Finding the Key S/D-H - American Academy of Osteopathy

FIND AGR & SEQUENCE OMT‘FIND, FIX & LEAVE ALONE”A.T. STILL, DO, MDCAN HAVE RIGHTNUMBERS BUT . . .HOW DO EXPERT LOGGERS DEAL WITH LOG JAMS ?• CLIMB THE TALLEST TREE IN AREA• IDENTIFY THE “KEY” LOG: BACKING UP THE LOGS BEHIND IT• DYNAMITE THE “KEY” LOG• JAM RELEASES … MECHANISM / RIVER DOES THE WORK !AMATEURS: START REMOVING LOGS FROM THE PERIPHERYAND EVENTUALLY GET TO THE “KEY” LOG 7

COMPLEXITY OF S/D - H( FRACTAL PHYSIOLOGY )*NOTE:• AVERAGESDON’T ACCURATELYDESCRIBE THEPHYSIOLOGICAL REALITY• BELL CURVEDOESN’T REFLECTCOMPLEX ACTIVITIES• CRUCIAL INFORMATIONAT TWO ENDS OFPOWER LAWFEW SIGNIFICANT VALUES, MANY MEDIUM VALUESAND LARGE # OF MIN. VALUES = COMPLEXITY# OF SOMATIC DYSFUNCTIONSAGR / SEQUENCING ( LEAST VARIABILITY )( POWER LAW: ACCURATELY DISPLAYS COMPLICATED PHYSIOLOGICAL PHENOMENA )8

THE BASIC PRINCIPLES AND TECHNIQUESYOU LEARN IN SCHOOL AREEQUIVALENT TO THEMELODY OF A TUNESIGNAL / PATTERN : HOMEOSTASISBUTEACH PATIENT IS LIKE AJAZZ VARIATIONSIGNAL + ‘NOISE’ / VARIATIONS : HOMEO-DYNAMICSBOTTOM-LINE !9

SITTING

RULE III: SPINAL MECHANICS IF A MOTION IS INTRODUCED INTO THESPINE, THE OTHER TWO MOTIONS BECOMERESTRICTED IF A SECOND MOTION IS ADDED, THE OTHERTWO MOTIONS BECOME RESTRICTED. WHEN A THIRD MOTION IS ADDED /STACKED, YOU HAVE“PHYSIOLOGICAL LOCKING”UTILIZING THE ELASTIC BARRIERAGR DEMONSTRATE THIS PRINCIPLE WITH NECKMOVEMENTS ( F/E, SB & ROTATION )WORKSHOP MATERIAL11

RULE III OF SPINAL MECHANICSAPPLICATION AND FINDINGS:NORMAL JOINT:• YOU ARE AT THE ELASTIC / PHYSIOLOGICAL BARRIER• THERE WILL BE A YIELD, SPRING AND “SOFT END-FEEL” WITHSEGMENTAL MOTION TESTING.• YOU CAN SPRING THE JOINT SIMULTANEOUSLY IN THREEPLANES OF MOTION ( JOINT PLAY - MENNELL )RESTRICTIVE BARRIER:• WHEN YOU CHALLENGE A DYSFUNCTIONAL AREA, THEREWILL BE GUARDING AND LOSS OF TISSUE YIELD.• JOINT SPRING IS LOST AND YOU PALPATE A “HARD END-FEEL”.FIND THE MOST RESTRICTED / DYSFUNCTIONALAREA ( AGR / KEY )GRADE DYSFUNCTIONAL REGIONS: I, II OR III12

