OPP EXAM I

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OPP EXAM I

When was AT STILL born?

August 6, 1828.

What 3 professions did AT Still's father do?

Farmer, Methodist minister, physician

What is Heroic Medicine?

It was the dominant system of medicine from late 18th-early 19th century. Believed most diseases caused by tension in blood vessels causing fever. Consisted of: blood letting, purging of stomach & bowels w/poisions (arsenic, calomel).

Describe the evens that lead to Still's first experience w/osteopathy.

Still's family moved from Tennessee-->Missouri. Here @ age 10 Still got a headache while outside & put a rope b/w 2 trees & leaned his head back on it & found it cured it.

When (year) did Still marry his first wife? His father moved away? He began as a physician?

1. 1849 married Mary Vaughn
2. 1852 Father moved to minister to Shawnee indians in Kansas
3. 1854: physician. Mostly trained by watching father.

What were some of the challenges to Orthodox Medicine during 19th century?

1. Samuel Thomson: thought ppl got sick b/c couldn't build enough heat to build off. gave plant remedies to make sweat/vomit.
2. Samuel Hahnemann: developed homeopathy: best drug to cure is one that causes similar symptoms in healthy ppl.
3. Sylvester Graham: Not a physician, believed if you cut out certain things from diet, dress properly, no promiscuity, follow nature's laws, you'll recover.
4. Franz Mesmer: Disease caused by unbalanced invisible fluid in body. Used magnetism & rubbing to cure. where word "mesmerized" came from.

What is Hydropathy?

wrapped patients in cloths dipped in freezing water & then person dunked in freezing water.

Pivotal Years:
When did Still marry his 2nd wife, enlist in civil war, give up on medicine & why?

1960: 2nd wife, Marry Turner
1861: Civil War (Union Army)
-gave up on medicine b/c more ppl died in civil war of disease than in battle. In Feb 1864 when 3 of his children died of spinal meningitis & in 1867 his father died of pneumonia. Said if he ever went back to medicine, he'd find a better way.

Still & Anatomy

fascinated by machinery & anatomy (raided graves of native americans, read as many anatomy books as he could obtain) thought of "Man as Machine" & correlated proper structure of the body w/health of person.
-if structure off=disease

What date is thought of as the date Still rejected traditional medicine?

JUNE 22, 1874.
-developed his concepts of osteopathy

When did he move to MO & what did he become known as here a year later?
-What did he come to believe about proper function?

-in Dec 1874 Still moved to Kirksville, MO & by 1975 was known as a magnetic healer.
-Was treating "flux"=diarrhea/disentary, using bonesetting (fixing small joint restrictions) Believed unobstructed structure allowed fluids/nerves to function properly (figured this out when he rolled over a log & it lessened his back pain.
1883: still incorporated "bone setting" into his practice to fix small joint restrictions.

What was Still's vision of health statement?

"Health is maintained by unobstructed blood flow & impulses of nerves"

WHat are the details of the 1st school of Osteopathy? (date, name, 1st faculty, 1st class info, Still's lecturing style)

Octo 1982 in Kirksville, MO American School of Osteopathy (ASO)
1st faculty: William Smith: Anatomy
1st class ~21 ppl, age 18-65 w/~5 women. (no women in any other med schools)
Lectures were analogy & parable.

Competitors to Osteopathy

Boneopaths, Neuro-osteopaths (worked on nerves), Chiropractic (D.D. Palmer was founder)

Licencing of DOs-1st & last states

1st: 1896: Vermont
Last: 1973: Mississippi

What was significant about the late 18 to early 1900s for Osteopathic Medicine?

many schools opened, Stills graduates were all over country & many called themselves "anatomic engineers".

When/where did the AOA form? What were their 3 goals?

(AT Still no longer in charge) 1897 in Kirksville to...
1. Eduacation: set standards @ schools b/c education at different schools was widely varied
2. Legislation: for licencing of DOs
3. Publications: research
*Same goals today

When did AT Still die?
When did MD & DO schools officially have the same length of study?
What were the 2 scopes of study for DOs at this time?

