Somatic Dysfunction in Osteopathic Family Medicine

SOMATIC DYSFUNCTION IN OSTEOPATHIC FAMILY MEDICINE WRITTEN UNDER THE AUSPICES OF THE AMERICAN COLLEGE OF OSTEOPATHIC FA...

Author: Kenneth E. Nelson | Thomas Glonek

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SOMATIC DYSFUNCTION IN OSTEOPATHIC FAMILY MEDICINE WRITTEN UNDER THE AUSPICES OF THE AMERICAN COLLEGE OF OSTEOPATHIC FAMILY PHYSICIANS

Editor

Kenneth

Nelson, DO, FAAO, FACOFP

E.

Pr ofessor, Departments of Osteopathic Manipulative Medicine, Family Medicine, and Biochemistry Chicago College of Osteopathic Medicine Midwestern University, Downers Grove, Illinois Associate Editor

Thomas Glonek, PhD Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University, Downers Grove, Illinois Chicago Osteopathic Family Practice Michael Reese Hospital, Chicago, Illinois

aco

fp

AmcriGIn College of 0

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teo pat h j

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Family Physicians

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,.

Lippincott Williams & Wilkins a

Wolters Kluwer business

Philadelphia· Baltimore· New York· london Buenos. Aires· Hong Kong' Sydney' Tokyo

Acquisitions Editor: Nancy Anas�asi Duffy Managing Editor: Kellv Horvath Manager: Linkins Editor: Julie I\lontalbano Terry Mall.on Compositor: International Typesetting and Composition Printer: R.R. Donnelley & Sons-Crawfordsville Copyright © 2007 Lippincott Williams & Wilkins Il!ustrations © 2007 American College of Osteopathic Family Physicians Camden Street MD 21201

530 Walnut Street Philadelphia, PA 19106 All rights reserved. This book is protected repmdmed in any form or :my means, storage and system withollt

copyright. No part of this book may be photocopying, utilized by any mfor permission [com copyright

(as a mailer product liah:lll negligence, or pllblisher is not wise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers' product infor mation and package inserts should be reviewed for current information, including conprecautions. dosages,

the United

America

Library of Congress Cataloging-in-Publication Data Somatic dysfunction in osteopathic family medicine / sponsored by the American College of Osteopathic Family Medicine; editor, Kenneth E. Nelson; associate editor, Glonek. cm. bibliogra phicli references. "5-3 3: 978-1-40) ISBN 1-4051-0475-9 1. Osteopathic medicine. 2. Manipulation (Therapeutics) I. Nelson, Kenneth E., DO. II. Glonek, Thomas. III. American College of Osteopathic Family Medicine. [DNLM: 1. Manipulation: Osteopathic. 2. Family Practice. .1. Patient-Centered Ph}'sician-P:n F(elations. S693 20071 2007

2006019403 The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the first arrangements additional

638-3030 or fdX (301) 223-2300.

of this to (301)

our cusromer

departmefll International customers shou

il

Visit Lippincott Williams & Wilkins on the Internet: http://t/JUJUJL . WWcom. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am ro EST. 600 09 567 8

11)

Dedicated to Andre V. Gibaldi, DO, FACOFP, family physician, educator, colleague, mentor, and friend.

Preface

As osteopathic medicine has grown and taken its rightful place in the mainstream of medical practice, the isolated environment in which we once taught our students and residents has given way to open-staffed hospitals. Consequently, our clinical edilcators are now as apt to be allopathic as they are to be osteopathic physicians. At this same time, and in part because of this progress, there has developed a need to demonstrate what we have that is distinctly osteopathic. The American Osteopathic Association has mandated that our residents demonstrate seven core competencies; the first of those competencies is osteopathic philosophy and osteo pathic manipulative medicine. Thus, there has arisen a need for a clinically oriented text that addresses the dis tinctive aspects of osteopathic medicine. In an attempt to fill that need, this text presents a contemporary understanding of the fundamentals of osteopathic philos ophy and the applied diagnosis and treatment of somatic dysfunction throughout the practice of family medicine. It is not intended to be a review of general med ical practice. There are many such texts. Nor is it intended to be a manual of osteo pathic manipulative treatment (OMT) procedures, although many examples of applicable procedures are provided throughout the book. Again , many excellent and more complete procedure manuals are available. Rather, this text provides medical students, residents, and physicians in practice with a description of how their patients may be empowered to take an active part in the establishment and maintenance of health; how the diagnosis and treatment of somatic dysfunction fosters a holistic, patient-oriented approach to health care; how somatic dysfunc tion affects the patient's health status; and the clinical logic for the use of OM T in the care of those patients with examples of possible procedural choices. All too often individuals consider OMT as an appropriate treatment only for musculoskeletal pain. Although this is one area in which the modality is effective, it is but a single application. Early osteopaths employed OMT to treat patients

with all manner of medical conditions. These pioneers were frequently criticized for their practices, for inappropriately treating cholecystitis or a myocardial infarc tion with OMT. This, of course, was not the case. Rather, these clinicians were treating the patient, attempting to alleviate the effects of somatic dysfunction upon the individual's overall ability to respond to the illness. They were addressing the effects of somatic dysfunction upon their patients mechanically as well as the effect it exerted upon circula tion and neurophysiology. Following in that original tradition, this text is focused upon the advantages of the diagnosis and treatment of somatic dysfunction in all types of patients, of all ages, with all manner of clinical conditions. The specific conditions discussed are used as exam ples of the clinical approach to broad categories of illness, and the reader is encouraged to generalize. After ail, there is consistency in the ways somatic dysfunction affects an individual mechanically and physiologically, whether the infirmity is gastrointestinal or upper respiratory. The answer to how I would "osteopathically" treat a patient with hypertension is ... the same way I would treat a patient with diabetes. The focus is upon the patient, in the context of his or her given illness, but still (pun intended) upon v

Preface

vi

the patient. Recognition of the inherent reliability of human anatomy and the univer sality of the presence and effects of somatic dysfunction fosters this approach. This

one of the most difficult medicine. Certainly, the speci

clmicians who affecting the context

and treated approprialc!Y, individual. Such a patient

i

paradigm,

significantly less frustrating disease-focused

than is a

especially when the problem

falls into

the broad and otten ambiguous category of functional Illnesses. Ihls is why osteo pathic medicine is applied so naturally to the practice of family medicine. This text is divided into four areas: philosophy and principles of patient care, categories of patients encountered, categories of clinical conditions encountered, and practice issues. Within these categories, the chapters that deal with the middle two begin with a discussion of the patient or clinical condition and are followed, in each case, with examples of the OMT procedures that could be applicable. We have attempted

examples from all categorics

selected are

representative of what t

has found

his or her experience.

assuredly must again the reader

procedures chapter have most text-it

procedures that other ell

Further,

intended as an OMl the examples of OMT

that: exam-

ples. They do nO[ represent [he exact procedure to

employed a[ all tlmes for a

given condition. OMT must be individually applied. After all, we are treating the patient, and every patient is a unique individual, as is every physician. Although the dysfunctional areas manipulated can be expected to demonstrate some consis tency for a given condition, the procedures that prove most effective for a given condition will differ from patient to patient as well as from clinician to clinician. for further inquiry into osteopathic medicine, we have included chapter references , which, though often pertinent-nclt ies supporting This texi less effort FACOFP, t of OsteopathiC

should not be considered dated.

continues to be

important-because if we do least we can demonstrate that come to light if it were It began as a request Department of Family Medicine cducJtion. Then

series of lectures for

a student and now a contributor to this project, Anette Mnabhi observed that the materials would lend themselves well to a textbook of clinical practice. Thls end product is the result of the clinical experience and much didactic research on the part of the contributing authors, overseen by the members of the American College of Osteopathic Family Practice (ACOFP), Committee for Osteopathic Principles and Practice, and a number of other conscriptees, who acted as peer reviewers. Gratitude must be expressed to the leadership of the ACOFP ,md Mr. Peter Schmelzer, Gratitude

of the ACOFP, for

project.

c\pressed to Patricia Nuccio,

ucational

coordinated resources and throughout this effort. measure must be extended associate

t

without whose broad-based

,

PhD, the

expertence

and long hours of dedicated effort, this book would have never been completed. Respectfully submitted, K. E.

