FINDING THE KEY SOMATIC DYSFUNCTION WORKSHOPfiles.academyofosteopathy.org/convo/2019/... · problem solving screening findings: •lower half problem solving: • forward bending

FINDING THE KEY SOMATIC DYSFUNCTIONWORKSHOP

2019 CONVOCATION: Student session

Edward G. Stiles, DO, FAAODist.Prof. OPP

University of PikevilleKentucky College

of Osteopathic Medicine

RepeatOverS/IJ

2019Screening Exam

• Principles• Applications

• Interpretation

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Stiles’: current screening examination( plus other reasons for obtaining good outcomes )

#1 Screening Foundational Principle: Law III of spinal mechanics

#2 “Blending Palpation”: 2 experiences+

• KCOM: Degenhardt – palpation drill data & realization !• KCOM / Legacy Project: cranial palpation data significance• minimal dysfunctions / max. adverse physiological effect

• match technique to nature of restrictive barrier•use

curved vectoring forces plus body mechanics to localize forces•focus: motorcycle truths – recent experience with resident

What maintains the Somatic Dysfunction ?23

BASIC PRINCIPLE: of screen3d Law of Fryette

. Identify “global neutral”( use translation )

. Introduce caudad “grounding” force. then introduce

side bending( use translation utilizing a vectored force )

. then add Rotation

( use translation )

. can then add flexion / extension

. Then identify regional AGR.. Then identify segmental AGR within the

region.•establish segmental diagnosis

•Match technique to the Restrictive barrier

Do both a standing screen bilaterally

and a sitting screen bilaterally.

. then Problem-Solve the findings.Ideally, problem solve as doing screen !

BioTensegrity:Continuous,body wide,

force transmission

system

Translation:moving an object along a line

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Cervical Screen:•Remember typical cervical vertebra follow Type II mechanics.

•Tip of thumb at the occipital base region.

•Rest of the thumb is located over the articular facets.

•Slowly introduce side bending down to the base of thumb.( use translation utilizing a vectored force )

•Does movement move smoothly through that area ?

•Slowly add rotation: move smoothly through area ?

•Is there a regional or segmental restriction ?

•Is the dysfunction upper ( atypical vertebrae ) or lower cervical ( typical vertebrae ) ?

•If it is upper cervical, are the suboccipital muscles restricting motion or does it have a “leathery” feel ( dura ) ?

•If muscular feel, diagnose the O/A or A/A dysfunction for that AGR

•If has “dura” feel, screen out the cranium for AGR

•If lower cervical area is AGR, identify key segmental S/D and establish a segmental diagnosis 2

5

x

Thoracic Screen:•Place tip of thumb in area base of thumb was during cervical screen.

•Thumb over the articular facets: the “listening hand”.

•Hand on shoulder is the “motion hand”

•Slowly introduce side bending using translation: does movement move smoothly caudad under the whole thumb ? Is there a segmental restriction ?

As side bend / translate by adding a vector force toward the palpating hand with the motion hand.

•Slowly add rotation using translation: does movement move smoothly caudad under your thumb ? Is there a segmental restriction ?

•When introducing motion, do it slowly, deliberately plus “blend in” to the bony level or can “spook” the CNS with rapid gross motions. The CNS will guard and mask crucial findings.

•You can add flexion / extension.

•If locate a segmental thoracic AGR, keep using the SB/R springing motions and palpate out along the related rib. If restrictions gets worse going laterally, It is a rib cage problem and screen the rib cage.

•If gets better going laterally, it is a vertebral problem.

•Is there a unilateral vertical band of tightness medial to the scapula ? If yes, AGR is probably in the upper extremity. Ipsilateral trapezius will also be tight. 26

Repeatover

Lumbar &

S/IJ

Lumbar and S/IJ:•Motion hand is still on the ipsilateral shoulder.

•Thumb is over the lumbar facets or S/IJ.

•Slowly, using translation, evaluate side bending and rotation components. Use vectored compression toward palpating site.

•Can also evaluate flexion and extension.

•Is there a regional restriction ?

•Is there a segmental restriction ? This could cause the regional restriction. ( Type I adaptation )

•Don’t get fooled by large areas of muscle guarding and determine if that is the AGR.

•The true AGR is usually very localized and has a very hard “end-feel”. Can’t locate a vectored area of spring / “joint play”.

