Osteopathic Principles & Practice, Term 2

Variables that predict 50% improvement in LBP

Age less than 40 Positive prone instability testing ∙Shows that patient has enough muscle strength to continue rehabilitating spine Presence of aberrant movements with motion testing ∙Any movements, even if they are in the wrong direction shows that the patient will show better improvement overtime. Straight leg raise greater than 91 degrees without radicular symptoms

The Allostatic Response

Allostasis is similar to homeostasis but homeostasis is more chemical and specific and allostasis is more holistic Allostasis has to do w/ things we can and can't control Generalized adaptive rxn to stress Compensation: ∙Postural ∙Mechanical ∙Metabolic Decomposition ∙Histopathological ∙Autonomic ∙Pain CNS implications/the neuro-endocrine-immune connection ∙Stress → CRH → ACTH → Cortisol ∙Stress changes hormones, which will change the level of cortisol ∙Cortisol can change the muscles, the mood, appetite, how the body metabolizes things, etc.

Patterns and Postures Emergy

Consider gears moving in different directions, resulting in imbalance

Integrative medicine "diseases" involve many different musculoskeletal functions

Having our background in Osteopathic Medicine, we are in a great position to use this area of medicine

Muscle Spindle Reflex

Mechanism for sensori-motor control = coupling between proprioceptive sensory feedback and motor command Muscle spindles relay sensory information on length and rate of changes in length of a muscle Force-producing muscle consists of extrafusal fibers innervated by alpha motor neurons (alpha efferents) ∙These are the major muscle fibers that cause contraction Muscle spindles consist of intrafusal fibers innervated by gamma motor neurons (gamma efferents) ∙The intrafusal fibers behave differently than the extrafusal fibers ∙These are parallel to extrafusal fibers and stretch with them ∙They contain nuclear chain, dynamic, and static nuclear bag fibers →Relay sensory information on length and rate of changes in length of muscle →Information is transmitted by Group Ia and Group II afferents back to the spinal cord The excitability of the muscle spindles is regulated by the activity of the gamma motor neurons ∙Ex: The gamma motor neurons serve as the thermostat →If a thermostat is increased it gets hotter →Likewise, when a gamma motor neuron is taut it causes muscle contraction ∙When gamma motor neurons fire, they cause the intrafusal muscle fibers to contract →This controls the resting tone ∙This makes the spindle more taut, which increases the overall excitability of the spindle (increasing the afferent discharge rate) ∙Spinal interneurons are involved that can increase or decrease activity of this reflex →They can be inhibitory or excitatory

Holistic medicine is defined slightly differently than integrative medicine

Medical care that views physical and mental and spiritual aspects of life as closely interconnected and equally important approaches to treatment ∙Physicians normally focus on the body ∙However, there is something more to the machine that is the human body, and holistic medicine incorporates these aspects So, Integrative Holistic Medicine is the art and science of healing that addresses care of the whole person: body, mind, and spirit

Before beginning any exercise program a clear diagnosis and elimination of potentially serious conditions is important

Medical red flags ∙Cauda Equina Syndrome ∙Back-related infection ∙Spinal compression fraction ∙Abnormal aneurysm These conditions require immediate referral and treatment NOT exercise

Other types of medicine

Mind-body medicine ∙It involves meditation practice and counseling Lifestyle medicine ∙This involves healthy eating and exercise therapy individualized for each patient Massage Chiropractic Rolfing Alexander therapy Ayurvedic medicine (a traditional approach from India) Yoga

Success of Counterstrain Treatment

Most effective if 100% of the pain is alleviated with positioning If the level 10 assigned pain is reduced to a 3 post-treatment, you can assume that you reduced 70% of the pain in 90 seconds

Muscle control requires constant sensory receptor feedback

Muscle spindles Golgi tendon organs Both have similar functions - both provide the body info about change of rate in the length of the stretch ∙Helps with proprioception and protecting body from mechanical injury But the way the muscle spindles and golgi tendon organs work is very different

Fast Aδ fibers

Nerve fiber that is most specific for location of nociception Use glutamate as the neurotransmitter Terminate mainly in the lamina marginalis of the dorsal horns The signal excites second-order (second order = second neuron in the pathway, there has been a synapse already in the pathway) neurons which immediately decussate (cross over) and travel to the thalamus, terminating in the ventrobasal complex Travel along neospinothalmic tract More information makes the signal clearer: ∙When only a-delta pain fibers are activated, the pain can be localized to within 10 cm When coupled with tactile receptors, the pain is nearly exactly localized

Dorsal Horn Circuitry Plasticity

Neurons in the dorsal horn display an adaptive plasticity in response activities related to afferent input from PANs Initially show an increased activity with exposure to constant stimuli termed "wind-up" ∙This will resolve with cessation of stimuli Prolonged exposure to stimuli leads to central sensitization that outlasts stimuli ∙This can progress to long term potentiation Long term potentiation/sensitization mechanisms: ∙Protein kinase activation with subsequent phosphorylation leads to changes in genetic expression →This is called transcription dependent sensitization →Changes in how DNA is expressed ∙Surrounding inhibitory interneurons can be depressed →Prolonged sensitization can cause loss of inhibitory cells ∙Rearrangement of synaptic connections also leads to reinforcement of long term sensitization →New connections are made and they can be part of sensitization process

Muscle firing patterns

Normal firing pattern is most efficient and effective use of muscles Abnormal firing patterns compensate and still accomplish the required motion, but in a dysfunctional fashion Facilitated hypertonic postural/tonic muscles fire quickly Inhibited dynamic/phasic muscles no longer participate in principle movement patterns Example: Hip extension (assessed prone) (Know this motion) ∙Normal sequence of firing in hip extension: (This can be tested on a pt.) →Hamstrings →Gluteus maximus →Contralateral lumbar erector spinae →Ipsilateral lumbar erector spinae ∙Abnormal: result of imbalance in the normal system →Over-activation of hamstrings and ipsilateral erector spinae →Contralateral erector spinae do not fire at all →Delayed or absent contraction of gluteus maximus (part of Dynamic/Phasic group - reciprocally inhibited) →May result in sacral problems ∙Poorest pattern →Thoracolumbar extensors or shoulder muscles initiate hip extension →Delayed or absent gluteus maximus contraction ∙These dysfunctions in hip extension lead to: →Anterior pelvic tilt: pelvis rotates anteriorly (upper lumbar muscles and hamstrings are tight + abdominals turned off) →Lumbar hyperlordosis with hip extension →Inability to maintain knee extension suggests hamstring dominance →Hypertonicity of hamstrings with increased bulk →Hypertonicity of thoracolumbar extensors with asymmetrical increased bulk →Atrophy of gluteus maximus

Segmental Facilitation

Not just one neuron → a whole segment of neurons The maintenance of a pool of neurons (i.e. motor neurons) in a state of partial or sub-threshold excitation Less afferent input is required to trigger the discharge of impulses May be due to sustained increase of afferent input, or changes w/in affected neurons themselves, or their chemical environment Once established, facilitation can be sustained by normal CNS activity ∙Once you get this, even if the thing that triggered it goes away, it will still be facilitated

Many other doctors would use medications to alleviate the pain and inflammation

OMT would not rule out using pharmacological agents, but would be the immediate treatment Muscle relaxants, pain medications, NSAIDs could all be prescribed after OMT is administered ∙Cyclobenzaprine (Flexeril) ∙Diazepam (Valium) ∙Naprosyn ∙Ibuprofen ∙Diclofenac (Voltaren)

Definition of tender point

Often palpable as an area with the following characteristics ∙Swelling of fascia ∙Muscle tendrils ∙Connective tissue ∙Nerve fibers ∙Changes in vascular elements Acute tenderness on pressure palpation Often in the belly of a muscle or at the musculo-tendinous junction Specific location associated with somatic dysfunction, not generic tenderness as found in fibromyalgia ∙Most of students will not have "classic" tender point ∙Feels like a pea/small nodule under the skin Tender points may also be related to: ∙Point where nerve pierces through fascia and/or myofascial structure ∙Viscerosomatic dysfunction ∙Referred pain from viscera ∙Infection and inflammation Careful history and physical is important in understanding the manifestation of a tender point, along with the complete care of the patient, and not just treatment of the symptoms

The practice of functional medicine

One definition of Functional Medicine is the "medical practice or treatments that focus on optimal functioning of the body and its organs, usually involving systems of holistic or alternative medicine" It is a subset of herbal and nutritional medicine The focus is on symptoms, such as GI sensitivity There are four R's to Functional Medicine ∙Remove →To eliminate things in our body contributing to poor health, such as certain food, pesticides, food additives, unwanted bacteria, and parasites ∙Reinnoculation →Probiotics and other friendly flora ∙Replace →Using supplements to support function ∙Repair →Using nutritional support to regenerate and heal the body The concept of dysbiosis and intestinal hyperpermeability involves these potential GI symptoms ∙Dysbiosis means that there is an imbalance of gut flora →It is caused by many factors, such as antibiotics, diet, stress, illness, and other medications →This can occur in the lungs, as there is flora in the respiratory tract ∙Intestinal hyperpermeability involves inflammation of mucosa, which leads to the hyperpermeability →It allows for incompletely digested food, parasites, yeast/fungi, and harmful bacteria to permeate mucosal lining ∙The theory with this is that it leads to hyperactive immune system, allergic reactions, and increased activity of the Hypothalamic/Pituitary/Adrenal (HPA) axis, which leads to a stressed system with many manifestations Dr. Fuller adapts the concept of IBS to the four R's of Functional Medicine ∙To "remove," there is a couple of approaches →There is the practice of an elimination diet →→→One can temporarily limit diet to low allergen, easily ingested diet, often with rice-based food supplements with added nutritional factors, often providing anti-inflammatory effects →→→One can temporarily eliminate alcohol and caffeine as well →Allow for a complete diagnostic stool assay →→→Look for pathogens, as well as measuring metabolites of digestion and populations of various bacteria in the gut →→→It looks for secondary metabolites of bile acids →→→The concept is to treat pathogens, identify deficiencies of beneficial bacteria, identify digestive problems related to function of stomach, pancreas, gall bladder, and look for patterns of unhealthy bacteria or fungal overgrowth →→→→→The small intestine is usually pretty stale, but there can be some bacterial overgrowth, which can cause IBS →→→Rifaximin and other non-absorbable antibiotics are useful for treating small bowel bacterial overgrowth →→→Also, use antifungals for yeast overgrowth ∙To "reinnoculate," look at probiotics, S. boulardii, and potentially fermented foods, like yogurt ∙To "replace," think about supplements to help digestive deficiencies, such as HCl, digestive enzymes, bile salts, minerals, and glutamines for enterocytes →Zinc can be lost in diarrhea, but replacement of zinc can help digestive enzyme function →Remember, in acid reflux, the acid reflux is not the problem (as it is supposed to be there) but the muscle tone is the problem →Also can use healthy fiber and prebiotics to "replace" ∙To "repair," look at the following aspects →Supplements to help improve dunction →Glutamine for cells of intestinal lining →Fish oil to decrease inflammation →Detoxification supplements to augment hepatic phase I and phase II (conjugation) detoxification →→→Some herbs can be helpful in stimulating phase II detoxification which is deficient in those with metabolizing problems →Maximize function and balance of HPA →→→Adrenal support with herbal medicines, such as licorice root, Suberian ginsent (eleuthero), rhodiola, ashwaganda →→→→→Licorice root can be a problem because it can raise blood pressure through a mineralcorticoid effect →Sometimes use salivary testing every six hours for 24 hours to measure cortisol and DHEA levels in a circadian fashion Ratios give an indication of adrenal stress/HPA activity

Chronic Pain Patterns

Over time, continued pain causes permanent changes to the spinal and supraspinal nervous system through multiple mechanisms ∙Amygdala can decrease in size on PET scans in people with chronic pain →Drugs that increase norepinephrine and serotonin can increase a growth factor that can improve the size of the amygdala, correlating with decreased pain ∙This also ties in with depression, where the same changes are seen in the amygdala Preventing the continuation of pain before these permanent changes occur (i.e. sensitization activating the pain matrix) is extremely important for well-being

Multilevel Influence of Primary Afferent Nociceptor (PAN) Fibers

PAN fibers trifurcate as they enter the dorsal horn ∙One branch enters at that segment ∙One ascends and enters the cord ∙One descends and enters the cord Cutaneous PAN fibers spread out to at least 2-3 segments ∙Very localized Visceral PAN fibers can have distribution of 5 or more segments ∙These are much more broad ∙Ex: Irritable broad syndrome and pneumonia The overlap of these patterns of input help to explain viscerosomatic and somatovisceral reflexes

Nociception

Pain is nociception, but nociception is NOT necessarily pain Pain is the emotional pain associated with nociception causing anguish and suffering Nociception is a biological process due to tissue damage Pain vs. nociception is similar to addiction vs. dependence

Nociceptive Non-adaption

Pain receptors adapt very little if at all This makes you aware of tissue damage as long as it persists Ex: As long as there is a knife in you, your body will keep telling you something is wrong so nociceptors keep firing

Prone instability testing

Patient lies on table, hips flexed to 90 degrees, legs lying over the table Press from posterior to anterior along lumbar spinous processes If activation of those muscles provides more stability that is a sign of instability

Spinal stenosis

Peripheral stenosis - development of arthritic changes in the transformanial space where nerves exit the spine Patients with this do not like extension because when you go into extension you cause some collapse of post-vertebral structures and you end up shutting down transforaminal spaces Flexion exercises have been shown to improve transforaminal spaces of the spine by up to 20%. Patients will exhibit "shopping cart" sign ∙Ask "Does your back start to hurt when you're in a grocery store and you exhibit leg burning which would be alleviated if you lean on a shopping cart/ walker?" ∙This is classic sign of neurogenic claudication ∙If the answer is yes - then that pretty much confirms spinal stenosis ∙Advise patient to strengthen abdominal muscles

Mechanism of Counterstrain

Placing injured tissue at rest or shortening injured tissue maximally: ∙Dampens neural excitation keeping muscle hypertonic and/or painful ∙Resets the gamma motor neurons Placing patient's tender point location at ease: ∙Normalizes the abnormal afferent (incoming) signal causing a reduction/normalization in the efferent (outgoing) signal Shortening muscle decreases spindle tension and lowers incoming signal ∙Decreases resultant outgoing signal ∙Increases distance between intrafusal fibers Normalization of muscle length/tension ∙Result = decrease in dysfunction and associated pain (ARTT) Mechanotransduction associated with precise positioning may result in down regulation of proinflammatory mediators

Atlantoaxial motion

Primary motion is rotation Small amount of cephalad to caudad translator movement accompanies rotation Smaller amounts of: ∙Forward and backward bending ∙Sidebending Dysfunctions are interpreted as rotational

Progressive endurance exercise and fitness activities

Progressive aerobic exercise to moderate levels has been universally endorsed, HOWEVER there is little to no benefit in high intensity aerobics Pts with low back pain have increased neural sensitivity to afferent stimuli including proprioception and movement ∙This underlying process is called "central sensitization" You'd like patients to have some aerobic fitness but you don't want to cross the line of too much performance and exacerbate their symptoms

Cells that carry nociceptive input through the dorsal horn

Projection cells - send axons up the ascending tracts ∙They project to the brainstem and thalamus ∙You have some injury, the information travels up to the brain and thalamus which relays further Local circuit interneurons - projections are confined to the segment that contains the cell body Propriospinal neurons - combination of properties of both projection and interneuron cells ∙Axons ramify in the spinal cord ∙Interconnecting various segments ∙Do not extend beyond the spinal cord ∙Respond mostly to nociception but also to other input, such as mechanical

Psoas Facilitation

Psoas facilitation is common and problematic Often see flexed hip - unilateral or bilateral Unilateral hip flexion will cause pelvic side shift to the opposite side Goes along with facilitated upper lumbar area Associated with type two dysfunction at T12, L1, L2 (location for muscle attachment and neurological input) ∙Can manifest as anterior "lumbar" tenderpoints ∙Treated with hip flexion Places lumbosacral area under compression, causing significant lumbosacral pain After treating anterior lumbar tenderpoints and thoracolumbar area, then can treat with muscle energy if not too acute Follow with home stretches Psoas Muscle Energy Treatment (PIR) Home Stretches for Psoas 1. Start with standing reset 2. Progress to prone reset 3. Advance to kneeling with pelvic tilt modification