June

Nelson 2005

7,

Contributors L

Zachary J. Comeaux. DO. FAAO Associate Professor Division of Osteopathic Philosophy and Practice West Virginia School of Osteopathic Medicine Lewisburg, West Virginia

David M. Driscoll. DO Assistant Clinical Professor of Medicine Tufts University School of Medicine Boston, Massachusetts Director of Inpatient Services, Department of Internal Medicine Lahey Clinic Peabody, Massachusetts

David B. Fuller. DO Assistant Professor, Department of Family Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Attending Family Physician North Baldwin Infirmary Bay Minette, Alabama

Thomas Glonek. PhD Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Chicago Osteopathic Family Practice Michael Reese Hospital Chicago, Illinois

Ann l. Habenicht. DO. FAAO. FACOFP Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Senior Staff, Department of Family Medicine Palos Community Hospital Palos Heights, Illinois

vii

viii

Contributors

Kurt Heinking. DO Associate Professor and Chairman Manipulative Medicine Medicine Downers

Jan Lei

DO

Adjunct Clinical instructor Department of Osteopathic Manipulative Medicine Midwestern University Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Douglas Community and Fami

Adjunct Assistall Dartmouth Hanover, Osteopathic Manchester Jorgensen Manchester, Maine

Raymond T. Jorgensen. MS. CPC President and Co-Founding Partner Priority Management Group, Inc. Pawtucket, Rhode Island

NMM/OMM Department of Surgery Medicine and Biosciences Idwin Infirmary

James Laub. MS. DO. MPH. FACPM Attending Physician Family Practice and Osteopathic Manipulative Medicine Grandview Medical Center Dayton, Ohio

Andrew Lovy. DO. FACN Past Chairman,

Psychiatry

Chicago

ic Medicine

Midwestern Downers Psychiatric Northeast

Council

Kirksville, Missouri

John McPartland. DO. MS Associate Professor Unitec School of Health Auckland, New Zealand

Contributors

Anette Karin Schilling Mnabhi, RN, M S N , DO Adjunct Clinical Faculty Department of Osteopathic Manipulative Medicine Midwestern University Downers Grove, Illinois Staff, Department of Family Medicine Rush Copley Medical Center Aurora, Illinois

Kenneth E. Nelson, DO, FAAO, FACOFP Professor, Departments of Osteopathic Manipulative Medicine, Family Medicine, and Biochemistry Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Nils Olson, DO, FACOFP Adjunct Professor of Family Medicine University of Des Moines College of Osteopathic Medicine Des Moines, Iowa Attending Physician, Department of Family Medicine Marshfield Clinic/Mercer Center Mercer, Wisconsin Midwestern University College of Osteopathic Medicine Chicago, Illinois Affiliate Staff, Howard Young Medical Center Woodruff, Wisconsin

Dean Raffaelli, DO Clinical Assistant Professor Departments of Family Medicine and Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Downers Grove, Illinois Midwestern University Attending Physician, Chicago Osteopathic Family Practice Michael Reese Hospital Chicago, Illinois

Thomas M. Richards, DO, FAAO, CIME Department of Neuromusculoskeletal Medicine Marshfield Clinic/Lakeland Center Minocqua, Wisconsin Community Preceptor Kansas City University of Medicine and Biosciences Kansas City, Missouri Attending Physician Primary Care Department Howard Young Medical Center Woodruff, Wisconsin

ix

x

Contributors

Joey Rottman, DO, FACOOG Associate Professor and Director of Clinical Clerkship Department of Obstetrics and Gynecology University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Stratford, New Jersey Professor, Department of Obstetrics and Gynecology Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Associate Professor, Department of Obstetrics and Gynecology Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Nicette Sergueef, DO (France) Adjunct Assistant Professor Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Sandra L. Sleszynski. DO. AOBI'JMM Adjunct Clinical Assistant Professor Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Downers Grove, Illinois

Charles J. Smutny III. DO. FAAO Assistant Professor, Clinical Osteopathic Medicine New York College of Osteopathic Medicine Old Westbury, New York NMM Residency Director North Shore LIJ at Plainview Plainview, New York

Frank C. Walton, Sr.. DO, FAAO Adjunct Associate Professor, Department of Family Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Program Director NMM-OMM Residency Westview Osteopathic Hospital Indianapolis, Indiana

Alice J. Zal. DO. FACOFP Adjunct Faculty, Department of Family Medicine Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Private Practice, Family Medicine Geriatrics Family Practice Staff Mercy Suburban Hospital/Montgomery Hospital Norristown, Pennsylvania

Reviewers

Joseph D. Allgeier, DO Program Director and Director of Medical Education Florida Hospital East Orlando Orlando, Florida

Richard K. Book, DO Active Medical Staff, Family Medicine Arkansas Valley Regional Medical Center La Junta, Colorado

Jeffrey S. Brault, DO Assistant Professor of Physical Medicine and Rehabilitation Mayo Clinic Rochester, Minnesota

Janet M. Burns, DO Assistant Professor of Osteopathic Manipulative Medicine Ohio University College of Osteopathic Medicine Athens, Ohio

Boyd Buser, DO, FACOFP Professor of OMM University of New England College of Osteopathic Medicine Biddeford, Maine

Sarah Cates Osteopathic Medical Student, 4th year Virginia College of Osteopathic Medicine Virginia Polytechnic Institute and State University Blacksburg, Virginia

Robert S. Dolansky, Jr. , DO Director of Medical Education St. Luke's Hospital, Allentown Campus Allentown, Pennsylvania

Mary E. Franz, DO, FACOFP Private Practice, Family Medicine Topeka, Kansas

Dan C. Galloway, DO, FACOFP Private Practice, Family Medicine Seasons Health Center Crown Point, Indiana

xi

xii

Reviewers

Ann L. Habenicht, DO, FAAO, FACOFP Professor, Department of Osteopathic M anipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Senior Staff, Department of Family M edicine Palos Community Hospital Palos Heights, Illinois

Patrick J. Hanford, DO, FACOFP Private Practice, Kings Park Urgent Care Center Lubbock, Texas

Wilbur T. Hill, DO, FACOFP Private Practice, Family M edicine (Retired) Liberty, Missouri

Howard H. Hunt, DO, FACOFP Professor of Family Medicine (Retired) West Virginia School of Osteopathic M edicine Lewisburg, West Virginia

Douglas J. Jorgensen, DO, MS, CPC Adjunct Assistant Professor of Community and Family Medicine Dartmouth Medical School Hanover, New Hampshire Osteopathic Manipulation and Pain Management Jorgensen Consulting, LLC Manchester, Maine

John N. Kasimos, DO, FCAP, FASCP, FAOCP Chair and Professor of Pathology Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Brian Loveless, DO Private Practice, Family Medicine Chino Valley Medical Center Chino, California

Barbara Peterson, DLitt Adjunct Associate Professor, Department of Internal M edicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

T homas M. Richards, DO, FAAO, CIME Department of Neuromusculoskeletal Medicine M arshfield Clinic/Lakeland Center Minocqua, Wisconsin Community Preceptor Kansas City University of Medicine and Biosciences

Reviewers

xiii

Kansas City, Missouri Attending Physician Primary Care Department Howard Young Medical Center Woodruff , Wisconsin

J. Jerry Rodos, DO, DSc, FAANP Clinical Professor, Department of Behavioral Medicine Chicago College of Osteopathic M edicine Midwestern University Downers Grove , Illinois

Steven F. Rubin, DO, FACOFP dist Adjunct Clinical Professor, Departments of Osteopathic Manipulative Medicine and Family Medicine University of M edicine and Dentistry of New Jersey, School of Osteopathic Medicine Stratford, New Jersey Private Practice, Family Medicine Fair Lawn, New Jersey

George T. Sawabini, DO, FACOFP Private Practice , Family M edicine Farmington Village, Michigan

Frank R. Serrecchia. DO, RDH Adjunct Assistant Professor, Department of Osteopathic M anipulative Medicine Chicago College of Osteopathic Medicine M idwestern University Downers Grove, Illinois

William H. Stager, DO, FACOFP Clinical Assistant Professor of Family Medicine and Osteopathic M anipulative Medicine NOVA Southeastern University College of Osteopathic Medicine Fort Lauderdale, Florida

Marline A. Wager, DO Professor of Family Medicine West Virginia School of Osteopathic M edicine Lewisburg, West Virginia

Earle Noble Wagner, DO, FACOFP Private Practice. Family Medicine Cheltenham, Pennsylvania

Elaine M. Wallace, DO, MSc Chair and Professor of Osteopathic Principles and Practice NOVA Southeastern University College of Osteopathic Medicine Fort Lauderdale, Florida

xiii

Anthony M. Will. DO Assistant Clinical Professor, Pre-clinical Division Arizona College of Osteopathic Medicine Midwestern University Glendale, Arizona

Alice J. Zal. DO. FACOFP Adjunct Faculty, Department of Family Medicine Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Private Practice, Family Medicine Geriatrics Family Practice Staff Mercy Suburban Hospital/Montgomery Hospital Norristown, Pennsylvania