-Died Dec 12, 1917.
-1920 both 4 years, pharm stated to be used for DOs
-DOs scope of practice- Broad (DOs should be able to do it all, won, able to practice all specialties, use of manipulation dropped) vs Lesion Osteopaths

What caused an increased use in manipulation (OMT)? What was significant about this?

1918-19: Influenza pandemic. (0.2% mortality rate for those using manipulation, 12-15% for not using)

When did pharm begin to be taught at ALL DO schools?

1927. Standards also increased @ schools (DO & MD) & clinical work increased due to flexner report of 1910: caused many schools to close.

What was significant about the 1920-40s for Osteopathic Medicine?

Increased # of DO hospitals b/c MDs wouldnt admit DO patients.

When were DOs allowed to join the armed forces?

1957-congress passed law allowing them in, 1966 they were commissioned as medical officers.

What was the landmark case in the 1950s for DOs?

DOs wanted the right to practice in all hospitals.

California & Osteopathy in 60s

DOs had a lack of support & poor clinical training facilities. There was a possible merger discussed b/w Ca Med Assoc & Ca Osteo Assoc which occurred in 1961. 2000+ DOs took a weekend course & got (useless) MD degree for 65$, called "little MDs". No DOs could practice in Ca anymore & there was no more licencing.

Where/when was the first DO school opened since 1920? What was so significant about this school?

1970: Michigan State University started 1st DO school since 1920 (1st university based DO school)

When was there a big surge in Osteopathic Medicine? When could DOs practice in Cali again?

In the 70s was a surge in the profession. 74 DOs could go back to Ca b/c the supreme court overturned amalgamation of MDs & DOs. Large growth of DO schools around the country.

What became the 3 focuses of Osteopathic Medicine in the Late 20th centrury?

Primary Care emphasis, health maintenance & prevention, evaluating/addressing the distinctiveness of DOs

What are the 4 basic tennents of Osteo. Med?

1. The body functions as a unit.
2. Structure & function are interrelated
3. The body possesses self-regulatory mechanisms.
4. The body has an inherent capacity to heal & repair itself.
(Test Qs will ask: which tennent does this most closely follow?

1. The body functions as a unit

All systems are interconnected. You can't separate mind-body-spirit.

2. Structure & function are interrelated

the nature of the structure (joints, ect) affect the function.
EX: scholiosis leads to problems beyond the spine: respiratory problems, enlarged heart

4. The body has an inherent capacity to heal & repair itself.

If structure & function work properly, the body will be able to better heal itself. (Scar tissue, clotting, immunity are exs of this).

What are the key points of the definition of osteopathy?

Musculoskeletal system as primary manifestation of health & disease
-influencing somatic systems by manipulation, one can restore normal anatomy & maximize health & comfort. Interested in achievement of normal body mechanics as central to good health.

What is the definition of osteopathic medicine?

a system of medicine that embraces all known forms of medical treatment & therapy, incorporating & being informed by science, philosophy, & practice of Osteopathy.

Superior/Inferior Axes (plane that it runs in, alternate descriptions)

-runs in coronal plane.
-Longitudinal (acceptable), vertical (insufficient), cephalad/caudad (common, not preferred)

Ant/Post axes (AP) (plane that it runs in, alternate descriptions)

Runs in saggital plane.
-Dorsal/Ventral, common but usually not used for describing axes.

right/left axes (plane that it runs in, alternate descriptions)

runs in transverse plane
also called transverse

How do you produce motion within the saggital plane, how many axes are in this plane?

Motion occurs around a R/L (transverse axis).
-sup/inf & ant/post are 2 axes in this plane.

How do you produce motion within the coronal plane, how many axes are in this plane?

divides body into front & back portions.
-2 planes are R/L & Sup/Inf
-to produce movement within plane, motion occurs around AP axis

How do you produce motion within the transverse plane, how many axes are in this plane?

2 axes: R/L & Ant/Post.
-to produce movement must move around sup/inf axis.