Integrative Holistic Medicine (IHM) for Irritable Bowel Syndrome (IBS)

Remember that this is not inflammatory bowel disease Dr. Fuller provides a number of several aspects of Integrative Medicine that can help treat IBS IBS is inappropriate overactivity of the muscles of the large intestine, going into spasm when they should not ∙Those with IBS are sensitive to stretch and can diarrhea or constipation Herbal and nutritional medicines are very popular Peppermint is a sterile hybrid of two other mints - spearmint and water mint ∙It has been used medicinally from ancient times to present, all around the world ∙It is safe to use according to the FDA ∙Oil from peppermint is obtained from steam distillation of above ground parts ∙Over 100 components have been identified, which is common in herbal medicine →One or two components can be extracted to be used ∙Some of the volatile oils in peppermint include menthol, menthone, isomenthone, menthyl acetate, and limonene ∙It contains flavenoids, such as luteolin, rutin, hesperidin, and erioeitrin →They have bile stimulating, antiviral, antioxidant, and antiallergic properties →These are studied in great detail ∙There are also phenolic acids, such as rosmarinic acid, which act as antioxidants ∙It is performance-enhancing, as the aroma may improve cognition, attention, and alertness, and it improves tactile performance ∙It has topical analgesic effects, especially to thermally sensitive fibers, nociceptors, and A delta fibers ∙There are a wide range of antibacterial and antifungal activities, both -static and -cidal →It also has antiparasitic and antiviral properties ∙It also acts as an antitussive agent, as it helps to decrease the cough reflex ∙Most importantly, it has GI effects, especially via menthol →It has antispasmodic effects on smooth muscle, probably due to a calcium channel blockade →It improves rhythmic peristaltic activity to keep rhythm regular →It relieves intestinal spasm →It increases bile secretion →It has an antiulcerogenic effect that may be antioxidant-mediated →Possible side effects include dermatitis and fresh breath →These effects can be a problem in a patient that has acid reflux disease →→→In this case, the tone of the lower esophageal muscles and sphincter are not working properly, so one would not wish to decrease these muscle's spasm even more via peppermint →→→For this reason, enteric coated peppermint oil is indicated in patients with IBS so the peppermint decreases spasm in the enteric muscles, passing right by the esophageal muscles Fennel is also used for IBS ∙It is native to the Mediterranean region ∙It is part of traditional herbal medicine in Europe and China and has many references in Greek and Roman literature →Ancient Greeks considered fennel a symbol of success ∙Today, fennel is widely used in India as an after-dinner breath freshener and to help with digestion ∙It has a mild licorice flavor and is safe according to the FDA ∙Side effects are really only involving an extremely rare allergy ∙There are many constituents, including anethole, estragole, alpha-pinene, trans-anethole, and limonene →We don't need to memorize constituents, they are there for our understanding ∙It has antispasmodic effects in the GI tract, via anticholinergic and calcium blocking effects ∙It is shown to be effective with infantile colic ∙IBS products are available with enteric coated peppermint oil and fennel, often with ginger as a third ingredient Probiotics are also used in IBS ∙They are live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host →They are similar to microorganisms found in the human gut ∙The normal human digestive tract contains about 400 types of probiotic bacteria, such as Lactobacillus and Bifidobacterium ∙Keep in mind that the number of bacteria in the human body is 10x the number of human cells in the body, making for a complex ecosystem →They produce hormones, signal back and forth, etc. →There are even some viral organisms in the body ∙They are present in certain fermented foods, especially yogurt ∙Prebiotics are complex sugars used as fuel by bacteria to stimulate healthy microorganisms and inhibit pathogens →They are found in a lot of plant-based foods →They help to promote healthy bacterial growth ∙Conference of the National Center for Complementary and Alternative Medicine and the American Society for Microbiology explored probiotics in 2005 →It determined that probiotics are useful in the treatment of diarrhea, IBS, to prevent and manage atopic dermatitis/eczema in children, and to prevent UTIs ∙They are helpful for antibiotic-associated diarrhea, C. difficile colitis, and IBS ∙Research is still underway regarding inflammation, immune regulation, cardiovascular effects, and other areas of interest such as ulcerative colitis →There is a theory that in inflammatory bowel disease, a cascade of events is set off to affect the normal flora of the gut Saccaromyces boulardii is a non-pathogenic yeast strain also used as a probiotic yeast to treat IBS ∙It was discovered by the French scientist, Henri Boulard in 1923 ∙It is isolated from skins of tropical fruit found in Indochina, and is long used to prevent and treat diarrhea ∙It is the only well known probiotic yeast at this time ∙It helps to prevent diarrhea associated with antibiotic use, tube feedings, and infectious diarrhea (especially of children) ∙It is very helpful in prevention and treatment of C. difficile-associated diarrhea →It produces a protein that both breaks down and inhibits the binding of C. difficile-produced toxin A to the brush border →It probably by promoting healthy bacteria ∙It has many effects and many mechanisms ∙It is postulated that it is a transient colonizer of the gut microflora but still exerts a significant probiotic effect by enhancing growth of native healthy bacteria and inhibiting pathogenic or over-growing organisms ∙One popular brand name for it is Florastor Other aspects can also be added to the IHM approach to the treatment of IBS ∙For instance, there are a number of dietary changes that can be instituted →A lactose-free diet helps some people significantly →A gluten-free diet helps other, but not everyone →→→Especially helps in those with Celiac's disease →A whole-food, plant-based diet usually helps, if transition is done gradually →→→If a transition to this diet from the Standard American Diet (SAD) is done abruptly, many methane substances can be produced, as Dr. Fuller terms this "the explosion" →The gas production occurs from changing the flora so quickly ∙It can also involve regular exercise, meditation, stress reduction/counseling, acupuncture and Traditional Chinese Medicine, and a functional medicine approach

Theoretical basis of counterstrain

Research currently supports three theories: 1) Proprioceptive Theory ∙Event/trauma produces rapid lengthening of a muscle →Example: Biceps = Muscle A ∙Afferent feedback indicates possible myofascial damage from a strain ∙The body tries to prevent myofascial damage by rapidly contracting Muscle A (biceps) →Defensive initiated protective nocifensive reflex and activation of alpha motor neurons ∙Results in a rapid lengthening of the antagonist or opposing muscle = Muscle B (Triceps) →This sudden lengthening of Muscle B may also cause it to reflexively contract ∙Result →Altered motor neuron activity maintains the two opposing muscle contractions →Potentially leads to development of tender points in Muscle A and/or B 2) Sustained Abnormal Metabolism Theory ∙Trauma produces change in myofascial tissue at the microscopic and biochemical levels ∙Tissue injury alters local body position, affecting microcirculation and tissue metabolism ∙Edema from tissue damage reduces normal circulation by compressing arterioles, capillaries, venules and lymphatic vessels reducing the supply of local nutrients and the removal of metabolic waste products ∙A neurochemical response is triggered to preserve further tissue injury and repair damaged tissues →Tissue oxygen and pH are low →→→Bradykinin formed and Substance P released resulting in vasodilation and tissue edema →Prostaglandins are released potentiating inflammatory response ∙Resultant tissue injury and the presence of these pro-inflammatory cytokines lowers the firing threshold of sensory neurons = facilitation →Causing localized neuronal sensitization and increased sensitivity to touch = Tender Point ∙The precise body positioning used in counterstrain improves local circulation and reduces the localized production of inflammatory mediators = TWO different mechanisms for why counterstrain may work for tender points 3) Impaired Ligamento-muscular Reflex Theory ∙Proposes that dysfunction may result from a protective reflex that occurs when ligaments and related myofascial structures are placed under strain ∙A localized sTrain (term used for counterstrain, but not usually) of a ligament can reflexively inhibit muscular contractions that increase the ligamentous strain while stimulating muscular contractions that reduce the strain Summary of theoretical basis of Counterstrain ∙Counterstrain tender point sensitivity represents an alteration in myofascial tissue function that reflects multiple underlying factors ∙After injury, nocifensive response is coupled with circulatory alterations, increased muscle tone and/or ligamentous injury ∙Injury results in →Ischemia with reduced muscle work capacity →Increased tissue sensitivity →Altered muscle spindle and proprioceptive activity →Tender points Dr. Nicholas said if you don't have Guyton Medical Physiology you need to read this text ∙These theories are different than even last year and the neurophysiology is constantly changing ∙Bottom line: understand muscle physiology, muscle spindle, balanced tension between muscle groups - Guyton Medical Physiology probably says this the best

Mechanism of Injury: Whiplash

Rotation can also occur during the whiplash injury ∙If the neck is rotated 45 degrees in either direction from the midline, the ability to normally extend decreases by 50% ∙The whiplash injury is made worse if the patient's neck was rotated while the injury occurred Strain or sprain can result from flexion, extension, side-bending, or rotation movements ∙Strains and sprains can occur in direct blows to the head, athletic injuries, MVAs (majority of injuries are caused by MVA), etc. When a car is hit from behind, the occupant's body is suddenly accelerated forward, leaving the head and neck to become relatively hyperextended to the rest of the body ∙This hyperextension occurs within the first 0.25 seconds following the impact →This movement is too rapid for the normal protective reflexes to engage, which causes the sprain and strain (whiplash) to ensue

Traditional Chinese Medicine (TCM) is an aspect of Integrative and Holistic Medicine

TCM originated in China and evolved over 2,500 years It classically involves acupuncture and Chinese herbal medicine A 2007 National Health Survey estimated 3.1 million U.S. adults had used acupuncture in the previous year Human body is a miniature version of the larger, surrounding universe Harmony between two opposing complementary forces, yin and yang, supports health ∙Disease results from imbalance between these two Five elements symbolically represent all phenomena in general and organ systems in particular ∙The elements include fire, metal, wood, earth, and water →They are not actually these things, just the name given to the concept →They have a generating sequence, so one promotes the next Qi (chi) is a vital energy that flows through the body maintaining health ∙It flows primarily along certain pathways known as meridians →If it refers to the heart, it is not just the anatomical heart, but the circulatory system as well, for example ∙These meridians correspond with functional organ systems ∙Acupuncture points are located along these pathways and are used to influence the function (chi) of these organs ∙There are twelve principle meridians and eight "extraordinary" meridians It also involves the five element theory and internal organ systems ∙There are generating and controlling cycles and a yin and yang organ with it →For instance, wood generates fire, but controls earth, according to the picture below ∙These correspond with specific meridians →For instance, the heart meridian goes out to UE, up to meet spleen meridian, and connects down to small intestinal meridian TCM does not separate mind, body, and spirit as western culture does ∙The five elements correspond to emotions, as well as organ systems →For instance, if you have a problem with your liver, you may have a problem with grief Diagnosis is made by history, pulses (from three positions and on two levels, such as deep and superficial), and looking at the tongue and the eye TCM has body maps for acupuncture, such as on the tongue, eye, ear, hands and feet ∙Reflexology comes from TCM ∙It is a very holistic approach, as each organ is associated with these maps There is evidence that acupuncture is supported in use to treat pain, osteoarthritis, nausea and vomiting, ∙There are many types and varieties of acupuncture ∙Medical acupuncture involves courses for physicians to learn acupuncture →An example of where it is taught is the Helms Medical Institute, University of California, Los Angeles School of Medicine →States vary in licensing requirements There are disciplines related to TCM theory as well that Dr. Fuller just mentions ∙Examples include chi kung (qui gong), tai chi chaun, and hsing I chaun It takes a long time to learn TCM/acupuncture ∙Find a physician to refer patients to for these practices ∙This adds to your medical repertoire ∙Consider referring if you have a patient with one of the following problems: →On-going problem that is not easily treated/resolved →After ruling out major problems, such as CA and aneurysms →→→It is alright to use once these problems are diagnosed →Patient is willing and able to go →Cost can be an issue, as it is often not covered by insurance

C2-C7 Somatic Dysfunction

Tends to be Type II-"like" Single segment, non-neutral ∙Several segments may be dysfunctional, but not as a true group like Type I

Muscle Spindle Reflex

The excitability of the muscle spindles is regulated by the activity of the γ-motoneurons When γ-motoneurons fire (gamma efferents) they cause the intrafusal muscle fibers to contract This makes the spindle more taut, which increases the overall excitability of the spindle (increasing the afferent discharge rate) Spinal interneurons are involved that can increase or decrease activity of this reflex

Advantages to using counterstrain

∙Non-traumatic ∙Increases patient confidence quickly ∙Relatively easy ∙Effective

Common teachings of counterstrain

"Fold and Hold" method of Counterstrain ∙One of the early methods used to teach counterstrain ∙Find a tender point associated with somatic dysfunction and collapse the tissues around it ∙Most effective: →Encircling the tender point using x, y, and z axes →Translatory motion Some osteopathic medical school OMM departments teach each specific tender point location and the 'classic Jones' treatment position to alleviate the tender point ∙We do not need to memorize every single point ∙Dr. Nicholas cares more about how the technique is clinically applied and understanding the neurophysiology that was in the beginning of lecture ∙Do not use the first edition of the atlas - NEED to use 2nd edition (or 3rd edition coming out in 6-8 months)

Atlantoaxial articulation

4 articulations ∙right and left zygapophysial joints ∙anterior odontoid articules w/ small facet on posterior aspect of anterior arch of atlas ∙posterior aspect of the odontoid is an articulation w/ transaxial ligament

Activate/Strengthen After Stretching

Activate and strengthen a weak, inhibited phasic muscle after stretching the hypertonic postural antagonist Gluteal muscles and lower abdominal muscles need to be strengthened, especially after stretching and lengthening facilitated psoas, piriformis, and hamstrings Aerobic exercise, such as walking, is very helpful at this stage

Lower Crossed Syndrome

Weak gluteus maximus Short, tight hip flexors (iliopsoas) Weak abdominals Short, tight erector spinae (particularly upper lumbar) Weak gluteus medius and minimus Short, tight tensor fascia lata, quadratus lumborum Posture characterized by anterior pelvic tilt and increased lumbar lordosis Hypermobility at L4-5, L5-S1 ∙Example: truck drivers experience anterior pelvic tilt with associated pain (particularly lumbosacral junction) and asymmetry as result of sitting for prolonged periods of sitting followed by heavy lifting →Result of lower cross syndrome; treat symptomatic low back pain accordingly Difficulty sitting up from supine (forward flexion)

Exercise prescription

Trunk coordination, strengthening and endurance exercises are often prescribed for patients who have been diagnosed with spinal instability ∙Often overprescribed ∙Only prescribe if a muscle weakness in one of those groups is discovered to be weak

Historical Background of Counterstrain

Developed by Lawrence Jones, D.O. in 1955 while attempting to treat a patient who had been unsuccessfully treated for the last several months ∙He placed the patient in a position of comfort and let him lie there for about 20 minutes ∙When Jones returned, the patient was asked to slowly stand and his pain was gone ∙After much experimentation, Dr. Jones discovered that the optimal time for this technique was 90 seconds Counterstrain was once called: ∙Spontaneous Release by Positioning ∙Strain-counterstrain ∙Jones Technique Jones identified discrete areas of tenderness associated with specific dysfunctions ∙Termed "Tender points" ∙Initially Jones only found posterior tender points ∙Anterior points were found later; increased efficacy of treatment Jones mapped location of tender points ∙Associated with specific somatic dysfunctions →Cervical, thoracic, lumbar spine, and pelvis →Upper and Lower extremities →Cranium ∙1964: Published 1st paper on this model ∙1980: Textbook published by American Academy of Osteopathy based on his FAAO thesis Functional Technique ∙Similar to counterstrain, but precedes it in history ∙Also indirect ∙Other indirect techniques →Functional →Facilitated Positional Release (FPR) →Balanced Ligamentous Tension (BLT) →Ligamentous Articular Strain (LAS) ∙Harold Hoover D.O. used Functional Technique →Palpated for ease of motion of a segment →Used gentle pressure and respiratory assist

Judgment of presence of aberrant movements

"Aberrant movement" includes the presence of any of the following: painful arc with flexion or return from flexion, instability catch, Gower sign and reversal of lumbo-pelvic rhythm. This is important because this is why patient will come into office - pts say they have low back pain that gets worse when they get up out of seated position, getting out of car, etc. Pain with motion is entirely different from just sustained back pain Painful arc of motion - specifically when going into or out of flexion happens in the MID RANGE OF MOTION - it is abnormal to have pain here ∙It is expected that the patient experiences pain at the end range of motion. Instability catch: deviation from the sagittal plane during flexion and extension ∙The body will attempt to take pressure off of certain structures if patient tries to shift out of flexion or extension when instructed to fle/ext ∙Often patients do not even realize that they have these deviations until they are pointed out to them. Gower sign: "thigh climbing" use your hands to push up against the anterior thighs to decrease low back load when returning to upright position - a sign of weakness, or injury Reversal of lumbo-pelvic rhythm: once patient is already in flexed position, they will bend knees because bending knees will make it easier to extend hips so they can use gluts instead of paravertebral muscles - also sign of weakness ∙Will need to determine what is causing this weakness- is it compensation for weak paravertebral muscles? Or weak glut muscles? Or both?