•Is there a unilateral band of tightness on just one side of the lumbar spine ? If yes plus the standing FBT is more dramatic than the sitting FBT, the AGR is in that leg.

•If the sitting FBT is more dramatic than the standing FBT, the problem is usually lumbar, sacrum or innominate. 27

PEARLS

•Fred Mitchell, Sr. DO, FAAO insight.

If you have a muscle or muscles that are very tight, don’t treat the muscle(s)

but determine what the muscle is trying to protect,

Effectively treat that S/D-H ! The muscle(s) problem will frequently resolve once the

“protected” S/D-H is effectively treated.

•What builds your reputation is: locating & successfully treating the

“minimal lesions that cause the maximal adverse physiological effect.”

Paul Kimberly, DO, FAAO 28

Once

the

bilateral standing screen and the

Bilateral sitting screen is completed,

It is time to problem solve the screening clinical findings !

First Question:Is the AGR-H an upper half problem ?Is the AGR-H a lower half problem ?

T12 is the reference pointfor upper and lower half. 29

PROBLEM SOLVING SCREENING FINDINGS

• FIRST QUESTION: IS AGR IN UPPER OR LOWER HALF OF BODY ? ( T12 REFERNCE POINT )

• UPPER HALF PROBLEM SOLVING• IS IT CERVICAL, THORACIC, RIB CAGE OR UPPER EXTRMEITY ?

• IF CERVICAL• O/A REGION ?

• MUSCULAR . . . O/A , A/A OR BOTH• DURAL . . . CRANIAL . . . SCREEN IT OUT AND FIND AGR / SUTURE

• TYPICAL CERVICAL . . . FIND AGR, DIAGNOSE AND TREAT • USE TECHNIQUE APPROPRIATE FOR THAT RESTRICTIVE BARRIER

• IF THORACIC AREA . . . FIND AGR ( MAYBE MORE THAN ONE . . . Dx HARDEST END-FEEL )• GETS MORE RESTRICTED AS PALPATE LATERALLY ALONG RELATED RIB = RIB

CAGE IS KEY S/D-H• EXAMINE RIB CAGE AND IDENTIFY KEY RIB OF DYSFUNCTIONAL PATTERNS• TREAT WITH TECHNIQUE APPROPRIATE FOR THAT RESTRICTIVE BARRIER

• GETS LESS RESTRICTED AS PALPATE LATERALLY ALONG RELATED RIB = VERTEBRA IS THE KEY S/D-H

• DIAGNOSE DYSFUNCTION• TREAT WITH APPROPRIATE TECHNIQUE

• IF UPPER EXTREMITY: IF YOU IDENTIFY A UNILATERAL BAND OF RESTRICTION ALONG THE WHOLE MEDIAL BORDER OF ONE SCAPULA, THE AGR CAN BE IN:

• S/C• A/C• RADIAL HEAD• WRIST • HAND . . . REMEMBER THE HOMUNCULUS• MULTIPLE S/D-H ? TREAT MOST RESTRICTED !

( FREQUENTLY OTHERS WILL ALSO RESOLVE )30

PROBLEM SOLVING SCREENING FINDINGS:

•LOWER HALF PROBLEM SOLVING:• FORWARD BENDING TESTS . . . FINDINGS CORRELATE WHEN TREATED IN THE

PATIENT SPECIFIC SEQUENCE ( VLEEEMING, FRYER, ETC. BOTH RIGHT AND WRONG )• IF STANDING FORWARD BENDING TEST IS MORE DRAMATIC THAN THE SITTING

FORWARD BENDING TEST:• AGR IS USUALLY IN THE LEGS . . . USUSALLY BELOW THE KNEE

• FIBULA: PROXIMAL &/OR DISTAL• TIBIAL ROTATION• FOOT AND/OR ANKLE• OCCASIONALLY IT IS AN UP / DOWN SHEARED INNOMINATE• IF THAT DOESN’T RESOLVE PATTERN . . .BALANCE HIP RESTRICTORS.

• USUALLY WILL ALSO HAVE A UNILATERAL BAND OF RESTRICTION ALONG THE IPSILATERAL LUMBAR SPINE WHEN L.E. IS THE KEY AREA.

