1. OMT EVALUATION Dr. Asif Islam PT,SMC,UOS.

2. Goals of the OMT evaluation  The OMT evaluation is directed toward three goals: 1) Physical diagnosis  To establish a physical, or biomechanical, diagnosis. 2) Indications and contraindications  To identify indications and contraindications to treatment. 3) Measuring progress  To establish a baseline for measuring progress.

3. Diagnosis: “determination of the nature of a cause of a disease”. Medical diagnosis: “Diagnosis based on information from sources such as findings from a physical examination, interview with the patient or family or both, medical history of the patient and family, and clinical findings as reported by laboratory tests and radiologic studies”. Clinical diagnosis: “Diagnosis based on signs, symptoms, and laboratory findings during life”. Differential diagnosis: “the determination of which one of several diseases may be producing the symptoms”. Radiological diagnosis

4. Physical diagnosis “diagnosis based on information obtained by inspection, palpation, percussion, and auscultation”. Diagnosis based on a physical examination of a patient.  refinement of the medical diagnosis and the functional status  The physical diagnosis is based on a model of somatic dysfunction that assumes a highly interdependent relationship between musculoskeletal symptoms and signs.

5.  In the presence of somatic dysfunction, there is a correlation between the patient's musculoskeletal signs and the production, increase, or alleviation of symptoms during a relevant examination procedure.  Musculoskeletal conditions that respond well to treatment by manual therapy typically present with a clear relationship between signs and symptoms.

6.  An OMT evaluation that shows no correlation between signs and symptoms  usually indicates that the patient's problem originates from outside of the musculoskeletal system  so that mechanical forms of treatment such as manual therapy are less likely to help.

7.  The manual therapist confirms the  initial physical diagnosis of somatic dysfunction with a low-risk trial treatment as an additional evaluation procedure.  For example, traction is the most common trial treatment for a joint hypomobility.  If the trial treatment does not alleviate symptoms or if symptoms are worsened, further evaluation is necessary and a different trial treatment is tested.

9. Indications and contraindications  Indications  Indications for treatment by manual therapy are based more on the physical diagnosis than on the medical diagnosis.  Restricted joint play (hypomobility)  an abnormal end-feel are the most important criteria for deciding if mobilization is indicated. Grade III stretch mobilization is indicated when a movement restriction (hypomobility) has an abnormal end-feel and appears related to the patient's symptoms.

10.  Hypomobility presenting with a normal end-feel and no symptoms, is not considered pathological, so not treated.  In such cases, the movement restriction is either due to a  congenital anatomical variation,  Or the symptoms in that area are referred from another structure.

11.  In patients who cannot yet tolerate examination or specific treatment with a biomechanically significant force,  within-the slack (Grades I-IISZ), mobilizations and other palliative modalities provide short -term symptom relief.  These symptom control treatments are primarily used as a temporary measure to prepare a patient to tolerate further specific examination or more intensive treatments (for example, a Grade III stretch movement) that will produce a more lasting effect.

12.  In patients with hypomobility due to muscle spasm in the absence of tissue shortening, relaxation mobilizations in the Grade I - II range are generally effective.  In the presence of excessive joint play (hypermobility), stabilizing (limiting) measures are indicated and Grade III stretch mobilization is contraindicated.

13. Contraindications for Mobilization  Inflammatory arthritis  Malignancy  Tuberculosis  Osteoporosis  Ligamentous rupture  Herniated disks with nerve compression  Bone disease  Neurological involvement  Bone fracture  Congenital bone deformities  Vascular disorders  Joint effusion May use I & II mobilizations to relieve pain

14. Specific contraindications to Grade III stretch mobilization  techniques include: » decreased joint play with a hard, nonelastic end-feel in a hypomobile movement direction  » increased joint play with a very soft, elastic end-feel in a hypermobile movement direction  » pain and protective muscle spasm during mobilization  » positive screening tests, for example, pain induced by compression tests

15. Measuring progress Changes in a patient's condition are assessed by monitoring changes in one or more dominant symptoms and comparing these changes with routine screening tests and the patient's dominant signs. Symptoms in the spine may include pain, changes in sensation, a feeling of greater strength or ease of motion, or reduced fatigue. Physical signs of spinal origin may include altered joint play, range of movement, reflexes, or changes in muscle performance.

16.  Periodic reassessment of the patient's chief complaints and dominant physical signs during a treatment session guides treatment progression.  If reassessment reveals normalization of function (e.g., mobility) along with decreased symptoms, Then treatment may continue as before or progress in intensity.

17.  When reassessment during a treatment session indicates that function is not normalizing  or that symptoms are not decreasing, be alert to the need for further evaluation to determine a  more appropriate technique,  positioning,  direction of force,  or treatment intensity.

18. Elements of the OMT evaluation

20.  4. Palpation (Includes tissue characteristics, structures)  5. Neurologic  and vascular examination  C. Medical diagnostic studies (Includes diagnostic imaging, lab tests, » Diagnostic imaging (e.g., X-ray, bone scan,  CT scan, MRI)  » Laboratory tests (e.g., analysis of blood and other body  fluids)  » Electrodiagnostic tests (e.g., EMG, NCS)  » arthroscopy, arthroplasty  » Punctures (e.g., biopsy, aspiration)

21.  For instance, before treating a patient who is unable to flex the lumbar spine, you must first determine if the limitation is due to  pain (e.g., lumbar radiculopathy),  hypomobility e.g., soft tissue contracture,  intraarticular swelling,  disc herniation,  nerve root adhesion,  weakness (e.g., peripheral neuropathy, primary muscle disease),  or a combination of those disorders.

22. D.D FOR OMT  The OMT practitioner must make three major differential diagnostic decisions when evaluating spinal somatic dysfunction:  » Determine whether the somatic dysfunction is primarily in the segment (e.g., the "anatomical joint") or associated soft tissues, including neural structures.  » Determine if joint hypo- or hyper-mobility is present, and whether it is pathological (i.e., associated with an abnormal end-feel.  » Determine whether treatment should be directed toward  pain control  or biomechanical dysfunction.

23. Diagnosis and trial treatment  Through the physical examination the therapist correlates the  patient's signs with their symptoms.  A relationship between musculoskeletal signs and symptoms suggests a mechanical component to a problem that should respond well to treatment by manual therapy.

24.  Before initiating a treatment plan, you should be confident in your answers to the following questions.  » Is there good correlation between the history and the physical exam?  » What is the patient's diagnosis (i.e., source of symptoms, mechanism of symptoms, contributing factors)?  What are the treatment priorities?  » Do I have enough information to begin treatment  or should I reexamine the patient?  Should I refer this patient for further evaluation?

25.  » What is the prognosis?  Can I help this patient?  What treatment do I have to offer?  » Are there precautions or contraindications to treatment?  » What is the patient's experience and understanding of their problem?  What is the impact of this problem in their life?  What are their expectations of treatment?

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