The Downward Spiral in Pain

Chronic Inflammation + Vasoconstriction + Muscle spasm (guarding/splinting response) = Maintenance and exacerbation of somatic disfunction Take away: Somatic dysfunction can become self-propagating ∙If something goes wrong in one place, it can go wrong in another place →Even once the first problem is corrected, the second problem can still keep going wrong ∙Thus, facilitation can cause more facilitation

Research into whiplash

Experiments causing whiplash in primates and simulating it in anthropomorphic dummies have enabled analysis of the manner in which injury occurs The hyperextension injuries induced in animals gave rise to various lesions including: ∙Anterior neck injury (including rupture of the anterior longitudinal ligament) ∙Muscle hemorrhage and tear (strain) ∙Intervertebral disc rupture ∙Esophageal hemorrhage ∙Superficial parenchymal hemorrhage →EEG changes (which correlates with the clinical observation that whiplash patients are often temporarily disoriented) →→→Changes in the brain or brain activity

4th Study - Non-thrust OMT and LBP

Goss et al studied changes in short-latency stretch reflex of erector spinae muscles in patients with chronic low back pain Intervention: single session of OMT consisting of muscle energy, myofascial release and strain counterstrain techniques ∙This uses a mixture of techniques Findings: patients with LBP exhibited a large asymmetry in the short-latency stretch reflex at baseline ∙After OMT this was reduced about 35% which is statistically significant ∙Findings suggest that OMT acts by down-regulating the excitability of the muscle spindles or other sites of the Ia-reflex pathway

Occipito-atlantal movement

Loss of symmetrical coupling is clinically significant ∙Side bending component is ~5° ∙Rotation ~5° OA coupling = rotation and sidebneding is to opposite sides

Glial cell activation can also occur:

Glial cells form a supporting matrix surrounding all CNS neurons, including those in the dorsal horn ∙Glial cells are the most abundant cell types in the CNS Types of glial cells include oligodendrocytes, astrocytes, ependymal cells, Schwann cells, microglia, and satellite cells Activated glial cells release pro-inflammatory cytokines and other substances that increase spinal facilitation and hyperalgesia They are protective short term, but long term can become part of a feed-forward loop with chronic pain

Muscle Imbalance of the Pelvic Girdle/Lower Extremity

Postural/tonic muscles facilitated... ∙Iliopsoas ∙Rectus femoris ∙Tensor fascial latae ∙Quadratus lumborum ∙Thigh adductors ∙Piriformis ∙Hamstrings ∙Lumbar erector spinae (especially upper) Phasic/dynamic muscles inhibited... ∙Gluteus maximus ∙Gluteus medius and minimus ∙Rectus abdominis ∙External and internal obliques ∙Peroneals ∙Vastus medialis (and lateralis) Tibialis anterior

'Maverick' tender points

These do not "follow the rules" ∙Usually cervical points ∙Example: flex with a posterior point when typically you would extend Fine-tune with small arcs of motion ∙Side bend away/rotate away (SARA) ∙Side bend-towards/rotate away (STRA)

Factors related to whiplash injuries

The amount of damage to the motor vehicle has little relation to the force applied to the cervical spine of the occupants ∙This is an issue when it comes to the legal aspects of whiplash injuries ∙There could be no damage to the car, and the victim could be in severe pain The acceleration of the occupant's head depends on the force imparted, the moment of inertia of the struck vehicle, and the amount of collapse or force dissemination by the crumpling of the vehicle

Referred Pain

What causes referred pain? ∙Convergence at dorsal root ganglion Convergence w/in the segment: classic picture of referred pain ∙Ascending impulses (pain) ∙Thalamic and cortical processing ∙Image →Visceral fibers are coming in on the left and skin nerve fibers coming in on the right but are converging on then neurons →Through labeled line principle, know the brain is pretty good at tracing where a signal came from, but convergence can confuse that →Brain knows when post-synaptic neuron fires, that it is either coming from the heart of jaw, but doesn't know for sure →When a person has great chest pain b/c of a MI, he can get referred pain to jaw and arm →→→No nociception in jaw or arm →→→Nociception in heart b/c there is tissue damage there →NOTE: Image is not correctly drawn, b/c it shows convergence in the spinal cord's dorsal horn →→→Synapses happen in the ganglia, not in the cord Referred pain localized along a dermatome (or dermatomes) ∙This is what patient complains about • Ex: "I have pain going down my arm" • Can be hard to explain to patient that pain in his toe has to do w/ something in his back

Contralateral Reciprocal Inhibition

Example: Flexion Ipsilateral flexor contraction triggers reflex inhibition of the contralateral flexor Increased contraction causes increased reciprocal inhibition = the harder the muscle contracts, the more it inhibits its antagonist Sustained contraction of an agonist ∙Such as with a chronic facilitated state ∙Can cause inhibition of the antagonist, which becomes weakened →Not true of bicep/tricep, but is true for other muscle groups Summary: A tight, sustained hypertonic muscle will inhibit both the ipsilateral antagonists as well as the contralateral agonists ∙Patterns of muscle tightness and inhibition can emerge

Speed's role in whiplash

FYI, motor vehicle accident = MVA, motor vehicle collision = MVC NOTE: You should still ALWAYS wear your seat belt, regardless of the information below In collisions <15mph (approximately), the driver can often brace with the steering wheel, and is less likely to sustain injury (vs. a passenger, who is in less of a position to brace) In collisions >20mph (approximately), the pelvis is thrust forward and the extension forces through the cervical spine are reduced (the pelvis absorbs them); this is only in a scenario when the patient is not wearing his/her seatbelt ∙The steering wheel can become a morbidity factor to the driver →Air bags help to decrease morbidity associated with the steering wheel Ironically, seat belts that can prevent thoracic and abdominal injuries can exacerbate cervical injuries, since they restrict the movement of the pelvis (negating the pelvic absorption of forces)

Principles of Motor Control

Four Components of Motor System ∙Premotor cortical regions: tone regulation ∙Motor cortex: tone regulation ∙Brainstem ∙Spinal cord Functionally interrelated ∙Stimulus from periphery initiates afferent input →This in turn triggers segmental spinal reflexes →Information carried centrally to brainstem and cortex ∙Cord level information proceeds through spinal pathways to muscle groups → patterns of tension and tightness result ∙Results in force generation, such as to displace a load →Ex: change in gait in response to tightness in hip ∙Responses to this activity return to spine with the original afferent stimulation ∙Information is processed rapidly at the spinal level →These changes are unconscious Initial afferent input stimulates brainstem and cortical structures Initiates descending pathways from brainstem and motor cortex Modulated through basal ganglia and cerebral systems Changes brainstem activity that descends through the cord (Do not need to memorize these pathways. This simply illustrates that the pathways are interconnected.) ∙Reticulospinal, vestibulospinal, tectospinal tracts ∙Rubrospinal tract Modulates cord reflexes, influencing muscle activity ∙Alpha motor neuron ∙Final common pathway ∙Results in muscle activity ∙Regulated locally by muscle spindle reflex and golgi tendon apparatus

C2

Functions as a transitional segment Atypical superior surface articulates w/ atlas ∙And to occiput through ligamentous and muscular attachments Inferior surface is similar to the typical segments below (oblique)

Muscle Receptors

Golgi Tendon Organs ∙Located in the collagen tissue fibers at the musculo-tendinous junction ∙Respond to the force of active contraction ∙When Golgi tendon organ is stimulated: →Motor firing to this (agonist) muscle is inhibited →Stimulates firing to its antagonist muscle group

Thoughts, Feelings and Words

Happen at a cortical level When nociception reaches the thalamocortical level, you become conscious of your perception of pain ∙At this point, thoughts, feelings and words are put to the event ∙Conscious memories form ∙Behavioral adaptations take place This can lead to: ∙Generalized musculoskeletal tension →Patient comes in with their muscles "humming" (highly facilitated) vs. totally relaxed →Someone who is facilitated does not do well with high velocity techniques vs. totally relaxed patient →Can use counterstrain techniques for facilitated patient (not written in stone, just through Dr. Fuller's experience) ∙Autonomic arousal is a big point ∙Visceral and motor responses ∙Increased stress-response (including hypothalamic-pituitary-adrenal axis) Chronic pain has a lot of biopsychosocial effects

Pain-Spasm-Pain Cycle

Is an important component of somatic dysfunction ∙It causes restrictive range of motion, tenderness, and tissue texture changes There is consistent evidence showing that OMT impacts this cycle One mechanism involves the muscle spindle fiber complex/reflex Pain leads to muscular hyperactivity, which in turn causes or exacerbates spasm ∙Ex: This is when the counterstrain technique is used There are two pathways likely involved with this cycle: ∙Nociceptive afferents directly transmit to excitatory interneurons and then to alpha motor neurons, resulting in increased muscle activation (contraction) ∙Feed forward loop involving nociceptors provide excitatory input to the gamma motor neurons that increase the sensitivity of the muscle spindles (increase gamma gain) →This increases spindle sensitivity increases the spindle afferent activity →Increasing excitatory input to the alpha motor neurons →Further increasing muscle activation and pain

Herbal medicine and nutritional medicine are the two biggest fields used in Integrative Holistic Medicine

It can also involve functional medicine, manual medicine (such as Osteopathic, chiropractic, and naturopathic medicine), and body work ∙Body work involves massage, rolfing, Alexander therapy, craniosacral therapy, etc. →Craniosacral therapy is similar to Osteopathic Medicine It also can involve acupuncture/traditional Chinese medicine, ayurvedic medicine, homeopathy, meditation/guided imagery, counseling, dietary changes, lifestyle adaptations, and even Yoga, Tai Chi, and Chi Kung

Integrative medicine is defined by several things

It is the practice of medicine that reaffirms the importance of the relationship between the practitioner and the patient It focuses on the whole person It is informed by evidence And it makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing This definition is from an organization called the Consortium of Academic Health Centers for Integrative Medicine Steering Committee The idea is that it is not alternative or different from mainstream medicine but rather embracing ideas that are outside of conventional medicine You don't have to be an expert in each approach to practice Integrative Medicine

Homeopathy

It is the treatment of disease by minute doses of natural substances that in full strength in a healthy person would produce symptoms of disease Much of this started in Philadelphia Treat "like" with "like" ∙For example, drinking too much coffee can lead to insomnia and agitation ∙Homeopathic remedy made with extremely diluted solution of coffee is used to treat these symptoms ∙While not the same philosophy as vaccines, there is overlap ∙From the Greek words homolog, meaning similar, and pathos, meaning suffering, like cures like It originated with Samuel Hahnemann (1755-1843) who was a German physician who decried the harsh medical practice of his day, such as blood-letting, purging, tinctures of arsenic, and opium ∙He searched for a safer medical treatment ∙He experimented by giving smaller and smaller doses of medicine ∙Smaller doses seemed safer and had more effect ∙He studied many like causes like substances ∙He documented his findings in books that were to become the foundation of homeopathic medicine ∙Concept of "vital dynamis" where a disease caused by deterioration of an immaterial vital principle in individuals →Remedies trigger a cure through bringing the body back into a state for healthy reception of this vital force ∙He serially diluted and succussing substance potentized the remedy with an immaterial power →Succussing is a pounding of the substance ∙Homeopathic College of Pennsylvania opened in 1848 and later merged with Hahnemann Medical College ∙Homeopathy declined in the 1860s in America but continued internationally, especially in Europe, South America, and India Homeopathic remedies start with a mother tincture, such as a plant or other natural substance ∙It is diluted and succussed to produce serial dilutions →Theoretically, the greater the dilution, the greater the potency →It was often added to a sugar pill base ∙There is not much evidence supporting the outcome ∙Architecture of water is an intriguing area of study for homeopathy ∙Used to treat symptoms and constitutional problems

Tensegrity Characteristics

Loading components in pure compression or tension means the structure will only fail if the cables yield or the rods buckle (i.e. tension is lost or structure is compromised) Preload, or tensional pre-stress, allows the cables to maintain shape and rigidity in tension Mechanical stability allows the components to remain in tension/compression as stress on the structure increases Both pre-stressed and geodesic forms have tensegrity characteristics Intrinsically self-stabilized because of the level of pre-stress and triangulation of forces so it is independent of gravity Forces acting on the tensegrity structure are immediately distributed throughout the structure so it is intrinsically integrated Allows a lot of flexibility with minimum damage ∙Resumes prior shape when applied forces cease This makes for very efficient, lightweight, and strong structures, independent of gravity Can be altered by modifying amount of tensional pre-stress within the structure or by repositioning the compression-resistant elements Geodesic tensegrity structures are stabilized through force triangulation ∙Example - dome ∙Also under pre-stress ∙Differ because the individual elements are capable of alternating between generating tension or resisting compression ∙It is not as intuitive that this structure has compression within it, but it does. This allows it to maintain its lightweight structure. Same complex mathematical rules apply to both tensegrity in the traditional sense, and geodesic tensegrity

Muscle spindles

Located in the belly of the muscle Give information about muscle length and rate of change of length ∙This is important for proprioception, for example knowing where your arm is in space Made up of three bands: ∙Two contractile bands on each end, one noncontractile band in the middle ∙Collagenous band separates the contractile bands from the noncontractile band 3-10 mm long Built around 3 to 12 intrafusal muscle fibers Few or no actin or myosin filaments End portions contract via gamma motor nerve fibers Noncontractile muscle fiber in the mid portion contains two sets of sensory fiber endings ∙Primary ending = annulospiral ending →"Coils" →Activated in both slow and rapid lengthening of muscle spindle fibers, tells body how much stretch ∙Secondary ending = spreads "like bush branches, creating a network around it" →Activated ONLY during slow lengthening of muscle spindle fibers Muscle fibers important in OMM due to their proposed mechanism of action during counter strain (utilizing tender points) ∙Counter strain technique = also known as strain counter strain →Developed by Dr. Jones →Patients will present w/ tender points (area within the muscle with an inappropriate amount of pain, overly painful) →→→Can resolve this pain by using counter strain = passively contracting the muscle (placing it in it's most relaxed position) and hold for 90 seconds → takes load off muscle, allows spasm to disappear, and pain resolves →→→Physicians can utilize Jones' tender points to anticipate common places where pt's have somatic dysfunction and then treat these tender points with counter strain →Alpha-gamma loop potentially involved with the tender point reflex

Long term expectations of cervical strains or sprains

Long term studies show that aches and pains (with no other evident physical cause) persist in 20-45% of patients with significant whiplash ∙Few of these patients have radicular pain X-ray studies show degenerative changes (such as arthritis) developing after cervical injury in 39% of patients ∙Only 6% of the population over age 30 develop degenerative changes over a comparable time (without injury) ∙Injury to the cervical spine can be a risk factor for developing arthritis The following early symptoms or signs may be associated with long term disability (Hohl 1974) ∙Persistent upper extremity pain and numbness ∙Interscapular pain ∙A sharp cervical curve reversal ∙One level of localized restricted cervical motion

Table of abbreviations that will be used for Counterstrain

Lower case s - side bending a little Upper case S - side bending a lot

Assessment for exercise prescription includes the following:

Lumbar range of motion - flexion, extension and side bending Segmental mobility Pain provocation with segmental mobility Judgments of centralization vs. peripheralization during movement testing (will talk about later) Prone instability testing (will talk about later) Slump test Straight leg test *Trunk muscle and power endurance* Passive hip internal rotation, external rotation, flex/ext *Judgment of presence of aberrant movements*

