OMM 4 EXAM 1

Pain Management Artificial Nutrition and Hydration

All patients deserve pain management at end of life (if required) NO rules and regulations, "it takes as much as it takes" Patient should never be allowed to experience unrelieved pain Monitoring: ask/patient report, vitals (HR, BP, RR), grimacing Principal of Double Effect or Secondary Effect: level of pain medication needed for adequate pain control results in the patient dying sooner than without that level of pain medication. The concept of double effect or secondary effect indicates that the primary and intended effect was to ease pain, NOT kill the patient •May be beneficial in some cases •May (Often) ends up being excessively burdensome •Can prolong the dying process

Pathophysiology concerning the Middle Ear and Eustachian Tube Dysfunction After treating the temporal bone, how else can I improve arterial flow to the ear to increase the antibiotic concentration

->Chronic Obstruction of Eustachian Tube Causes -Mucosal swelling -Hyperplastic adenoids -Tight SCM? -> Pressure Equilibration Dysfunction -Increased negative pressure within middle ear -Aspiration of nasopharyngeal secretions -Impaired drainage -> Fluid Build-up -Decreased oxygenation -Decreased granulocyte function -Bacterial Colonization RESOLUTION Remove Obstruction of Eustachian Tube -Decrease edema -Mechanically enhance motility -Optimize lymph drainage -> Pressure Equilibration •Decreases negative pressure within middle ear •Removes mechanism for aspiration of nasopharyngeal secretions Decrease Fluid Build- Up -Increased PAO2 -Increased granulocyte function -Eliminate medium for bacterial colonization A.T1-T4 articulation

Lymphatic Drainage

1. Clear the obstructions 2. Activate the diaphragm pump 3. Work proximal to distal Treatment Sequence Example for HEENT •Thoracic Inlet Release •Address SD: cervicals, upper thoracics, 1st/2nd ribs, clavicles. SCM, Scalene muscles. •Thoracoabdominal diaphragm doming •Mandibular drainage •Galbreath Technique/Pharyngotympanic Tube Pump •Facial and cervical effleurage

5 Minute Osteopathic Clinical Consult: Sinusitis

2 Minute Treatment -Thoracic inlet MFR -Trigeminal Stimulation (supra/Infraorbital massage) -Frontal/Maxillary effleurage 5 Minute Treatment - Periauricular drainage -Cervical effleurage

Meralgia paresthetica

¡Presentation ¡characterized by a burning, tingling, or numbness sensation over the anterior lateral aspect of the thigh ¡ ¡Mechanism ¡entrapment of the lateral femoral cutaneous nerve ¡nerve becomes entrapped about 1 cm medial to the anterior superior iliac spine ¡ is a consequence of jeans that are too tight or pelvic somatic dysfunctions affecting the lateral femoral cutaneous nerve as it passes under the inguinal ligament, near its attachment at the anterior superior iliac spine (ASIS). ¡ ¡Diagnostic ¡decreased sensation to light touch and/or pin prick in the lateral femoral cutaneous dermatome distribution ¡ Somatic dysfunction may involve the L2 or L3, Psoas, Inominate ¡Treatment ¡Decompression of the nerve with loose clothing ¡OMT

Venous sinus drainage- refresher

•Approximately 85% of the venous drainage from the head occurs via the internal jugular veins. •They pass through the jugular foramina, located along the occipitomastoid suture between the occipital and temporal bones. •Altered temporal bone motion and occipitomastoid compression may impair venous flow through the jugular foramen and may lead to congestion in the head. •Please review the steps for venous sinus drainage as it is a very beneficial, general purpose cranial treatment • •Still Point (CV4) •Diaphragm Releases - Pelvic - Respiratory - Thoracic Inlet - Hyoid - Occipital Cranial Base •Frontal Lift •Parietal Lift (two parts) •Sphenobasilar Compression-Decompression •Temporal Techniques - Temporal Evaluation - Finger in Ear •Occipitomastoid Decompression •TMJ Compression and Decompression •Dural Tube Evaluation •Still Point (CV-4)

Recognize and Differentiate Epidural vs Subdural Hematoma

•Both are due to head trauma •Epidural •Arterial Bleed between skull and dura •Rapidly expanding = Increased ICP •Symptoms can include a rapid onset of a severe headache, loss of consciousness, and neurological deficits on one side of the body. There may be a brief period of unconsciousness followed by a lucid interval before deteriorating. •On imaging studies such as CT scans, epidural hematomas often appear as a lens-shaped or biconvex mass that does not cross suture lines •ER: Emergent Surgical evacuation of the hematoma •Subdural •Venous Bleed between dura and arachnoid layer •Symptoms can include headache, confusion, drowsiness, and neurological deficits. Unlike epidural hematomas, subdural hematomas may not always have a lucid interval •Subdural hematomas typically present as crescent-shaped collections on imaging, and they may cross suture lines •ER but you have more time. Treatment may involve observation, medications, or surgical intervention depending on the severity and type of subdural hematoma

Autonomic Nervous System: Glands

•CN7 àPterygopalatine ganglion à CN V2 to lacrimal gland, nasal mucosa, sphenoid & posterior ethmoid sinuses. •PNS activity: some vasodilation. mostly goblet cell mucus secretion. Secretions are thin, clear, watery. •Inflammation à hyperactive sensitized mucosaà exaggerated PNS response. •Neuropeptides: Vasoactive Intestinal Peptide, NO, neuropeptide Y, Enkephalin, Somatostatin, etc. Airway Patency + ↑Mucus Quality (normal tone) / ↑ Amount (if hyper stimulated) + Ciliary Function ≈ ↑ Mucociliary Clearance •What bones does CN7 traverse through? maxilla, Temporal •What bones are associated with sphenoid/ethmoid sinuses and nasal mucosa? sphenoid, maxilla, palatine, ethmoid, vomer.

Capacity vs Competency

•Capacity is the patient's ability to understand the benefits, risks, and alternatives to a proposed intervention •Competency is a legal term referring to global decision making - NOT a decision made by a physician

Generalized Anxiety Disorder

•Characterized by excessive anxiety and worry occurring more days than not for at least 6 months •Individuals finds it difficult to control the worry •Anxiety and worry are associated with 3 or more: •Restlessness or feeling on edge •Easily fatigued •Difficulty concentrating •Irritability •Muscle Tension •Sleep Disturbance •Metabolic •Nutrition •Pharmacologic •SSRI, SNRI, BZDs, Buspirone, Adrenergic agents •Neurologic and Behavioral •Psychological: CBT •Combination Psychotherapy and Pharmacotherapy • •Biomechanical •OMT • •Respiratory/Circulatory •Aerobic Exercise

TMJ Dysfunction: Diagnosis TMJ Dysfunction: Examination

•Clicking or Popping: Most common •Pre-auricular pain •Limited jaw movements •Tenderness on palpation •Deviation of jaw to one side with opening or closing •Other symptoms: -Jaw, ear, and facial pain, headache, masticatory muscle pain, fatigue and tightness, jaw locking 1.Facial symmetry or asymmetry 2.Midline deviation of mandible during opening / closing 3.Measurement of jaw opening (40 mm) (3 fingers) 4.Assessment of joint noises 5.Palpation of TMJ and surrounding areas 6.Assessment of musculature: cranial, cervical, thoracic 7.Craniosacral motion 8.TMJ palpation through the external auditory meatus 9.Somatic dysfunctions common in cervical and thoracic spine/upper ribs (last area of compensation) 10.Dental examination

Before diving into each type of reflexes and some clinical cases two very important concepts:

•Concept 1: Considering all reflexes integrate at the spine and a process of facilitation could occur, it can be concluded that the spine is an organizer of disease processes and a target for OMM!! •Concept 2: Considering the crosstalk of reflexes that integrate at the spine (autonomic and somatic), then it is obvious that specific trigger points associate with specific noxious stimuli: a fundamental pillar for OMM diagnosis!!