NEW INSIGHTS ABOUT SCREENING EXAM• AFTER THE HX, PE AND OVERVIEW CHART ( INITIAL VISIT ) COMPLETED• WITH THE PATIENT STANDING, PUT BOTH HANDS ON THE PATIENT’S SHOULDER:• TO SHOW WHAT YOU’R DOING IS NON-TREATENIING . . . MY ORIGINAL HYPOTHESIS• TAKE TO THEIR “GLOBAL D.B.P.” USING ANT. / POST. TRANSLATION. . . THEN WITH MINIMALSIDEBENDING LATERAL TRANSLATION FLOWS IMMEDIATELY ! !• ALSO ADD SLIGHT CAUDAD PRESSURE WHICH INTEGRATES THE DYNAMIC SACRALMECHANICS INTO THE “GLOBAL EQUATION”• WHEN USING THE SHOULDER FOR INTRODUCING MOTION, MONITOR IPSILATERALCLAVICAL, PECT. MINOR, ANT. A/C AREA & PLACE THUMB @ T 1 . . .MONITORING / BALANCING MULTIPLE ANTERIOR AREAS / PLUS USE PALM TOINTRODUCING A VECTOR TOWARD THE MONITORED AREA ( LISTENING HAND )• WITH THE “LISTENENING HAND”, USE “BLENDING PALPATION” DURING THESCREEN AND AS YOU MOTION TEST . . . IDENTIFY THE “REGIONAL D.B.P.” ATEACH SITE BEING MONITORED• NOW “LISTENENING HAND” CAN BECOME A “CHALLENGING HAND”• COMPLETE THE STANDING SCREENING EXAM . . . BOTH SIDES . . . IDENTIFY THE“REGIONAL D.B.P.” POSITION @ EACH AREA• SAME PRINCIPLES APPLIES DURING SITTING SCREENING EXAM• FIND THE A.G.R. . . . PROBLEM SOLVE TO IDENTIFY KEY S/D-H• IDENTIFYING THE GLOBAL AND REGIONAL D.B.P. ENABLES THE FUNCTIONAL AREASTO FUNCTION WELL AND DYSFUNCTIONAL TO COME TO THE SURFACE ! 13

SCREENING EXAMINATION:• VISUAL EXAMINATION• PALPATORY EXAMINATIONHOW APPLY PRINCIPLE III ?• PALPATE ( REGION ) LATERAL TO SPINOUS ANDMEDIAL TO THE TRANSVERSE PROCESS( LISTENING HAND & MOTION CHALLENGING HAND )• USING MOTION HAND: START IN NEUTRAL AND SIDEBEND AND PALPATE ROTATION IN OPPOSITEDIRECTION . . . USE SWEEPING MOTIONS ( TYPE I )• THEN INTRODUCE FLEXION OR EXTENSION ANDSIDEBENDING AND ROTATION IN THE SAMEDIRECTION . . . USE SWEEPING MOTIONS ( TYPE II )• DO SLOWLY AND MONITOR THROUGHOUT ( LISTENING HAND )• CHARACTER OF “END-FEEL” IS ESSENTIAL FACTOR• SEQUENTIALLY MOVE ‘LISTENING HAND’ DOWN SPINEAND REPEAT . . . FIRST IN NEUTRAL , THENUSING TYPE II . . . USE SWEEPING MOTIONS• REPEAT DOWN TO S/IJ’s• DO BILATERALLY PLUS WHILE SITTINGWHERE ISA.G.R. ? 14

SEQUENCING: examination -TASKSDURING THE PALPATORY EXAMINATION, USE TESTINGMOVEMENTS AS FOLLOWS: ONE HAND INTRODUCES MOVEMENT . . . MOVEMENT HAND OTHER HAND MONITORS THE SEGMENTAL RESPONSE . . .THE ‘LISTENING HAND’ BLENDS IN WITH TISSUES JOINT MECHANICS MONITORED PARASEGMENTAL TISSUE RESPONSE MONITORED SLOW “SWEEPING” MOVEMENTS UTILIZED( TENSEGRITY STRUCTURE: 60, 120, etc. degree angles ) *DELIBERATE MOTION: INTERPRETING THE “END-FEEL” FIRM BUT GENTLE: “VELVET COVERED BRICK” ( LISTENING HAND ) USE THUMB ( ‘LISTENING HAND’ ) TO SEGMENTALLY SPRINGTHE DYSFUNCTIONAL AREA TO FIND A.G.R. WITHIN AREA EXAMINE BOTH STANDING & SITTING*NOTE: WHEN SPINE IS FUNCTIONAL THE ‘LISTENING HAND’GLIDES LATERALLY TOWARD PRODUCED CONVEXITY 15

SCREENING EXAM:further interpretationsHUME / DALTON / KINGERYIDENTIFY AGR / regional areaIDENTIFY AGR / segmental level ( PALPATE BILATERALLY )• IF CRI F&E ARE RESTRICTED = VERTEBRAL DYSFUNCTION• IF FINGERS ROTATE = PALM FACES EITHER• VISCERA• CHAPMAN’S REFLEX POINT . . . WHICH INHIBITS / NORMALIZES ?• IF FINGERS GLIDE LATERALLY• IN THORACIC AREA =• RIB DYSFUNCTION• FIND KEY RIB, NORMALIZED INITIAL FINDING• MULTIPLE UPPER CERVICAL = CRANIAL• C 3-5 : HYOID . . . THE INTEGRATOR OF ANTERIOR BODY ?• MULTIPLE UPPER THORACIC = UPPER EXTREMITY• MULTIPLE LUMBAR = LOWER EXTREMITY• OVER SACRUM• WHILE SITTING = S/IJ DYSFUNCTION• WHILE STANDING = GAIT DYSFUNCTIONNOTE: DEVIATION TOWARD SIDE OF DYSFUNCTIONIF HAVE MUTLIPLE AREAS, Rx ONE THAT NORMALIZES AGR16