Lymphatic pump techniques

Manual stimulation of lymphatic flow Pedal, abdominal, or thoracic outlet Rhythmic force in supine or prone position Supported by research ∙2005 study measured flow thru thoracic duct of 5 dogs →Dog model used due to the need to cannulate the thoracic duct →Therapy increased lymphatic flow from 1.57 mL/min to 4.8 mL/min →Lymphatic pump technique was less effective than physical activity, which caused an increase from 1.47 mL/min to 5.81 mL/min ∙1998 study measured lymphatic and splenic pump techniques' effect on vaccines →20 subjects got hepatitis B vaccine with hepatic and splenic pump, 19 got vaccine w/o manipulation →Tx was 3x p/week for 2 weeks →50% of experimental group had protective response (≥10mlU/mL) with avg titer of 374 mlU/mL →16% of control group did with average of 96 mlU/mL ∙2007 study measured lymphatic pump technique effect on leukocyte count and flow through thoracic duct →Lymph was collected at baseline and during lymphatic pump treatment (LPT) in 8 dogs →LPT significantly increased leukocytes, macrophages, neutrophils, total lymphocytes, T cells, and B cells ∙2013 study measured LPT on lymphatic and immune systems →Lymph collected from thoracic duct pre-LPT, during 4 m of LPT, and 2 hrs post-LPT from 5 dogs →→→A second LPT was applied after a 2 hr rest pd →Both LPT treatments significantly increased TDL flow, leukocyte count, total leukocyte flux, and the flux of IL-8 and other immune mediators measured Dalrymple pedal pump technique ∙To encourage lymphatic return ∙May be performed prone or supine Miller thoracic pump ∙To encourage lymphatic return ∙May be performed prone or supine ∙Modifications made for female patients Splenic pump ∙Spleen plays important role in blood filtration, and may become congested during infection →Treat with splenic pump (contraindicated in mononucleosis or splenomegaly or hepatomegaly) Effleurage ∙Directly engaging lymphatic vessels ∙Frequently last technique performed in ENT sequence ∙Can do in any part of body →Ex: done on upper arm to treat thoracic inlet

Sensory receptors = afferent receptors, take info in the brain into the CNS

Many different types, which include: ∙Free nerve endings (touch and pressure) ∙Pacinian corpuscles (fast vibration, 30-800 Hz) ∙Ruffini's end organ (pressure and joint rotation) ∙Meissner's corpuscle (touch, slow vibration, 2-80Hz) ∙Golgi tendon apparatus (muscle stretch and load) Each stimulus reaches a specific area of the brain ∙Labeled line = pathway the stimulus triggers, line of nerves to specific sensory area in the brain →Ex: Sound goes to auditory center, touch goes to touch centers ∙Brain function/specific anatomy is based on where the specific receptors are within the brain All receptors work through a change in the membrane electrical potential of the receptor ∙Different ways to change the membrane include: →Chemical (smell) →Deformation (stretch) →Temperature change (changes permeability) →Electromagnetic radiation (light)

Centralization and directional preference exercises and procedures

Meta-analysis reviews demonstrate that centralization is present in more than 2/3 of those with sub-acute LBP and 52% of those with Chronic LBP Centralization is associated with good outcomes Peripheralization with poor outcomes In general don't want to see either of these patterns, but if you do, you want to see a progression from peripheralization to centralization Can be done at home or under physician care Most people were found to have a directional preference: ∙Directional preference: immediate, lasting improvement in pain from performing repeated lumbar flexion, extension or side gliding movements ∙Results of one study (not referenced): 74% of pts exhibited a directional preference as follows: 83% extension, 7% flexion and 10% lateral glide

Summary: OMT and Pain-spasm-pain Cycle

Musculoskeletal pain increases nociceptive input from somatic structures ∙Muscles, tendons, ligaments, bone, annulus fibrosis can increase this input Increased nociceptive input increases excitatory input to the γ-motoneurons This increases muscle spindle afferent activity, particularly in response to stretch or change in muscle length This increased activity, along with nociceptive input, involuntarily activates α-motoneurons and muscle fibers leading to spasm Spasm increases pain, which increases spasm, leading to the Pain-Spasm-Pain cycle OMT attenuates nociceptive input and also reduces the sensitivity of muscle spindle fibers to stretch (partly by reducing gamma gain) This decreases excitatory input to the α-motoneuron pool, decreasing muscle activity This reduces involuntary muscle contraction and will restore motion to affected tissues Conclusion: OMT acts to disrupt the Pain-Spasm-Pain cycle through multiple techniques

20% of yoga practitioners have suffered some physical injury while practicing

Not as bad as it sounds when comparing to other sports If patient is very devoted to yoga but getting problems with specific poses you can try to get across to them that they can separate the benefits of the breathing exercises while refraining from poses that cause pain When in doubt follow the age old sports medicine mantra...too much of any thing can be a bad thing ∙Help your patients to figure out what specifically bothers them so that they can avoid it in the future/be careful when doing those poses ∙As a general rule; "if it hurts, don't do it" ∙Does not mean that the patient will never be able to do it again, but that the body at the very least needs a break from the movement. Remember to use your common sense and medical judgment when giving advice about these complimentary forms of bodywork ∙Patients with obvious contra-indications to treatment should be educated as to how they can change or tailor they're program based on their medical diagnoses ∙"If it hurts don't do it" ∙Ex. Spinal stenosis and yoga Don't make blind or biased judgments about a specific modality or group of practitioners In order to assess the value of a given treatment in a given patient... ∙Use objective measures including muscle strength testing, ROM, instability testing ∙Use subjective measures including frank decrease and progression from centralization to peripheralization of subjective pain

The Anterolateral System (ALS)

Pathway to consciousness ∙2˚ neuron to thalamus ∙3˚ neuron to cortex ALS is divided into two tracts ∙Neospinothalamic →Conducts fast Aδ type fibers →Glutamate-mediated transmission →→→Fast pathway (takes milliseconds) →→→Broken down and reabsorped quite rapidly →Terminate in lamina I (lamina marginalis) →→→Do NOT worry about this now →Excite second-order neurons (post-synaptic neurons) →Decussate through anterior commissure →Terminates in brain stem and thalamus ∙Paleospinothalamic →Older system →→→In lower-order animals NOT higher-order animals →Slow C-type fibers →Glutamate and Substance P-mediated transmission →→→Substance P has a slow turnover →→→Builds up in synaptic cleft (takes seconds) →Terminate in lamina II and III (substantia gelatinosa) →Excite second-order neurons →Decussate through anterior commissure ∙Important: Know the difference between these two tracts

Dr. Andrew Weil's Program in Arizona presents defining principles of Integrative Medicine

Patient and practitioner are partners in the healing process All factors that influence health, wellness, and disease are taken into consideration, including mind, spirit, and community, as well as the body Appropriate use of both conventional and alternative methods facilitates the body's innate healing response Effective interventions that are natural and less invasive should be used whenever possible Integrative Medicine neither rejects conventional medicine nor accepts alternative therapies uncritically ∙Dr. Fuller tells a story to reflect the point that we, as physicians, still want to know how these alternative methods work and why they work the way that they do with particular patients Good medicine is based in good science; it is inquiry-driven and open to new paradigms Alongside the concept of treatment, the broader concepts of health promotion and the prevention of illness are paramount ∙People are interested in what they can do to be healthy Practitioners of integrative medicine should exemplify its principles and commit themselves to self-exploration and self-development ∙You, as a physician, cannot ask a patient to quit smoking if you, yourself, smell of nicotine

Viscerosomatic reflexes

Pneumonia and OMT ∙Viscerosomatic reflex for lungs are T1-T4, reflecting pathways of sympathetic innervation →Same pathways involved in visceral afferent and autonomic efferent activity →Basically, the same highway is carrying info in both directions ∙Also parasympathetic viscersomatic via vagus nerve →The nerve originates at occiput, C1, C2 ∙OMT studies with hospitalized pneumonia patients showed 25% reduction in hospital stays and shorter duration of IV antibiotics "Wind-up" phenomenon ∙Viscerosomatic reflexes display summation →Temporal - one neuron fires continuously →Spatial - many neurons firing at the same time ∙Sustained stimulation causes increased autonomic response = increased sensitivity and responsiveness through multiple mechanisms ∙Can be nociceptive and non-nociceptive input ∙Involves spinal gray matter, specifically interneurons synapsing with motor neurons of both autonomic and somatic systems ∙Afferent input from different portions of the body can summate to activate the reflexes ∙A subliminal afferent input from one part of the body can add to other stimuli to cross the threshold of wind-up

Summary of Central Sensitization

Primary afferent nociceptors sends signals to the dorsal horn Dorsal horn cells carry nociceptive input up the spinal cord via: ∙Projection cells, local circuit interneurons, propriospinal neurons Dorsal horn plasticity if continued: ∙"Wind-up" ∙Transcription dependent sensitization ∙Depression/loss of inhibitory interneurons Secondary hyperalgesia Glial cell activation Ventral horn activity alterations This is the basis for viscerosomatic reflexes Ascending pain pathways can focus on: ∙Spinoreticular tracts ∙Spinothalamic tract ∙Thalamus Goes up the Cerebral Cortical Pain Matrix ∙Including the amygdala among other structures ∙Endogenous pain control systems can kick in to down regulate system Allostasis ∙The concept of end balance and continued state ∙HPA axis involvement ∙Also involves Anxiety, depression

Sprains and strains are graded according to primary, secondary and tertiary injuries

Primary cervical strain or sprain characteristics: ∙No major trauma has occurred ∙The injury is microscopic ∙Little to no bleeding and swelling is occurring ∙There may be slight muscle spasm and hypertonicity ∙Pain may be absent; if present, pain is minimal to moderate ∙The injured joint or tissue maintains its stability; no need to immobilize the injured joint ∙Recovery time is 1-4 weeks, strain or sprain will heal on its own Secondary cervical strain or sprain characteristics: ∙These injuries are more macroscopic ∙The tissue surrounding the damaged area is also involved ∙There is moderate to severe bleeding/ecchymosis and swelling ∙Spasm and/or hypertonicity are more likely to be present ∙The patient presents with moderate to severe pain ∙The joint or tissue maintains relative stability ∙Recovery time is 4-6 weeks using conservative treatment or no treatment Tertiary cervical strain or sprain characteristics: ∙There is complete tissue rupture ∙This is a macroscopic injury ∙There is severe bleeding, perhaps hemorrhaging, and swelling present ∙There is definitely spasm and/or hypertonicity of related muscles to guard or splint the injured area ∙The joint is unstable, and there needs to be an immobilization tactic used to stabilize it →Splints, braces, and casts are examples of ways to immobilize the joint ∙Recovery time is about 6-8 weeks with surgical, non-conservative treatment →Treatment must be surgical; non-conservative treatment will not work

Tensegrity of Bone - Femur

Proximal and distal ends the bone widens, consisting of cancellous bone instead of compact bone ∙Cancellous bone is organized around geometric triangulation, providing maximum stability, aiding in receiving and dissipating forces through a joint Femur is an example of a tensegrity structure composed of pre-stressed and triangulated components

Endocannabinoid System

Research is still early on about this endogenous system Widespread effects across the body, especially CNS ∙Affects neurotransmitter regulation (important!) ∙Neuroplasticity (involves spinal cord, cortex, brainstem) ∙Central sensitization ∙Spinal facilitation ∙Subcortical and cortical learning processes Affect structures including: ∙Spinal cord ∙Hippocampus ∙Hypothalamus ∙Basal ganglia ∙Amygdala ∙Cerebellum ∙Cerebral cortex Plays a role in: ∙Neuroprotection (protection against insults) ∙Autonomic function ∙HPA axis activity ∙Immunity ∙Inflammation ∙Connective tissues, including myofascial structures ∙Nociception ∙Pain perception Also been shown to play a role in: ∙Short-term memory ∙Cognition ∙Mood ∙Emotion Spans the spectrum from neuromusculoskeletal effects to psychoneuroimmunology Part of the body's inherent complex self-regulatory homeostatic system With limited research, OMT has been shown to: ∙Elicit cannabimimetic effects through the endogenous cannabinoid system ∙Affect serum levels of endocannabinoids, especially anandamide (AEA) ∙Trigger changes affecting mental state, such as relieving anxiety (associated with endocannabinoids activity)

Core retraining

Retrain coordination and activation of abdominals, gluteals, and lower lumbar erector spinae Pelvic tilts to teach the pt to allow the back to lie flat on the table. Keeping the hips on the table, hold these positions for 3 seconds each: ∙Posterior = "12 o'clock" ("towards chin") ∙Anterior = "6 o'clock" ("towards feet") ∙Left = "3 o'clock" ∙Right = "9 o'clock" Pelvic see-saw: hips come off the table Curl, reverse curl, extension sequence: activate abdominal muscles, while not firing the hip flexors ∙Lower abs ∙Upper abs

Central Sensitization and Secondary Hyperalgesia

Sensitization of the dorsal horn neurons alters their response properties and behave differently This can cause expansion of the neurons receptive fields ∙Causes secondary hyperalgesia →Non-injured contiguous tissue (next to the injured tissue) to the primary site of injury will develop increased sensitivity to mechanical stimuli →→→Ex: Dorsal horn is receiving inputs from heart, skin, and forearm muscle →→→If patient is having heart pain, the nerves in the dorsal horn can also cause arm pain →Can involve noncontiguous receptive fields →This stimulation results in the sensation of pain ∙This likely contributes to tender points and trigger points, where one applies pressure that triggers points

Convergence

Several (or many) neurons converge on a single neuron (or smaller group of neurons) This idea is important for referred pain

OMT and Lymphatics/Immunity

Somatic Dysfunction (SD)Inhibits body's ability to heal itself - fascial planes can "block off" regions ∙Allows accumulation of pathogens ∙Allows accumulation of inflammatory soup →Cytokines, mediators, etc ∙Decreases tissue respiration →Poor blood-flow, oxygenation, and nutrient supply ∙Increases clinical discomfort of patient (pain) ∙Can be self-perpetuating →One SD can cause others SD in Infection ∙Local tissue texture changes →Inflammation makes vessels leaky→ increased interstitial fluid→ edema →Boggy, edematous tissues →→→Agar for colonization →→→Allows accumulation of cytokines, lymphokines, etc. →Congestion inhibits lymphatic return ∙Fascial restrictions →Not necessarily caused by infection →→→Poor posture and SD →Mechanically impede lymphatic return →Easily treated with OMT (as well as moist heat) ∙Diaphragmatic restrictions →Clinical diaphragms are areas where horizontal tissues transect normal lymphatic flow →Abdominal diaphragm= respiratory diaphragm →Thoracic inlet/outlet →→→Anatomical inlet is synonymous with clinical outlet and superior thoracic aperture—this is the outlet often referred to in OMM →→→Anatomical thoracic outlet is synonymous with inferior thoracic aperture →Tentorium cerebelli →Pelvic diaphragm →Popliteal fossae →Arches of feet ∙Facilitated segments (especially T1-T4) ∙Splenic congestion Treating SD ∙Fascial restrictions →Use myofascial release →Diagnose fascial restrictions in all planes of motion →Direct technique →→→Engage all restricted barriers →→→Hold until tissue changes from gel to sol →→→Feel "creep" of fascial release (about 15 sec) →→→Reassess →Indirect technique →→→Move fascia to ease →→→Hold until tissues release (about 15 sec) →→→Follow "ease" back to neutral →→→Reassess ∙Diaphragmatic restrictions →Abdominal diaphragm →→→Motion tested by feeling diaphragmatic excursion, SB, R, and F/E →→→Treat with direct or indirect myofascial release or balanced ligamentous tension →Thoracic inlet/outlet →→→Motion test for R, F, or E →→→Treat with myofascial release or balanced ligamentous tension →Pelvic diaphragm (ischiorectal fossa) →→→Motion test for R, F, or E →→→Treat with myofascial release or balanced ligamentous tension →→→Contraindication: pregnancy, for inability to lay prone comfortably