Transference, Professional Boundaries and OMM

•Concern raised for use of OMM is the issue of transference •Transference is the redirecting of thoughts, feelings, and desires toward a new object •However psychiatrist training allows for better understanding of the patient and the patient's defense and proper use of transference •Evidence to support OMM's role as an adjunctive treatment in a comprehensive treatment plan •Several targets for OMM •Chronic Pain •HPA Dysregulation •Chronic Stress

Non-maleficence Examples of Violations:

•Failing to provide adequate symptom relief •Minimizing hope •Providing unnecessary procedures •Failing to stop treatments and diagnostic tests when they do not match goals of care •Failing to provide information and support to family

Pterygopalatine Ganglion Technique

•For dry, hard to drain nasal and sinus mucus, gently stimulating the pterygopalatine ganglion causes reflex stimulation of the parasympathetic path, resulting in thin mucus secretions. •Conversely, irritation of the sphenopalatine ganglion causes a "sphenopalatine syndrome", characterized by "engorgement of the mucous membranes, photophobia, tearing and pain behind the eyeball, nose, neck, ear or temple" •For patients with irritative symptoms and tenderness at the sphenopalatine ganglion, gentle massage can reduce structural pinching and reduce hyper-parasympathetic input to nasal and sinus epithelium

Osteopathic Structural Exam and Neurology Exam

•Inspection of the patient walking and standing, from an anterior, posterior, and lateral view, looking for static and kinetic structural asymmetries • Performance of the standing flexion test • Performance of the standing lateral flexion test • Performance of the seated flexion test • Assessment of seated trunk rotation • Assessment of seated lateral flexion • Seated cervical assessment for flexion, extension, lateral flexion, and rotation • Supine rib assessment for structural asymmetries and inhalation and exhalation motion restrictions • Supine upper extremity assessment for structural asymmetries, tissue texture changes, and quality and quantity of motion • Supine and prone lower extremity assessment for structural asymmetries, tissue texture changes, and quality and quantity of motion ¡Motor Strength ¡Sensation ¡Reflexes ¡DTR UE ¡DTR LE ¡DERMATOMES

Bipolar Disorder

•Mean Age approx. Age 18 •Criteria have been met for at least one manic episode •Mood disturbance and increased energy •Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning •Manic Episode •A distinct period of abnormality and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy lasting at least 1 week and present most of the day nearly every day •MDD •Depressive episodes •Metabolic Model •Nutrition, PUFAs 1,000mg/day •Pharmacologic •Start with one medication and titrate •Lithium - antisuicidal and neuroprotective effects •Mood stabilizers •Neurological and Behavioral Model •Psychologic: CBT, Behavioral Therapy •Psychotherapy and pharmacotherapy •ECT • •Biomechanical Model •OMT • •Respiratory/Circulatory •Aerobic Exercise

Tension HA summary

•Most common type of headache. •Females > Males. Can run in families. •Bilateral, occipitofrontal, pressure/tightness/band like, mild-moderate intensity. •Not associated with movement or other triggers except hormonal cycle. •Associated with anxiety, depression, stress. •Mechanism: Myodural nocioreceptors receive nociceptive input from pericranial muscles & fascial (dural) strain which converge with the Trigeminal Nucleus Caudalis. When the signal is intense, sensitization of the entire pain pathway (peripheral & central) can occur. The facilitation causes a painful sensitivity to usually non-noxious stimuli, like a muscle contraction.

Medical Conditions with Psychiatric Manifestations

•Neurological Conditions •Delirium, Epilepsy, Dementia, Multiple Sclerosis, Huntington, Alzheimer, Parkinson Diseases • •Metabolic Conditions •Nutritional Deficiencies (Vitamins B12, A, D, Zinc) •Thyroid Disease •Hypoglycemia or Hyperglycemia •Addison •Cushing Diseases •HIV, Syphilis, TB, Prion Disease, Encephalitis •Wilson Disease, SLE, Neoplastic Disease, Electrolyte Abnormalities • •Respiratory/Circulatory Conditions •CVA •Embolism •Hypoxia •Cardiac Disease

Parasympathetics to Head and Neck

•Note that parasympathetic innervation follows cranial nerve VII (facial nerve) and innervates the nasal cavity and sinuses. •Excessive parasympathetic stimulation causes excessive secretion. This causes congestion that blocks flow- and provides a medium for microbial growth. The facial nerve enters the internal auditory canal within the temporal bone, •synapses at the geniculate ganglion •then exits (as the greater petrosal nerve), •travels medial to the trigeminal ganglion, •then traverses the foramen lacerum to synapse in the pterygopalatine (also called "sphenopalatine") ganglion. •The parasympathetic fibers that exit the pterygopalatine ganglion innervate the mucosa of the sinuses, nares, and pharynx.

Primary Adjunct

•OMT is the primary treatment modality because the cause is in the musculoskeletal system. •Treating SD of lumbar spine in a patient with back pain after lifting a heavy object. •OMT improves healing by promoting self-healing mechanisms and removing obstructions. •Treating fascia of thoracic duct to improve lymph drainage in cases of upper respiratory tract infection •Decreasing neurological facilitation due to visceral disease, as mediated by the autonomic nervous system.

Palliative Care All hospice is palliative care, but not all palliative care is hospice

•Palliative Care = Palliative Medicine = specialized medical care for people living with serious illnesses •Focused on providing patient with relief from distressing symptoms & stress of serious illness, regardless of diagnosis •Goal: to improve quality of life for both patient and their family •Provided by multidisciplinary team Hospice is a model of palliative care restricted to terminal illness Hospice provides comfort when cure is no longer possible Palliative care is appropriate at any stage in serious illness

Somatovisceral Reflex

•Pectoralis trigger points may contribute to cardiac rhythm dysfunction, demonstrating a somatovisceral response. •Supraventricular tachyarrhythmias have been documented to arise from trigger points located in the right pectoralis major muscle (at the fifth intercostal space midway between the nipple line and the sternal border). •Pectoralis trigger points are also found in association with slumped posture and rolled forward shoulders. •Improvement in both of these dysfunctions has been shown to return the patient back to normal cardiac function.

