1
Q
OMT is indicated for adults with SD related to…
A
URI (rhinitis, sinusitis, cold, Eustachian tube dysfunction), headache (cephalgia), temporomandibular joint dysfunction (TMJ), pharyngitis, cranial neuropathies, head trauma, vertigo, psych
2
Q
OMT is indicated for kids with SD related to…
A
NAS Difficulty latching Plagiocephaly Otitis media URI Head Trauma
3
Q
Symptoms of sinusitis
A
Headache/facial pain
Runny nose
Nasal congestion
Fever
4
Q
Causes of sinusitis
A
Viral
Bacterial
Fungal
5
Q
What decreases the body’s immune response regarding anatomy of sinusitis?
A
Tissue swelling
Impaired blood flow
Impaired lymphatic drainage
6
Q
Increased sympathetic tone from upper thoracics can cause ___________ and thicken mucus as well as _________ lymphatic flow and response.
A
Vasoconstriction; decreasing
7
Q
__________ parasympathetic tone can cause tearing and runny nose.
A
Increased
8
Q
Dysfunction of the upper cervical/suboccipital areas can cause irritation of the _____ nerve
A
Vagus
9
Q
Cranial dysfunction can affect the ______ of the sinuses as well as ____________ to the head
A
Drainage; parasympathetics
10
Q
Goals for treatment of URI
A
Improve drainage
Treat offending organism
Support patient
11
Q
What are the 5 models of osteopathic care?
A
- Respiratory-circulatory
- Neurological
- Biomechanical
- Metabolic-energy
- Behavior
12
Q
What can facial effleurage be used for?
A
Promote lymphatic drainage from the head (resp-circ model)
13
Q
Neurological model with URI
A
Trigeminal stimulation, sphenopalatine ganglion stimulation
14
Q
Primary headaches
A
- Migraine headache
- tension-type headache
- trigeminal autonomic cephalgias (cluster)
15
Q
Secondary headaches
A
Due to another pathology/injury
16
Q
Red flags
A
- First and/or worst headache of the patient’s life
- Headache beginning after 50 years of age or before 5 years of age
- Occipital headaches in children
- Headache with signs of systemic illness (fever, stiff neck, rash)
- Abnormal neurologic exam
- Headache subsequent to head trauma
- Headache associated with alteration in or loss of consciousness
- Headache triggered by exertion, sexual activity, or Valsalva maneuver
- New or severe hypertension
- New headache in patients with cancer, immunosuppression, pregnancy
- Different than the normal pattern
17
Q
Migraine headaches
A
- Side: unilateral (usually frontotemporal)
- Character: pulsating
- Intensity: moderate to severe
- Duration: 4-72 hours
- Triggers: maybe
- Associated symptoms: nausea/vomiting and/or photophobia/phonophobia; may have auras or prodromes
18
Q
Tension-type
A
- Side: bilateral
- Character: tightening/pressure
- Intensity: mild to moderate
- Duration: 30 minutes to 1 week
- Triggers: anxiety, stress, depression, poor posture
- Associated symptoms: may have photophobia or phonophobia, but not both
19
Q
Cluster
A
- Side: strictly unilateral, orbital, supraorbital and/or temporal
- Intensity: severe to very severe
- Duration: 15 minutes to 3 hours or longer
- Triggers: alcohol, histamine, or nitroglycerine during a cluster period
- Associated symptoms: occur in series or clusters; ipsilateral facial symptoms such as edema, congestion, lacrimation, sweating, miosis, and more; restless/agitated
20
Q
TMJ
A
- Describes a number of clinical problems: clicking/grating within the joint, mechanical restrictions, jaw/ear/facial pain, headache, neck pain, and stiffness
- May be acute or chronic
- Most common non-dental cause facial pain
- It is believed that the etiology is likely multifactorial
21
Q
TMJ joint itself…
A
- Synovial joint between condyle of mandible and mandibular fossa of temporal bone
- Fibrocartilaginous disc
- Complex motion - hinge, lateral glide, protraction, retraction
22
Q
Symptoms of TMJ
A
- Chronic pain in the muscles of mastication described as a dull ache, typically unilateral
- Pain may radiate to the ear and jaw and is worsened with chewing
- Bruxism, teeth clenching
- Locking of the jaw or asymmetrical movement when attempting to open the mouth
- Clicking or popping, usually when displacement of the articular disk is present
- A bite that feels uncomfortable or different from usual
- Headache , neck, shoulder, and back pain
- Increasing pain over the course of the day
- History of jaw and/or facial trauma
23
Q
Acute approach to treating TMJ
A
OMT
Stretching the joint capsule
NSAIDs if needed
Muscle relaxers if necessary
24
Q
Chronic approach to TMJ
A
- more difficult
- best managed with team approach
25
OMT techniques for TMJ
- Suboccipital inhibition
- C1 treatment
- Temporalis MFR
- Masseter inhibition
- AC7 and AC8 counterstrain
26
Viscerosomatic reflexes SD in LRI