Contents

Preface

v vii

Contributo r s

xi

Reviewers

xxiii

List of Abbreviations

SECTION I 1

Philosophy and Principles of Patient Care 1

Patient Empowerment, J. L. Laub

2

Osteopathic Distinctiveness, K. E. Nelson

3

Diagnosing Somatic Dysfunction, K. E. Nelson Standing Structural Examination Supine Structural Examination Palpation for Tissue Texture Abnormality, Layer Palpation Regional and Segmental Examination of the Cervical Spine Examination of the Occiput (CO on (1) Examination of the Atlas (C1 on (2) Segmental Examination of the Cervical Spine (C2 on C3 to C7 on T1) Evaluation of the Upper Thoracic Region (T1 T4) : Using the Head and Cervical Region as a Lever Evaluation of the Upper Thoracic Region (T1-T4): Using the Thumbs to Assess Motion Evaluation of the Lower Thoracic Region (T5-T12): Using the Shoulders as a Lever Regional and Segmental Examination of the Lumbar Spine Motion Test for Sacroiliac Articular Dysfunction Standing Flexion Test Seated Flexion Test

22 23 25 25

The Manipulative Prescription, K. E. Nelson

27

6 12 17 17 18 19 19 20 20

-

4

21 21 21

xv

xvi

Contents 5

Viscerosomatic and Somatovisceral Reflexes, K. E. Nelson

Red Reflex Skin Drag Beal's Compression Test Inhibitory Pressure Treatment of Chapman's Reflexes Soft Tissue/Range of Motion, Patient on Side, a Stimulatory Procedure Soft Tissue/Range of Motion, Patient Prone Rib Raising to Stimulate Sympathetic Activity 6

Psychoneuroimmunology, J. L. Iwata

33 49 49 50 50 51 51 52 53 56

SECTION II Patient Populations 7

The Psychiatric Patient, A. Lovy

8

The Pediatric Patient, N. Sergueef and K. E. Nelson

Lumbopelvic Release Thoracic Release Cranial Membranous Release Sphenobasilar Release Occipital Release Occipitomastoid Release Frontal Release 9

The Female Patient, K. E. Nelson and J. Rottman

Structural Examination of the Obstetric Patient Sacrum, Inhibitory Pressure Lumbar Paravertebral Muscles (Soft Tissue) Psoas Release (Indirect) Psoas (Muscle Energy) Anterior Sacrum (Muscle Energy) Anterior Sacrum Leg Pull (HVLA) Posterior Sacrum Leg Pull (HVLA) Piriformis Muscle (Muscle Energy) Posterior Innominate Dysfunction (Muscle Energy) Anterior Innominate Dysfunction (Muscle Energy) Symphysis Pubis Superior or Inferior Shear (Muscle Energy) Ischial Tuberosity Spread (Myofascial Release) Sacrum Diagnosis and Treatment (Cranial) 10

The Surgical Patient, J. M. Krettek

Compression of the Fourth Ventricle, CV-4 (Cranial) Cervical (Soft Tissue/Articulation) Thoracic, Patient on Side (Soft Tissue) Lumbar Paravertebral Muscles (Soft Tissue)

73

73 87 98 98 99 99 101 101 102 105 112 113 114 115 116 117 118 119 119 121 121 122 123 124 127 132 133 134 134

Contents

11

12

xvii

Rib Raising

135

R ib Balancing

135

Pedal Pump (Dalrymple's Pump)

136

Pectoral Traction to Enhance Motion of the Diaphragm

136

Wound or Scar Release (Indirect)

137

The Athlete, K. P. Heinking

139

Anterior Lateral lVIalleolus (Muscle Energy)

151

Indirect Hamstring Release (Myofascial Release)

152

Knee (Indirect Myofascial Release)

153

Anterior Innominate Dysfunction (Muscle Energy)

154

Plantar Fascitis (Counterstrain)

155

Epigastric Thrust (HVLA)

156

Biceps, Long Head (Counterstrain)

157

The Geriatric Patient, K. E. Nelson, A . L. Habenicht, and 1\1. Sergueef

159

Cervical Treatment (C2-(7), Patient Supine (Still Technique)

171

Cervical Treatment (C2-(7) , Patient Seated (Still Technique)

13

172

Thoracic Dysfunction (Still Technique)

173

Lumbar Dysfunction (Still Technique)

174

Sacrum (Facilitated Positional Release)

175

Simple Cervical Isometrics (Exercise)

176

Cervical Isometrics (Exercise)

177

Simple Calf Strengthening to Stabilize Gait ( Exercise)

178

Calf Strengthening to Stabilize Gait ( Exercise)

178

Gluteal Strengthening to Stabilize Gait (Exerc ise)

179

The Patient at the End of Life, A. J. Zal

181

Anterior Thoracic Tender Points Tl-T 6 (Counterstrain)

189

Anterior T horacic Tender Points Tl-T12 (Counterstrain)

189

Posterior Thoracic Tender Points Tl-T4 (Counterstrain)

191

Posterior Thoracic Tender Points T5-T12 (Counterstrain)

192

Posterior Thoracic Tender Points,Alternative Procedure T9-T 12 (Counterstrain) Anterior Lumbar Tender Points (Counterstrain)

192 193

Posterior Lumbar Tender Points (Counterstrain)

194

Lateral Tender Points for Lateral L3, Lateral L4, and UP5L

195

Lateral Recumbent Treatment of the LP5L Tender Point

195

SECTION III

Clinical Conditions 14

197

The Patient with Otitis Media, D. B. Fuller,

197

Posterior Chapman's Reflexes from Otitis Media

201

Galbraith's Procedure

201

xviii

Contents

Traction on the Pinna Cranial Vault Hold for Spheno-occipital Synchondrosis Torsion Temporal Bone Dysfunction (Cranial) Pterygoid Fossa Decongestion, Sphenopalatine Ganglion Procedure 15

206

208 214 216 216

The Patient with a n Upper Respiratory Infection,

K. E. Nelson Upper Thoracic Spine (Muscle Energy) Diagnosis of Elevated First and Second Ribs First Rib (HVLA) Second Rib (HVLA) Acromioclavicular, Anterior Clavicle (HVLA) Acromioclavicular, Posterior Clavicle (HVLA) Cervical (Soft Tissue/Articulation) Cervical (Indirect Balancing) Cervical Posterior (HVLA) Atlas Posterior (Muscle Energy) Atlas Anterior (HVLA) Occiput Posterior (Muscle Energy) Occiput Anterior (Muscle Energy) Occipitoatlantal (Myofascial Release , Direct) Trigeminal Nerve Procedure of Bailey Facial Effleurage Submandibular Percussion Anterior Neck Soft Tissue, Lymphatic Procedure Thoracic Lymphatic Pump 17

203 204

The Patient with Temporomandibular Joint Pain and Dysfunction, J. McPartland EVA Procedure (Cranial) Jaw Lock Open Lock Correction Jaw Lock Closed Lock Correction

16

202

218 224 225 226 227 228 228 230 230 231 232 233 234 235 236 237 239 239 239 240

The Patient with a Lower Respiratory Tract Infection, Z. J. Comeaux Observation and Palpation Rib Raising Rotation and Rib Raising Rib Articulation, Seated Paraspinal Muscle Stretch: Lateral Recumbent Occipitoatlantal Release Cervical Paraspinal Muscle Release Cervical Articulatory Release Cervical Articulatory Release, Oscillatory Release Diaphragmatic Release Diaphragmatic Release Alternative (Doming the Diaphragm)

243 248 249 250 250 251 251 252 252 253 253 254

Contents

18

xix

The Patient with Hypertension, D. M. Driscoll

262

Local Scan of the Cervical Area ( Functional Diagnosis)

272

Segmental Definition of Cervical Somatic Dysfunction (Functional Diagnosis and Treatment)

273

Segmental Definition of Thoracic Somatic Dysfunction (Functional Diagnosis and Treatment)

19

20

274

The Patient with Congestive Heart Failure, K. E. Nelson

279

Cervical (Facilitated Positional Release)

285

Thoracic Inlet (Myofascial Release)

286

Scapulothoracic (Myofascial Release)

287

Lymphatic Pump (Oscillatory Modification)

288

T horacoabdominal Diaphragm Release

288

The Patient with Gastrointestinal Problems, K. E. Nelson and A. L. Habenicht

291

Patient Supine for Flexed or Extended Thoracic Somatic Dysfunction, HVLA

21

301

Transabdominal Stimulation

302

The Patient with Thyroid Disease, D. J. Jorgensen

304

Upper Thoracic on Side, Extended: HVLA and Articulatory Treatment

317

Upper Thoracic on Side, Flexed: HVLA and Articulatory Treatment Diagnosis of Elevated First and Second Ribs

319

First Rib,Facilitated Positional Release

320

First Rib, HVLA

321

Second Rib, HVLA

321

22 The Patient with Parkinson's Disease, C. J. Smutny,III Cervical (Soft Tissue)

23

3 18

324 331

Cervical (Muscle Energy)

331

Inhalation Second to Sixth Ribs (Muscle Energy)

333

Inhalation Seventh to Tenth Ribs (Muscle Energy)

334

Exhalation First and Second Ribs (Muscle Energy)

335

Exhalation T hird to Fifth Ribs (Muscle Energy)

336

Exhalation Sixth to Tenth Ribs (Muscle Energy)

337

Thoracic Cage Balancing (Indirect)

338

Cross Pisiform or "Texas Twist" (HVLA)

339

Psoas Release (Balanced Ligamentous Tension)

340

The Patient with Larson's Syndrome: Functional Vasomotor Hemiparesthesia Syndrome, F. C. Walton, Sr.