Attention Deficit Hyperactivity Disorder

•Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development over 6 months •Children>Adults •Adult Presentation •Poor time management •Trouble Initiating and completing task •Trouble with multitasking •Procrastination •Avoidance •Many adults with ADHD had ADHD in childhood •Metabolic •Nutrition - underrated importance •Pharmacologic - stimulant medication • •Neurological and Behavioral •CBT, Social skills therapy, Parent management training • •Biomechanical •OMT • •Respiratory/Circulatory •Aerobic Exercise

Major Depressive Disorder

•SIGECAPS •Sleep •Interest (anhedonia) •Guilt •Energy •Concentration •Appetite •Psychomotor Agitation •Suicide or Suicidal Ideations •Symptoms need to be present for 2 weeks •4 or more symptoms for MDD •2 or more symptoms for Dsythymia •Evaluation tools = most common is PHQ9 in adults •Beck Depression Scale for Teenagers •Children Depression Scale for kids 7 and older •Treatment •Metabolic Model - Nutrition •Pharmacologic - SSRIs mainstay usually takes 4-6weeks for effect •Neurologic and Behavioral Models •CBT, Vagal Nerve Stim, Transcranial Magnetic Stimulation, ECT, •Biomechanical •OMT •Respiratory/Circulatory •Aerobic Exercise

Nervous System: Middle Ear

•SNS = T1-4, controls arterial dilation •PNS of middle ear mucosa = CN XI, tympanic nerve •Sensory - TM main innervation is auriculotemporal nerve (V3), only pain. There is a minor, nonconstant, and overlapping supply from CN VII, IX, X. OMT Address SNS viscerosomatic reflex: T1-4, Ribs 1-4 for arterial vasodilation •Address PNS secretion of middle ear mucosa: cranial OMT •Decrease pain (CN V, VII, IX, X): cranial OMT, Periauricular MFR and other lymphatic techniques The 2 minute treatment •Head: Periauricular drainage The 5 minute treatment •Head: Supra/infraorbital massage (Trigeminal Stimulation) •Head: Sphenopalatine ganglion stimulation •Cervical: MFR, IND, ART, CS

Role of Decision Maker

•SUBSTITUTED JUDGMENT: if the patient could speak for themselves, what would they say •BEST INTEREST: act on what decision maker believes is in patient's best interest

Sacrum Dysfunction OMT: Acute Stage (0-7 Days) OMT: Subacute Stage (1 week - 1 month) OMT: Chronic Stage (1-3 months or longer)

Cervical Hyperextension and Hyperflexion forcibly pulls the sacrum up via its dura connections from its floating position between the ila. •The occiput and sacrum usually have the same dysfunction and are named by the motion of the base. - Occiput extended : Sacral base extended • • Because of this relationship it is important to address cranial sacral mechanism before addressing the pelvis interaction with the sacrum. Characteristics •Acute muscle contraction •Limited ROM, can be severe •Tissues warm, edematous, possible ecchymosis •Neck, upper back, shoulders painful; can radiate to head or extremities OMT 1st Address cranium & sacral dysfunction. Restore the Primary Respiratory Mechanism. Promote lymphatic drainage: thoracic inlet and diaphragm release. Anterior cervical effleurage. Cervical Tender Points: Counterstain Cervical & thoracic spine: Gentle, indirect methods: ST, Myofascial release (MFR), Facilitated Positional Release (FPR), gentle Muscle Energy (ME) Address rib dysfunctions Pelvis: IND, ME •Characteristics •Acute muscle inflammation subsides, but tissue tension remains. •ROM improving •Pain still present, not as severe. •May have myofascial trigger points OMT Same as acute OMT. After 1st visit can start to add direct method techniques as tolerated, use caution Lymphatic drainage to affected extremities Moist heat can help Patient Homework Active/Passive ROM Isometric exercises as tolerated Refer to physical therapy if needed/able Characteristics •Milder pain with/without radiation •May have residual limited ROM •Chronic TART changes OMT Address all body regions. Treat Myofascial Trigger Points & Tender Points Emotional support Set realistic goals, encourage, empathize. Consider counseling. Patient Homework Muscle Strengthening Vigorous active ROM Address lifestyle ch

The somatic reflex arc

Consists of afferent neurons with cell bodies located in the dorsal root ganglia and efferent neurons with cell bodies located in the ventral horn of the spinal cord. Interneurons with cell bodies located in the spinal gray matter may intercalate between the central process of the afferent fiber and the efferent cell body (ventral root) or associated dendrites.

The autonomic reflex arc

Consists of primary afferent neurons with cell bodies in the dorsal root ganglion, interneurons in the spinal gray matter, and efferent neurons located in the intermediolateral nucleus of the spinal cord. The efferent pathway features a second set of efferent neurons located in a peripheral ganglion. This pattern is modified in the brainstem to place the afferent neuron in a cranial nerve ganglion and the interneurons and efferent neurons in brainstem nuclei

Resolution of Sinusitis Involves

Remove Obstruction of Sinus Ostia -Decrease edema Promote Mucociliary Clearance -Mechanically enhance motility -Optimize lymph drainage -Hydration -Remove toxins (anticholinergic meds, antihistamines, cigarette smoke, mold) -> Pressure Equilibration -Decreases negative pressure -Removes mechanism for aspiration of nasopharyngeal secretions -Improved motility of secretions -Increased oxygenation -Increased granulocyte function -Eliminate medium for bacterial colonization

The Reflex

A response to an stimuli traveling through an afferent or incoming limb from a sensory receptor The response includes an output (efferent) limb that is usually a motor component to either somatic (musculoskeletal) or visceral structures terminating in synaptic connections that may either activate or inhibit activity in these structures (examples will be highlighted in subsequent slides and clinical cases). Reflex networks are influenced by excitatory and inhibitory signals coming from higher or lower levels of the CNS (they can be amplified or suppressed). The picture is an oversimplification as it involves multiple pathways: think in the patellar reflex: from the patellar tendon that causes the quadriceps femoris muscle to contract, resulting in a knee jerk. For the knee jerk to occur, axons provide signals that inhibit the motoneurons innervating the antagonist muscle. When the stretched muscle contracts, the antagonist muscle is inhibited to allow a smooth movement to occur. In addition, other branches from the incoming axons go to: Up the spinal cord to other spinal areas (e.g., to the arms if the patellar reflex was stimulated), to the brain stem, and down the spinal cord to lower spinal centers (yes, you can voluntarily modify the response).

To promote thinning of the sinus secretions, I can consider performing:

A.Cranial OMT for SD of sphenoid

Which of the following is a proper treatment sequence or drainage pattern of the lymphatic system of the head/neck?

A.MFR of the thoracic outlets. Then cervical and mandibular MFR, followed by cervical effleurage.

Which of the following structure-function relationships is correct?

A.Sphenobasilar (base of sphenoid) flexion influences Vomer flexion into a "sinus pump" action

Mucus

Airway Patency + Mucus Quality & Amount + Ciliary Function ≈ Mucociliary Clearance Factors of Airway Patency Anatomic strictures: collapsed bridge/ nasal arches, deviated septum, nasal polyps Foreign Body: KiDs! Neural dysregulation à hyperactive or hypertrophied mucosa Lymph/venous congestion related to trauma, allergies, infection, or cranial dysfunction. Mucus Quality Influencers Tobacco smoke, environmental pollutants Also paralyzes cilia Environmental Temperature (can cause vasodilation/constriction of vessels in the nose) Humidity - moisten or dry passages Oxygen concentration Irritants: mechanical, chemical, allergens (dietary/environmental) Medications: rebound congestion, drying side effects Hydration status Neuromediators: Vasoactive intestinal peptide, Nitrous oxide, substance P, calcitonin gene-related peptide, etc. Mouth vs Nose breathing?

