1. Osteopathic Medicine
John M Lavelle, D.O.
Spine Physiatrist

2. Andrew Taylor Still, MD Conventional MD, Civil War
3 children died of spinal meningitis
Disillusioned with the medical care of the day
New philosophy of disease prevention
Unleash the body’s inherent ability to heal itself
“Search for health; anyone can find disease”
Studied anatomy and developed techniques
Began to identify the inter-relationship of structure and function

3. Osteopathic Medicine
The body is a unit; the person is a unity of body, mind, and spirit
The body is capable of self-regulation, self-healing, and health maintenance
Structure and function are reciprocally interrelated
Rational treatment is based upon an understanding of basic principles of body unity, self-regulation, and the interrelationship of structure and function

4. 1892 Inaugural Class of the American School of Osteopathy (Class included five women)

5. Definition of Osteopathic Medicine
“A system of medical care with a philosophy that combines the needs of the patient with the current practice of medicine, surgery, and obstetrics, with emphasis on the interrelationships between structure and function, and an appreciation of the body’s ability to heal itself.“ - Glossary of Osteopathic Terminology

6. What to Treat?
The first question becomes: Does the patient have a significant musculoskeletal component to their problem?
To obtain an answer:
-You need data from a musculoskeletal evaluation.
-You must assess this data in relation to the patient's problem.
If you identify musculoskeletal dysfunction (somatic dysfunction, code 739), and conclude that this dysfunction is associated with a patient problem or symptoms, you have established the indication for OMT

7. Somatic Dysfunction
An impaired or altered function of related components of the somatic (body framework) system: skin, fascia, muscle, arthrodial, and related vascular, lymphatic, and neural elements.

8. Conceptually, somatic dysfunction:
is a disturbance of the normal function of somatic structures.
possesses characteristics identifiable by means of palpation (TARt).
appears to be based on a neurophysiological phenomenon.
brings about deleterious effects on health when present.
is amenable to improvement by the application of manual forces to the soma in the form of OMT.

9. T.A.R.t. Tissue Texture Abnormality What does it feel like?
Palpable evidence of physiologic dysfunction.
Reflects disturbance in local tissues, related organs, or entire system
Found in skin, fascia, muscles
May reflect physiologic dysfunction of specific spinal segments
What does it feel like?

10. Identification of T.A.R.t.
ACUTE
CHRONIC
Temperature
Increased
Coolness
Texture
Boggy, rough
Thin, smooth
Moisture
Dry
Tension
Ropey, stringy
Tenderness
Greatest
Present, but less
Edema
Yes No
Erythema test
Redness lasts
Fades quickly

11. T.A.R.t. Asymmetry Visual Palpatory
** Treat dysfunction, not asymmetry.

12. T.A.R.t. - Quantitative - Qualitative - The Barrier Concept applies
■ Restriction of motion
- Passive vs active motion
- Quantitative
How much does it move?
- Qualitative
How well does it move?
- The Barrier Concept applies

13. T.A.R.t. - palpatory tenderness - subjective - not always reliable
- does NOT need to be present for somatic dysfunction diagnosis

14. Principles of Motion
H.H. Fryette, D.O. (a CCOM grad) first described the principles of physiologic spinal motion in the 1920’s.
These are the principles that we use today to describe typical spinal motion--both segmental and groups of segments.
The TWO principles he described are Principles I and II.

15. Fryette’s Principle I
When the spine is in neutral (absence of marked flexion or extension), and sidebending is introduced, a group (3 or more) of vertebrae rotate into the produced convexity.
Maximum rotation occurs at the APEX.
Rotation and sidebending occur to OPPOSITE sides.
Group (Type I) mechanics:
Rotation left Sidebending right

16. Fryette’s Principle II
When flexion or extension is sufficient to localize forces to a single segment (non-neutral position), rotation and sidebending occur to the SAME side.
The segment rotates into the produced concavity.
Single segment (Type II) mechanics.
Rotation and sidebending right

17. The Barrier Concept “Barrier” defines the limit of motion.
The Barrier Concept describes motion in a joint or in tissue in one plane.
A neutral point exists along with barriers.
The presence of somatic dysfunction will alter normal barriers and produce a pathologic neutral point.

18. The Barrier Concept Neutral point (point of maximum ease)
Physiological barrier (ACTIVE motion)
Anatomical barrier (PASSIVE motion)
In the absence of somatic dysfunction.

19. The Barrier Concept EX: somatic dysfunction
Restrictive barrier—change in range of motion.
Pathologic neutral now formed--a new point of ease (in the presence of somatic dysfunction).
Direct technique engages the restrictive (pathologic) barrier.
Indirect technique moves toward pathologic neutral.

20. The Barrier Concept
Describes the range of motion, or QUANTITY, of tissue motion.
The QUALITY, or Endfeel of motion, is perceived as an anatomic or physiologic barrier is approached.
Used to describe osteopathic manipulative techniques.