Definition of Posture. 5 different types of posture.

distribution of body mass in relation to gravity over a base of support. Each is different based on position.
1. standing
2. sitting
3. side-lying (lateral recumbent, must specify which side)
4. Prone (face down lying)
5. Supine (lying face up)

Ideal Standing Posture in coronal, transverse & saggital plane

-coronal: look for symmetry in: hands should hang parallel to trunk, feet shoulder width (more E efficient)
-Transverse: look for symmetry in: forearms medially rotated 20 degrees relative to anatomic position, lower extremities rotated 20 degrees laterally.
-Saggital: look for proportionality in: plumb line relationships (center line), feet positioned as in anatomic position (slightly turned out)

Ideal standing position from a lateral view
-cervical, thoracic, lumbar, transitional articulations

physiological curves in the saggital plane:
1. C: Convex forward w/a normal lordosis.
2. T: Concave forward w/normal kyphosis
3. L: Convex forward w/normal lordosis
4. S: concave forward w/normal kyphosis
5. Transitional: are always sites of problems. C7 on T1, T12 on L1, L5 on sacral base

Where should the physician stand to observe lateral standing posture?

Should stand to R or L of patient & a plumb line should be dropped from the ceiling along the body midline.

Where should the plumb line fall for lateral posture in relation to the lateral malleolus, anterior axis of knee, hip, sacrum, shoulder joint, C vert, external auditory meatus, coronal suture

Slightly anterior to Lat Malleolus, slight ant to ant knee joint, slightly post to hip joint, through center of gravity @ S2, through axis of shoulder joint, through bodies of most C vert, through external auditory meatus, slightly posterior to apex of coronal suture.

What is the "relaxed posture"

Line of gravity falls behind hip joint & knee joint & in front of ankle.
-Chest backwards, abdomen slightly protruding, gluteal extensors relaxed, iliofemoral ligament under tension, tension in knee extensors b/c line falls behind knee (quads), abdomen mm keep body from falling backward, back mm extensors relaxed, calf mm under tension as line of gravity in front of ankle joint, center of gravity is backwards.

What is "military posture"

gravity line shifted to in front of hips, knees & ankles.
-Thorax fwd, abdomen drawn in, pelvic inclination increased, knees held rigidly straight, head stretched fwd, increased tension of hip extensors & inc tension in hips, increased tension of plantar flexors of ankle, center of gravity more fwd.

What is the ideal sleeping position?

Firm surface, lie on side w/head on pillow (to keep head & neck in anatomical position), knees flexed (so low back is resting in slightly rounded position), pillow b/w knees

What is the idea seated position?

Firm cushion, so buttocks don't sink), legs parallel to floor, feet flat on floor, back supported.

Accommodation

a self reversing, non-persisting adaption (shifting around in seat when uncomfortable)

Compensation

result of body's homeostatic mechanisms acting on whole body unit. Functional changes when body trying to make best of less-than-ideal situation (mm may tighten, relax to accommodate irregular body positions.) Takes place over time.

Decompensation

The breakdown of compensatory mechanisms wherein the homeostatic mechanisms are overwhelmed (partially/totally). When body can't compensate anymore & pain occurs. Usually can be reversed.

Factors producing decompensation

1. Congenital: Hemivertebra (improperly formed vertebra) & bone/joint deformity
2. Body habitus changes: weight gain, pregnancy
3. Gait changes: flat feet, heel changes
4. habits: occupation
5. Trauma: herniated disk, acc/deceleration injury ("whiplash")
6. Somatic dysfunction: sacral base unleveling
7. Loss of muscle tone: polio, muscular dystrophies
8. mental attitude

Types of decompensation

saggital plane decompensation (lordosis, kyphosis)
coronal & transverse: scoliosis, short leg syndrome (happens in runners)

functional vs structural changes

function=physiological changes
structural=anatomical changes

Somatic Dysfunction Definition

Impairments or altered function in the somatic body system framework. This includes skeleton, arthrodial (joints), & myofascial structures & their related vascular, lymphatic & neural components.

what are the 3 main causes of somatic dysfunction?