- T2-T7 facilitation
- OA dysfunction
- Chapman points: 3,4 anteromedial intercostal spaces and T3-4 transverse processes
27
Structural factors for SD in LRI
Rib restriction, segmental restriction, muscular restriction
28
Lymphatic factors for SD in LRI
Diaphragm tension, MF restriction
29
Acute SD
Hot, moist, edema, tense, prolonged red reflex, type II
30
Chronic SD
Cool, dry, thick, ropy, blanching, type I and II
31
Neurologic model for LRI
- Upper cervical treatment (parasympathetic normalization)
- Suboccipital inhibition
- OA myofascial release
- T2-7 treatment (sympathetic normalization and improves chest excursion)
- Soft tissue
- Rib raising
- Segmental myofascial release/ muscle energy
32
Suboccipital inhibition can be used to normalize _______ tone
Vagal
33
Biomechanical model for LRI
- Restoring proper rib and vertebral segment motion:
- Improves chest excursion
- Helps decrease muscle fatigue
- Helps to decrease the work of breathing
34
Respiratory/Circulatory model for LRI
- Lymphatic OMT improves breathing and immune response
- Diaphragm treatment improves breathing and lymphatic flow
- Thoracolumbar (TL) Diaphragm
- Cervicothoracic (CT) Diaphragm
- Sibson’s fascia
- Lymphatic pumps improve lymphatic and venous drainage
- Thoracic pump
- Pectoral traction
- Pedal pump
35
CT diaphragm tension limits drainage from _____ ______. _______ duct passes through it twice
Entire body; thoracic
36
TL diaphragm tension limits drainage from...
Abdomen, pelvis, LE
37
Thoracic pump is contraindicated with...
aspiration, pulmonary embolism, acute congestive heart failure, COPD (rebound)
38
_______ ________ is a gentler alternative to thoracic pump
Pectoral traction
39
Relative contraindications for OMT for LRI
-Pulmonary embolism
-Unstable congestive heart failure
-Unstable arrhythmia
Others
-Acute rib fracture
-Lung cancer
-Aspiration
-Chronic obstructive pulmonary disease (Noll 2008)
-Severe osteoporosis/elderly
40
OMT for acute/subacute LRI
- Thoracic, rib, diaphragm techniques
- Autonomic normalization with rib raising, suboccipital inhibition
- Thoracic pump
41
OMT for chronic LR dysfunction
- Every 1-4 months to help prevent exacerbations
| - Daily home exercises for thoracic and rib mobility
42
OMT for patients with LRI ultimately helps because it....
- normalizes autonomics (reduces bronchospasm, reduces and thins secretions)
- improves chest excursion, helps decrease muscle fatigue and the work of breathing
- improves immune response and lymphatic and venous drainage.
43
What is croup?
Inflammation of larynx, trachea, and large bronchi
44
Clinical findings of croup
Inspiratory stridor is key
| -Also barking cough, hoarse voice
45
Diaphragm innervation
Phrenic n. from C3-5
46
Right lobe has __ lobes
3
47
Left lobe has __ lobes
2
48
Perforating structures of diaphgram
IVC, esophagus, aorta, azygous vein, thoracic duct
49
RALS
Right pulm a. Anterior to bronchus; Left is Superior
50
Perforating structures "I ate 10 eggs at 12"
- IVC @ T8
- Esophagus @ T10
- Aorta @ T12 (plus azygous v and thoracic duct)
51
Non-cardiac chest pain
constant, point tenderness, pain changes with positional changes, located in shoulders or between scapula, made worse with pressure on precordium, epigastric region
52
How many lung fields do you auscultate?
10
53
Pack years...
PPD*number of years smoked
54
In a patient with history of moderate-severe COPD, you would expect to inspect....
Barrel chest
55
Pectus carinatum
Sternum protrudes outward
56
Pectus excavatum
Lower sternum indents
57
What breathing pattern leads to barrel chest?
Air trapping
58
Cheyne-Stokes breathing
Varying periods of increasing depth interspersed with apnea
| Seen in very sick patients, brain damage, cerebral or drug associated respiratory compromise
59
Air trapping
Increased difficulty getting breath out
60
Kussmaul breathing
Rapid, deep, labored
breaths
Seen in metabolic acidosis
61
Biot breathing
Irregularly interspersed periods of apnea in a disorganized sequence of breaths
Seen in severe or persistent increase of intracranial pressure, respiratory compromise from drug poisoning, brain damage at medulla
62
What is expected from someone with COPD with palpation?
Decreased tactile fremitus (more air produces less vibration) and chest excursion (doesn't expand as much)
63
Respiratory distress signs
Dyspnea, labored breathing, diaphoretic, retractions (sinking in with each breath), cyanosis or pallor, mental status, accessory muscle use, nasal flaring, lip pursing, tripod
64
Accessory muscles during inspiration
Trapezius, scalenes, SCM
65
Which lobe is an aspirated object most likely to land in when upright?