Tension Headache Cervicogenic Headache Migraines OMT Treatment Considerations for Migraines

Bilateral, usually occipital or frontotemporal band Pressure, tightness, gradual onset Mild to moderate minutes - hours Responds to medication •Stress, anxiety, depression, hormone cycle •No exertional trigger Myodural trigger leading to supraspinal facilitation of TNC. Usually unilateral. Frontal, occipital, lateral or vertex. May radiate along ipsilateral head, neck, shoulder/arm Deep non-throbbing, non-piercing. Moderate to severe Lack pattern but are often episodic. Last hours to days. Poor response to medications •May have history of neck trauma •Triggered by neck movements •+/- Scalp paresthesia Cervical disease causing cervical nerve root irritation & TNC facilitation. CNX and CNXI sensory input can as well. •Migraines are a common recurrent headache syndrome affecting approximately 18% of women and 6% of men in the United States •Are generally one-sided, pulsating, or throbbing, with moderate to severe pain that interferes with, or prevents, normal activity and that worsens with ordinary daily activities. • •They are usually accompanied by nausea or vomiting and photophobia and/or phonophobia •May be preceded by symptoms that include: fatigue, difficulty in concentration, sensitivity to light or sound, neck stiffness, blurred vision, nausea, yawning, or pallor. • • An aura is a complex of neurological symptoms that occurs just before or at the onset of a migraine headache •Migraine headache, also known as vascular headache (more specifically arteries), is produced by constriction followed by dilatation of the intracranial vessels •Consider evaluating... •CRI, SBS, Temporal, Sphenousquamous Suture area, Jugular Foramen •May also consider Suboccipital area, C2, T1-T4 • •Treatment •OCMM best to do either before or after migraine •Gentle IND, BLT, MFR, CS

pharyngitis Considering the innervation for the pharynx, where can we assess for SD to decrease facilitation of pain?

CN 10, CN9, CN 11 occipital bone temporal bone OA cervical spine Upper thoracic spine 1st and 2nd ribs The 2 minute treatment •Cervical - effleurage The 5 minute treatment •Thoracic Inlet Release: MFR •Anterior Cervical Arches MFR •Head - Periauricular MFR •Cervical effleurage

: Cranial Nerves and anatomical relationships of concern

CN III - Oculomotor N levator palpebrae superioris inferior oblique Superior rectus inferior rectus medial rectus Superior Orbital Fissure Sphenoid CN IV - Trochlear N Superior Oblique (contralateral to the nucleus) Superior Orbital Fissure Sphenoid CN VI - Abducens N Lateral Rectus Superior Orbital Fissure Sphenoid

Making a Diagnosis

Categorical •Classifying mental disorders involving assessment of whether the individual has a disorder, on the basis of symptoms and characteristics typical of the disorder Allows for diagnosising Dimensional •Dimensional approach to classifying mental disorders is to quantify patient's symptoms or other characteristics and represent them with numerical values on one or more scales •Focuses on the extent in which a person has a disorder

CN V - Trigeminal Nerve

Cell bodies originate: pons - one for motor and one for sensory Function: sensory anterior 2/3 of the tongue; motor to mm of mastication Composition: sensory and motor V1 - ophthalmic Superior Orbital Fissure Sphenoid Lesser and Greater wings V2 - maxillary Foramen Rotundum Sphenoid Body V3 - mandibular Foramen Ovale Sphenoid Body

How does somatic dysfunction(SD) of the upper cervical spine play a role in tension headache? 1. How does cervical somatic dysfunction create cranial dura strain? 2. What is happening to the muscles associated with the cranium?

Somatic Dysfunction of the cervical spine can: •Induce cranial SD and fascial strain leading to pain. •Dural trigger - Dural attachment sites outside of cranium: C2, S2 •Create myofascial strain leading to compression of occipital nerves. •Myogenic trigger •C2 nerve roots innervate inferior tentorium cerebelli The 2 cranial bones are covered with dense connective tissue, termed periosteum on the external surface, and dura mater on the internal surface. The dura mater is divided into a periosteal layer and a meningeal layer.

radiculopathy

¡Presentation ¡Patients commonly complain of unilateral leg pain with or without back pain, typically in a dermatomal distribution, with or without the following: ¡Muscle weakness ¡Paresthesias (e.g., tingling, numbness, burning, gnawing, or sharp-shooting pain) ¡Muscle atrophy ¡ Antalgic gait ¡Imbalance ¡Knee or ankle instability ¡Frequent trips and falls ¡Mechanism ¡ a herniated nucleus pulposus, osteoarthritic spur, advanced spondylolisthesis, or mass lesion ¡ ¡Diagnostics ¡HX and PE: DERMATOMES ¡MRI ¡ ¡Treatment ¡PT, CS Injection, OMT, Acupuncture, Surgery

Schematic of neural interactions at the spinal level, indicating the complexity of even simple reflexes

Input to the spinal cord sends collaterals up and down the cord and is affected by ascending and descending influences, as well as input from the opposite side of the cord. Input courses through several synapses and interneurons before acting (in thoracolumbar cord) on both somatic and sympathetic motoneurons. In cervical and sacral cord areas, parasympathetic pathways are involved.

Principles of OCMM

Cranial Rhythmic Impulse (CRI) 1.The palpable rhythmic impulses on the human skull able to palpate the rhythm in all body areas 2.Cycling 8 - 14 times per minute in normal adults 3.Requiring very gentle proprioceptive palpation 4.Separate from the cardiovascular pulse and pulmonary respiration 1.Inherent motility of the brain and spinal cord. 2.Fluctuation of cerebrospinal fluid. 3.Mobility of the intracranial and intraspinal membranes. 4.Articular mobility of the cranial bones. 5.Involuntary mobility of the sacrum between the ilia.

MOLST / POLST

MOLST = Medical Orders for Life Sustaining Treatment POLST = Physician Order for Life Sustaining Treatment Intended for people who have a serious illness. Serves as doctor ordered instructions to ensure that in case of an emergency you receive the treatment you prefer MOLST Resuscitation Mechanical ventilation Tube feeding Use of antibiotics Requests not to transfer to an emergency room Requests not to be admitted to the hospital Pain management CAN BE UPDATED

DNR DNI

DNR=do not resuscitate no comfort measures do everything up to CPR order written by physician all natural death •DNI = do not intubate •Use all interventions up to intubation

Bell's Palsy

Definition: a unilateral lower motor neuron facial paralysis resulting from dysfunction of the facial nerve (VII) Etiology: unclear; viral infection, exposure to cold air Associated with psychological distress Often self-limiting; patient slowly regains facial tone and movement tx:Protect the eye OMT Psychological support Prednisone Antivirals

Physiologic Motion of the Midline and Paired Bones

Midline Bones •Flexion/Extension •Midline bones •Occiput •Sphenoid •Sacrum •Ethmoid •Vomer Paired Bones •External/Internal Rotation •Paired Bones •Temporal •Parietal •Frontal •Zygoma •Maxilla •Palatine •Nasal •Lacrimal •Inferior Conchae •All other paired bones such as extremities, ribs

Cervicogenic Headache ~Headache or face pain of cervical originReferred pain from a structure innervated by C1,C2, or C3.

First 3 cervical nerves innervate their associated facet and uncovertebral joints, as well as intervertebral discs, cervical muscles, ligaments, vertebral artery, cervical spinal dura, posterior scalp, and lower layer of tentorium cerebelli. Mechanism: •Structures innervated by the cervical nerves can refer pain to the head and face via the Trigeminal Nucleus Caudalis. •Nociceptive and inflammatory stimuli of the respiratory and upper GI system via the afferent sensory nerves of the Vagus can converge with afferent fibers of the upper cervical spine. This increased activity in the cervical region triggers an efferent cervical response (i.e. muscle contraction), creating a a viscerosomatic reflex. •C5-C7 afferent nociceptive input can ascend 1 to 3 levels before entering the dorsal horn, allowing convergence with TNC.