1. stress alteration of the somatic tissues which prevent the components from returning to resting states.
2. Macrotrauma or major trauma: accients, surgery, birth, major diseases (pneumonia, abdominal disease, ulcers)
3. Microtrauma: gravity, irritants, poor diet, lack of sleep, emotional upsets

TART Mnemonic for diagnosis of somatic dysfunction (what to look for)

T-Tenderness
A-Assymmetry
R-restriction of motion
T-tissue texture abnormality (spasm, swelling, knots, heat or cold, boggyness means fluid filled)

STAR Mnemonic for somatic dysfunction

S-sensitivity
T-tissue texture change
A-asymmetry
R-restriction of motion

Vertebral motions & how to name them

Flexion, Extension, Side-bending (Lat flex) =always named for side that's concave
-Rotation: named by the motion of a point on the anterior/superior surface of a vertebral body. (So if you rotate & head turns R along w/spine, that is R rotation).

Motion definition & 2 types

A change of position w/respect to a fixed system. A process of a body changing position in terms of direction, course & velocity.
1. Active Motion: movement produced voluntarily by the patient
2. Motion induced by physician while the patient remains relaxed.

Barriers to motion

1. The normal limit of motion
2. a restriction or binding point felt when a joint is put through its range of motion.
*An accurate knowledge of normal motion is essential to the diagnosis & treatment of somatic dysfunctions

Anatomic Barrier

The limit of motion imposed by the anatomic structure (absolutely as far as something will go), this is the limit of passive motion.

Physiologic Barrier

The limit of active motion. Can be altered to increase range of motion by warm-up activity.

Restrictive Barrier

a functional limit within the anatomic range of motion which abnormally decreases the normal physiologic range of motion. Ex: a knot in a muscle restricts the motion you should be able to achieve were it not there.

Pathologic Barrier

Permanent restriction of joint motion associated w/pathologic changes of tissues (ex: contracture=shortened mm or joint, osteophytes=bony growths).

Elastic Barrier

the range b/w the physiologic & anatomy barrier of motion in which passive ligamentous stretching occurs before tissue disruptions.

OMT definition

the therapeutic application of manually guided forces by a DO to improve physiologic function and/or support homeostasis.

OMM definition

the application of osteopathic philosophy, structural diagnosis & the use of OMT in the diagnosis & management of a patient

2 classifications of OMT techniques

1. Direct Technique: any technique engaging the restrictive barrier & then carrying the dysfunctional component towards or through the restrictive barrier.
2.Indirect: a manipulative technique where the restrictive barrer is disengaged; the dysfunctional body part is moved away from restrictive barrier until tissue tension is equal in one or all planes & directions.

What is the purpose of lymph vessels? what are the 3 main functions?

Collect extravasated fluid from tissues, filter lymph (extracellular fluid) & return lymph to circulation
1. cardiovascular assistance w/managing fluid
2. immunological
3. transportation of fats from small intestine to veins

Lymph Cardiovascular assistance

This is how fluids, which are needed back in circulation, return from interstitial tissues to blood.
Path: lymph capillaries collect the fluid-->prenodal vessels-->nodes-->post nodal vessels-->trunks-->collecting ducts (R lymphatic duct or thoracic duct (which is just the L duct which collects from more of the body than the R. R does R arm, R head, & a few others)

Immune role of lymph

primary organs: red bone marrow & thymus- production & early selection of lymphocytes.
Secondary organs: lymph nodes, spleen, lymphatic nodules (pharaygeal tonsils): sequester mature lymphocytes, sites of lymphocyte activation by antigen. Mature Lymphocytes recirculate between the blood and the peripheral lymphoid organs until they encounter their specific antigen.

Fat Transportation
-lacteals

lacteals: lymph vessels found in the intestines that transport lipids into lymph fluid (chyle). lipids are then transported to the blood via thoracic duct & sent to the liver for further processing. Lipids are then transported to the blood via thoracic duct & sent to the liver for further processing.