Right lower lobe
66
Which lobe is an aspirated object most likely to land in when someone is laying down?
Right upper lobe
67
Tension pneumothorax
Life-threatening condition in which air enters pleural space with each breath and stays trapped, compressing lung and other thoracic structures
68
What would be a clue for suspected right-sided tension pneumothorax?
Trachea deviation to left
69
Crackly, crinkly sensation on palpation or auscultation
Crepitus
70
What does crepitus indicate?
Air in subcutaneous tissue (subcutaneous emphysema) - rupture somewhere in resp, infection with gas-producing organism
71
Friction rub
Palpable, coarse, grating vibration; inspiration and expiration
72
Hyperresonance
Hyperinflation (emphysema, pneumothorax)
73
Dullness
Diminished air exchange or fluid (pneumonia)
74
Normal lung sounds
- Vesicular (low-pitched, low intensity - healthy lung tissue)
- Bronchial (highest pitch and intensity - trachea)
- Bronchovesicular (moderate pitch and intensity - major bronchi)
75
Crackles/Rale
- Character: fine, medium, or coarse crackling sound; high-pitched. Discontinuous sound.
- When is it heard: inspiration
- Cause: disruptive passage of air through the small airways.
76
Crackels/rales possible pathologies
early inspiratory>> chronic bronchitis;
| late inspiratory >> pneumonia, CHF, or atelectasis
77
Rhonchi
- Character: coarse low pitched; may clear with cough
- When is it heard: inspiration and expiration
- Cause: passage of air through an airway obstructed by thick secretions, muscular spasm, new growth or external pressure
78
Rhonchi possible pathologies
Asthma, COPD, tumor
79
Wheezes
- Character: whistling, high pitched bronchus, musical-like sound/squeak
- When it is heard: inspiration or expiration, generally louder on expiration
- Cause: relatively high velocity air flow through a narrowed or obstructed airway
80
Wheezes pathologies
asthma (reactive airway disease)
acute/chronic bronchitis
foreign body (very localized)
81
Friction rub
Dry crackly grating (“machine-like quality”), low pitched sound, “leather-on-leather” sound.
Heard in both inspiration and expiration.
Suggests pleurisy
82
Stridor
High-pitched, piercing sound
Heard during inspiration
Due to obstruction high in the respiratory tree
83
Bronchophony
Have patient say 99>>positive = increased sound
84
Egophony
Have patient say "E, E, E" >>positive = "A, A, A"
85
Whispered pectoriloquy
Have patient whisper "1, 2 3" >> positive - increased sound
86
Retropharyngeal abscess
a life-threatening deep neck space infection that has the potential to occlude the airway; occurs in the potential space extending from the base of the skull to the posterior mediastinum between the posterior pharyngeal wall and prevertebral fascia
87
Peritonsillar abscess
infection of space between the palatine tonsil capsule and pharyngeal muscles
differentiate between branchial cleft cyst and thyroglossal duct cyst
88
Branchial cleft cyst
type of birth defect in which a lump develops on both sides of a child’s neck or below the collarbone; incomplete involution of branchial cleft
89
Thyroglossal duct cyst
fluid-filled pocket in front of neck, just above voice box; forms in tissue sometimes leftover from development of thyroid gland.
90
Epstein's pearls
small cysts that appear in a baby’s mouth that look like tiny white bumps; present in many babies and completely harmless unless they’re showing signs of pain
91
Oral thrush
fungal infection caused by Candida albicans where it accumulates inside the lining of your mouth (candida is normal, but can overgrow in case of thrush); causes creamy white lesions on tongue or inner cheeks that can spread to the roof of your mouth, gums, tonsils, or back of throat
92
Tooth eruption 7+4 rule
```
7 months - teething
11 mo - 4 teeth
15 mo - 8
19 mo - 12
23 mo - 16
27 mo - 20
```
93
Conductive hearing loss
Reduced transmission of sound to middle ear (problem in auditory canal, tympanic membrane, middle ear)
94
Causes of conductive hearing loss
Cerumen impaction, otitis media with effuction, acutre otitis media, otitis externa, foreign body, cholesteatoma, stiffening of ossicles, otosclerosis
95
Indications of hearing loss
Turns TV loud, hears better in noisy environment, asks for things to be repeated, speaks softly, bone conduction>air conduction with Rinne, lateralization to affected ear with Weber
96
Sensorineural hearing loss
Reduced transmission of sound to inner ear (cochlea, associated structures, CN VIII)
97
Causes of sensorineural hearing loss
damage to CN VIII, congenital infection, genetic hearing impairment, genetic syndromes, systemic disease, ototoxic medications, trauma, tumors, or prolonged exposure to loud occupational and recreational noise
98
Indications of sensorineural hearing loss
Complains that people mumble, has difficulty understanding speech, speaks loud, air conduction>bone conduction but less than 2:1 with Rinne, lateralization to unaffected ear with Weber
Respiratory
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