Perspective of Muscle Balance/Imbalance

Structure and function are intimately inter-related ∙Recall tensegrity: whole system can be affected by muscle imbalance When treating a patient (pt) presenting with musculoskeletal problems always ask - Why this pattern? ∙Need to not only treat, but also determine the cause for more meaningful, long-term treatment Another question - When OMM intervention has achieved maximum mobility and balance, then how will this be maintained? Addressing muscle imbalance is an important ingredient for long term success ∙During treatment at pt visit ∙Home stretches and exercises = exercise prescription →Needs to be simple and effective →Ensure pt performs these exercises well →Ideal pts seek at-home exercises to increase therapeutic value →Doctors should be coaches, not nagging (offer at-home exercise as a possibility, but do not force it)

Treatment of cervical strain or sprain

Studies show that patients with these injuries, whose pain was treated more completely, have less long term problems ED Stiles, D.O., came up with an equation for treating patients based on Osteopathic philosophy ∙Medication and surgery are used to treat the pathology or abnormality, but OMT is used to treat the patient →If OMM is not available, PT or occupational therapy should be used for the patient Medications used for these injuries include: ∙Anti-inflammatories ∙Muscle relaxants ∙Analgesics ∙Dr. Noto Bell uses prescription strength ibuprofen or naproxen (sometimes diclofenac); cyclobenzaprine, metaxalone, or even diazepam; APAP (tylenol) with codeine, tramadol +/- APAP, oxycodone +/- APAP Also recommend OMT, exercise, and physical therapy to patients Please note that bed rest and/or immobilization (immobilization with a cervical collar) is not generally necessary, nor good for these patients ∙Early movement after the injury can be beneficial to regaining normal movement of the c-spine Other forms of treatment ∙Traction →This treatment is not good initially ∙Gentle range of motion or stretching exercises →These should be performed right away if they can be tolerated →Patient should practice this each day ∙Physical therapy →This treatment should be used only when restricted to non-mobilization modalities

1st Study: Effect of OMT on Pain-spasm-pain Cycle:

Study by Howell et al showed effect of OMT on patients with Achilles tendinitis Intervention: Single treatment session with strain-counterstrain Electrophysiologic Measurement: short-latency stretch reflex and H-reflex in gastrocnemius/soleus muscle complex ∙Short latency reflex - involuntary reaction of muscle following stretch, occurring in milliseconds →Neural pathway mediating this reflex is monosynaptic →It involves Ia-afferent fiber and a homonymous alpha motor neuron (M-wave) →Stretch a muscle and the reflex kicks in →Through the muscle spindle complex ∙H-reflex - similar to stretch reflex except that it bypasses the muscle spindles →It cannot be modulated by gamma efferent system If an intervention alters the stretch reflex, but not the H reflex then its likely doing so through alteration of muscle spindle sensitivity Intervention group with counterstrain showed statistically significant reduction in the amplitude of the short-latency reflex (M wave) compared to the control group (with no change in H-reflex) ∙It also showed decreased subjective ratings of symptoms →Ex: Soreness, stiffness, and swelling - patients felt better ∙This suggests that the counterstrain OMT reduced the excitability of the gamma motor neurons by decreasing nociceptive activity Theoretically, reducing excitability of the muscle spindle reflex will decrease hypertonic muscle tone at rest and during submaximal effort You can have tension and not have pain

Clinical presentation of cervical strain or sprain

The patient may not feel neck pain for up to 24 hours after the injury The pain may develop within minutes, though not necessarily in the cervical spine, and may radiate to other areas: ∙Interscapular region ∙Chest ∙Occiput ∙Upper extremities The patient commonly will complain of a headache The dermatomal pattern of pain is often not helpful in locating the patient's abnormality in more severe cervical strain/sprain injuries that involve neurologic impairment Suboccipital pain can reflect damage to any cervical segment and not exclusively to the occipitoatlantal and atlantoaxial regions Some patients complain of pain or numbness along the ulnar aspect of the hand ∙This can be due to nerve root irritation, but may also be a reflex from scalene spasm, 1st rib dysfunction, or any contribution of tension in the superior thoracic aperture (also called the thoracic outlet) ∙As an Osteopathic physician, you will know that this symptom can result from compression anywhere along the distribution of the ulnar nerve. You may be able to use OMT to lessen this symptom Other symptoms that occasionally result from cervical extension injuries: ∙Dysphagia- difficulty swallowing →Early onset of dysphagia can be due to pharyngeal edema or retropharyngeal hematoma →Patients must be carefully evaluated for this, as this is a serious condition ∙Visual disturbances →These can result from vertebrobasilar injury or cervical sympathetic chain injury →Visual changes themselves are not useful prognostic indicators, however Horner's syndrome may indicate serious injury →→→Horner's triad is made up of partial ptosis (droopy eyelid), miosis (constricted pupil), and anhidrosis (lack of sweating) →→→These symptoms are seen on one side of the face only, or ipsilaterally ∙Tinnitus- ringing in the ear →This symptom may be due to vertebrobasilar or TMJ injury →On impact, the jaw is thrown inferiorly during rear impact/injury →On impact, the jaw is thrown superiorly during frontal impact/injury ∙Vertigo- dizziness →If early and severe, may be a sign of severe hyperextension injury ∙It is important to get the time of onset of symptoms from the patient. Some of the symptoms above are associated with severe conditions if they occur early after the injury

Notes of litigation of whiplash in context of MVA

There is a variable prognosis with whiplash that can be difficult to predict Cases of whiplash are seen in the medico-legal environment much more than in the clinical environment ∙After whiplash injuries, people are more likely to call a lawyer than a doctor ∙There is little clinical or radiologic evidence seen in whiplash cases due to the unpredictable nature of the injury ∙These factors raise the possibility that psychosocial factors may be as relevant as physical pathology in determining outcome Factors that are associated with poor outcomes following whiplash injury: ∙Pre-injury back pain ∙High frequency of PCP visits ∙Evidence of pre-injury visits to PCP for depressive or anxiety symptoms ∙Patient was in the front seat of the vehicle →People are less likely to be belted in the back seat, and therefore suffer less whiplash ∙Patients that present with pain radiating away from the neck after injury An article from the Journal of Bone and Joint Surgery (2004) compared pain and functional disability in 4 groups of patients who had suffered injury to the cervical spine ∙The outcome: Mean follow-up of 3.5 years; patients who sustained fractures of the cervical spine had significantly lower levels of pain and disability than those who had received whiplash injuries and were pursuing compensation, but had similar levels to those whiplash sufferers who had settled litigation or had never sought compensation A retrospective study of 102 whiplash patients at 2 years follow up (unsure if the cases in this paper were litigated) had the following results ∙35% of patients still had symptoms ∙Prognostic indicators included age, occipital headaches, referred symptoms, interscapular pain, abnormal neurological signs, positive radiological findings and osteoarthritic changes of the cervical spine ∙Symptoms that persisted for more than 2 months indicated prolonged disability

Basic Counterstrain Procedure

Through musculoskeletal exam, diagnose somatic dysfunction (ARTT) Identify tender point associated with somatic dysfunction Use the pad of your finger on the tender point, NOT your fingertip (don't probe) Press to identify pain ∙Not heavy or therapeutic pressure ∙Quick impulse (on/off) ∙Only enough to identify pain is present Once you elicit a tender point response (patient will make this evident), tell the patient to remember that pain as a "10" = Quantifying the initial tenderness - this is different in counterstrain as it is part of the treatment ∙DO NOT ASK patient to rate the pain on a scale of 0-10 as you would in the subjective part of a patient history Place the patient in the position of maximum/optimal comfort while monitoring the tender point ∙First obtain a gross reduction of tenderness in the typical or 'classic position' recommended for this tender point location and dysfunction →Jones' classic position that takes a pain of "10" to a "3" 80% of the time →→→If can't get pain down to a "3" the technique will not work ∙The key is that the patient needs to be completely at rest ∙Fine tune position through small arcs of motion until tenderness is completely alleviated →As close to 100% as possible →At least 70% ∙Finger does not apply constant pressure on the point →Pressure is applied intermittently to evaluate success of positioning →Back off, fine tune, recheck until goes from 10 to 0 ∙As the somatic dysfunction resolves, you will have a palpatory sensation of ease of tissue tension (softening/melting)

Testing sciatic neuritis vs. disc problem

To test if this is a pure sciatic neuritis or a disc problem (at the dorsal root level), Dr. Evan made the patient sit with her legs hanging over the edge of the table, flex her torso, then extend her leg and dorsiflex one foot at a time ∙If this sciatica originated at a dorsal root level then the patient would not be able to extend and dorsiflex her right leg without immediately leaning back to put weight on her hands (guarding) →Patient would feel immediate back pain

Occipito-atlantal articulation (OA or C0-C1)

Two articulations formed by the: ∙Occipital condyles (are convex) ∙Superior articular facets of the atlas (are concave) Primary motion is forward and backward bending Smaller amount of coupled side bending and rotation

Scientific-Clinical Theory of Janda

Vladimir Janda, MD, DSc (1928-2002) ∙Specialist in Physiatry and Rehabilitation Medicine at the University of Charles, Prague, Czech Republic ∙Researched normal and abnormal muscle function at both basic science and clinical levels for over 50 years ∙Influenced osteopathic medicine Predictable recurrent patterns of muscle response to dysfunction ∙Postural-tonic muscles respond to dysfunction by facilitation, hypertonicity, and shortening ∙Dynamic-phasic muscles become inhibited, hypotonic, and weak →Termed pseudoparesis Muscle firing patterns ∙Muscle dysfunction also leads to sequence in which muscles chains fire ∙Altered muscle firing patterns shown with electromyographic (EMG) studies for specific activities, such as hip extension and abduction Muscle imbalance syndromes ∙Lower crossed syndrome of the pelvic girdle ∙Upper crossed syndrome of the shoulder girdle ∙Layer syndrome from cranial to caudal Dr. Janda's work was a departure from conventional rehab approach, which focused on strengthening of the muscle, focusing instead on identifying muscle imbalance sequences and treating with stretching, muscle re-education, and proprioceptive/balance training ∙Interested in changing the resting tone of some muscles, thus preventing the inhibition of the antagonist, returning balance to the muscles This dovetails with the osteopathic approach quite well Dr. Janda spoke at osteopathic meetings, especially AAO Convocations Phil Greenman, DO, FAAO (Michigan State University) integrated Janda's ideas into an osteopathic paradigm and treated people very successfully for many years Taught a course that has survived him, Exercise Prescription as a Complement to Manual Medicine

Why would we use integrative medicine?

We are seeking something missing from conventional medicine People want rapport with a practitioner and a patient-focused approach They want a hands-on approach, and one that does not focus on pharmacology and surgery Some people have a reluctance to engage "allopathic medicine" Patients have problems that have not been solved by conventional medicine or have had treatment failures due to conventional medicine People are attracted to approaches that acknowledge and include the concept of inherent healing and vital forces People want an approach that complements conventional medicine "Integrative holistic physicians characteristically view symptoms in the context of an underlying problem, attempting to treat the cause, rather than to suppress the symptoms alone" Remember that this is not "alternative medicine," it is combining complementary and conventional medicine We can use a little bit of it, a lot of it, there is no all-or-none response

More characteristics of tensegrity

Weak materials become stronger than would be expected Discrete movements can emerge as complex, with non-linear movement patterns ∙So it becomes something that is very sophisticated Whole system simultaneously adapts to forces that have been introduced to the system in a very efficient fashion Structure and function are very inter-related ∙Change in shape can lead to a change in function: ∙Can happen all the way down to a biochemical and genetic level ∙Every part in a tensegrity structure is reliant on the entire structure for its existence = inter-dependent It is a hierarchical cascade, thinking that the greatest and least, macro and micro, are all interconnected into a single whole

Whiplash is a specific type of strain/sprain

Whiplash is what the majority of this lecture is focused on Whiplash is more a mechanism of injury rather than the injury itself What is whiplash? ∙Whiplash occurs in situations where the C-spine is taken beyond its normal range of motion; specifically in extension ∙Whiplash can occur in motor vehicle accidents (MVAs), sports injuries, falls, etc. Some characteristics associated with whiplash syndrome: ∙Strain, sprain, fracture, subluxation, neuromuscular damage, etc. Descriptions of whiplash ∙In 1925, Crow introduced the term whiplash to describe the cervical spine pain suffered by pilots whose airplane takeoffs were catapult assisted →Some pilots lost consciousness after takeoff, and lost control of their aircraft; the majority of these suffered from persistent neck pain severe enough to justify retirement ∙In the 1960's, McHenry described whiplash: "A body in motion may be suddenly stopped, or a body at rest may be struck from behind. A complicating factor may be the second jar when a vehicle struck from behind jams into another object in the front." ∙Also in the 1960's, Heilig, a doctor from PCOM, described two phases of whiplash: →1st phase: The sudden acceleration of the lower part of the body, with the snapping back of the head until it also picks up the acceleration, which has been delayed by the resting inertia →2nd phase: the whipping forward of the head when the lower part of the body has decelerated

Tensegrity

"A concept of tensile integrity that can be applied to biological systems and illustrates many of the concepts of osteopathic medicine" Original concept of tensegrity was developed by the American author, inventor, scientist, architect, early environmental activist, and philosopher, R. Buckminster Fuller

4 Safety Factors Impacting MVA-related cervical sprain and strain

A firm seat back Seat belt/shoulder strap A high stiff headrest ∙When the headrest is lower than the area of the inion, it can act like a fulcrum. The head resting against it will be thrown upward and can extend over the headrest An inflatable airbag to prevent recoil

Ventral horn activity with sensitization

Central sensitization leads to altered dorsal horn activity ∙Expanding receptive fields create a zone of increased sensitivity, as in secondary hyperalgesia Connection with the ventral horn (neuronal and glial) can then alter activity patterns of the large ventral horn alpha motoneurons ∙This can produce muscle hypertonicity and spasm

Trunk and muscle power and endurance

Trunk flexors, extensors, lateral abdominals, transversus abdominis, hip abductors and hip extensors must be assessed

Pain mechanism

∙Convergence - divergence ∙Information processing in spinal cord ∙Reflex options ∙Referred pain ∙Facilitation

Clinical Application - Trapezius

35 year old male presents with complaint of upper back and lower neck pain for the past two months, aggravated by working, sitting at computer terminal. He also notes some soreness in right shoulder the past three weeks. Exam reveals tight, facilitated upper trapezius with T4 Ex, Rr, Sr and a fourth rib that is posterior on the right as well as C4 N, Rr, Sr. Right middle scalene is also tight and restricted, along with right pectoral muscles. Shoulder exam reveals tenderness at the long head of the right biceps tendon. Jobe's sign (empty can test) is negative. Postural exam reveals anterior head carriage and anterior pelvic tilt. How can this pt's findings be explained by muscle imbalance? ∙Upper trapezius facilitation ∙Goes along with segmental and rib dysfunction at level of T4 ∙As well as lower cervical and scalene dysfunction ∙Lower trapezius is likely inhibited, leading to scapular instability ∙Which in turn leads to overuse problems at the shoulder joint, in this case bicipital tendonitis How do you treat this pt? ∙Address cervical and thoracic/rib dysfunctions as well as scalene ∙Perhaps counterstrain the hot bicipital tendon What do you do next? ∙Teach home stretches →Upper trapezius →Levator scapula →Scalene Once pt has improved and facilitated muscles are lengthened and less overactive, then treat with lower trapezius/rhomboid activation exercises to strengthen these previously inhibited muscles

Allodynia

A non-noxious stimulus is painful

Hyperalgesia

A noxious stimulus is more painful than expected Ex: A pinch should hurt someone, but NOT put them in agony

Divergence

A single neuron collateralizes and makes contact w/ several (or many) neurons Makes things less specific b/c it spreads them out, but gives more information

Mechanical low back pain is an extremely common condition worldwide

A third of the population is suffering from lower back pain Leading cause of disability and work absence worldwide 1 year incidence of first ever low back pain exacerbation is approximately 11% 1 year incidence of any low back pain is 36%

Myofascia can also serves as a tensegrity role

Some structures cross the midline so if you are treating a person with right shoulder problem might have a left hip or knee issue

Increased incidence associated with both sedentary lifestyles and those with a very active lifestyle

Active lifestyles that are especially correlated with LBP include bodybuilding, weight lifting, and rowing

How are jerk reflexes mediated?

