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

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Presentation on theme: "Osteopathic Medicine Osteopathic Medicine John M Lavelle, D.O. John M Lavelle, D.O. Spine Physiatrist."— Presentation transcript:

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

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

3 Osteopathic Medicine Osteopathic Medicine The body is a unit; the person is a unity of body, mind, and spirit 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 The body is capable of self-regulation, self-healing, and health maintenance Structure and function are reciprocally interrelated 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 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? The first question becomes: Does the patient have a significant musculoskeletal component to their problem? To obtain an answer: To obtain an answer: -You need data from a musculoskeletal evaluation. -You need data from a musculoskeletal evaluation. -You must assess this data in relation to the patient's problem. -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 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. 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. is a disturbance of the normal function of somatic structures. possesses characteristics identifiable by means of palpation (TARt). possesses characteristics identifiable by means of palpation (TARt). appears to be based on a neurophysiological phenomenon. appears to be based on a neurophysiological phenomenon. brings about deleterious effects on health when present. 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. 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 Tissue Texture Abnormality Palpable evidence of physiologic dysfunction. Palpable evidence of physiologic dysfunction. Reflects disturbance in local tissues, related organs, or entire system Reflects disturbance in local tissues, related organs, or entire system Found in skin, fascia, muscles Found in skin, fascia, muscles May reflect physiologic dysfunction of specific spinal segments May reflect physiologic dysfunction of specific spinal segments What does it feel like? What does it feel like?

10 Identification of T.A.R.t. ACUTECHRONIC TemperatureIncreasedCoolness Texture Boggy, rough Thin, smooth MoistureIncreasedDry TensionIncreased Ropey, stringy TendernessGreatest Present, but less EdemaYesNo Erythema test Redness lasts Fades quickly

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

12 ■ 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. ■ tenderness - 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. 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. Maximum rotation occurs at the APEX. Rotation and sidebending occur to OPPOSITE sides. Rotation and sidebending occur to OPPOSITE sides. Rotation left Sidebending right Group (Type I) mechanics:

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. “Barrier” defines the limit of motion. The Barrier Concept describes motion in a joint or in tissue in one plane. The Barrier Concept describes motion in a joint or in tissue in one plane. A neutral point exists along with barriers. A neutral point exists along with barriers. The presence of somatic dysfunction will alter normal barriers and produce a pathologic neutral point. 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) Neutral point (point of maximum ease) Physiological barrier (ACTIVE motion) Physiological barrier (ACTIVE motion) Anatomical barrier (PASSIVE 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. Restrictive barrier—change in range of motion. Pathologic neutral now formed--a new point of ease (in the presence of somatic dysfunction). Pathologic neutral now formed--a new point of ease (in the presence of somatic dysfunction). Direct technique engages the restrictive (pathologic) barrier. Direct technique engages the restrictive (pathologic) barrier. Indirect technique moves toward pathologic neutral. Indirect technique moves toward pathologic neutral.

20 The Barrier Concept Describes the range of motion, or QUANTITY, of tissue motion. 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. The QUALITY, or Endfeel of motion, is perceived as an anatomic or physiologic barrier is approached. Used to describe osteopathic manipulative techniques. 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. 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. Long muscles are involved with postural patterns and group curves, but lack segmental specificity. The deep intersegmental muscles are most involved with segmental dysfunction. The deep intersegmental muscles are most involved with segmental dysfunction.

22 Palpation

23 Somatic Dysfunction

24  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 length 3,4. 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? Ultimately, you must come to a conclusion regarding the musculoskeletal findings. Are they significant? Are they related to the patient's problem? Are they related to the patient's problem? What was the probable etiology? What was the probable etiology? Are they related to other findings? Are they related to other findings? What are the probable effects of this dysfunction? What are the probable effects of this dysfunction? What is the expected outcome if the musculoskeletal findings are treated with OMT? What is the expected outcome if the musculoskeletal findings are treated with OMT?

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

32 Low Back Pain

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

34 MECHANICAL (97%) <1% EACH <1% EACH TRAUMATIC FRACTURE TRAUMATIC FRACTURE SPONDYLOLYSIS SPONDYLOLYSIS FACET SYNDROME FACET SYNDROME CONGENITAL CONGENITAL INSTABILITY 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? Onset of Pain: acute or chronic? Location of Pain: midline, lateralized? Location of Pain: midline, lateralized? Radiation of Pain: down one leg or both legs? Radiation of Pain: down one leg or both legs? Strength: unilateral or bilateral loss of leg strength? Strength: unilateral or bilateral loss of leg strength? Loss of bowel or bladder control? Loss of bowel or bladder control? Type of pain: ache, burning, throbbing, Night Time? Type of pain: ache, burning, throbbing, Night Time? Intensity of Pain Intensity of Pain Parasthesia? Parasthesia?

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

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

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

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

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

41 Neurologic Testing LE

42 Reflexes

43 Diagnostics: Straight Leg Raise Goal: To identify neurological impingement in the lumbar spine. Goal: To identify neurological impingement in the lumbar spine. Patient Position: supine, with the leg being tested medially rotated and the knee extended. 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. 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. 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. Goal: To identify neurological impingement in the lumbar spine. Patient Position: supine, with the asymptomatic leg medially rotated and the knee extended. 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. 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. 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. Goal: To identify sciatic nerve irritation. Patient Position: Supine, with the affected leg internally rotated. 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. 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. Positive Finding: pain reproduced with palpation of the sciatic nerve.

46 Diagnostics: Hoover Test Goal: To test for malingering. Goal: To test for malingering. Patient Position: Supine. 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. 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. 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 Goal: to assess for intrathecal pathology Patient Position: supine 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. 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. 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. Goal: To identify an upper lumbar nerve root lesion and/or femoral nerve root irritation. Patient Position: Prone. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 MRI or CT if severe neuropathy; when tumor, fracture or infection are strongly suspected or unimproved sciatica > 4 weeks

52 Disc Protrusion

53

54 Demonstration

55 www.brownforussenate.com 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.77-89. 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: 297-304, 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), 221-226, 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): 577-582


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