SCREENING EXAMINATION:OSTEOPATHIC PROBLEM - SOLVINGQUESTION # 1: AGR in upper or lower half of the body ? ( T 12reference point )UPPER HALF OF THE BODY : is AGR in CERVICAL, THORACIC, RIB CAGE OR UPPER EXTREMITY ?• Cervical: if cervical, is it ?• Upper / atypical vertebrao Muscular end-feel: A/O, AA or botho Dural end-feel: cranial ( screen for AGR )• Typical vertebra C 2-7o Find key type II dysfunction: ERS or FRS• Thoracic: if thoracic, is it ?• If have a horizontal band of tightness it is either vertebra or rib cageo If spring increases as palpate laterally along the related rib = vertebra. If multiple vertebral dysfunctions, treat the mostrestricted vertebral dysfunction firsto If spring decreases as palpate laterally along the related rib = rib cage. Screen rib cage for key rib dysfunction. If multiple ribpatterns exist, treat out of pattern ones first then the in pattern ribs. If multiple in pattern ribs, treat mostrestricted first.• Upper extremity:• If have a unilateral vertical band of tightness along the medial border of one scapula, it means AGR is in the upper extremity onthat side. Rule out: A/C, S/C, shoulder, elbow, wrist or hand for AGR.LOWER HALF OF THE BODY: IS AGR in LUMBAR, SACRUM AND PELVIS OR LOWE EXTREMITY ?• Forward bending tests ( FBT )o If standing FBT is more positive than the sitting FBT, the AGR is in the lower extremity ( usually the ipsilateral side ) Rule out:o Tibial rotationso Fibula dysfunctions ( proximal and distal )o Foot of ankle dysfunctionso If no major dysfunction are present, check the hip restrictors: treat using the sacral axeso Treat AGR in lower extremityo If the sitting FBT is more positive than the standing FBT, the problem is in either the lumbar spine or sacrum / pelviso After the patient returns to the erect position following the sitting FBT, re-screen the lumbar and sacroiliac regionso If AGR is in the lumbar area, treat the AGR ( NSR, FRS OR ERS )o If the AGR involves the sacrum or pelvis, follow the ‘Mitchell Axis Model’ sequence• Treat any innominate upshear or downshear: disrupt all 3 transverse axes• If none, treat any pubes dysfunctions: markedly disrupt sacral mechanics• If no pubes dysfunctions or after they are treated, treat any sacral dysfunctions. Now sacral axes will all befunctional.• Once the sacrum is functional, treat any innominate rotational dysfunctions or innominate inflares or outflaresNote: this examination enables you to attain amazing histories !17

TOTALSCREENSCREENING EXAMINATION( RATIONAL FOR WHAT WE ARE DOING )REGIONALDYSFUNCTIONIDENTIFIEDSEGMENTALDYSFUNCTIONIDENTIFIED• UPER HALF OF BODY• CERVICAL• ATYPICAL• DURAL . . . CRANIAL• O/A, AA OR BOTH• TYPICAL C2-7• THORACIC• RIB CAGE• UPPER EXTREMITY• LOWER HALF OF BODY• LUMBAR• SACRUM OR PELVIS• LOWER EXTREMITIESREMEMBER THE QUOTE OF OSTEOPATHIC ‘GIANTS’• WARD: “START AT THE PORT OF ENTRY WHICH IS THE AREA OF MAXIMAL 3-D RESTRICTION” ( POET 3 )• JONES: “TREAT THE MOST ACUTE TENDER POINT OR THE MOST HYPERTONIC MUSCLE FIRST”• MAGOUN: “INITIALLY IT IS GOOD FOR STUDENTS TO LEARN A DIAGNOSTIC AND TREATMENT PROTOCOL BUTEVENTUALLY YOU WILL ALMOST INTUITIVELY GO RIGHT TO THE ‘HEART OF THE PROBLEM”• McCOLE: “THE GREATER OSTEOPATHIC LESION COMPLEX: WHICH ENCOURAGES ALL THE CHANGES TAKINGPLACE THROUGHOUT THE BODY AS A RESULT OF ‘FIXED POSTURAL TENSION’ @ VERTEBRAL LEVEL”18

