PPC/OMM Exam 1
centered on "holistic patient oriented care"
centered on "disease" or symptoms
Celtic healing practitioners who used manual therapy as an integral part of their care
(royal family down to smallest hamlet used bone setters"
ex. the Sweet family of New England 1830s in the Northeast emigrated in the 1850s to the West
Andrew Taylor Still
Born 1828, Died 1917
Researched for 10 years, 1874 osteopathy officially began
Founded the first American school of Osteopathy in 1892
First school of osteopathy was titled? where? and in what year?
American School of Osteopathy in Kirksville (ASO)
Roots of the word Osteopathy
Pathos (or) pathine- to suffer
Official Osteopathic Emblem
The Staff of Asclepius
(more associated with healing than the Magical Staff of Hermes
John Martin Littlejohn
Both a DO and MD
Treated by AT Still in 1897
Founded Chicago School of Osteopathy in 1900
Began ASO training in 1898 and graduated in 1900
Moved to England in 1913 and began the BSO in 1917
Founder of Chiropractic (opened his first school in Davenport, Iowa in 1897)
1895 received first adjustment, visited Kirksville prior to opening his first school
Maintenance of static or constant conditions in the internal environment
The level of well-being of an individual maintained by internal physiologic harmony that is the result of a relatively stable state of equilibrium among the interdependent body functions
Remaining stable by being variable
Coined by McEwen and Stellar in 1993
The physiological costs of chronic exposure to fluctuating or heightened neural or neuroendocrine response that results from repeated or chronic stress.
(It is used to explain how frequent activation of the body's stress response, essential for managing acute threats, can damage the body in the long run)
4 Tenets of Osteopathic Philosophy
1. The body is a unit
2. The body possesses self-regulatory, self-healing,
and health maintenance mechanisms
3. Structure and function are reciprocally interrelated.
4. Rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.
Osteopathic Philosophy and Principles (where they derived the 4 tenets from)
- Man is Triune in nature consisting of body, mind and spirit.
- The body is a unit.
- Structure & Function are reciprocally interrelated.
- The body possesses self-regulatory mechanisms.
- The body has the inherent capacity to defend and repair itself.
- When normal adaptability is disrupted, or when environmental changes overcome the body’s capacity for self-maintenance, disease may ensue.
- Movement of body fluids is essential to the maintenance of health.
- The nerves play a crucial part in controlling the fluids of the body.
- There are somatic components to disease that are not only manifestations of disease but also are factors that contribute to maintenance of the diseased state.
There are somatic components to disease that are not only manifestations of disease but also are factors that contribute to maintenance of the diseased state.
The somatic components which Osteopathic physicians look for and treat are called somatic dysfunction
Host + Disease = Illness
Allopathic Care focuses on (in reference to rational treatment)...
Osteopathic Care focuses on (in reference to rational treatment)...
What we look for AND treat
Impaired or altered function of related components of the somatic system (body framework) : skeletal, arthroidal, and myofascial structures, and related vascular, lymphatic and neural elements (somatic components of disease that are manifestations of the disease but also lead to maintenance of the disease state)
Appear to be based on neurophysiologic phenomenon
Diagnostic Criteria for Somatic Dysfunction
Tissue texture changes
Asymmetry of structure
Restriction of motion
tenderness to palpation (least noteworthy)
First question to ask yourself when figuring out what to treat
Does the patient have a significant musculoskeletal component to their problem?
How to answer the question of "what to treat"
Need data from a musculoskeletal eval and assess data in relation to the patients problem
If you identify musculoskeletal/somatic dysfunction (remember TART) and relate it to the pt.'s problem, you have indication for OMT
Classification of Somatic Dysfunction
Duration: Acute vs. Chronic
Etiology Primary (usually traumatic) vs. Secondary (compensation for primary or MSK problem)
Motion name the dysfunction by what motion remains, or what direction the structure can still move towards
Location Single Component- single vertebral unit (i.e. rib, fibular head, inominate at SI joint), Multiple Component- several vertebrae in a group (i.e. tarsal bones, pelvic girdle), Abdominal/Pulmonary
Tissue Texture Change
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
Acute vs. Chronic
See chart in ppt for more details
Asymmetry of Structure
Restriction of Motion
Asymmetry and restricted range of motion occur as a result of somatic dysfunction that creates a restrictive barrier
Motion loss is maintained by the restrictive barrier
Passive vs Active motion
Quantitative-How much does it move
Qualitative-How well does it move?