21. Palpation
Muscles are arranged so that the longest (extrinsic) muscles are the most superficial, the short muscles (intrinsic) are the deepest.
Long muscles are involved with postural patterns and group curves, but lack segmental specificity.
The deep intersegmental muscles are most involved with segmental dysfunction.

22. Palpation

23. Somatic Dysfunction

24. Somatic Dysfunction
Findings may include muscle hypertonicity, skin sensitivity and diffuse severe tenderness.
Palpable muscular tension may be related to cycle between inappropriate mechanoreceptor reporting and exaggerated muscular response which can maintain an inappropriate spinal reflex.
Local sympathetic hyperactivity exaggerates the muscle spindles response to changes in length3,4. Muscles innervated by these segments are kept in a hypertonic state with subsequent impediment to spinal motion.

25. FACILITATION
The facilitated segment is the physiologic cornerstone of somatic dysfunction. In segmental facilitation, a spinal segment receives exaggerated input from somatic or visceral structures.
Facilitation is the maintenance of a pool of neurons (internuncial) in a state of partial or sub-threshold excitation. Facilitation involves the general somatic nerves as well as the autonomics.1, 2, 3

26. Spinal Facilitation
Somatic dysfunction leads to prolonged inappropriate sympathetic bombardment
The maintenance of a pool of neurons in a state of partial or subthreshold excitation…less stimulation is required to trigger the discharge of impulses. 1, 2

27. Facilitation

28. Facilitation

29. Facilitation

30. Thought Process
Ultimately, you must come to a conclusion regarding the musculoskeletal findings. Are they significant?
Are they related to the patient's problem?
What was the probable etiology?
Are they related to other findings?
What are the probable effects of this dysfunction?
What is the expected outcome if the musculoskeletal findings are treated with OMT?

31. Finally, how do we treat? Direct techniques Indirect techniques
Soft Tissue
Myofascial Release
Muscle Energy
High Velocity/ Low Amplitude (HVLA)
Indirect techniques
Counterstrain
Facilitated Positional Release
Still Technique
Balanced Ligamentous Tension

32. Low Back Pain

33. Causes of LBP 97% MECHANICAL 2% REFERRAL FROM OTHER DISEASES
1% SERIOUS NON-MECHANICAL SPINAL CONDITIONS

34. MECHANICAL (97%) SOMATIC DYSFUNCTION SPONDYLOLISTHESIS 2%
<1% EACH
TRAUMATIC FRACTURE
SPONDYLOLYSIS
FACET SYNDROME
CONGENITAL
INSTABILITY
SPONDYLOLISTHESIS 2%
SPINAL STENOSIS 3%
COMPRESSION FX 4%
DISC HERNIATION 4%
INCLUDES CAUDA EQUINA
SPONDYLOSIS 10 %
DISC/BONE DEGENERATION
NONSPECIFIC/ IDIOPATHIC 70%
SOMATIC DYSFUNCTION

35. History Onset of Pain: acute or chronic?
Location of Pain: midline, lateralized?
Radiation of Pain: down one leg or both legs?
Strength: unilateral or bilateral loss of leg strength?
Loss of bowel or bladder control?
Type of pain: ache, burning, throbbing, Night Time?
Intensity of Pain
Parasthesia?

36. Observation Lordosis Scoliosis Pelvic Obliquity Pelvic tilt
Hair tuft (faun’s beard)
Lipoma
Step off deformity
Gait
-trendelenburg
-antalgic
-foot drop/slap
-circumducted

37. Palpation Spinous Process Transverse Process Interspinous ligaments
Sacrum
Associated anatomy of Hip and Pelvis
Paraspinal musculature
Abdominal musculature

38. Range of Motion Forward Flexion: 40 to 60 degrees
Extension: 20 to 35 degrees
Lateral Flexion: 15 to 20 degrees
Rotation: 3 to 18 degrees

39. Dermatomes L1: Groin and upper thigh L2: Mid and anterior thigh
L3: Lower anterior thigh
L4: Medial Malleolus
L5: Great toe and instep
S1: Lateral Foot
S2: Posterior Knee
S3:-S5: Concentric Circles about the anus.

40. Reflexes Patellar: L3-L4 Medial Hamstring: L5-S1 Achilles S1-S2
Superficial Abdominal: T7-L1
Beevor’s Sign: positive if the umbilicus moves during active quarter sit up.
Cremasteric Reflex: T12-L2
Anal Wink: S2-S4

41. Neurologic Testing LE

42. Reflexes

43. Diagnostics: Straight Leg Raise
Goal: To identify neurological impingement in the lumbar spine.
Patient Position: supine, with the leg being tested medially rotated and the knee extended.
Examiner Position: The examiner then flexes the hip until the patient complains of pain in the back or leg occurs.
Positive Findings: If the pain is primarily in the back, disc is more likely herniated centrally. If the patient’s pain is more radicular, the herniated disc is more likely herniated laterally. Also, the range of hip flexion for this condition is found between 35 and 70 degrees of flexion. If the hip is flexed to greater than 70 degrees before pain, then hamstring etiology must be ruled out.