Afferent signal from muscle spindle fiber resulting in a monosynaptic efferent motor signal

Reflex Options

Afferent-efferent ∙Somato-somatic →Something goes wrong in the musculoskeletal system and there are reflexes that cause something else to go wrong in other parts of musculoskeletal system ∙Somato-visceral →Something wrong in the musculoskeletal system and there are reflexes that cause something to go wrong in the visceral organs ∙Viscero-visceral →Something goes wrong in the internal organs and a reflex causes something to go wrong in another internal organ ∙Viscero-somatic →Something wrong in the internal organs and a reflex causes something to go wrong in the musculoskeletal system DRG cells ∙Can be somatic or visceral ∙Secretory properties - can secrete things into the interstitium that can change themselves and adjacent cells →Ex: secretes substance P as NT →Substance P buildings up in system in seconds →Every time it fires, more substance P released and starts to build up, will float around in interstitium →→→Causes other nerves to fire →→→Can tear holes in lymphatic and blood vessels causing edema, also causes inflammation

Position of comfort follows certain rules for tender points

Anterior tender points = forward bend (flex) Posterior tender points = backward bend (extend) Tender points lateral to midline = side bend ∙Specific Example: C5 ESRRR →Patient positioning follows the indirect nature of the technique →Positioning for C5 ESRRR = →→→Extend →→→Side bend right →→→Rotate right →Tender point for this dysfunction is usually opposite rotational/side bending freedom →This equates to the mnemonic ESARA = Extend, Side bend Away, Rotate Away →Tender point located left articular pillar of C5

Typical Cervical Segments

Articulate at the vertebral bodies w/ disc Uncinate process → "joints of Luschka"

Coupling at the OA

Atypical Exhibits 1st law of physiologic motion coupling whether neutral or non-neutral b/c of: ∙Lateral atlanto-occipital ligament (membrane) ∙Relationship of the slope of the side of the superior facets of the atlas, and the divergence posteriorly

Upper Cervical Segments

Atypical ∙Occipito-atlantal (C0-C1) ∙Atlanto-axial (C1-C2) ∙Function as an integrated unit

Two Basic Types of Pain Fibers

Aδ Fibers ∙Responsive to intense mechanical stimulus ∙Fast conducting, sharp, localized ∙Myelinated (saltatory conduction: jumping between nodes of Ranvier) ∙Action Potential travels at 6-30 m/sec (picture of rabbit) ∙Axon is 2-5 µm in diameter C Fibers ∙Responsive to a variety of stimulus ∙Slow conducting, burning, aching, NOT as well localized ∙Non-myelinated (non-saltatory conduction) ∙Action potential travels at 0.5-2 m/sec (picture of turtle) ∙Action is 0.2-1.5 µm in diameter

Localization of Pain

Aδ fibers more specific than C fibers Has to do with the anatomy of the brain through labeled-line principle ∙Idea that one specific channel gets from somewhere in the periphery of the body into a specific place in the brain There is mapping of the human on brain based on what part of the brain correlates with what part of the body During brain surgery, surgeons expose the brain and wake patient back up ∙Map brain by zapping it with electrodes ∙Use this to find more specific areas of brain function ∙Ex: Make elbow tingle and leg shake ∙Though the brain is a bundle of nerves, it has NO sensation ∙The dura is extremely sensitive ∙Parenchyma ("meat" of organ) of brain does NOT have much sensation The cerebral cortex ∙Parietal lobe ∙"The homunculus" →It is important to think about this when considering brain surgery and the neurological system in general

Blood and Lymph

Blood distributes both cell-mediated and humoral responses Lymphatic system ∙Allows for: →Antigen collection and presentation →Drainage of products of immune response →Return of nutrients to blood ∙Lymph Vessels →Distribution grossly similar to blood vessels (run close in proximity) →Interstitial fluid collects in lymphatic capillaries →Lymphatic capillaries feed larger lymphatic vessels ∙Lymph Nodes →Filtration of lymph →Particulate or harmful matter is trapped by reticular fibers →Macrophages remove waste →Allow exposition of antigen to immune cells ∙Drainage →Thoracic duct →→→Drains left side of head, left upper extremity (LUE), and cysterna chyli →→→Passes through thoracic outlet and ultimately drains into left subclavian v. →Right lymphatic duct →→→Drains right side of head, right upper extremity (RUE), heart, and lungs →→→Passes through thoracic outlet & drains into right subclavian v. ∙Thoracic Outlet →Bony structures - First ribs, first vertebra, and manubrium (down to the angle of Louis) →Soft tissue structures - Fascia from scalenes, longus coli, and platysma ∙Lymphatic Flow →Lymphatic vessels have one-way valves (Similar to the structure of veins) →Passive Pump →→→Gravity (Ex: tell pregnant women with leg edema to elevate their legs) →→→Interstitial Fluid Pressure →→→Contraction of Skeletal Muscles →→→Respiratory Diaphragm →→→→→Inspiratory decrease in intra-thoracic pressure →→→→→Expiratory increase in intra-thoracic pressure →Active pump →→→Smooth muscle dilation and contraction (ex: brisk walk)

Biotensegrity of Musculoskeletal System

Bones are seen as the discontinuous compression-resistant struts Muscles, tendons, and ligaments (also fascia) are the tension elements Movement occurs when muscle locally increases the amount of tension within a given component of the whole system If you twist your body to the left, it puts a load on some structures but relaxes others. ∙This also applies for the forces you generate when treat using OMM Components of the musculoskeletal system can also be seen individually as biotensegrity structures: ∙Spinal column ∙Pelvis

Reflex Somatic Dysfunction

Dr. Allison stressed importance of this chart Referred pain is unrelated to sympathetics

Pain patterns during movement testing

CENTRALIZATION - occurs when the location of the patients symptoms is perceived to be more proximal in response to single repeated motions or sustained motions PERIPHERALIZATION - the opposite of centralization when perception is in a more distal location i.e. calf or foot Example of this is when patient is asked to flex/ext or laterally shift the pelvis and trunk while standing prone or supine- is their pain more distal or proximal? Centralization is more a positive shift in treatment than peripheralization

Disadvantages to using counterstrain

Can have "stoic patients" who don't "get it" Quantifying pain Takes time to treat Adverse reactions 1-2 days post treatment that can last up to 24-36 hours ∙Treat with Acetaminophen and water Some patients (particularly geriatric) cannot be placed in appropriate treatment position because of other positional considerations/limitations Some patients are unable to relax their muscles sufficiently for treatment positioning or the return to neutral to be truly passive ∙Don't want to fight the patient

Muscle spindles continuously send signal to the brain

Can send two types of signals to the brain, either positive or negative ∙Increased from baseline during contraction creates positive signals ∙Decreased from baseline during relaxation creates negative signals

Risk factors for increasing incidence of LBP (lower back pain)

Cardiovascular hypertension Smoking Obesity Depression/anxiety The first three are vasculopathies, decreasing the ability of the body's connective tissue to heal and consequently decreasing the ability of the body to bounce back from lower back pain

Introduction to Sprain and Strain

Cervical sprain and strains are microscopic or macroscopic injuries to the soft-tissues of the C-spine The words strain and sprain are often used interchangeably, but they actually mean two different things ∙Strains are musculotendinous soft tissue injuries (STrain- Tendon) ∙Sprains are injuries to ligaments ∙You strain a muscle and sprain a ligament Both strains and sprains occur by the same mechanisms of injury Sprains or strains can be microscopic or macroscopic Sprains or strains can be acute or chronic ∙Acute injuries can be microscopic or macroscopic ∙Chronic injuries are usually microscopic

Facilitation

Changing the resting membrane potential Relative depolarization Lowers excitation threshold - makes it easier to shoot an AP Operative in chronic pain syndromes (migraine, fibromyalgia, etc.) ∙Recurring pain coming from an initial noxious event Image shows that resting potential for sensitized neuron (facilitated neuron) is higher than normal neuron

The Downward Spiral

Chronic inflammation + vasoconstriction + muscle spasm(guarding/splinting response) = Somatic dysfunction maintenance and exacerbation

Ipsilateral Reciprocal Inhibition

Co-contraction ∙Stimulation to both limb flexor and extensor muscles ∙Stabilizes a joint, restricting movement (Ex: flexor-extensor) Reciprocal inhibition about a joint ∙Always occurring ∙Ex: In knee extension, hamstrings relax and quads tense ∙Example: Extension →Extensor group contracts →Flexor group is reciprocally inhibited = relaxes →Allows for controlled flexion activity →Same is true for flexion

Muscle Spindle Intrafusal Muscle Fibers

Contain nuclear chain, dynamic and static nuclear bag fibers Relay sensory information on length and rate of changes in length of a muscle ∙Has a lot to do with resting tone Information is transmitted by Group Ia and Group II afferents back to the spinal cord

Clinical Application/Treatment of muscle imbalance

Core retraining and balance/proprioceptive training ∙Ex: hamstrings and upper lumbars over-firing, while core abdominal muscles aren't firing Stretch and lengthen the hypertonic postural muscles (particularly hamstrings, Piriformis, iliopsoas) ∙OMT ∙Home exercise program = exercise prescription →Ex: hamstring stretch at home can significantly positively enhance results Activate and strengthen the previously inhibited dynamic/phasic muscles ∙Example: simply giving hip extension exercises to strengthen the gluteus muscles will not effectively activate the gluteus muscles because these muscles are inhibited; instead, must strengthen the hypertonic muscles first (to rid the muscle groups of hypertonicity and reciprocal inhibition), and then work on strengthen the gluteus muscles. Gentle aerobic exercise, such as walking or swimming, for maintenance

Instances where Counterstrain may not elicit response

Costochondritis Referred pain

Examples of combining techniques

Counterstrain and Soft Tissue/Myofascial Release ∙Contributes further to neurophysiologic and textural changes in affected tissue such that ongoing nociceptor firing is decreased Counterstrain and Muscle Energy ∙May potentiate the resetting and dampening of excited neural components ∙May treat the articular and soft-tissue components of somatic dysfunction Counterstrain and HVLA ∙May treat the articular and soft-tissue components of somatic dysfunction

Osteopathic Approach

Decreasing nociceptive input would be very helpful ∙As seen in counterstrain and HVLA - all affecting muscle spindle fibers Use OMM diagnosis and treatment to decrease allostatic load and effect positive changes towards a higher functioning state of equilibrium ∙Improve ability to cope with stressors and allostatic load ∙Beneficial effects are biophysiological or more ∙Recognize cause and effect (structure/function) Work with body's inherent ability to heal itself These last two points are two of the tenants of Osteopathic medicine

Layer Syndrome of Muscle Imbalance: alternating bands of hyper- and hypo- tonicity

Described by Janda Characterized by alternating bands of muscle tightness and weakness on the dorsal surface of the body Tight gastroc/soleus, hamstrings Weak glutei and lower erector spinae Tight thoracolumbar erector spinae Weak rhomboids, lower trapezius Tight upper trapezius, levator scapulae, cervical erector spinae

How does the body know when a sensory receptor is receiving more or less stimulation?

Determining kind of painful vs. super painful? ∙By more or less frequent action potentials When a receptor is stimulated, it approaches its receptor potential threshold ∙This causes firing of action potentials ∙The higher the stimulation rises above the threshold, the greater the frequency of action potentials ∙The farther you go above the threshold, the more frequent the firing of the action potential becomes ∙Action potentials = ON/OFF, not graded →"Either fires or it doesn't" →This is important for pathology Receptors "adapt" ∙With prolonged stimulation, the frequency of action potential falls →Even if you are above the threshold, over time will fire fewer and fewer action potentials per second ∙Pacinian receptors adapt to "extinction" rapidly →Becomes refractory to stimulus ∙Joint capsule receptors adapt slowly Slowly adaptive receptors = tonic receptors ∙Golgi tendon apparatus adapts slowly giving the brain constant information on muscle contraction and load on tendons Rapidly adaptive receptors = phasic receptors ∙Pacinian corpuscles adapt to pressure rapidly ∙They give information about change as it happens ∙They fall silent when change stops ∙"They are only interested in change that is actively happening, vs the tonic receptors which tell you what's going on over a long period of time" Intensity can be increased in two ways: ∙Spatial summation = greater number of fibers firing simultaneously ∙Temporal summation = fixed number of fibers firing with increased frequency ∙*Both of these lead to summation = reached firing threshold on the soma of the neuron* Two types of pain are transported differently: ∙Fast, sharp pain from mechanical or heat travels on small a-delta fibers between 6-30 m/sec ∙Slow, chronic pain from chemical, mechanical, or thermal stimuli travels on C fibers between 0.5-2 m/sec

Neurophysiology of Counterstrain

Dr. Nicholas says we have to understand physiology and neurophysiology for this technique ∙Mechanism for how tender points are generated and why technique works is changing in research Constant feedback is required through the autonomic nervous system and circulatory system Two main components of PNS ∙Afferent (sensory) pathways provide input from the body into the CNS →Sensory Nerve Endings (receptors) constantly monitor variation in temperature, ischemia, inflammation, and body position (proprioception) ∙Efferent (motor) pathways carry signals to muscles and glands

Theoretical Causes of Muscle Imbalance

Dysregulation (malregulation) of the CNS ∙From cord level or higher centers (including learned behavior) ∙Leads to altered agonist and antagonist reactions and response →Ex: learning to pitch a baseball or hold the violin ∙Loss of control of integrated function Postural adaptation to gravity ∙Faulty posture leads to altered center of gravity ∙Initiates mechanical responses and muscle adaptation Change in mechanical behavior of joints leads to neuroreflexive alteration in muscle function ∙Ex: loss of motion from hip arthritis ∙Can lead to long term changes = cord memory → muscle imbalance Habitual movement patterns emerge Noxious stimuli present ∙Mediated through segmental reflexes and centrally mediated pathways ∙Example: Segmentally - nociception facilitates alpha motor neurons to flexors in limbs and extensors in the neck and trunk ∙Ex: plantar fascitis Muscle balance responds to physical demands ∙Tight muscles become tighter ∙Weak muscles become weaker ∙Motor controls become more asymmetric Psychological influences ∙Example: Emotional tension → physical tension → chronic changes →Ex: tension in shoulders as result of emotional tension

Modalities as adjuncts to care

Each group of practitioners has a different standard for training and different philosophy behind their practice Yoga ∙Adopted as a modern form of exercise and wellness in the western world in the mid 1970's to early 1980's ∙Core of yoga is centered around exercise, breathing and meditation ∙Yoga teachers spend between 200-500 hours of training →The required training varies state by state. There is no national standard. Know types of yoga because patients will use terminology ∙Hatha: basic/beginner yoga - centered on the process of holding physical postures. Considered a gentle introduction to basic poses with the benefits of increased flexibility and strength →Low impact/very basic ∙Vinyasa: Builds on hatha →Focus on smooth transition from pose to pose. ∙Bikram: Popularized by Bikram Choudury this is performed in heated rooms to increase the physical intensity. Poses are performed in a specific sequence. →A lot more demanding →A lot more increase in flexibility →Patients with certain co-morbities should not be doing this (ex. Pregnancy, vertigo) ∙Ashtanga: This is a rigorous style of yoga that follows a sequence of specific postures that are all linked to a breath →They are always performed in the same order →This is a hot, sweaty, physically demanding practice →Not performed in hot room ∙Feldenkrais →Is an experiential movement therapy that aims to breakdown aberrant patterns of movement throughout the body →Habitual movement patterns and repetitive motion can cause stress and lead to the breakdown of the connective tissue →→→Can be consciously addressed and changed by the patient →Feldenkrais practitioners must receive approximately 700 hours of training (significantly more than yoga) →Randomized controlled studies have shown some benefit from Feldenkrais therapy and are promising although more work should be done →Principle form of injury and caution is the over dependence on this technique with the subsequent neglect of other more accepted modalities ∙Rolfers →Require approximately 750 hours of training →Direct pressure bodywork that aims to reorganize all fascia in the body and help the fascia to function as a unit →→→Similar to deep tissue massage but focus not just on muscle but on fascia →→→Goal is to have all fascia work as a whole unit →Has been shown to allow for more efficient use of muscles →→→Allow the body to conserve energy and creates more refined patterns of movement →Most Rolfers start out as medical practitioners →Rolfing is a series so you should be mindful of when someone is trying to sell a series of body work to your patient →→→Whenever a patient is told that they need to complete an entire series for improvement both the patient and the practitioner should be weary Medical massage ∙Massage practitioners have approximately 500 hours of training divided between classroom time and practical training ∙Medical or therapeutic massage unlike many other forms of bodywork and complimentary medicine has been well studied ∙It functions by restoring local ROM, decreasing muscle tension and increasing blood flow ∙Medical massage has been used to treat... →Carpal tunnel syndrome →Sciatica →Migraines/headaches →Constipation →Fibromyalgia →Plantar fasciitis →Edema (especially lymphatic) →Thoracic outlet syndrome →Repetitive use injuries ∙In the commonwealth of Pennsylvania medical massage can be covered by some insurance companies if an rx is written by an appropriate practitioner: MD, DO, DC ∙Guidelines state: →Rx has to be written by one of those practitioners →Practitioner has to be on site when medical massage is performed →Massage therapists must be licensed and must write up appropriate note Chiropractic ∙The most common form of manipulative (spinal specifically) bodywork with approximately 55,000 practitioners in the United States ∙Chiropractors currently receive 4 years of training with most Chiropractic colleges requiring a college degree for admission ∙Founded in 1890 by D.D. Palmer Chiropractic →Science is based on improving the function of neural structures of the body and their ability to regulate homeostasis, by manipulation of the spine →D.D. Palmer was one of A.T Still's students but only did 1 year of the 2 year program and then went on to set up his own school ∙Modern day chiropractors treat everything from low back pain to whiplash →If your patient really likes their chiropractor and you don't see that any harmful work is being done, support them ∙Their services are covered by insurances, however at a surprising low rate (avg 12-30 dollars) →Chiropractors can use and bill insurances for many physical therapy modalities in their offices including heat and cryotherapy, massage devices/chairs, traction devices etc →Will often prescribe a series of work which should be a red flag →Physicians cant bill for modalities like heat and cryotherapy, massage devices/chairs, traction devices, etc.