342

Spinous Process T hrust (HVLA)

351

Fixed Point, Rotation (HVLA)

352

Reverse Rib (HVLA)

353

Contents

Ribs Posterior (Elevated) Tender Points, Patient Seated (Counterstrain)

356

Ribs Anterior (Depressed) Tender Points, Patient Seated (Counterstrain)

24

The Patient with Fibromyalgia/Chronic Fatigue Syndrome, A. K. Schilling Mnabhi

25

357

360

Piriformis Muscle Tender Point (Counterstrain)

375

Hamstring Release ( Myofascial Release)

376

Knee (Myofascial Release)

377

Tibiofibular Balancing (Indirect)

378

Plantar Fascial Tender Point «(ounterstrain)

379

The Patient with Chronic Pain, Headache, T. Richards

383

Knee in the Back, Upper T horacic Type II Extended Dysfunction (HVLA)

395

Knee in the Back, Upper T horacic Type II Flexed Dysfunction (HVLA)

26

396

Reverse Rib (HVLA)

397

Elevated First and Second Ribs, Patient Prone (HVLA)

398

(1 Posterior (Counterstrain)

399

Sutherland's Occipitoatlantal Decompression (Cranial)

400

Occipital Condylar Decompression (Cranial)

401

Frontal Lift (Cranial)

402

Parietal Lift (Cranial)

404

The Patient with Back Pain: Short Leg Syndrome and Postural Balance, K. E. Nelson and A. K. Schilling Mnabhi

27

426

Posterior Sacrum, Trunk Rotation (HVLA)

427

Lumbar Walk-Around (HVLA or Muscle Energy)

428

Psoas Spasm (Muscle Energy)

429

Psoas Stretch, Standing (Exercise)

430

Psoas Stretch, Prone (Exercise)

432

The Patient with Back Pain: Postural Decompensation in the Sagittal Plane, N. A. Olson

28

408

Constant Rest Position

434

Lumbosacral Release (Direct Myofascial Release)

447

Pelvic Tilt (Exercise)

448

Psoas and Quadriceps Stretch Kneeling (Exercise)

449

Dry-Land Swim (Exercise)

450

The Patient with Scoliosis, K. E. Nelson

452

Lazy-Person Exercise (Mobilization)

461

Group Curve Mobilization (Articulation, HVLA, or Muscle Energy)

461

Back Extension Exercises (Stabilization)

463

Torso Curls Exercises (Stabilization)

463

Reverse Torso Curls Exercises (Stabilization)

464

Contents

xxi

SECTION IV

Practice Issues 29

The Office, D. Raffaelli

30 Progress Notes and Coding, D. J. Jorgensen, R. T. Jorgensen, and K. E. Nelson 31

466 466

470

The Standardized Medical Record, S. L. Sleszynski and T. Glonek

490

Appendix

513

Index

519


A-A,atlantoaxial (joint) AACOM,American Association of Colleges of Osteopathic Medicine AAFP,American Academy of Family Physicians AAO,American Academy of Osteopathy ABG,arterial blood gas ACL, anterior cruciate ligament ACOFP,American College of Osteopathic Family Physicians ACTH, adrenocorticotropic hormone, corticotropin ADLs,activities of daily living AEA,anandamide,arachidonylethanolamine 2-AG,2-arachidonylglycerol AIDS,acquired immune deficiency syndrome ALT,alanine amino transferase AMA, American Medical Association ANA,antinuclear antibody (panel) ANS,autonomic nervous system AOA, American Osteopathic Association AP curve, anteroposterior curve ART, articulatory treatment ASIS,anterior superior iliac spine AST, aspartate transaminase AVM, arteriovenous malformation BA, body areas BLT, balanced ligamentous tension/ligamentous articular strain BIVII, body mass index BMT, balanced membranous tension BPH, benign prosthetic hypertrophy BTS,British Thoracic Society C2, 3, etc. , cervical vertebral segments CAE,certified association executive CAM,complementary and alternative medicines CAP, Clinical Assessment Program

xxiii

xxiv


CAP, community acquired pneumonia CBC, complete blood count CC, chief CCK, receptor

CCR5, chemok

Control and Prevention

CDC, Centers

CDROM, compact disk read-only memory CF IDS, chronic fatigue and immune dysfunction syndrome CF S, chronic fatigue syndrome CHF, congestive heart failure CME, continuing medical education CMS, Center

Standards

c NOS, constitutive C NS, central CI\I X, cranial transferase

COMT, catechol

COPD, chronic obstructive pulmonary disease CPC, Certified Professional Coder CPM, continuous passive motion CPT, current procedural terminolog y CR, cranial, cranial osteopathy (see also OCF ) CRH,

ng hormone Ise

CS, counterstrai CSF, cerebrospi CT, cervica CT, computed tomography CV-4, compression of the fourth ventricle DAs, dopamine agonists DASH, dietary approaches to stop hypertension DBP, diastolic blood pressure DBS, deep DECIDA acid

technetium-99m diisopropyl scintigraphy

DIR, direct DIT, diiodotyrosi DJD, degenerative joint disease DNR, do not resuscitate


DO, Doctor of Osteopathy, Doctor of Osteopathic Medicine DSM-IV- TR, Diagnostic and Statistical Manual of Mental Disorders: 4th Text Revision

DVD, digital video disk E&M, evaluation and management EEG, electroencephalogram EENT, eyes, ears, nose, throat EKG, electrocardiogram EMG, electromyogram ErvlR, electronic medical record EMS, electrical muscle stimulation ENT, ears, nose, throat EPF, expanded-problem-focused eSOAp, ESR, erythrocyte sedimentation rate EV-4, expansion of the fourth ventricle FACOFp, Physicians FAAO, Fellow of the American Academy of Osteopathy

FM, fibromyalgia FPR, facilitated positional release GAS, general adaptive syndrome GERD, gastroesophageal reflux disease GH, growth hormone GHAA, Group Health Association of America GI, gastrointestinal GMS, general mUlti-system (examination) GVA, general visceral afferent neuron H&P, history and physical HCFA, Health Care Financing Administration HCPCS, HCFA's Common Procedural Coding System (pronounced "hickpicks") HDL, high density lipoprotein HEENT, head, eyes, ears, nose, throat HIDA, hepato nuclear medicine biliary tract scans HIPAA, Health Insurance Portability and Accountability Act HIV, human immunodeficiency virus HLA, human leukocyte antigen

xxv

xxvi


HPA, hypothalamic-pituitary adrenal (axis) HPI, history of present illness HS CRp, high sensitivity C-reactive protein HVLA, high-velocity, low-amplitude ICD-9CM, International Classification of Disease, Ninth Clinical Modification ICHD-2, International Classification of Headache Disorders, 2nd ed. ID, internal derangement IDET, intradiscal electrothermal therapy IGE, immunoglobulin-E IL-1, -6, and so on, interleukin ILA, inferior lateral angle (sacrum) I ND, indirect (treatment) I NR, integrated neuromuscular release IT, Information Technologies (Department) JNC 7, Seventh Report of the Joint National Committee on High Blood Pressure KO H, potassium (kalium) hydroxide L1, 2, etc., lumbar vertebral segments LAS, ligamentous articular strain/balanced ligamentous tension LBORC, Louisa Burns Osteopathic Research Committee LC-NE, locus ceruleus-norepinephrine axis L HR H, leuteinizing hormone releasing hormone MA, Medical Assistant MAO-B, monoamine oxidase B MD, doctor of medicine MD M, medical decision-making ME, myalgic encephalopathy ME, muscle energy MFR, myofascial release MIT, monoiodotyrosine MODE MS, Musculoskeletal Outcomes Data Evaluation and Management System MPD, myofascial pain dysfunction MRI, magnetic resonance imaging MSA, mUltiple system atrophy NAD H, nicotinamide adenine dinucleotide (reduced form) NC, noncontributory