44. Diagnostics: Well Leg Raise
Goal: To identify neurological impingement in the lumbar spine.
Patient Position: supine, with the asymptomatic leg medially rotated and the knee extended.
Examiner Position: The examiner then flexes the hip until the patient complains of pain in the back or leg occurs.
Positive Findings: Pain recurring in the back or symptomatic leg. This test helps to reinforce a positive straight leg raising test.

45. Diagnostics: Bowstring Test
Goal: To identify sciatic nerve irritation.
Patient Position: Supine, with the affected leg internally rotated.
Examiner Position: The examiner flexes the leg until pain is reproduced and then the knee is flexed until the pain is diminished. The examiner then pushes into the popliteal fossa.
Positive Finding: pain reproduced with palpation of the sciatic nerve.

46. Diagnostics: Hoover Test
Goal: To test for malingering.
Patient Position: Supine.
Examiner Position: The examiner places the hands under both heels. The patient is then instructed to lift ONE leg at a time.
Positive Findings: If the patient is attempting to lift one leg, downward pressure is unconsciously applied by the contralateral leg. If no downward pressure is felt, the patient may be malingering.

47. Diagnostics: Milgram Goal: to assess for intrathecal pathology
Patient Position: supine
Examiner Position: The examiner instructs the patient to raise both legs off the table approximately two inches. This position is held for 30 seconds.
Positive Findings: Inability to initiate or maintain position, or pain. Indicative of intrathecal or extrathecal pathology, or pressure on the spinal cord.

48. Diagnostics: Prone Knee Bending Test
Goal: To identify an upper lumbar nerve root lesion and/or femoral nerve root irritation.
Patient Position: Prone.
Examiner Position: The examiner passively flexes the knee to the buttock. If the patient cannot flex the knee, passive hip extension can be induced.
Positive Findings: Pain in the lumbar, buttock or posterior thigh for a upper lumbar lesion. Anterior thigh represents a possible irritation of the femoral nerve.

49. Diagnostics: Stork Test
Goal: to identify spondylolisthesis and/or facet joint pathology.
Patient Position: The patient stands on one leg and then extends the spine. This position is repeated with the other leg.
Positive Findings: pain in the back. A unilateral fracture is indicated when pain is localized to one side with standing.

50. Diagnostics: Slump Test
Goal: to assess for neurodynamic tension.
Patient Position: Seated with the legs hanging over the edge of the table, the hips in neutral position, and the hands placed behind the back.. The patient is then put in a sequential series of positions.
1: The patient is asked to slump forward into thoracic and lumbar flexion, while the cervical spine is held in a neutral position.
2: The examiner pushes down on shoulders to maintain flexion while the patient actively flexes the cervical spine.
3: The examiner then applies pressure on the head to maintain cervical flexion while the patient is instructed to actively extend the knee. With the examiners caudad hand, passive dorsiflexion is initiated.
The test is repeated with the other leg, and finally, with both legs.
Positive Findings: reproduction of pain when the knee is extended, and symptoms are decreased when the cervical spine is extended, or increased symptoms when the patient is positioned are indicative of tension in the neuromeningeal system.

51. DIAGNOSTIC TESTING
X-Ray/MRI if Red Flag or if index of suspicion is high enough.
MRI or CT if severe neuropathy; when tumor, fracture or infection are strongly suspected or unimproved sciatica > 4 weeks

52. Disc Protrusion

54. Demonstration

55.
Vote

56. References
1. Patterson, M.M., “A Model Mechanism For Spinal Segmental Facilitation.” JAOA, Vol. 76, 4-14, 1976.
2. Korr, I. M.: “Sustained Sympathicotonia as a Factor in Disease.” In: The Collected Papers of Irvin M. Korr. Edited by Barbara Peterson. Copyright 1979, A.A.O., second printing, 1988, pp
3. Passatore M., Grassi C., and Flippi G. M.: “Sympathetically-induced Development of Tension in Jaw Muscles; the Possible Contraction of Intrafusal Muscle Fibers.” Pflugers Arch. 405: , 1985.
4.Passatore M., Filippi G. M., Grassi C.: Cervical Sympathetic Nerve Stimulation Can Induce an Intrafusal Muscle Fiber Contraction in the Rabbit. In: The Muscle Spindle (Boyd, I.A. and Gladden, M.H. Eds), , Macmillan, Basingstoke & London, 1985.
5.Kuchera M., Kuchera, W., Osteopathic Considerations in Systemic Dysfunction. Kirksville: KCOM Press, 1991.
6.King et al. Osteopathic manipulative treatment in prenatal care: a retrospective case control study. J Am Osteopath Assoc. 2003; 103(12):