UPPERHALF ?• CERVICAL ?• DURAL ?• UPPER CERVICAL ?• LOWER CERVICAL ?• THORACIC ?• THORACIC ?• RIB CAGE ?• UPPER EXTREMITY ?DOSCREENFIRSTDECISIONOMTAGRS/DLOWERHALF ?• LUMBAR OR PELVIS ?• LUMBAR ?• PELVIS ?AXES MODEL• UP / DOWN-SHEAR• PUBES• SACRAL DYSFUNCTIONS• INNOMINATE ROTATIONS• LOWER EXTREMITY ?19

HOST + DISEASE = ILLNESSAGR / SEQUENCEDOMT CAREOBSERVECLINICAL RESPONSESUPERIMPOSE ONCELL SCHEMATICPARADIGMDEVELOP A PATIENT UNIQUEPATHOPHYSIOLOGICAL HYPOTHESISOUTCOME:S/D-HFINDINGSMAYENABLEENHANCEDPATIENTSPECIFICALLOPATHICCARESTRUCTURAL EXAM:VIEW AS AN‘OSTEOPATHICREQUIREMENT’OR AS AUSEFULCLINICALTOOL ?20

FINDING THE A.G.R.SEQUENCINGWHY AN IMPORTANT CLINICAL TOOL ?MECHANO-TRANSDUCTIONAUTOPOIESISS/D-HIMPACT ?GRACOVETSKYDATA21

HOW DO YOU KNOW IF YOU ARETREATING IN SEQUENCE ?1. ALL LANDMARKS MATCH THE DIAGNOSIS WHENTREATING AN AREA IN THE APPROPRIATESEQUENCE / ORDER2. DON’T SEE A LOT OF “CRAZY PATTERNS”3. DON’T SEE A LOT OF UNCOMMON DIAGNOSESPLUS ALL THE FINDS FIT THE DIAGNOSIS4. TREATING IS LIKE SWIMMING IN WATER AND NOT INPEANUT BUTTER5. WHEN YOU CHANGE AGR, 20-30 +% OF ALL THEBODY’S DYSFUNCTIONS WILL CHANGE. WHENTREATNG OUT OF SEQUENCE, ONLY THE TREATEDAREA CHANGES . . . AND RESPONDS POORLY !22

HOW DO YOU KNOW IF YOU ARETREATING OUT OF SEQUENCE ?1. SEE A LOT OF “CRAZY PATTERNS”2. SEE A LOT OF UNCOMMON DIAGNOSESPLUS ALL THE FINDS DON’T FIT THEDIAGNOSTIC PATTERN3. TREATING IS LIKE SWIMMING IN PEANUTBUTTER RATHER THAN IN WATER,ie.,ITS HARD WORK.4. EXACTLY THE SAME PATTERN OF SOMATICDYSFUNCTION KEEPS RETURNING WITHEACH VISIT.5. ONLY THE TREATED AREA CHANGESWITH LITTLE IMPACT ON THE REST OF THEBODY23

# 1FRS L # 2R 1-9INSP.# 4R. A/ISITTING# 3L/RTORSIONMODELS:• POSTURAL• PODIATRY• DENTAL / TMJ• CV / RESP• AGR / SEQTHEN CAN136 EXPLAIN

CRANIAL PATTERNMAY BE‘SECONDARY’TO THIS S/D PATTERN# 1FRS L # 2R 1-9INSP.# 4R. A/ISITTING# 3L/RTORSION• # 1: CAUSE FLAT / Tx LUMBARS 2d TO FRS L• Tx LUMBARS INHIBIT ABDOMINALS ?• CAUSE HEAD FORWARD• # 2: CAUSE HIGH L. SHOULDER• # 3: CAUSE LOW L. SACRAL BASE• CAUSES FLAT LUMBAR AREA• CAUSE SHORT L. LEG / LOW S.B.• CAUSE SCOLIOSIS• #`4: CAUSE LONG RIGHT LEG• AGGREVATE LOW L. SACRAL BASE• # 5: INTRODUCE CRANIAL ADAPTATIONS• CRANIAL S/D . . . WANT TO TREAT 1 ST ?MODELS:• POSTURAL• PODIATRY• TMJ• CV / RESP• AGR / SEQTHEN CAN136 EXPLAIN