NK, natural killer (cells) NO, nitric NOS, NO nflammatory drugs

NSAID, OA, occi OCF,

cranial field

OIVlM, osteopathic manipulative medicine OMT, osteopathic manipulative treatment OP T!, osteopathic post-graduate training institutions OS, organ systems OTH, other treatments used (region)

PAG, periaq PAH,

hypertension

PAN,

nociceptors

P C, personal PCP, phencyclidine P D, P arkinson's disease PET, positron emission tomography P F SH, past family, medical, and social history PhD, doctor of philosophy PI, pelvic index P IPIDA,

PTSD,

acetanilido-iminodiacetic

disorder

PPD, (tuberculin) purified protein derivative PSIS, posterior superior iliac spines PSP, progressive supranuclear palsy P SS, pelvic side shift PT, physical therapy PT U, RA, rheumatoid RAI U,

uptake

ROM, range REM, rapid RF, rheumatoid factor RICEM (principle), rest, ice, compress, elevate, medicate

xxvii

xxviii


RN, registered nurse ROS, review RP R, rapid SARS, severe

ratory syndrome

SBP, systol synchondrosis

SBS,

SF36, Rand 36-ltem Health Survey SI, sacroiliac (joint) SNS, sympathetic nervous system SOAP, subjective, objective, assessment, plan SOQ, Specialized Osteopathic Questionnaire SOS, Sing

(SOAP note form)

SPEeT, sing

ission computed

SS, SSRI, selective

reuptake inhibitor

ST, soft tissue STDA, soft-tissue, deep articulation SP, substance P T1, 2, etc., thoracic vertebral segments T3, triiodothyronine T4, thyroxine asymmetry, range

TART, tissue

lectrical nerve stimulation

TENS, tra

hormone

TRH, thyrotropi

attack

TIA, transient

TMJ, temporomandibular joint T NF, tumor necrosis factor TRH, thyrotropin-releasing hormone TSH, thyroid-stimulating hormone UPDRS, Unified P arkinson's Disease Rating Scale VIP, vasoactive intestinal polypeptide WHO, World

Ith

ization

tenderness

SECTION

I

Philosophy and Principles of Patient Care

CHAPTER

1

Patient Empowerment James L. Laub

INTRODUCTION After y ears working in a variety of hospitals and clinics in the military, facilities where medical doctors and doctors of osteopathic medicine worked side by side, occa sionally a patient newly assigned to the installation would ask when first checking in to the medical facility, "Do you have any DOs on the staff?" I thought I knew why, so I never-nor did any of the other staff members-ask why the patient requested an osteopathic physician. One day in my clinic, I had an allopathic medical student shadowing me for the afternoon. The patient, who had more than 20 years of mil itary service and whom I had seen on several previous visits, struck up a short con versation with the student while I was finishing the note in the chart. In the con versation, he mentioned that he always preferred osteopathic physicians and sought them out at every opportunity. When the student asked why, his answer surprised me a bit: "Because they listen better." Mine was a neuromusculoskeletal medicine clinic. More than 90% of the treatment I gave was OMT (osteopathic manipulative treatment). My patients were all referred from their primary care physician. This patient was assigned at a nearby military installation and drove 50 miles to see me for his chronic myofascial pain, which was showing marked

improvement. But his number one reason for seeking my counsel as a physician apparently was that my osteopathic colleagues and I were known to him to be good listeners. Moreover, I believe he was saying that his osteopathic physicia�

2

Section I • Philosophy and Principles of Patient Care

was listen i ng at the level needed to under sta n d

him and t hereby showed respect for

his persp ecti ves con cerning his health care. Respect i ng patien ts' perspe ctives makes them part of the treatment team an d

establishes the basis for empowering them active ly to seek solutions to their own medical issues. The empowere d pa tient is not just the s ufferer ; the empowered patient is

a

collegial m em ber o f the team seeki ng the m ost e ffect ive t h erapeutic

pl an . As with any form of parti cipati ve management, the p atie nt is a stakehol der in the success of the t h erapeut i c plan, not the su bject of it. This starts with good liste n ing , but it is necessary to do more than JUSt good l isteni ng to ma k e patient e mpowerment wo r k. Heal ing occurs from wi th in; the first step to a ssisting patients to get past the bar riers to th ei r own hea l ing power is for them to develo p a pe r

sonal commitment to th e t h e rapeut ic plan for their own rec overy. The most effec

tive way to secure th a t commitment is to ensure th a t patien ts are partn e rs in the

p l an's dev elopm ent. T h eir partnersh ip in the process is most e asily don e t hrough a patient-cent er ed medical practice. The next few paragraphs e xp l or e and contrast the patient-centered m e di cal practice model with what is perhaps the more famil iar physician-centered mode l. Later on the ch a pter addresses how the patient

centered model is the cornerstone of effective patient e mpowerment . T he physician -cente red model is a parent-child transacti on I in which the patient is expected to be passive and dependent on the doctor's advice in an uneq u al rela

tion shi p. Teaching is designed to keep information simple to facilitate retention. The

health profess ional holds valued medical information and conveys it to the pati ent,

who is expected to absorb it uncrit i cally. The chief issue in the physician-cente red model is the pa tient who is unable to understand or to retain the information or who lacks the motivation to comply. The model assum es that a ra tional argument is suf

ficient to pers u a de pati ents they need to change their behavior to accommodate the health message. In this relationsh i p, t he p rim ary reason for failure is the bad, non compliant patient who just wouldn't do what the doctor said. Also, in this re lat i on s hip, a patie nt who ga t h ers outside information ch allenges th e verac ity of the h ea lth pro fessional and is often admonished or criticized for doing so. The re fore, the energy to improve t h is system is expended in ge tting patients to com p ly. Metrics (e.g., we ight, laboratory va lues, blood pressure) are used for j udgm ent.

The p atie n t-center e d model is an ad u lt -adult transaction I in which tbe patient part i cip ates as an equal pa r tner with the p ro fe ssional to make informed judgments

and devel op a pe rsonal therape u t i c plan. This model see ks to e li c i t and satis fy

patients' expressed needs as a first step toward taking greate r control over their own heal th . Patients'

involvement in decision ma ki ng is the key part of the educa

tional process itself. Use of the p atien t-centere d m odel deve lop s our patients' understanding and encour ages se lf-r e liance , with access to information necessary

to exercise control over their own body. The energy to improve this system is spent e ncouraging pati ents to share and refl ec t upon theif e xi st ing understandi ng as a basis for future l earning. Metrics are used for self-evaluation.

P at i ents have th e c apa b i l i ty to monitor the p e rfor m a nce of their body conti n

uou sly. When t h ey assess s omet h ing and find it awry, t h ey attempt to make

a

de te rm i nat i on as t o what may be the probl em from their k now le dge, abi lity, and

e x pe rience ( diagnosis) . They go on to decide what to do about it, aga in from

their knowledge, abili t y, and experience (treatment). And finally, they watc h f or

t he ir e xp ec te d outcome (follow-up). Patients seek counsel wh en t h e pro bl em is ou tsi de of their knowledge, a bi lity, or experience to diagnose or treat or when there is no improvement at follow-up. I s u bmit that doctors of osteopath ic m edicine go through the same process with patients. And if treat m ent fails, clinician s do the

Chapter 1

• Patient Empowerment

3

same thing: seek the counsel of a specialist and call it a referral. True primary care medicine occurs before the patients even are present. Osteopathic physician s show patients a desire to understand by consulting patients as they would a referring physician. It is necessary to respect the fact that patients have exceeded their level of expertise and exchange information collegially, discuss courses of action, what outcomes to expect, and when they should occur. In addition, when patients gather information on their condition from outside sources, they are providing more data to draw upon. No one's knowledge is infinite, and when a colleague shares knowl edge, it has the potential to contribute to better decision making. An inquiring patient is not challenging the physician's veracity but participating in an effort to achieve a suc cessful therapeutic dec i sion from the team. And that participation also enfranchises the patient as a stakeholder in the success of the therapeutic plan. Not long after osteopathic physicians attained full practice rights, the search was on to find out what makes them distinct. Apparently with full practice rights comes the loss of the osteopathic equivalent of the H oly Grail. In an excellent 1993 article,

].