The Barrier Concept applies
Tenderness to Palpation
Subjective, not always reliable and doesnt need to be present for somatic dysfunction diagnosis.
Acute Tissue Changes
Articular mobility-sluggish, guarded motion, range restricted
Myofascial-flaccidity then contraction
Vascular-heat, erythema and/or edema
Neural-skeletal pain, (visceral irritation)
Chronic Tissue Changes
Mobility-limited range, quality good
Vascular-constriction (cool, dry, blanched)
Neural-tenderness, paresthesia , itching, sympathicotonia , visceral effects
The Barriers Concept
Limitation of motion described in a joint or in tissue in 1 plane
A neutral point exists along with barriers
The presence of somatic dysfunction will alter normal barriers and produce a pathologic neutral point
The range of normal active motion occurs between the physiologic barriers
A normal joint has a midline or neutral point within its range of motion
The limit to motion (bind vs. ease)
Bind-Restriction in one direction
Ease-Freer motion in other direction
End point of normal physiologic motion
The range of normal active motion occurs between the physiologic barriers
End point of permitted passive motion
Motion beyond the anatomic barrier damages anatomic structures
End point of permitted motion in somatic dysfunction
Also known as pathologic barrier
Movement toward the restrictive barrier exhibits bind
Goal of OMT
Is to restore homeostasis utilizing concepts of the unity of the living organism’s structure (Anatomy), and function (Physiology) and using the art of medicine and surgery in all of its branches & specialties.
The therapeutic application of manually guided forces by an Osteopathic Physician to improve physiologic function and /or support homeostasis.
Positioning in the direction of the restrictive barrier
Activating force is applied
Movement through restrictive barrier
eg. drawer analogy/yanking the drawer
Positioning away from restrictive barrier
Move tissues in a direction that is freer
Release by inherent forces
Components of a General History
Subjective, ok to use quotation marks
OLD CARTS (if pain complaint)
C- character/characteristics, how they describe the pain
A- aggravating/alleviating factors
R- radiating/relevant lab value
T- tx tried
S- severity 1-10 scale, intermittent vs. chronic
Associated information- was there an injury? has this happened before? if so, what was done for you? was it effective?
Immediately relevant ROS in HPI
use 8 attributes of a symptom!!!
medical conditions (with onset if known), hospitalizations, immunizations, and preventative health
Where do secondary dx typically come from
Who, what, when, where, why, what is relevant
Mom, dad, sister, brother, children
Ages (and ages at time of death)
Include genetic testing here
FED TACOS (food, exercise, drugs, tobacco, alcohol, caffeine, occupation, sexual hx)
illicit drugs*, tobacco*,alcohol consumption*,occupation*
Not always relevant: diet, exercise, caffeine, sexual hx, travel hx
Name, dose, compliance
OTC and herbals
orals, injectables, transdermals,
Allergy AND rx
APPROPRIATE INFO FROM EACH SYSTEM
Average Life Expectancy
US 79.38 (ranked #53)
Leading Causes of Death
Preventable Causes of Death
Heart Disease Tobacco
Respiratory Diseases Infectious Diseases
Diabetes Car Accidents
Age appropriate screenings
- blood pressure
- colon cancer
- weight problems
- sexually transmitted infections (STIs)
and incorporate into the plan
Economic Importance of Prevention
Every $1 spent on immunization saves $16.50 in medical costs and indirect costs, such as disability.
´Every $10 bike helmet generates $570 in benefits to society.
Visual acuity-as early as age 3
Colon cancer-age 50 or sooner depending on family history
Pap-beginning at age 21 and ending at age 65
AAA (abdominal aortic aneurysm)-age 65 for men
´Prostate cancer?- age 55-69...present info and let pt. choose
CC, HPI, ROS
Physical Exam (list general survey WD/WN/NAD and exams you have done/deferred): general appearance, vital signs; system headings, osteopathic findings, labs and diagnostic testing
Differential Dx in order of likelihood; Most likely to least likely (minimum of 3 possible dx that directly relate to the chief complaint; more is better)
Secondary Dx: tobacco or alcohol abuse, other chronic medical problems not related to the visit, health maintenance risk factors/counseling on them
What you need to find out: Labs, X-rays or other tests.