Lymphatic Drainage face

First sign of lymphatic congestion may be: supraclavicular fullness Check the "choke point" Eustachian Tube Dysfunction: Typical complaint of "Plugged Ear" - Could be secondary to nasopharyngeal infection -Serous otitis, etc. Parotid Lymph nodes - receive lymph from the anterior wall of the external auditory meatus Submandibular nodes - receive lymph from the nose, frontal, maxillary, and ethmoid sinuses Retropharyngeal nodes - receive lymph from the nasal part of the pharynx, and auditory tube The Deep Cervical Lymph nodes - receive lymph from the above. One node of particular significance is the jugulodigastric because it principally drains the tonsils.

Trigeminal and Greater Petrosal Nerve (in the Middle Cranial Fossa) Trigeminal Neuralgia

For our purposes, we need to recognize that rotation of the temporal bone can impinge on the: Trigeminal ganglion causing facial pain. Greater petrosal nerve (from the facial nerve), causing increased parasympathetic stimulus to the mucosa of the nose and sinuses Trigeminal neuralgia is characterized by lancinating pain in the distribution of the trigeminal nerve. All 3 branches can be affected, with the maxillary nerve the most common Trigeminal neuralgia (also called tic douloureux) can be triggered by movement or sensations (especially cold) in some area where sensation is supplied by the trigeminal nerve. Although clinical reality is often more complex, one area to look at is trigeminal nerve impingement from an abnormally rotated temporal bone.

Ethical Frameworks

Foundation of medical ethics is supported by four pillars -Autonomy: Autonomy = the quality or state of being self governing Autonomy à the patient has the right to choose or refuse treatment -Non-maleficence: •Non-maleficence = First, do no harm -Beneficence: •Beneficence = the quality or state of doing or producing good •Beneficence à provider should act in the best interest of a patient -Justice: •Justice = concerns distribution of health resources equitably •Fair allocation of resources •Physician's first obligation is to the patient •Physician is obligated to use technology and resources judiciously •Care to address needs regardless of race, gender, culture

How can smoking affect drainage of paranasal sinuses?

Increases sympathetic tone leading to decreased mucus production causing dry mucosa

TMJ and Temporal Bone Temporomandibular Joint

Note that the condylar process of the mandible articulates with the mandibular fossa of the temporal bone. TMJ dysfunction can be caused by temporal bone malposition. With TMJ dysfunction, one gets: TMJ pain Clicking with jaw opening Jaw deviation to the opposite side on opening -Ellipsoid, Synovial joint Mandible: articular condyle Temporal bone: mandibular fossa and articular tubercle Fibrous Articular disc Lateral pterygoid attaches to disk and draws anteriorly with opening- when tight- prevents posterior motion -Innervated by CN V3

Some differences between the sympathetic and parasympathetic...

Note that the preganglionic axons reach the sympathetic trunk by passing over the white ramus, and the postganglionic axons leave the ganglion to join the peripheral nerve by passing over the gray ramus. Once in a ganglion, a preganglionic axon can ascend or descend multiple levels to reach ganglionic neurons in the cervical or lower lumbar and sacral regions. The solid red axons are preganglionic fibers; the dashed red fibers are postganglionic fibers; the blue axons are primary afferent fibers.

Palliative Care vs Hospice

Palliative Care: based on patient and family need, not based on prognosis Hospice: Certified prognosis of <6 months Palliative Care: appropriate at any stage of severe illness from time of diagnosis to bereavement for family Hospice: end of life, at any time when life expectancy <6months, on average length of stay =21 days Palliative Care: All appropriate treatments and/or services available Hospice: must forgo curative treatments for illness in which provided eligibility Palliative Care: Provider bills under Medicare part B and through other payers Hospice: defined Medicare (and other payer) benefit Palliative Care: widely available in hospital settings, growing in community settings Hospice: widely available in community and institutional settings

Restore normal autonomic tone Whiplash Summary

Parasympathetic System •Address cranial and sacral dysfunctions (CN:2,3,7,9) •Suboccipital release/ST inhibition to reset vagal tone. Sympathetic System Thoracic & Ribs 1- 5 (Head) •Correct SD •ST Inhibitory pressure to decrease sympathetic tone •Cervical SD may be stimulating cervical sympathetic ganglia Whiplash Associated Disorder (WAD) •can affect the entire body •Affects all ages, most commonly middle aged females​. •Neck pain is most common complaint, only 1/3 have complete resolution. Why??? • Mechanism: 1.At first impact, the heads remain stationary which causes a traction injury. 2.Then the head moves in the opposite direction of the external force, causing hyperextension or hyperflexion of the cervical spine. The order of extension & flexion depends on the direction of the force. 3.Then a reflexive recoil response will cause the head to move in the same direction of the external force. ​ •Cervical hyperextension tends to cause more damage. •Systematic reviews of RCTs: OMT + exercise reduces pain and increases ROM for acute and chronic pain compared to either treatment alone. (FOM)

Ear Tug - Treatment of Temporal Bone

Pulling the ear lobe laterally can help disengage a stuck temporal bone- helps to pull it from the V Arms parallel, thumb pads in ear at the antihelix, index and middle fingers in opposition to the thumbs on the posterior surface of the external ear Use less than 2 ounces of force to take out slack and ease the ears away from the head at an angle of about 45° posterior laterally by increasing wrist flexion not pulling on the ears. This distracts the petrous portion of the temporal bone away from the sphenoidal articulations at the clivus Hold traction several minutes, sensing releases and/or unwinding process Release traction very slowly Provides potential to release the tentorium cerebelli and enhance temporal function

The Vagus Functional components "Trouble in Vagus"

Somatic motor fibers start in the cell body in the nucleus ambiguous supply the majority of muscles to the pharynx and larynx, responsible for swallowing and speech. Visceromotor fibers come from the dorsal motor nucleus of the vagus supplying viscera of the thorax and abdominal cavities. Somatic sensory fibers from the superior ganglion carry pain, temperature, and touch related impulses from the external ear to the nucleus of the spinal trigeminal tract. Visceral sensory fibers from the inferior ganglion carry impulses from the pharynx and larynx, the aortic arch and body, the thoracic and abdominal viscera. Central processes are projected to the solitary tract nucleus. Special sensory fibers have cell bodies in the inferior ganglion and carry taste related impulses from the posterior pharynx, terminating in the nucleus of the solitary tract. •Unilateral lesions of the nucleus ambiguous cause hoarseness, dysphagia, tachycardia, and deviation of the uvula to the side opposite the lesion. •Unilateral lesions of the dorsal motor nucleus are not manifested clinically, although bilateral lesions are life-threatening. •The recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx accept the cricothyroid muscle. •Para-tracheal lymphadenopathy or an aortic aneurysm may compress the recurrent laryngeal nerve, causing hoarseness secondary to paralysis of the vocal cords.