F. Peppin lists six potential activities for osteopathic distinction.2 After discrediting

each , he suggests that touch is a better candidate. Peppin includes a statement from an osteopathic physician who claims "true" osteopathic medicine no longer exists in the United States and a statement from another who suggests it is not any one of his six factors but the collection together that makes osteopathic medicine distinct, an osteopathic collage.2 While pursuing this search is beyond the scope of this chapter, one irrefutable item does bind all osteopathic physicians the letters "DO" after one's name. Fewer than 5% of physicians in the United States have an osteopathic profes sional degree. As with any minority, the actions of one frequently speak for many. The action of a medical physician usually only speaks to how the patient population regards that one individual. But the action of an osteopathic physician frequently speaks to how the patient population regards osteopathic physicians collectively. Thus, doctors of osteopathic medicine entrust part of their reputation to each other and should do their best for one another. Patient empowerment is not anything that's u niquely osteopathic. Patients

will

hold the empowering allopathic physician in high regard, also. But the empower ing osteopathic physician may well engender a positive reflection on our entire profession. I always felt a sense of pride when a family transferred into our

mili

tary installation and requested to see a DO. It told me one or more of my osteo pathic colleagues had left them with an identifiably positive experience. The pride continued along with

a

profound sense of responsibility when tbe staff chose to

send that family to me to continue their care in that sa m e identifiably positive way. Regardless of the chosen specialty it is necessary to continue the legacy, listen well, ,

practice patient-centered medicine, and empower patients. The material in this chapter comes from a collection of concepts that I have taken and tested in the laboratory of life. Certainly, the concept of empowerment is not new and is easily traceable in both the clinical and management literature over 50 years.3,4 I received my original exposure to participative management con ce pt s in the mid-1970s as a graduate student at the University of Utah. Especially significant to me were the writings of Douglas McGregor5

and Abraham

Maslow,6 along with the lectures and writings of F rederic k Hertzberg.7,8 There

I also had the good fortune to take

a

course in social psychology from Martin

Chemers. Since at the time I was a military officer, I could easily take a collage of

academic concepts and test them fro m my positions as a manage r and leader. From

this empirical immersion, my use of and confidence in empowerment evolved. Later, when I embarked on my quest to study osteopathic

m edicine,

I discovered

4


I had learned some tools to describe what some of my clinician mentors had dis

covered apparently by trial and error. Empowerment, whether in a clinic or at a worksite, has a demonstrated history of success. Thomas Gorclon4 has an excellent

description of his experiences in tl-le preface of Making the

Patient Your Partner,

including his exposure to the clinical work of Carl Rogers in clinical psychology

in the 1950s. I recommend the book by Go r don and Edwards4 to any clinician who wants to learn more in this area.

Later, after my osteopathic internship, I reentered the military and was exposed

to the work of W. Edwards Deming9 in quality management. I now was reener gized to expand the empowerment concepts from my management background

into my clinic. r learned from both coworkers and patients; my appreciation for the value of empowerment continued to evolve. In preparing for this chapter, I came across the work of Carl E. Schneider,lo The Practice of Autonomy, in which he discusses the development of autonomy as Thus, the use of empowerment concepts

a

sociological movement in our society.

in a population whose desire for autono

my is on the rise is a terrific combination for success. Additionally, I recently came upon the work of Daniel Fisherll and his use of empowerment as the basis for suc cess with schizophrenic patients. At least on the surface, empowerment appears to be just a portion of a larger sociological movement. And I, as a subject in this movement, have merely read, listened, tried, and learned. If anyone feels I've encroached u pon his or her intellectual property, I humbly beg forgiveness. Where I believe this treatise fits

in osteopathic literature is perhaps in the

revered stature the osteopathic profession gives to physicians who have engen dered empowerment in the practice of osteopathic medicine. Despite the profes sion's inability heretofore to codify what those revered osteopathic physicians do,

the profession subjectively embraces them. Reverence begets emulation , and emu lation begets a culture (treat tile person, not the disease).

HOW TO BE ON A TEAM WI TH AN EM POWERED PATIEN T Teams can take one of three basic forms. The first is the synergistic team. The syn ergistic team exploits t he ideas and participation from each of its members and seeks to reach a set of conclusions that is superior to what any individual on the

team could do alone. The second is the leader-follower team. The leader-follower team designates one member as the expert who autonomously selects the set of conclusions for the team. The third is the antagonistic team. The antagonistic team is one in which internal conflict, personal interest, and politicking usually attempt a compromise set of conclusions that often are inferior to what many of the mem bers could have accomplished individually.

If we wish to be part of a synergistic team as we empower our patients, here are

t\VO basic rules: There is no room for ego in clinical encounters. This is easier to understand in concept than to accomplish in fact. Ego challenges cause a visceral reaction. That reaction has to be recognized for what it is and discarded at the same emotional level it enters, before the physician can continue witb the patient interaction. Empowering the patient does not abrogate the responsibility of the clinician. No two combinations of patient and illness are the same. Each will require a unique interplay among the decision team members. Each will demand a con tribution from the clinician at some level given the situation.

Chapter 1

• Patient Empowerment

5

References 1. Berne E. Whar Do You Say Afrer You Say Hello? New York: G r ove , 1972. 2. Peppin JE The osteopathic distincrion: fact or fancy) J Med Humanir 1993;14(4):203-222. 3. Siegal B, August Y. Help Me to H ea l . Carlsbad, CA: Hay House, 2003. 4. Gordon T, Edwards WS. Making the Parient Your Parrner. Wesrporr, CT: A u b urn House, 1995. 5. McGregor D. The Human S ide of Enterprise. 25rh Anniversary Printing. New York: McGraw Hill, 1985. 6. Ma sl o w A. Motivarion and Personality. 2nd ed. New York: Harper & Row, 1970. 7. Hertzberg F. Work and the Narure of Man. London: Harper Collins, 1966. 8. Hertzberg F. Motivation ro Work. Somers er, NJ: Transaction, 1993. 9. Deming WE. The New Economics for Industry, Government, Educa tion. 2nd ed. Cambridge, MA: MIT, 2000. 10. Schneider CEo The Practice of Autonomy. New York: Oxford U n i ver s ity Press, 1998. 11. Fisher D. Narional Empowerment Center. Available at http://www.power2u.org. Accessed Februa ry 20, 2005.

Osteopathic Distinctiveness Kenneth E. Nelson

IN TRODUCTION Osteopathic medicine is a success. With the new millennium, this nineteenth cen tury medical reactionary movement is well established within the mainstream of contemporary medicine. Success, however, has come with a price. Mainstream acceptance has resulted in the assimilation of the allopathic model of practice by osteopathic physicians to the detriment of their reactionary heritage. The osteopathic profession is being challenged to demonstrate its unique quali ties and thereby justify its existence as an independent institution within American health care. To do so, osteopathic distinctiveness must be identified, measured, and validated. The responsibility to prove osteopathic distinctiveness ultimately belongs to the osteopathic academic community, basic scientists and clinicians alike. Since contemporary osteopathic medicine has become mainstream, it is logical to look to its origin to identif y its distinctiveness. The philosophy of osteopathic medicine is based on four key principles:1 1. The body is a unit; the person is a unit of body, mind, and spirit.

2. T he body is capable of self-regulation, self-healing, and health maintenance. 3. Structure and function are reciprocally interrelated. 4. Rational treatment is based upon an understanding of the principles of body

unity, self-regulation, and the interrelationship of structure and fun ction. 6

(I)

..... .. I') (

Chapter 2 • Osteopathic Distinctiveness --�.

(a)

FIGURE 2. 1

-.... . .. (b)

-

.... . .. (c)

--

7

--

A schematic representing cause-and-effect logic.

