-Multi-professional approach

-Soft food diet, chew slow with small bites

-Self massage, and excercises promoting proper jaw posture

-OMT to stabilize joint, restore function and motion

Front 90

What type of OMT does TMJ respond the best to?

Back 90

GENTLE OMT...

Front 91

What is the most important component of the holistic approach to GI health care?

Back 91

Nutrition

Front 92

_____ are a group of palpable nodular areas of tissue texture change that have a diagnostic and therapeutic significance.

Back 92

Chapman's Points

Front 93

How does ↑ sympathetic tone affect the GI system?

Back 93

- increases vascular tone

- decreases tissue perfusion and nutrient/O2 supply to tissues and thus increases the need for anaerobic glycolysis.

- relaxes the gallbladder and biliary ducts and decreases glandular secretions and peristalsis, producing constipation or ileus.

Front 94

How does ↑ parasympathetic tone affect the GI system?

Back 94

increases the secretion of digestive enzymes amylase and lipase.

- It also causes contraction of the gallbladder and biliary ducts and increased glandular secretions and peristalsis, producing diarrhea**

Front 95

4. How does circulatory stasis affect the GI system?

Back 95

decreases efficiency of fascial diaphragms and decreases tissue perfusion

Front 96

If OMT fails to relieve somatic dysfunction in the GI system, what should you consider?

Back 96

Viscerosomatic Etiology

Front 97

Stomach/Gallbladder/Liver

Sympathetics:

Parasympathetics:

Back 97

SNS: T5-T9

PNS: Vagus

Front 98

Small Intestines

Sympathetics:

Parasympathetics:

Back 98

SNS: T9-T11

PNS: Vagus

Front 99

Large Intestine/Rectum

Sympathetics:

Parasympathetics:

Back 99

SNS: T8-L2

PNS: Vagus (ascending) , S2-S4

Front 100

Know the Anterior Chapman's Points.... I'll cover those in the OPP Review cards...

Back 100

ok?

Front 101

remember that Kribs had a breech baby and they fixed it by...

Back 101

Balanced ligamentous tension to the sacrum

MFR to the abdomen/uterus

Front 102

OMT for people with Parkinson’s disease has been shown to:

****

Back 102

Improve gait
Reduce stiffness and rigidity
Reduce falls
Stabilize medication
Improve cranial somatic dysfunction
Improve mental status


(Note: Avoid ME in Parkinson's Patients d/t clonus and tremor ---> shit won't work..)

Front 103

what is the difference btw primary and secondary dysmenorrhea?

Back 103

rimary- (spasmatic) menstrual pain in the absence of pelvic disease- a diagnosis of exclusion. Affects up to 50% of females and has a classic history of:
-Earlier age at menarche
-Long menstrual periods
-Heavy menstrual flow

Secondary- (congestive) menstrual pain resulting from anatomic anomaly and/or definable pelvic pathology such as that seen in women with endometriosis or chronic pelvic inflammatory disease.
Average age 30-45 years.

Front 104

With billing and coding, there are 10 regions of the body used for somatic dysfunction assesment. What are they?

Back 104

head
cervical
rib
thoracic
lumbar
sacrum
pelvis
upper extremity
lower extremity
abdomen/viscera