Autonomic Nervous System: Glands cont

T1-T4-> SCG -> ICA-> deep petrosal n. ->vidian n. -> pterygopalatine ganglion -> to sinuses via arteries & CN V2 Increased Sympathetic tone Arterial/Lymphatic vasoconstriction : •↓ nutrients & oxygen. metabolic waste buildup Ability to mount an immune response and obtain effective concentration of medications is reduced by vasoconstriction and tissue congestion. Glands: decreased mucus production •Dryness, decreased protective barrier. Breakdown in mucosa à infection. Cellular: goblet cells mucus changes • secretions thick/stickyà difficult clearing • All the above cause epithelial hyperplasia, leadidng to decreased airway patency ↓Airway Patency + ↓ Mucus Quality & ↓ Amount + Ciliary Function ≈ ↓ ↓ ↓ Mucociliary Clearance

Kidney stone and testicular pain - Viscerovisceral reflex

T10-L1​-> Greater & lesser splanchnics​-> Kidney & ureters (upper)​ T9-10, L1-2​-> S2-S4​-> Testicle and epididymus​

Dysmenorrhea and IBS: Viscerovisceral reflex

T8-L2​-> S2-S4​-> Transverse Colon & rectum​ T10-L1​-> S2-S4​-> Uterus​

Tentorium Cerebelli and Temporal Bone

The red dotted line in the right picture shows the attachment of the tentorium cerebelli to the temporal bone. The left diagram suggests how the tentorium cerebelli surrounds the trigeminal ganglion

Principal nerve orifices of the face

The superior orbital notch (sometimes a foramen) Direct access to ophthalmic nerve, V1 The infra orbital foramen Direct access to infra-orbital nerve, maxillary nerve, V 2 Zygomatico-orbital foramen for the zygomaticofascial nerve (maxillary nerve, V2) The mental foramen Direct access to the mental nerve, a branch of the mandibular nerve (V3)

Lateral Pterygoid Myofascial Referred Pain

Trigger points in the lateral pterygoid muscle can refer pain to the maxillary area. Lateral pterygoid trigger points also cause pain in the TMJ in 2 ways: Myofascial referred pain The lateral pterygoid pulls the condylar process of the mandible forward, a necessary motion for jaw opening. If 1 of these muscles is weak or hypertonic, there will be unbalanced joint movement, leading to pain in the TMJ.

Physician Assisted Suicide (PAS)

Verification of terminal status No depression Waiting period Repeated request of physician assisted suicide Ability to swallow the prescribed medication NOT EUTHANASIA AOA and AMA OPPOSED to Physician Assisted Suicide "Such a practice puts the physician in the position of making a determination as to whether to be on the side of working to save a patient or on the side of working to kill a patient"

Maxillary Sinus Drainage

Vomer "sinus pump" §Vomer moves into flexion and extension, influencing IR and ER of the maxilla. §Thus, limited vomer motion ≈ limit maxillary motion. §Maxillary motion is essential to the drainage of its contents as the foramen for exit is in the middle of the bone, not the bottom, suggesting that motion (pumping) is essential to the mobilization of fluid/sinus drainage

A 19-year-old male presents with nasal congestion, pharyngitis, and fever for 2 days. Where would you expect to find viscerosomatic reflex findings? A 13-year-old female presents with nasal congestion, maxillary pain, and fever for 2 days. On physical exam, the maxillary sinuses are opaque on X-ray, and the nasal mucosa is dry and red. What physiological process do you want to address?

a)T1-4 a)Decreasing sympathetic stimulation of the head

Cranial Nerves- VII

exits via stylomastoid foramen motor to facial expression sensory to anterior 2/3 of tongue secretory to submandibular, sublingual and lacrimal Overlies the sphenoid, occiput, temporals, cervical fascia •Unilateral facial paralysis, loss of taste sensation in the anterior two thirds of the tongue, tinnitus and deafness (vestibulocochlear nerve)and loss of tearing (greater petrosal nerve)result from lesions within the internal auditory meatus • •Unilateral facial paralysis and loss of taste sensation in the anterior two thirds of the tongue results from lesions within the facial canal proximal to the takeoff of the chorda tympani •Isolated unilateral facial palsy results from lesions distal to the stylomastoid foramen

Cranial Nerve and the anatomical pathway - which cranial bones are of concern?

uVestibulocochlear Nerve (CN VII) uPathway uCell bodies in the medulla of the brain stem uTravels thru the internal auditory meatus uIs housed within the petrous portion uDivides to form uVestibular nerve uCochlear nerve uAssociated cranial bones: uTemporal - temporal bone was IR - can result in asynchronous input from the vestibular apparatus to the brainstem

Morton neuroma

¡Presentation ¡CC: Distal foot or toe pain, usually in 3rd or 4th toes. Aggravated by walking and wearing shoes ¡ ¡Mechanisms ¡Enlarged nerve that usually occurs in the interspace between the 3rd and 4th metatarsals ¡ ¡Diagnostics ¡Palpating the 3Rd-4th interspace and squeezing the forefoot from side to side to recreate the patient's pain or palpate an audible click (Mulder sign) ¡ ¡Treatment ¡Change shoes ¡Inject local corticosteroids ¡OMT - decrease edema and related muscle spasm ¡Refractory cases - Surgery

Bell palsy

¡Presentation ¡Inability to smile, pucker the lips or kiss, keep liquids in the mouth, drooling, close one eyelid, and raise an eyebrow are common complaints. Severe symptoms of unilateral facial paralysis and ineffective tear production sometimes progress to corneal ulcerations ¡Mechanism ¡inflammation and compression of the facial nerve and results in unilateral paralysis or paresis of the muscles of facial expression. It is the most common facial mononeuropathy ¡Diagnostic ¡Bell phenomenon—the upward movement of the eye on attempted closure of the lid due to weakness of the orbicularis oculi—is a pathognomonic sign ¡Treatment ¡Many patients recover spontaneously within 1 to 3 weeks, with standard of care being administration of oral corticosteroids with or without the addition of an antiviral medication, for example, acyclovir, if within 3 days of onset

Carpal tunnel syndrome

¡Presentation ¡Pain and Paresthesias in the Thumb, Index, and Long Finger ¡Vague weakness, often described as dropping things, is common ¡Mechanism ¡entrapment of the distal branches of the median nerve as it passes through the carpal tunnel ¡Predisposing systemic diseases include: Hypothyroidism, Diabetes mellitus, Pregnancy, Leukemia, Paraproteinemia, Gout ¡Diagnostic ¡Physical examination reveals a sharply demarcated median nerve sensory deficit, confined to the palm, often splitting along the long finger or ring finger. Motor examination reveals a weakness of the thumb abductor, thumb opposer, and distal thumb flexor. ¡Treatment immobilization with wrist splints, especially during sleep, and avoidance of the provocative activities

Tarsal tunnel syndrome

¡Presentation ¡Pain anywhere felt along plantar surface ¡Mechanism ¡Posterior tibial nerve runs through the tarsal tunnel which is covered by the flexor retinaculum. When compressed or inflamed can cause irritation to the posterior tibial nerve. ¡Pes Planus = increased risk ¡Diagnostics ¡PE, US, MRI ¡ ¡ Treatment ¡In-Shoe Orthotics ¡OMT - plantar fascia, arches medial and longitudinal, talonavicular, navicular/cuboid ¡Corticosteroid injections

Peroneal nerve entrapment

¡Presentation ¡Paresthesias or pain in the feet in the distribution of the peroneal nerve ¡Lower leg - anterior and lateral tibia and interweb 1st and 2nd toe - superficial peroneal nerve ¡Interweb of 1st&2nd toes only - deep peroneal nerve ¡Mechanism ¡A vulnerable site for entrapment or trauma exists as the common peroneal nerve (common fibularis nerve) passes behind the fibular head ¡Diagnostics ¡PE ¡EMG ¡ ¡ Treatment ¡OMT to the fibular head

myelopathy

¡Presentation ¡Patient complaints depend on the site of the lesion. There can be deficits in sensation, motion, strength, balance, gait, and/or problems with defecation or micturition. ¡ ¡Mechanism ¡Trauma to the spinal cord from herniated discs, penetrating objects, shearing or compression high-impact forces, and metastatic cancer are common causes of myopathy. Infections can lead to transverse myelitis. ¡ ¡Diagnostics ¡The physical findings in myelopathy classically reveal a sensory level. Spinothalamic-mediated pain and temperature and dorsal column-mediated touch, vibration, and position sense are disturbed below the level of spinal cord disturbance. ¡ ¡Treatment ¡Treatment for trauma is supportive, including surgery to stabilize the spine to prevent further damage to the spinal cord. Infectious myelitis can respond to corticosteroids if diagnosed early. Tumors can be debulked with radiation or surgery.