These individual principles, however, are not necessarily unique to osteopathic medicine, and they are extremely difficult to quantify. Consistent with principle 1, contemporary osteopathic physicians claim to be holistic. This is an admirable trait, but it is not distinctly osteopathic. Holism has been all but usurped by contemporary alternative medicine, and increasing num bers of practitioners are approaching their patients in this manner. Consistent with principle 2, contemporary osteopathic physicians claim to be patient oriented (as opposed to disease oriented). Although allopathic medicine focuses upon the diagnosis and treatment of disease , the practice of medicine is acknowledged to be highly personaJ.2 With the progressive understanding of the role of the immune system, much of the contemporary treatment of disease is focused on assisting the patient's ability to respond to the illness. An apparent difference (consistent with principle 3) is the diagnosis and treatment of dysfunction in the musculoskeletal system. Yet many doctors of osteopathic medicine do not use osteopathic manipulation, and a number of medical doctors, most notably in physical medicine and rehabilitation, employ manual therapy. Principle 4 appears to identify the distinction by combining the first three prin ciples to form a system for clinical practice. If osteopathic medicine is distinctive and the understanding of somatic dysfunction in the context of the patient's level of wellbeing occupies a pivotal position in that distinctiveness, then it is the appre ciation of the significance of dysfunction of the neuromusculoskeletal system that offers osteopathic physicians a uniquely holistic system of clinical logic. HOLISTIC LOGIC

The logic of Western science, and consequently Western medicine, is Aristotelian (Fig. 2.1). It seeks to understand systems by reducing them to the sequential rela tionship of their smallest parts (alamos). Therefore , in Figure 2.1, the sequence could represent an individual (I) who gets caught in the rain (a), which lowers his resistance (b) . He is exposed to a virus (c), which causes him to catch a cold (n. Comparatively, holistic logic may at first appear to be an oxymoron. Holism is an acceptance of the totality and indivisibility of a system. It is nonlinear. It is exemplified by the Taoist philosophy of ancient China. Such a nonlinear system might be illustrated (Fig. 2.2) as the determination of a resultant vector. As multi ple forces act upon the individual (I), the resultant vector or outcome (I') is the development of disease or the maintenance of health.

I) ( '(I)Y ' (c)

(a)

'(b) FIGURE 2.2

A schematic representing holistic logic.

8


STRUCTURE, FUNCTION, AND DYSFUNC TION The third principle, describing the relationship between structure and function, gives rise to the recognition of somatic dy sfunction. The diagnosis and treatment of somat ic d ysfunction d ifferentiate osteopathic med icine from allopathic medicine. Somatic d ysfunction is impaired function of fundamentally normal anatomy. It is not pathol ogy. Rather, it is thought to predispose to and, once established , maintain pathology. The mechanics of somatic dysfunction have been described .I,3-S Somatic d ysfunc tion may occur as functional impediment due to altered soft tissue (muscular, liga mentous, fascial) tensions, articular motion restriction, or any combination of these components. Articular dysfunction of typical spinal segments (adjacent vertebrae possessing zygapophyseal joints and intervertebral discs) may occur as group dys functions composed of three or more consecutive segments , or as segmental dysfunc tions composed of two adjacent segments. Articular dysfunction of atypical spinal segments and appendicular joints is determined by their unique anatomy. The response of the axial musculoskeletal system to the force of gravity is nearly always asymmetric. Most ind ividuals have unequal leg length, with resultant pelvic unleveling.3 Therefore, everyone is pred isposed to compensatory group and seg mental spinal dysfunction.s Add to this the asymmetry imposed by dominance (left- and right-handedness), stresses from activities of daily living, and trauma (micro and macro), and it is understandable that musculoskeletal problems are so widespread. Somatic dysfunction, both group and segmental dysfunctions, occur in response to sid e-bend ing forces.4 The physiology of somatic dysfunction has been extensively studied.6-9 The greater bod y of scientific literature has been reviewed and compared to the pro posed mechanisms of somatic dysfunction.10,11 Van Buskirk12 offers a nociceptively rooted model for spinal somatic d ysfunc tion as follows: 1. A peripheral focus of irritation results in activation of nociceptive neurons.

These may be somatosensory or general visceral afferent neurons. 2. These primary afferent neurons synapse in the dorsal horn of the spinal cord

with internuncial neurons. 3. Ongoing afferent stimulation of insufficient intensity to reach firing potential results in the establishment of a state of irritability (facilitation) of the inter nuncial neurons. 4. Additional afferent activity from any source results in a segmenral response to

significantly less stimulus than would normally be required. 5. Such activity from internuncial neurons, which synapse with ventral horn motor

neurons, results in segmentally related myospasticity. Stimulation of internuncial neurons, which synapse in the intermediolateral cell column of the thoracic and upper lumbar cord, will produce a segmentally related sympathetic response (somatic and/or visceral). The same response to stimulation applies to the parasympathetic efferent system. Moreover, internuncial neurons travel up and down the spinal cord for several segmenrs and further synapse with the spinothal amic tract. These neurons are, thus, capable of initiating a broad response.

SPINAL SOMATIC DYSFUNC TION AS A FOCAL POIN T FOR HOLISM A focus of irritation producing spinal facilitation can affect structures in segmentally related derma tomes, myotomes, sclerotomes, and viscerotomes . If the peripheral focus of irritation is the result of vertebral articular dysfunction, the paravertebral

Chapter 2 • Osteopathic Distinctiveness

9

myospasticiry and sensitivity found with spinal dysfunction resul t. If a peripheral somatic focus of irritation (dysfunction or pathology) produces a ventral horn motor response, the result is a somatosomatic reflex. If the somatic focus of irritation pro duces a response in the intermediolateral cell column or a parasympathetic nucleus, the result may be a somatovisceral or a (sympathetic) somatosomatic reflex. In a sim ilar fashion, general visceral afferent activity is capable of producing viscerosomatic

and viscerovisceral reflexes. As such, the spinal cord links seemingly unrelated systems and structures in a manner that fosters a clinical system of logic, rendering it more inclusive or holistic.

Clinical Example A pai:ient presents with d ysesthesia of the palmar surface of the right hand consis

tent with a d iagnosis of carpal tunnel syndrome of uncertain etiology. Upper extremity complaints have been specifically linked to upper thoracic somatic dysfunction.13 Although the involved somatosensory innervation, the med ian nerve, should result in somatosomatic reflex findings paravertebrally from C6 to TI, such findings are more typically encountered in the upper thoracic region. The

sympathetic innervation of the upper extremity arises from

TI to T4. Autonomic

nerves contain afferent as well as efferent neurons. Therefore, "sympathetic affer ent" neurons from the right upper extremity are capable of producing facilitation in the upper thoraCic region lateralizing to the right. Facilitation, lateralizing to the right in the upper thoracic region, may be the result of primary spinal d ysfunction. Spinal segmental dysfunction with facilitation also can result from postural accommodation to pelvic unleveling or from environ mental stresses with resultant sym ptoms referable to the right hand. Viscerosomatic andlor somatovisceral mechanisms m ay also be present. The h igh thoracic region receives general visceral afferent input from m yocardium, lungs, and esophagus.14 Pathology in any of these organs is capable of producing nigh thoracic facilitation. Facilitation of upper thoracic spinal segments can result in a reflex visceral response. Tachycardia through the sympathetic innervation of the sinoatrial node of the heart is an example. Further, somatic dysfunction of minor intensiry may be am plified through cen tral facilitation by emotional stress. Spinal segmental facilitation has been shown to result in segmentally related soft tissue edema. IS Edema of the contents of the carpal tunnel can compress the median nerve. Thus, the upper thoracic spina I segmental facilitation, of whatever etiology, can produce or maintain carpal tunnel syndrome. As such, the symptom s of carpal tunnel syndrome may be the result of organic pathology of the wrist. They may be a manifestation of a somatosomatic reflex from upper thoracic somatic dysfunction, either primary or as postural accommo dation, or they may be a reflex from visceral pathology. Finally, th e entire situa tion may be increased

by the patient'S mental status.

Conversely, carpal tunnel syndrome may result in spinal facilitation

with sec

ondary (reflex mediated) spinal somatic d ysfunction and untold effect upon seg mentally related viscera.

DISCUSSION From this description of the mechanics and physiology of spinal somatic d ysfunc tion, it can be seen how seemingly unrelated structures are linked through the axial central nervous system. A logical argument can be mad e as to how one might

10


alleviate a tachyarrhythmia by treating carpal tunnel syndrome or how a proton pump inhibitor might be employed to decrease the inflammation of reflux esophagitis (viscerosomatic reflex T3, right), thereby reducing the median nerve compression of a right-sided carpal tunnel syndrome. These are, of course, hypothetical proposals, presented merely to illustrate how the appreciation of somatic dysfunction Jeads to the development of a distinctive form of clinical logic that is unique to osteopathic medicine. The basic science is sound, but much more should be done in the areas of functional anatomy, biochemistry, and physiology. The preceding discussion deals superficially with only the mechanics and neurophysiology of somatic dysfunction. No mention is made of the effect of somatic dysfunction upon circulation, the immune system, and homeostasis. From the perspective of clinical research, such complex problems are best pur sued as outcome studies, for which massive amounts of data are necessary. The development of such a database is predicated upon effective data gathering. The American Osteopathic Association (AOA) requires that a musculoskeletal exami nation be incorporated into the medical record. In the hospital, this is typically recorded in the admitting history and physical examination. It is, therefore, imper ative that this portion of the medical record be completed with particular diligence. The American Academy of Osteopathy (AAO) has developed and validated a series of outpatient osteopathic SOAP (subjective, objective, assessment, plan) note forms for outpatient use (see Chapter 31).16--18 The Des Moines College of Osteopathic Medicine and Surgery is developing an Internet-mediated central database for purposes of electronically gathering information pertaining to the practice of osteopathic medicine. The validity of the degree of osteopathic physi cians rests to a significant extent upon the results of this future research and con sequently upon the efficacy with which they participate in these projects.