Definition of Counterstrain

Educational Council of Osteopathic Principles (ECOP) definition: ∙"A system of diagnosis and treatment that considers the dysfunction to be a continuing inappropriate strain reflex, which is inhibited by applying a position of mild strain in the direction opposite to that of the reflex; this is accomplished by specific directed positioning about the point of tenderness to achieve the desired therapeutic response" Counterstrain is an Indirect Treatment ∙Patient's somatic dysfunction is treated by →Palpating an associated myofascial tender point, then →Moving the body to a position of "ease" (spontaneous tissue relaxation) while simultaneously monitoring the tender point to make sure it shuts it down →Very "simple" technique Further Description of Counterstrain ∙Can also be described as relieving tension on the injured tissue and 'counter-straining' the opposing or antagonistic tissue or muscle group →Strain in the case of Counterstrain is NOT just referring to myofascial/soft tissue structures as it normally does →Can also affect ligamentous supporting structures and joint or facet locking →Recall that sprain usually applies to ligamentous structures

A couple of other treatments with IHM & IBS

Enteric coated peppermint capsules with fennel (+/- ginger) Gentile to daily aerobic exercise OMT to address viscerosomatic and somatovisceral reflexes in the thoracic, thoracolumbar, and upper cervical areas Stress reduction Meditation, in particular, Mindfulness Meditation ∙One study showed 38% reduction in symptoms presented by researchers at the University of North Carolina at Chapel Hill Traditional Chinese Medicine and Ayervedic medicine have their own approaches

The Somatosensory System

Entire system of feeling in the body Dermatomal distribution ∙Boards includes questions from a few, specific dermatomal patterns Trigeminal nerve distribution in head ∙Dermatome man does NOT include the head There is quite a bit of overlap

Chains - LE Flexor and Extensor Slings

Ex: standing from a seated position transitions knee/hip from flexion to extension Ex: change in flexion/extension in gait Extensor sling for hip/lower extremity ∙Gluteus maximus, rectus femoris, gastrocnemius ∙Hip extension, knee extension, ankle plantar flexion Flexor sling ∙Iliopsoas, hamstrings, tibialis anterior ∙Hip flexion, knee flexion, ankle dorsiflexion Gait Cycle ∙Flexion and extension chains alternate between facilitation and inhibition, and reciprocate between right and left limbs ∙Example: flexor chain activated in the swinging leg while extensor chain is activated in the stance leg Trunk Muscle Slings ∙Anterior trunk muscle sling ∙Spiral trunk muscle sling ∙Posterior trunk muscle sling

Joints of Lushka

Found at postero-lateral corners of disc Helps in gliding movements during forward and backward bending Protects from posterolateral disc herniation Prone to degenerative changes (lipping) ∙Occasionally causes encroachment at anterior aspect of the lateral intervertebral canal ∙Uncovertebral joints ∙Uncinate processes

Nociceptors

Free nerve endings ∙NOT encapsulated ∙Responsive to noxious stimuli and local tissue chemistry associated with it

Principles of Physiologic Motion & Cervical Motion

Fryette's principles are not included in the cervical region b/ of: ∙Atypical facets in the upper segments ∙Oblique plane of the facets in the lower segments ∙Shape of the vertebral bodies, ligamentous attachments, and muscular insertions

Neurotransmitters

Glutamate = acts instantaneously, lasts for few milliseconds ∙Rapid half life, immediately degraded Substance P = released slowly, builds concentration over minutes ∙Builds up in synaptic cleft

Hyperpathia

Greater noxious stimulus required to trigger action potential with pain shooting directly to maximal intensity and lasting longer than appropriate Requires a greater stimulus than normal to fire an action potential The resting membrane potential is lowered NOT raised Pain goes to maximal intensity and persists long after noxious stimulus is gone

Positioning for counterstrain

Hold position of maximum comfort for a minimum of 90 seconds Remind patient to relax and not "help" you The finger can be lightly maintained on the tender point to: ∙Palpate/assess changes in the tender point ∙Periodically re-assess positioning of the patient by intermittently pressing on the tender point After 90 seconds ∙Very slowly return the patient 'passively = physician' to the neutral position ∙Recheck the tender point Reassess diagnostic components of somatic dysfunction (ARTT)

Much of the research performed on yoga has suffered from small sample sizes, selection bias, lack of randomization and of poor methodological quality

However, people that say they do yoga usually love it Report both physical and mental benefits Used to treat depression, fatigue, pain, hypertension and heart failure

Increased morbidity in certain conditions with counterstrain treatment

Hyperpositioning/Extension of the neck in patients with vertebral osteophytes can cause light headedness or neurological symptoms (e.g. pain radiating down their arm) due to neuroforaminal encroachment

Cervical Regional Testing

If flexion-extension restriction is greater than sidebending-rotation restriction, think OA If a patient presents w/ neck pain and on physical exam demonstrates only rotational limitation, think A-A dysfunction If mostly sidebending limitation w/ some limitation of rotation, think C2-C7

Tips for successful counterstrain treatment

If there are multiple tender points treat most acute tender point first Treat generally no more than 3 tender points in an area of the spine and no more than 6-8 per treatment ∙Mainly because it will take too much time Use re-evaluation of what you treated in a prior visit as a way of evaluating the "effectiveness" of treatment or response to treatment

Somatic Dysfunction: Causes & Effects

Image shows how pain can lead to a variety of pathways and cause changes throughout body ∙Mediated by anatomical connections through the nervous system ∙DO NOT MEMORIZE

Exercise and low back pain

Important to know protocols that are used by physicians, physical therapists, chiropractors, etc. that monitor a patients pain to be objective about other specialists' work enabling one to see benefits that were not originally anticipated

Increasing spinal instability causes low back pain and is associated with various factors:

Increasing age Females have increased incidence because of more ligamentous laxity, which is a precursor for spinal instability Manual labor increases incidence of sprain and strain ∙Sprain and strains also damage and overload the proprioceptors ∙If proprioceptors are not treated can lead to a proprioceptive deficit Lower educational status are less likely to receive care ∙Acute back pain is likely to turn into chronic if not treated

Permanent change can occur in dorsal horn circuitry

Inhibitory GABAergic interneurons will undergo apoptotic cell death following excessive activation Loss of these neurons decreases inhibition of spinal cord circuits leading to a more easily excited segment

OMT in cervical strain or sprain

Initially, or for acute injuries, you will use indirect techniques For subacute or chronic injuries, you can use indirect or direct techniques Note: while timing can be a guide, the severity of the injury and the patient's tolerance to treatment dictates the modality you will use (direct vs. indirect) OMT: Indirect options ∙Osteopathy in the cranial field (OCF), also called "Cranial" →When doing this technique you are also considering the sacrum because of its connection through the dura mater of the spinal cord →This is an excellent modality to address the sequelae of trauma to the head and neck (visual, tinnitus, nausea, etc.),while balancing longitudinal tension through the spine ∙Counterstrain →Use caution when extending the patient's neck, as there can be vertebrobasilar involvement with some whiplash injuries ∙Myofascial release ∙Balanced ligamentous tension ∙Facilitated position release ∙Muscle energy →Even though this is a direct technique, the patient may tolerate reciprocal inhibition in the acute setting OMT: Direct techniques ∙Soft tissue ∙Myofascial release ∙Muscle energy, specifically post-isometric relaxation ∙HVLA

Muscle stretch reflex

Initiated by sudden stretch of the muscle spindle Type I A proprioceptor nerves enter the dorsal root and synapse with anterior motor neurons in a monosynaptic pathway ∙Monosynaptic creates shortest possible time delay for reflex Muscle contracts ∙Dynamic stretch reflex (both primary and secondary endings) for initiation of muscle jerk ∙Static stretch reflex (primary endings) for sustained contraction after initial jerk

Muscle Spindle

Intrafusal Fibers ∙Register changes in muscle length ∙Central region has non-contractile fibers innervated by afferent sensory receptors →1a afferent annulospiral sense for length & velocity of length changes of the muscle →2a afferent flower spray only sense change in length ∙Periphery of central region has contractile fibers innervated by gamma motor efferent nerves →Responsible for change in muscle tone to maintain constant tension on central portion of muscle spindle →→→Gamma 1 (dynamic): sensitive to rate of change →→→Gamma 2 (static): sensitive to degree of stretch →An increased firing of gamma motor efferent receptors to cause contractile fibers to increase tension on the central portion of the muscle →→→This increases the afferent sensory receptors feedback →→→This increases the alpha motor neuron firing causing contraction of the extrafusal muscle fibers

C3-C7 Facets

Just to be clear: inferior facet of C2 to superior facet of C7 Superior facets ∙Face backward, upward and medial (BUM) ∙At angle approximating 45° ∙Oblique in plane

Golgi tendon organs

Located in the muscle tendons Give information about tendon tension and rate of change of tendon tension

C1 and C7 are the only parts of the cervical spine with true transverse processes

Longus coli, longus capitis, and scalene muscles attach to the lateral tubercles of C2-C6

Vertebral Artery

Major significant in manipulation of the cervical spine Begins its relationship at C6-C7 Runs through tranverse foramen and exits at superior C1 Turns posteriorly over posterior arch of atlas ∙Penetrating posterior occipitoatlantal membrane ∙Then enters foramen and magnum Normal vertebral arteries can narrow as much as 90% of the luminal size on the contral lateral side to cervical rotation ∙This is exacerbated in extension (backward bending)

2nd Study: fMRI evaluation of OMT and LBP

Muscle functional magnetic resonance imaging measures muscle activity by T2 (transverse relaxation time) This can investigate individual muscles at a deep level more effectively than surface EMG Study showed reduction in psoas hyperactivity with OMT via fMRI in patients with nonspecific acute low back pain ∙Not a pinched nerve Intervention: single session of OMT Measurement: fMRI T2 images of multiple muscles of low back area In patients with LBP psoas T2 asymmetry reduced immediately following OMT ∙Statistically significant ∙Correlated with reduction in back pain Study suggests that in patients with low back pain, OMT can normalize psoas muscle activity ∙OMT will reduce the activity of the hyperactive side and disrupt pain-spasm-pain cycle

Ascending Pathways for Pain

Nociceptive input into the dorsal horn is projected upstream to the brainstem and thalamus via dorsal horn neurons with long axons Spinoreticular tract - terminate in nuclei of the medulla, pons and midbrain ∙Target sites include catecholamine cell groups and other nuclei ∙Many of these areas regulate much of the descending brainstem-spinal cord projections and so could play a role in modulation of pain Spinothalamic tract - dorsal horn neurons also project above the midbrain to the thalamus, where perception takes place. Thalamus - functions with the cortex in perception ∙Nociception ∙Feeling of pain (where nociception becomes pain) ∙Associated emotions (i.e. anxiety or depression) Cerebral Cortical Pain Matrix ∙Transition from sensation to perception ∙Pain facilitation well documented ∙Forebrain responds to ascending signals • Can also turn off pain receptors (Can lift a car off of a child) ∙Provides descending modulatory information that can influence many ascending signals ∙Pain localization component ∙Emotional-motivational component ∙No one portion of the cortex can entirely account for pain perception Amygdala ∙Amygdala is important to know for the test ∙Located on the medial aspect of the temporal lobe ∙It receives projections from: • Most of the associative portions of cerebral cortex • Brainstem (especially pain pathways) ∙Key role in forming memories associated with fear-provoking stimuli • Shown on fMRI ∙Efferent fibers from the amygdala provide a strong drive on the hypothalamic and brainstem areas involved in sympathetic-adrenal system ∙Some input to the amygdala is subcortical • Via thalamus, bypassing cortical processing ∙Traumatic or painful events can cause facilitation • Predisposes to misinterpretation of innocuous stimuli ∙It plays a role in chronic pain states as well as those of depression and anxiety • Studies show atrophy of amygdala in people with long term depression Pain matrix ∙Many different areas of CNS involved in pain: • Somatic sensory cortex • Insular cortex • Anterior cingulate cortex • Prefrontal cortex • Amygdala • Parabrachial nucleus • Thalamus • Hypothalamus ∙A nociceptive system from primary afferents through the cerebral cortex ∙Significantly modulated by interactions of ascending and descending pathways ∙Feelings and emotions related to pain are an emergent property of this distributed neural network ∙This system is dynamic and plastic • Continually responds to nociception • Continually changes as a result of nociception ∙Involved in suffering or learning and adapting

Allostatic Mechanisms

Pain, and the stress it creates in the body and brain, can be an allostatic process ∙Allostasis is described as an effort to respond to a challenge (allostatic load = stress placed on system) to restore homeostasis ∙Allostasis is also defined as chronic state of disordered homeostasis that allows survival of the organism at the expense of its well-being ∙So if something is not right, but still operative, the body is able to function with that, but it is not at the optimum balance. →Example - sustained HTN and chronic pain cause an osteoarthritic hip that changes your gait Allostatic (feed-forward) process involves: ∙Primary afferent fibers (PAN) with peripheral sensitization ∙Spinal cord with central sensitization, including segmental facilitation, which send the pain upward to the forebrain ∙Forebrain areas, including the amygdala: →Link pain and emotion →Drives the Hypothalamic-Pituitary-Adrenocortical (HPA) axis ∙Can lead to sustained levels of cortisol and norepinephrine leading to physiological/systemic dysregulation ∙Can affect sleep, pain perception, heart rate, BP ∙Can lead to anxiety and depression

Clinical assessment of cervical strain and sprain

Palpation ∙Try to feel tissue texture changes (tension, ropiness, etc.) →Very soon after the injury, the tissues will feel hypertonic, warm, and boggy (boggy feels like a wet sponge),there may be edema (fluid build-up) ∙Examine for loss of motion regionally and inter-segmentally ∙Those with pain over the posterior elements and spinous processes are not as likely to be seriously injured as those with anterior point tenderness →With an extension first injury, the anterior muscles are being stretched traumatically initially Radiologic evidence ∙Before performing OMT on patients, rule out fractures, dislocations, subluxations, etc. ∙The loss of cervical lordosis (a straightening of the C-spine) may or may not be a significant factor, as uninjured patients have this asymptomatically →The straightening of the spine can be due to muscle spasms ∙Reversal of the cervical curve, especially if it is sharply demarcated at one level, indicates significant abnormality Which one of the radiographs is clinically significant based on the information given above? ∙The radiograph on the left shows a straightening of the C-spine ∙The radiograph on the right shows a reversal of the cervical lordosis occurring between C4 and C5 →This is clinically significant