Sciatica neuralgia

¡Presentation ¡most commonly affecting patients between ages 30 to 50 ¡characterized by sudden onset of unilateral sharp and aching pain that radiates from the buttock to the posterolateral thigh and leg to the plantar and lateral foot. ¡often occurs after physical activity that strains the low back but can occur slowly over time in cases of degenerative joint or disc disease ¡Some patients have pain in the anterolateral thigh if the compression is from an L4 disc herniation ¡May or may not have foot drop ¡ ¡Mechanism ¡sciatic nerve is derived from the spinal nerve roots of the fourth and fifth lumbar and first two sacral spinal nerves. Compression of the sciatic nerve most commonly occurs close to the spinal column from fragments of herniated nucleus pulposus or osteoarthritic bony growths at the L4-L5 or L5-S1 levels ¡Piriformis Syndrome May indicate contralateral psoas syndrome ¡ ¡Diagnostics ¡Deep tendon reflexes are diminished or absent depending on the nerve root involved ¡Straight leg raise test ¡Somatic dysfunction: Lumbar/Pelvis/Sacrum, Psoas hypertonicity, Piriformis hypertonicity ¡MRI ¡Treatment ¡OMT ¡PT, CS Injections ¡Pregabalin, Gabapentin ¡Surgery for HNP

Thoracic outlet syndrome

¡Presentation ¡pain, tingling, coolness, dysesthesia, and numbness of the upper extremity, usually in the ulnar distribution ¡pain is usually worse with the arm elevated or abducted ¡ ¡Mechanism ¡ compression of the neurovascular bundle in the region of the thoracic outlet ¡ ¡Diagnostic ¡Physical findings include sensory loss, particularly in the ulnar distribution ¡ Adson test is used to determine the state of the subclavian artery, which may be compressed by an extra cervical rib or by tightened anterior and middle scalene muscles ¡ ¡Treatment ¡Osteopathic management of thoracic outlet syndrome includes appropriate structural evaluation with particular attention to the cervical, thoracic, costal, scapular, and brachial mechanical relationships ¡ OMT consisting of myofascial-releasing maneuvers to the restrictive musculoskeletal structures can be usefu

Special Tests

¡Spurling maneuver ¡ Cervical radiculopathy ¡ Babinski sign ¡Upper Motor Neuron Lesion ¡Hoffmann sign ¡Upper cervical ¡Lasègue sign ¡Sciatica ¡Lhermitte's sign ¡MS

Headaches overview

¡one of the most frequent presenting complaints to both the general practitioner and the neurologist ¡Most headaches are mixed tension type and migraine ¡Pain can result from noxious stimulation of the eyes, ears, mouth, and nasal cavities Pain-sensitive intracranial structures include the venous sinuses and their tributaries, the dura (particularly at the base of the brain), and the arteries of

Spinal disorders overview

¡patients complain of deep and aching pain in the affected region of the spine. Often, the pain is worse in certain positions or with certain activities ¡ ¡pain is generated in the nerve root, patients describe a variety of pain sensations, including electric, burning, stabbing, dull, sharp, or tearing pain ¡ ¡Unilateral lesions of the spinothalamic tract cause contralateral numbness to pain and temperature ¡ ¡ lesions of the posterior columns cause ipsilateral loss of position sense, light touch, and vibration ¡ ¡ Limb weakness results when there is an abnormality in the anterior horn cells or corticospinal tracts. ¡The weakness can be accompanied by atrophy if it is in the lower motor neurons or spasticity if in the upper motor neurons.

V3: Motor Functions

´Muscles of mastication ´Temporalis ´Masseter ´Medial pterygoid ´Lateral pterygoid ´MATT ´Mylohyoid ´Anterior belly of digastric ´Tensor veli palatini ´Tensor tympani

Right Inferior Alveolar Nerve

Ø2-year history of intermittent neck pain Øradiates to the right side of her jaw and face rated 6/10. ØOne month prior to the onset of pain, she had a repeat root canal on her 1st and 2nd molars due to ongoing pain and suspected recurrent infection. ØJaw pain is sharp and shooting or throbbing, with intermittent muscle spasms. ØPain is aggravated by chewing, menstruation, and stress

How do we evaluate from the Behavioral model?

•. Biological •Neuropsychiatric •Genetic •Physiologic • •2. Psychological •Strengths •Vulnerabilities •Defense Strategies •Drives both conscious and unconscious •Transference •Counter transference •3. Social •How individual sees and is seen in the community social group •Relationships within family/social group •Work •Religion •Ethnicity •Socioeconomic

Motivational Interviewing

•4 Principles of Motivational Interviewing •Resist •Understand •Listen •Empower •R - patients often know what would be the best solution but ambivalent about the necessary change. Physicians resist the urge to convince patients •U - Understand patient concerns and values and motivations through reflective listening •L - Listening is the basis for all other components •E - Empower patients and their hope for change

Warning Signs

•Abrupt and severe onset •Sudden change in pattern or severity in chronic setting •Neck stiffness · Positive Kernig or Brudzinski's sign •Photophobia •Altered Mental Status •Neurological deficit •Fever or unexplained systemic sign •Progressively worsening, severe pain despite treatment •Vomiting precedes headache •New onset if over 50 •Interrupts sleep or present immediately on awakening •Elevated blood pressure not responding adequately to treatment •"worst headache my life" •"thunder clap" followed by immediate pain •Accompanied by seizure

VISCERO-SOMATIC REFLEX Viscerosomatic Reflex - Explanation

•Afferent impulses (nociceptive) from an injured or diseased organ stimulate efferent pathways to a somatic structure •Pectoralis trigger points may occur as a viscerosomatic reflex in patients with cardiac disease such as with coronary artery disease. •In one study with 72 patients, chest muscle trigger points were found in 61% of these patients. •Treatment of these trigger points helped to reduce the coronary spasm though careful analysis of the visceral disturbance is still required. •However, if these trigger points are not treated, they can be a source of recurrent chest pain since the healing of the primary visceral dysfunction does not always result in a spontaneous recovery to the somatic tissues. •Recurrence may be prompted by pectoralis muscle exposure to the cold or the overuse of this muscle.

What are the consequences of the reflex Interactions

•Afferent input from somatic structures might be expected to have some influence on visceral organs and input from visceral structures to have some effect on somatic organs. •Thus there are four major types of reflexes: 1. Somato-somatic​ reflex 2. Viscerosomatic reflex​ 3. Somatovisceral reflex 4. Viscero-visceral reflex

Reflexes important to OSTEOPATHIC MEDICINE

•Somato-somatic* Localized somatic stimuli producing patterns of reflex response in segmentally related somatic structures •Viscerosomatic reflex* Localized visceral stimuli producing patterns of reflex response in segmentally related somatic structures •Somatovisceral reflex* Localized somatic stimulation producing patterns of reflex response in segmentally related visceral structures •Viscero-visceral reflex* Localized visceral stimuli producing patterns of reflex response in segmentally related visceral structures •The provocative associations between tender points, trigger points, acupuncture points, and motor point tenderness suggests that the accessible neural components found at these regions reveal the facilitated status of the connected structures. •These sites do not, in their entirety, indicate that the problem is exclusive to this site but may be part of a chain attached to deeper and more elaborate structural dysfunction. •Maintained muscle tightness, ischemia, and sustained nociceptive activation, either through an activated axonal reflex and/or sustained neuroplastic response, may trigger the necessary environment to create the manifestations encountered on palpating the tenderness to these regions.