What you need to do:
1. Medications-name dose, frequency, etc.
2. Procedures (including OMT with type of technique performed or planned). Procedure notes go here for procedures done during visit.
4. Patient education (e.g. pathophysiology of condition, health counseling)
What they need to do:
1. Return (follow-up)
2. Understand/Humanism (e.g. Patient voices understanding and agreement with above plan. Patient has insurance to help with costs and good support system. Work accommodations/note/etc.)
Functions of Skin
Protects against penetration of external microbes and/or foreign substances
Helps regulate body fluid loss
Helps regulate body temperature
Contains nerve endings and sensory receptors
Affects vitamin D conversion
5 Layers of the Edermis
4-5 layers depending on where the skin is found (thick skin vs. thin skin)
Stratum corneum (top)
Stratum lucidum (thick vs. thin)
Stratum basale (bottom)
(Acronym: Come, Let's Get Some Bitches)
2 Layers of the Dermis
Indications for Total Body Skin Exam
Personal history of skin cancer
Increased risk for melanoma
Changing or concerning skin lesions
Undiagnosed skin condition in a new patient
Follow-up for patient’s who have extensive skin conditions
Describe the size, shape, color, border, arrangement, and distribution
Develop as the primary skin lesion(s) evolves (i.e. scale, crust, erosion, ulcer, fissure, atrophy)
Circumscribed flat lesion
Less than 10mm diameter
Flat and non-palpable
10mm or greater diameter
Elevated, circumscribed, solid palpable lesion
Less than 10mm diameter
Elevated, superficial lesion containing serous (clear) fluid
Less than 10mm in diameter
Circumscribed and elevated lesion containing serous (clear) fluid
10mm or greater in diameter
Superficial and elevated lesion containing purulent fluid
Firm, elevated, circumscribed
Different books vary in what size defines this lesion
Usually 0.5 or 1 cm – 2cm
Solid and elevated lesion
Diameter greater than 2cm
Elevated and circumscribed lesion with flat top surface
10mm or greater diameter
Transient firm plaque caused by fluid infiltration into dermis
Size can vary
Excess of dead epidermal cells
Dried cellular debris and serum
Focal area of epidermal skin loss
Focal area of epidermal and dermal skin loss
Sharply defined loss of epidermis and dermis in linear fashion
erythematous periphery with central clearing to some extent
Widespread 2-3mm evenly pigmented tan/brown macules w/irregular but well-defined borders
Brown evenly pigmented annular macule (or patch if >10mm) with irregular but well defined borders
Scattered red papules with even and well-defined border
Discrete soft tan pedunculated papules
ABCDEs of Melanoma
Takes a column down to the subq layer
Excisional Biopsy and Excision Removal
Electrodessication and Curettage
Usually destroy warts, the OTC doesn’t work as well because it doesn’t get the skin cold enough, fast enough
Sensitivity to sensations originating inside the body
Feeling through the development of psychomotor skills
See the structures that you are palpating by having a thorough knowledge of the anatomy
Create a visual mind-image
Analysis and Interpretation
Thinking and Knowing
Must be correlated with a knowledge of functional anatomy, physiology, and pathophysiology.
Practice to know the difference between normal and abnormal
The application of fingers to the surface of the skin or other tissues, using varying amounts of pressure, to selectively determine the condition of the parts beneath
Which part of the body is best/most sensitive to skin and temperature
Dorsum of the hand
Which part of the body is best/most sensitive for palpation
Pads of the fingers (thumb and first 2 fingers most sensitive)
Sensitive to pressure and vibration
Textures smaller than 200um can be sensed on the finger tips due to these (rapidly adapting –Phasic)
Sensitive to light touch and very sensitive to vibration (rapidly adapting)
sensitive to vibration (slow adapting)
Receptive to sustained response to pressure
Sensitive to stretch
Register degree changes in joint position,and register thermal changes and can register for prolonged periods of time
Krause End Bulbs
Receptor for vibration
Resitance to deformation (i.e. hydrated-returns to normal position almost immediately vs. dehydrated- “tents”-keeps deformed shape longer than expected.)
brought about by the D.O.
movement done to the subject
performed by the subject
deliberate, conscious, muscular activity
activity unconsciously generated within the body
can be perceived at 1 micron!
ex: respiration, circulatory or electrical patterns