• IF THE SITTING FORWARD BENDING TEST IS MORE DRAMATIC THAN THE STANDING FORWARD BENDING TEST, AGR IS USUALLY EITHER:

• LUMBAR SPINE• SACRUM AND/OR INNOMINATE ( ROTATIONAL DYSFUNCTIONS )

• WHEN PATIENT COMES BACK UP AFTER DOING THE SITTING FORWARD BENDING TEST, RESCREEN OVER LUMBAR AND S/IJ AREARS:

• IF AGR IN LUMBAR REGION . . . DX AND TREAT LUMBAR S/D• IF THE AGR IS IN THE PELVIS ( S/IJ ) USE THE FOLLOWING SEQUENCE

( AXES MODEL SIGNIFICANCE )• UP / DOWN SHEARED INNOMINATES: ALL 3 AXES IMPACTED• CEPHLAD / CAUDAD PUBES: LEG LENGTH CHANGE ? IMPACT S/IJ MECHANICS• OUT OF PATTERN L5 / SACRUM DYSFUNCTIONS• SACRAL DYSFUNCTIONS: THEN ALL AXES LINED UP / FUNCTIONAL• INNOMINATE DYSFUNCTIONS: ITA FUNCTIONAL

REMEMBER THE SIGNIFICANCE OF THE HOMUNCULUS 31

Once the AGR-H screen is completed: summary• Problem Solve the significance of the screen findings

( this can be done as you screen each area ! )• Is it an upper half problem ? If answer is YES

• Is it upper cervical: O/A, A/A or dural / cranial ?• Is it lower cervical ?

• Is it thoracic ? Vertebra or rib cage ?• Is it thoracic / upper extremity ?

• Is it lower half problem ? If answer is YES• Is it lumbar ?

• Is it sacrum and/or innominate ?• Is it lower extremity ?

• Go to AGR-H # 1: • match the technique to the R.B. !

• Treat AGR-H # 1

• Rescreen for AGR-H # 2• match the technique to the R.B. !

• Treat AGR-H # 2

• Rescreen for AGR-H # 3• match the technique to the R.B. !

• Treat AGR-H # 3• RE-EVALUATE FOR TOTAL BODY CHANGES

after each AGR-H is treated32

Issues to include:

•If there are more than one AGR:treat the one with hardest end feel

•If 2 AGR’s “equal”: test vectoring, at each site, to see which is the most restricted and has the hardest end feel

•Treat out of pattern ribs before treat the in pattern rib patterns•With rib pattern dysfunctions,

always treat the key rib.•If AGR same in both standing and sitting, treat in that area.

•If “AGR” is key: multiple areas improve after it is treated.

•Finished with OMT when most recent area treated and it doesn’t change or fights you.

• “peeling layers”off the life time onion !

•Sequencing often allows amazing histories to emerge.33

X

X

XTreating:

•the cause ?• the effect ?

“virus inSoft-ware”

analogy

O.K.C. 1994Bob Forman, PhD

Chair Physiology OU Med School

After 2008Engineering Biomechanics of Human Motion

Robert L. Williams, PhD Ohio [email protected]

Treating A.G.Ror

2d. S/D –Adaptation ?

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CLINICAL ANALOGIES:

“FOLLOW THE BOUNCING FOOTBALL” AS YOU TREAT THE PATIENT THROUGH THEIR UNIQUE SEQUENTIAL PATTERN:

F.L. MITCHELL,Sr., D.O.

PEELING “LAYERS OFF ONION”Bad wk. Q: EVER FELT LIKE THIS BEFORE ? YES, 10 YRS. AGO . . .

SNOWFLAKES

FIELD OF WALLS

WOODEN RECORDER

RUBIC CUBE:

MULTI-NUMBERED COMBINATION LOCK:WON’T OPEN IF CORRECT NUMBERS INTRODUCED

IN THE WRONG SEQUENCE !15

2018 FRC committee: “good, well designed, innovative & valuable”( over 300 abstracts were submitted, 70 selected for poster presentation )

Jaap van der Wal, M.D., PhD. AnatomyBrought architectural concepts / BioTensegrity to anatomy

Treatment Goal:Work with the “innerness” of body

“the fascia is the organ of innerness.”

•BioTensegrity•Mesodermal embryonic derived structures:

Mesokinetic, fascia & viscera connection( sometimes being on an apparent tangent may be on course )

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