Upper Crossed Syndrome

Postural/tonic muscles facilitated ∙Levator scapulae ∙Upper trapezius ∙Sternocleidomastoid ∙Scalenes ∙Pectorals ∙Flexors of upper extremity Dynamic/phasic muscles inhibited ∙Middle and lower trapezius ∙Serratus anterior ∙Rhomboids ∙Supraspinatous ∙Infraspinatous ∙Deltoid ∙Deep neck flexors (posterior translation of head) ∙Extensors of upper extremity Notice: trapezius behaves as both postural/tonic muscle and dynamic/phasic muscle. Therapeutically important to consider structure-function relationships Help fix posture: lengthen tight muscles, activate weak muscles later

Summary of central sensitization

Primary afferent nociceptors transmit signals to the dorsal horn Dorsal horn cells carrying nociceptive input ∙Ex: Projection cells, local circuit interneurons, propriospinal neurons Dorsal horn plasticity ∙The "wind-up" phenomenon ∙Transcription dependent sensitization ∙Depressed/loss of inhibitory interneurons Secondary hyperalgesia - recruits other areas to sensitize Glial cell activation Ventral horn activity alterations (muscle tone and spasm) Viscerosomatic reflexes Ascending pain pathways ∙Spinoreticular tracts ∙Spinothalamic tract ∙Thalamus Cerebral Cortical Pain Matrix ∙Amygdala Osteopathic approach: ∙Decrease nociceptive input ∙Use OMM diagnosis and treatment to decrease allostatic load and effect positive changes towards a higher functioning state of equilibrium ∙Improve ability to cope with stressors ∙Beneficial effects are biophysiological and more ∙Recognize cause and effect, structure and function ∙Facilitate the body's inherent ability to heal itself ∙Recognize the triune of body, mind, and spirit

Muscle Fiber Type

Slow-twitch muscle ∙Oxidative metabolism predominates ∙High capillary density (red color) ∙Slow twitch speed ∙Used often in muscles with tonic or postural function ∙React to functional disturbance by shortening and tightening Fast-twitch muscle ∙Glycolytic metabolic pathway predominates ∙Low capillary density (white color) ∙Fast twitch speed ∙Fatigue rapidly ∙Phasic function (turn on and off quickly) ∙React to functional disturbance by weakening Muscles are a mixture of both fiber types

Neck Flexion Sometimes Inhibited

Some pts with upper crossed syndrome have difficulty arising from supine position without extending cervical spine Extensors are overactive and fire inappropriately Aggravated by other hypertonic, overactive postural muscles such as sternocleidomastoid and scalenes Attempts at neck flexion actually involve head moving anteriorly without appropriate use of neck flexors Inhibited Neck Flexors Need Training ∙Then...activate the previously inhibited neck flexors, if needed ∙Can do so with posterior translation ∙Other exercises too, such as eccentric strengthening

Spine & Tensegrity

Spine needs to move freely and dynamically, be lightweight, and self-stabilized while protecting vital neurologic structures inside Tensegrity model fulfills these requirements Pre-stress within spine from ligaments, small rotator muscles, and larger erector spinae muscles - details still need to be worked out

Intralaminar nuclei

Stimulation of the intralaminar nuclei of the thalamus has a strong arousal effect on the entire brain (arousal system), make it physiologically impossible for someone in severe pain to sleep ∙"Pain is actually waking you up" ∙Anatomical reason why pain keeps you awake, important evolutionarily ∙Becomes important when patient complains of not being able to sleep at night due to pain, can treat this as a physician

Bodily defenses for preventing infection

Structural defenses- 1st line defense, most of which sequester infection ∙Integument ∙Mucosa ∙Cilia ∙Epithelial barriers ∙Fascial barriers Other defenses- 2nd line defense ∙Phagocytes ∙Natural flora 3rd line defense ∙Cell-mediated immunity →Primarily T-cells →→→Cells directly kill cells displaying targeted antigens (virally infected cells, cancerous cells, etc) →Activation of macrophages ∙Humoral immunity →Primarily plasma cells →→→Mature B-cells responsible for antibody production →Antibodies →→→Allow complement fixation →→→Block receptor sites →→→Cause agglutination (clumping) and opsonization of pathogens

3rd study - MEP Evaluation of HVLA and LBP

Study by Clark et al studied neurophysiological effects of OMT on motor evoked potential (MEP) induced by transcranial magnetic stimulation Intervention: single HVLA spinal manipulation thrust to patients with chronic low back pain and controls Measurement: corticospinal and stretch reflex excitability Participants exhibiting an audible response with HVLA, "pop" had a substantial reduction in the short latency stretch reflex This suggests that OMT can act by down-regulating the excitability of the muscle spindles or other sites of the Ia-reflex pathway Overall, this study produces evidence by reducing activity of muscle spindle fiber reflex

Biotensegrity

Tensegrity concepts applied to biological organisms Can occur at all levels: ∙Musculoskeletal ∙Organ system ∙Organ ∙Tissue ∙Cellular ∙Molecular

Tensegrity principles

Tensile integrity is a structural principle ∙Isolated components (strut or bar) under compression, inside a net (elastic string) of continuous tension Compressed components (e.g. bars, struts) do not touch each other in many of the structures Pre-stressed tension components (e.g. cables) delineate the system in three dimensions

Cervical Functional Anatomy

The cervical region can be separated into 3 distinct biomechanical areas: ∙Occipito-atlantal (C0-C1) ∙Atlanto-axial (C1-C2) ∙C2-C7 →Oblique facets b/w these vertebra →Remember that the facets b/w C7 and T1 are coronal

Fascia

The continuum of fascia throughout the body allows it to serve as a body-wide mechanosensitive signaling system A problem in one part of the body can be quickly transmitted to another part of the body via fascia Fascia plays a dynamic role in transmitting mechanical tension, as well as electrical signals via piezoelectric properties, and may be able to contract in a smooth muscle-like fashion Fascia does not contract like muscle, but it has some contractility to it Fascia is richly innervated Fascia plays an important part in proprioception Remember, when performing OMM, to keep all of this in the context the greater whole and start to listen with your hands to feel connections between different parts of the body

Some OMT outcome in cervical strain or sprain

The following are results of studies that support the use of OMT for cervical strains and sprains Most of the information was obtained from the British Medical Journal Studies will sometimes show no statistically significant difference between OMT and care using pharmacotherapy and/or physical therapy ∙Dr. Noto Bell's thought on this is that medications have side effects and can be costly to the patient, and PT requires co-pays and often has capitations. Her opinion is that if OMT does the same thing at PT and medications, without the side effects, extra co-pays, and capitations on insurance, then why not perform it for your patient? You are already charging the patient a co-pay to visit your office - you can bill insurance for the OMT and the patient may not need the PT or medications, which can be costly

Guarding posture

The guarding posture can be caused by acute strain of deep myofascial structures and/or sprain of ligamentous supporting structures (facet capsular ligaments &/or annular fibers of intervertebral disc) Beware because the ligaments are loaded with nociceptors ∙Possible damage to the annulus fibrosis of an intervertebral disc ∙The nucleus pulposus of the disc does not have nociceptors ∙The outer 1/3 - outer ½ does have nociceptors ∙Often times a slipped disc will have microtears in the annulofibers which causes severe pain and guarding posture ∙Check to make sure this forward flexion ∙Do not do HVLA or PIR ME because they could cause disc herniation ∙Soft tissue techniques would also cause pain

Endogenous pain control systems

There is a pain control system to regulate when, and to what degree, nociception and the impression of pain occur In response to injury the body can suppress transmission of pain through the spinal cord, facilitating the ability to focus on escape and survival ∙Example - If you are fleeing a large animal that's coming after you, you're not going to be worried about your torn toenail, you're going to be running for your life ∙Example - If someone surprises you at night on the Philadelphia streets, your heartbeat goes up in a fight or flight response. You're not worried about your back pain (down-regulated by endogenous pain pathway) to focus on survival tactics ∙Can reverse process in safe situation to assess injury ∙Story - Dr. Fuller used to play basketball and dislocated a finger once →He went to the ER to get it reduced, but it didn't get hurt because he was hyped up about the game he was playing The brain modulates spinal activity ∙Regulating information allowed to rise to consciousness Descending pathways from the cortex down to the central pathways modulate dorsal horn and spinal trigeminal nuclei input ∙Via neurotransmitters such as serotonin and norepinephrine ∙Can suppress pain or enhance our sensitivity to pain like a thermostat dialing up and down Pain modulation system modulates nociceptive input that comes in at the level of spine and midbrain Some of the forebrain structures, especially in the limbic system, exert strong regulation over these pathways Complex supraspinal networks, influenced by emotions and hormones, can inhibit or enhance our feeling of pain from a noxious stimulus ∙Two people can have the same painful stimulus, but only one suffers →This is because suffering occurs at a higher cognitive level Social and psychological factors play a big role in pain perception ∙For someone who has had trauma in the past, an event may trigger pain and a lot of recall in comparison to someone who has not experienced that pain before Components of this endogenous pain control system are intricately intertwined with areas controlling the autonomic nervous system (including norepinephrine) and activity of somatic motor neurons in the ventral horn of the cord (affects muscle resting tone)

Facilitation/Sensitization

There is a raised resting membrane potential The neuron exists in a hyper-excitable state Less stimulus is required for action potential This is common in both hyperalgesia and allodynia Remember: pain fibers do NOT adapt, they keep firing ∙There are other methods already discussed for how the body can reduce pain

High rate of false positives with imaging use

Therefore, one has to treat LBP from a clinical perspective It is extremely difficult to determine the exact cause of LBP People who may have no symptoms still often show evidence in imaging of spinal abnormalities ∙Example: 20-76% of people without LBP show evidence of herniated disc material on CT, MRI and myelography By contrast, 47% of people with LBP have no abnormality identified on imaging LBP is always a clinical diagnosis, and imagining should be used to back up that diagnosis

Despite its potential benefits yoga can cause many sports injuries both acute and related to over use

Thoracic outlet syndrome Degenerative arthritis of the cervical and lumbar spine Retinal tears Spinal stenosis Common Peroneal nerve damage (yoga foot drop) ∙Results by putting the ankle in a position which drives the femoral head up for long periods of time ∙Dorsiflexion is related to this problem due to the relation of the femoral head to the malleolus Knee injuries including torn muscles All diseases of hyperextension

Hamstrings

Tonic/postural = facilitated Can have a significant affect on pelvis via sacrotuberous ligament Respond well to counterstrain and/or muscle energy Home stretches very important in addressing long term dysfunction: 15-30 seconds, 2-3 reps, 1-2 x day

Piriformis Facilitation

Tonic/postural muscle Can occur opposite a unilateral psoas restriction due to pelvic side shift Contributes to sacral dysfunctions Can irritate sciatic nerve Home exercises very helpful after OMT: held for 15-30 seconds, 2-3 reps, 1-2 x day ∙Counsel the pt not to do this too much (may irritate the muscles)

Tonic/Postural versus Dynamic/Phasic Muscles

Tonic/postural muscles have more slow twitch fibers ∙Tend to get tight when disturbed ∙Example of pelvis and hip region: →Hamstrings →Iliopsoas →Piriformis →Tensor fascia lata →Rectus femoris →Thigh adductors Dynamic/phasic muscles have more fast twitch fibers ∙Example of pelvis/hip region: →Vastus medialis and lateralis →Gluteus medius →Gluteus maximus →Gluteus minimis

Primary Afferent Nociceptors (PAN)

Transmit signals to the dorsal horn of the spinal cord Both neurons and glia cells in the dorsal horn are affected There are many interconnections made at the spinal level

Pain Suppression

Two divisions: Activation of the Analgesia system ∙The brain can suppress afferent pain signals →Periaqueductal gray and periventricular areas send signals to the raphe magnus nucleus and the nucleus reticularis paragigantocellularis →→→Do NOT worry about this anatomy now →→→Dr. Allison just wants to introduce these words →These efferent signals then travel to the pain inhibitory complexes in the dorsal horns of the spinal cord →→→Dorsal horn is where the signal comes into the brain →This blocks further afferent pain signals and withdrawal reflexes Inactivation of pain pathways ∙Two kind of substances: →Exogenous opiates (e.g. Morphine) →Endogenous opioid substances (e.g. beta-endorphin, met-enkephalin, dynorphin) ∙Bind µ receptors in brain and spinal cord →Important: opioids bind µ receptors ∙Act on synaptic receptors and alter excitability

Osteopathic Principle

Uncle Andy: "There are somatic components to disease that are NOT only manifestations of disease, but also are factors which contribute to the maintenance of the disease state." This quote is talking about the idea of facilitation becoming self-promoting after the initial insult is withdrawn Pain syndromes are "a pain in the neck" for a physician ∙Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD): disease entity that gives physician ability to diagnosis if there is pain through Hyperalgesia, Allodynia, Hyperpathia, and physical changes in body (skin color change, hair loss, muscle atrophy) ∙Most patients complain to physicians about pain ∙Problem for physicians is that pain is subjective (causes disconnect) ∙In last 100 years, physicians have developed how to deal with patients with pain →Ex: If every patient who says their ankle hurts and you get an X-ray, the physician will order 1000s of useless X-rays ∙Ottawa Criteria: helps the physician decide whether to get an X-ray by relying partly on patient's description of pain and partly on how the physician can elicit it (gives control to the physician) →Ex: Fibromyalgia: need certain number of places above and below the waist that feel pain, but half of physicians are NOT even sure if it is real

Trapezius

Upper trapezius ∙Facilitated, hypertonic, restricted ∙Plays into somatic dysfunction of cervical, suboccipital, and shoulder areas Lower trapezius ∙Inhibited, hypotonic, weak = "pseudoparesis" ∙Causes lack of stabilization of scapulae →Along with inhibited rhomboids ∙Predisposes to shoulder problems such as impingement syndrome, rotator cuff syndrome Upper Trapezius, Levator Scap, & Scalenes ∙First: Stretch the hypertonic, facilitated upper postural muscles (15 seconds, 2-3 reps, 1-2 x day) ∙Upper trapezii ∙Levator scapulae ∙Scalenes Stretching/lengthening the upper trapezius ∙Takes time - OMT and home exercise program ∙As upper trap lengthens and the hypertonicity normalizes then the inhibition of the lower trap will dissipate = dis-inhibition Then it is beneficial to activate and strengthen the lower trapezius

Once this information is used to establish an objective baseline of their functional capacity

Use non-physical therapy or other modalities to treat their back pain Imperative to know what other specialists are doing to your patient Each modality has its strength As long as the patient is progressing towards increasing strength, endurance, flexibility, centralization and a decrease in subjective pain, they should be supported to continue

Slow C-type fibers

Use substance P and glutamate as neurotransmitter Terminate in the substantia gelatinosa of the dorsal horns Ultimately stimulate the intralaminar nuclei of the thalamus ∙Traveling in a different pathway, different labeled line way of getting to the brain Localization of pain from C fibers in the paleospinothalmic tract is poor, usually only to a body region

Visceral Pain

Usually travelled on C-type fibers from T1 - L2 Goes to Thalamus on the Insular cortex

Convergence of Visceral and Somatic Input in Dorsal Horn

Visceral afferent fibers enter the cord through the dorsal root into the dorsal horn Visceral and somatic PAN input overlap (like heart and arm) ∙Many cells can be driven by either visceral or somatic input This is consistent with viscerosomatic and somatovisceral reflexes

Golgi tendon reflex

When stress on a tendon becomes too great, the Golgi tendon organs send afferent signals that ultimately excite inhibitory interneurons ∙Interneurons are usually inhibitory (but can also be excitatory) This prevents excess stress on muscles and tendons, protecting against injury It also allows the stress to be evenly distributed across an entire muscle rather than having some fibers bear too much weight Involuntary reflex in which the muscle will go flaccid to prevent muscle from ripping off the bone Strictly inhibitory, only makes muscle relax ∙Can cause only a portion of the muscle to relax (as opposed to other portions) →This helps properly distribute weight across the entire muscle to avoid injury through "ripping some of the fibers"

C2-C7 Motion

b/c of the above oblique facets, shape of vertebral bodies, and disc, the motions are: ∙flexion-extension (forward/backward bending) ∙coupled sidebending-rotation to the SAME SIDE →follows 2nd law of physiologic motion