Anatomy of the lymph system
path, afferent & efferent vessels

A capillary network consisting of arterial, venules & lymphatic capillaries, fluid is collected-->pre-nodal collecting vessels (afferent: going to the nodes, only found in lymph nodes)-->lymph nodes-->post-nodal collecting ducts (efferent to the nodes, also found in thymus & spleen)-->trunks-->ducts

Lymph capillaries aka initial or terminal lymphatics
-features

-slightly larger than blood capillaries, 0.1-100 mircom diameter
-allow interstitial fluid in but not out for "one way permeability"
-single layer of nonfenestrated (no windows in cells) endothemial cells that overlap
-incomplete basement membrane, lack tight junctions.

Lymph capillary function & features

-found in the skin in a superficial capillary netwrk. when interstitial pressures > intraluminal pressures, fluid flows into lymph capillaries. When pressure greater inside the lumen, overlappin cells adhere tightly & fluid cannot get back out. Recovers fluid from periphery & delivers back to CV system

Anchoring filament of lymph capillary epithelial cells

anchoring filaments contain elastin, & attach the endothelial cells to surrounding tissue.

Contents of lymph fluid

-similar to the content of plasma. Fatty acids + fats= chyle Chyle is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids (FFAs).
-Also contains immune cells (WBC w/a high [lymphocytes] after the nodes] + antigen-presenting cells + dendritic cells].
-Is clear to straw colored liquid

Pre-nodal collecting vessels function

-drain superficial capillary network, transport lymph to regional nodes (via afferent vessels).
-possess smooth muscle cell layers to allow intrinsic contractile properties.
-130-150 microm diameter

Collecting nodes

-small circular ball-shaped organs
-part of the immune system (b cells, t cells, other immune cells)
-distributed widely throughout the body
-acts as filters or traps for foreign particles (bacteria, viruses, cancer cells).

Structure of nodes

Outer cortex: a fibrous capsule which extends inward to form trabeculae.
-Inner medulla
-Hilum
-Elastin & reticular fibers form reticular network (RN) or sinuses which are packed w/WBC, adheres to dendritic cells & macrophages

Post-Nodal collecting vessels --> trunks

-Carry lymph b/w successive sets of lymph nodes & to larger lymphatic collecting vessels (trunks).
-150-160 microm
-Eventually drain lymph into lymph ducts.

Trunk locations (5)

-Subclavian
-Jugular
-Bronchomediastinal
-Intestinal
-Lumbar (x2)

Cysterna Chyli

collecting reservoir located @ L2 which collects lymph from:
-Intestinal trunks
-Lumbar trunks

Properties of lymphatic ducts

-generally thin walled, w/smooth mm, secondary vessels & organized lymphangions (functional unit of a lymph vessel).

Path of thoracic duct

drains lymph from the cysterna chyli, ascends upward & then drains lymph from rest of body (except right Upper extremity) & empties into the L internal jugular & subclavian veins (there are large anatomic variations among different people).

Right Lymphatic Duct

-Drains lymph from the right upper extremity, right head, neck & chest. Returns lymph into the veins @ the right jugulo-subclavian.

Movement of lymph
-rate
-dependent on:

10mm/sec
-local interstitial fluid P & EC membrane strain
-Intraluminal & interstitial oncotic P (a form of osmotic pressure exerted by proteins in blood plasma that usually tends to pull water into the circulatory system.)
-Systemically: intrinsic contraction of lymphangion smooth mm & external compressive F

Causes of Flow disturbance

-Local: interstitial fluid P, Extracellular membrane strain
-Systemic:
Intrinsic: contraction of the lymphangion smooth mm
Extrinsic: external forces acting on the lymph vessels=local cardiopulm P, venous stasis.