Designated Decision Makers

•Specifies who should make decisions in the event a patient is unable •Named person / people should be informed •Named person should know what the patient's wishes are •Named person should feel comfortable with designation •Named person should be comfortable with documented decisions

Diagnosing Viscerosomatic Reflexes

•Take a through history, Listen to the patient. •Palpation: Emphasis is placed on TART •Special attention is given to the costotransverse area. •Sympathetic chain ganglia are anterior to the rib heads. •Skin •Texture •Temperature •Moisture •Subcutaneous tissue •Bogginess (localized edema) •Superficial and deep musculature •Tone •Irritability •Often involves two or more segments, hard barrier with deep muscle springing • (a.k.a. very restrictive/noncompliant) •Poor response to treatment: reoccurs almost immediately or within hours

•A 43-year-old female presents with nasal and sinus congestion and watery eyes for 2 weeks. She has no history of allergies. On physical exam, the nasal mucosa are pink and slightly swollen, she is afebrile, the sinuses are clear, there is no maxillary or ear pain, and the pinnae are normal-appearing and the same on the left and right. At this point, what would be most appropriate to check and treat: •A 17-year-old male presents with nasal congestion and fever. His nose has felt sensitive to the air passing through it, and now he is starting to feel congestion in his nose. He does not have any allergies. On physical exam, he has a temperature of 100 F, the nasal mucosa appears dry, and the sinuses are moderately congested. There is no maxillary or ear pain, and the cervical and thoracic spine show no significant somatic dysfunction. The most appropriate treatment option at this time would be:

•The pterygopalatine ganglion •. Stimulation of the pterygopalatine ganglion

What are the consequences of the signal integration at the spine: The concept of facilitation is introduced

•The spinal cord interneurons that receive visceral and somatic information stimulate both autonomic and somatic motor efferent nerves. •The somatic motor excitation produces local somatic dysfunction, which, in turn, excites somatic nociceptive neurons which converge back on the same interneurons. •These converging inputs lower the threshold for firing the interneurons, sensitizing them and making then conducive of action potential at a lower stimuli: This phenomena is referred to as segmental facilitation. •Although pain is often a symptom of these reflexes. a lower level of firing could activate the cerebral cortex resulting on a pain perception (facilitation). •It is produced by nociceptor input, so that diseases presenting with pain are the most likely to produce significant reflex patterns. •Inflammation has been shown to greatly increase the firing of nociceptors. Therefore, diseases that involve inflammation are likely to produce reflex phenomenon, with or without the perception of pain.

Freeing the Anterior Vagus Nerve-

•To determine which direction to have them look, observe the uvula for deviation. The pathology is on the opposite side of the deviation. Retest by observing for midline positioning. (If not sure have them hold both sides sequentially.) •Head is held in the midline. The gaze is held until they swallow, yawn or sigh spontaneously. •If the uvula deviation persists, assign this as "homework" daily. •Holding the head in the vault hold or cradle it in your hands will allow you to sense the shift/release. (It is not necessary for the treatment to work)

Tension Headache - Mechanism

•Vascular, Supraspinal (neurological), and Myogenic integrated model in tension type headache and migraine. •Most patients with migraines have tension headaches, and many with mostly tension headaches also report migraines. •Migraines are believed to have a vascular trigger. •Tension headaches have myogenic trigger. •Both cause supraspinal facilitation via Trigeminal Nucleus Caudalis (TNC), which leads to sensitization to a nociceptive stimuli (trigger) that normally would not cause pain. •i.e. a tight suboccipital muscle now triggers a headache

Autonomics to Head and Neck Sympathetic Stimulation of Head and Neck

•Visceral nociceptive innervation usually follows the autonomic innervation of the organ (in reverse, of course) •Therefore, if there is nociception from a head or neck organ, facilitated segments will be found in T1-4. •Sympathetic stimulation of the nose and sinuses increases the goblet cells (producing a thick sticky mucus) •It also reduces secretion. If this occurs for too long, the mucosa can crack, allowing bacteria past the mucosal defense system

The sinuses Sinus drainage

•When normal, nasal accessory sinuses are capable of self-drainage. The lining of the mucous membrane is composed of ciliated columnar epithelium, the motion wave of the cilia is always directed to the ostium, or opening into the nasal fossa, and the quantity of secretion is just enough to keep the mucous membrane moist. •All sinuses drain towards the median plane so that when lying down with the head turned to one side, the sinuses in the upper side drain more readily with the aid of gravity and the sinuses on the lower side tend to drain more slowly. •They ALL work when the cranial and facial bones move as intended. •Each sinus drains most readily when the position of the head is such that the lowest portion of the sinus is its ostium •frontal sinuses: erect position, standing or sitting •maxillary sinuses: lying down on the back •sphenoid sinuses: lying face-down with forehead lower than the chin •ethmoid sinuses: may drain directly into the nasal cavity, the frontal sinus, or into one another. Drainage therefore may be very simple or very complicated. •Obstruction in the pharynx will obstruct the lymph drainage from the nose, impact the vagus and other nerves as well as the superior cervical sympathetic ganglia which can result in a variety of symptoms in multiple organs of the body. (Mucous membrane connections)

Stretching Pterygoid muscles

•With gloved finger, apply pressure to the muscle inside the mouth •Gently slide along the muscle to stretch it and identify any tender points that can be resolved with inhibition. •Notice that the lateral pterygoid muscle travels medial to lateral. •Place your finger in the ceiling of the pocket between the upper molars and the cheek, palpate posteriorly. Avoid applying upward pressure on the palatine

Cluster Headache TMJ Disorder - another pain in the head TMJ Pathophysiology Clinical Manifestations: TMJ OMT Approach to Evaluate TMJ

•characterized by severe to very severe unilateral pain in and around one eye •"sensation of an ice pick behind the eye" •Attacks are brief (30 minutes to 2 hours) and happen from once every other day up to eight times per day in clusters that typically last for a few months • •The attacks may be provoked by alcohol, histamine, or nitroglycerine. • •Men are affected six times more frequently than women. • •Treatment with high flow oxygen •TMJ dysfunction is the most frequent source of facial pain after toothache •The TMJ has been described as the most complex joint in the body because it not only acts as a hinge joint but also permits a gliding movement, where the condyle of the mandible slides along the squamous portion of the temporal bone. •Its etiology is multifactorial and includes somatic asymmetries leading to malocclusion, jaw clenching, bruxism, increased pain sensitivity, and psychological symptoms, such as stress and anxiety. •The bottom-line etiological basis of the symptomatology (i.e., pain, tenderness, and spasm of the mastication muscles) is muscular hyperactivity and dysfunction •Patients with TMJ syndrome commonly present with complaints of facial pain, jaw range-of-motion (ROM) restriction, jaw noise (clicking or popping), and headaches or neck pain. •Earache is not uncommon. •Many patients report a recent history of jaw trauma (e.g., wisdom tooth extraction) • Acute or chronic problems with bruxism or the clenching of teeth. •Facial pain is usually periauricular, worsened by chewing. Periauricular pain may be unilateral or bilateral. •Headaches, either tension or migraine, may be triggered by TMJ syndrome.' The treatment of TMJ dysfunction has three components: 1. Identifying and eliminating any treatable cause 2. Osteopathic manipulative treatment 3. P