Location of head & neck nodes

-Preauricular (anterior to ear)
-Posterior auricular (behind ear)
-Occipital (back of head)
-Tonsillar
-Submandibular
-Submental
-Superficial cervical
-Deep cervical
-Supraclavicular

Anterior & Posterior Cervical

In front of & behind SternoCleidomastoid m

Anterior & posterior Axillary

ant & post axilla

Epitrochlear

medial cubital fossa

sublingual

below the tongue

Lymph Content

Lymphocytes (2000-20000 mm cubed)
-2gm-6gm% proteins
-fats, salts
bacteria, viruses, fungi
antigens & antibodies
-similar components of plasma w/less concentration of high molecular weight components due to capillary filtration

Lymph flow
-what causes plasma to leak from arteries & how much, how is it returned to circulation? rate a day.

high intra arterial capillary P causes 20-30 L of plasma to leak from arteries/day which becomes interstitial fluid. 90% is reabsorbed by veins, 10% drained from ISF by lymph capillaries.
-2 to 5 L of lymph pass through thoracic duct/day

Lymph Capillary Propulsion

-Lymph capillaries have no intrinsic propulsion. They depend on extrinsic F for propulsion (respiratory motion, skeletal mm cc (contraction), intestinal motion (peristalsis), interstitial P, oncotic P=colloid osmotic P, P pulse from adjacent arteries & arterioles, other mechanical F (massage, exercise)

Lymph Collecting ducts
-Flow direction
-Lymphagion

Flow is unidirectional from periphery to the central vasculature & is maintained by funnel-shaped valves.
-Lymphangion: is a branch between 2 valves in the collecting lymphatic vessels which contain smooth mm for intrinsic propulsion.

Thoracic duct
-originates
-path

Originates @ L2 as the cisterna chyle & passes through the thoracoabdominal diaphragm @ the aortic hiatus. It arches 3-4 cm above the clavicle & empties into venous circulation via L internal jugular & L subclavian. It is responsible for draining most of the body.

About how many lymph nodes are there throughout the body?

600-700 widely distributed.

Right Lyphatic Duct
-what does it drain
-where does it empty into?

drains R head, neck, chest & R upper extremity.
-Drains lymph back to the CV system @ R internal jugular & R subclavian.

Organs which contribute most to 1. fluid management, 2. immunity, 3. lipid removal

ALL organs contribute to all 3
1. CV system, renal, urinary
2. immune: spleen, thymus
3. intestinal tract, liver, gall bladdar

Which 6 tissues do not have lymphatic capillaries?

1. CNS
2. Bone marrow
2. superficial skin
4. deep peripheral nerves
5. Endomysium muscle (meaning within the muscle, is a layer of connective tissue that ensheaths a muscle fiber)
6. cartilage

Diaphragm
-Medial crura
attaches to:
-Aortic hiatus contents

-Medial crura: acts as a pump for cysternal chyle. Can obstruct flow when tense
-Attaches to: 12th ribs, intervertebral cartilage & upper 3 lumbar vertebrae.
-Connect to form the aortic hiatus through which passes: the aorta, azygous vein & thoracic duct

Stomata of diaphragm

under EM on the peritoneal side Stromata (small lymph vessels) can be seen. These holes absorb from the peritoneal/pelvic cavity, pleural & pericardial cavities, posterior body wall & Lower extremity, then drains into cysterna chyle
-NO regulates opening & absorption.

role of diaphragm in Inhalation/exhalation

inhalation: diaphragm contracts & descends causing air to rush into the lungs (due to neg P), chest wall expands (sternum & ribs to make room for lungs), abdomen bulges, thoracic spine extends.
Exhalation: diaphragm relaxes, chest mm passively recoil, air pushed out of lungs, chest wall drops & thoracic spine flexes

Pulmonary system - lymph vessels present?

it was previously thought that except for limited areas close to the bronchioles, none were in deep pulmonary lobes, but an article in 2009 found lymphatics in deep tissues & around small blood vessels of lungs

GI tract lymph vessels

Lymph tissue found in lamina propria (mucous membranes lining the tract). Called GALT (clusters of lymph nodes in tonsils, peyers patches of ileum & appendix) where lymphocytes congregate.
-Study in 2005 said GALT should fight pathogens, not food antigens, but this seems to be occurring in western societies.

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