References 1. Ward RC, ed. Fo un dations for Osteo pa th i c Medicine. 2nd ed. Philadelphia: Li pp incott Williams & Wilkins, 2002. 2. Fauci AS, ed. Harrison's Principles of Internal Medicine. 14rh ed. New Yo rk: McGraw Hill, 1998;1. 3. Schwab WA. Principles of Manipulative Treatment: The Low Back Pr o b lem. 1965 Yearbook. Vol 2. Indianapolis: American Aca de my of Osteo pa t h y, 1965;95. 4. Fryette HH. P rinc i pl es of Ost eopat h ic Technique. J nd ia napoli s: American Academy of Osteopat hy, 1954, 1980. 5. Nelson KE. The management of low back pain: S ho r r leg syndrome/postural balance . AAO J 1999;9(1 ):33-39. 6. Beal MC, ed. Lo u isa Burns, DO, Mem o ria l. 1994 Yearbook. Indianapolis: American Academy of Os teopathy, 1994. 7. Beal MC, ed. Selected papers of John Stedman Denslow, DO. 1994 Yearbook. Indianapolis: American Academy of Os teo pa t hy, 1994. 8. P e terson B, ed. Tile Collected Pape rs of Irvin M. Korr. Indianapolis: American Academy of Osteoparhy, 1979. 9. King HH, ed. The CoUected Papers of Irvin M. Korr. Vol. 2. Indianapolis: American Academy of Osteopathy, 1997. 10. Patters on MM, Howell IN, eds. The Ce n tra l Connection: Somarovisceral and Viscerosomaric I n ter a c rion . 1989 inrernational symposium. Athens, OH: University Classics, 1992. 11. Will ar d FH, Pa tter so n MM, eds. Nociceprion and the Neuroendocrine-Immune Connection. Athens, OH: University Classics, 1994. 12. Van Buskirk RL. Nociceprive reflexes and the somatic d ys f uncrio n: a m od el . J Am Osteopath Assoc 1990;90:792-794, 797-809 [review].

Chapter 2 • Osteopathic Distinctiveness

11

13. Larson NJ. Osteopathic manipulation for synd romes of the brachial plexus. J Am Osteopath Assoc 1972;72:378-.384. 14. Van Buskirk RL, Nelson KE. Osteopathic family practice: An application of the primary care model. In: Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia: Lippincort Williams & Wilkins, 2002;292.

15. Ramey K et al. MRI assessment of changes in swelling of wrist structures following OMT in patient s with ca rpal tunnel syndrorne. AAO J 1999;9:25-3l. 16. Nelson KE, Glonek T. Computer/outcomes: Hardcopy SOAP note preliminaty report: Family physician. Fam Physician 1999;3:8-10. 17. Sleszynski SL, Glonek T, Kuchera WA. Standardized medical record: A new outpatient osteo pathic SOAP nOfe form: Validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc J 999;99:516-529. 18. Sleszynski SL, Glonek T, Kuchera WA. Outpatient osteopathic single organ system muscu loskeletal exam form: Tra i n in g a nd certification. J Am Osteopath Assoc 2004;104:76-81.

Diagnosing Somatic Dysfunction Kenneth E. Nelson

INTRODUCTION Somatic dysfunction is a distinctly o steopathic diagnosis. It is unique in contempo rary medicine in that it is considered to be central to the practice

of osteopathic

medicine, yet it is not o rganic pathology. It is functional impairment. Somatic dysfunction is present to a greater or lesser d egree in all individuals. It should be part of the approach to the care of any patient to identify the relative importance of somatic dysfunction in the overall clinical presentation and to address it appropriately. Osteopathic manipulative treatment (OMT) is the defin itive treatment of somatic dysfunction. The e ffective use

of

OMT is predicated

upon the effective diagnosis of somatic dysfunction.

"Somatic Dysfunction Defined A. Somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic. and neural elements. Somatic dysfunction is treatable using OMT The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters (1) the position of a body part as determined by palpa tion and referenced to its adjacent defined structure, (2) the directions in which motion between two adjacent structures is freer, and (3) the directions in which motion is restricted. Somatic dysfunction may be primary or secondary. 12

Chapter 3 • Diagnosing Somatic Dysfunction

13

B. Acute somatic dysfunction: Immediate or short-term impairment or altered func tion of related components of the somatic (body-framework) system; characterized in early stages by vasodilation, edema, tenderness, pain, and tissue contraction; diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion, and tissue texture change (TART). C. Chronic somatic dysfunction: Impairment or altered function of related compo nents of the somatic (body framework) system, characterized by tenderness, itching, fibrosis, parestheslas, tissue contraction; identified by TART. D. Primary somatic dysfunction: 1. The somatic dysfunction that maintains a total pattern of dysfunction. 2. The initial or first somatic dysfunction to appear temporally. E. Secondary somatic dysfunction: Somatic dysfunction arising either from mechan ical or neurophysiologic response subsequent to or as a consequence of other etiologies." A T Still'

Secondary somatic dysfunction may be mechanical, as is seen with sacral dys function resulting from unequal leg length, or it may be of neural reflex origin, as a

viscerosomatic or somatosomatic reflex.

Because somatic dysfunction is functional impairment and not organic pathology, primary somatic dysfunerion is completely reversible when correctly diagnosed and specifically treated wit h OMT. Secondary somatic dysfunction also responds to OMT, but it will recur unless the primary condition is identified and treated. Somatic dysfunction that is a reflex response to visceral pathology (viscerosomatic reflex) typically does not respond to

OMT until the underlying visceral pathology is treated.

Somatic dysfunction independently is responsible for a great deal of discomfort that cannot be attributed to organic cause. Because it manifests through the nerv ous and vascular systems as well as the musculoskeletal system, it can result in a broad array of symptoms. Somatic dysfunction also contributes to the effect of organic pathology. Somatic dysfunction of the thoracic spine, ribs, and diaphragm results in decreased thoracic compliance, increasing the severity of existent congestive heart failure. It also exerts deleterious eHeer upon viscera receiving innervation from the same spinal segment (somatovisceral reflex).

DIAGNOSIS The physical diagnosis of somatic dysfunction is accomplished by palpation. TART, a mnemonic for the four diagnostic criteria of somatic dysfunction, stands for the following: Tissue texture abnormality Asymmetry of position Restriction of motion Tenderness The presence of any one of these is justification for the diagnosis of somatic dysfunction. Palpation for tissue texture abnormality is probably the most efficient screen for somatic dysfunction.

The qualitative aspects of tissue texture abnormality, as indi

cated in the definitions given previously, are used to differentiate acute from chronic

14


somatic dysfunction. T he degree of tissue texture abnormality indicates the severity of the somatic dysfunction. Mechanical somatic dysfunction typically demonstrates asymmetry of position and restriction of motion. Asymmetry of position is stressed in the diagnostic par adigm of muscle energy. Restriction of motion is stressed in the diagnostic para digm of articular dysfunction . Tenderness must not be confused with pain. Pain is the subjective awareness of nociceptor activity. Tenderness is pain elicited upon palpation. As such, tenderness is an objective physical finding. Tenderness is often elicited as an involuntary pain response, a muscular twitch or facial wince, to diagnostic palpation, and may be employed to confirm the diagnosis of somatic dysfunction following the observa tion of tissue texture abnormality. Like tissue texture abnormality, tenderness is indicative of the severity of somatic dysfunction. Although the site of the patient's pain may demonstrate tenderness, it is fairly common for significant findings of somatic dysfunction to be adjacent to or distant from the site of pain. Commonly, the motion restriction of somatic dysfunction places compensatory stress upon adjacent structures, with resultant pain in those adjacent structures. The pain, however, may be distant from the etiologic dysfunction, presumably because of shared innervation (often sympathetic). This innervation results in a trigger point at the location of the responsible dysfunction which when palpat e d reproduces the distant pain. Tissue texture abnormality and tenderness in the absence of the findings of mechan ical somatic dysfunction, particularly restriction of motion, are indicative of somatic dysfunction of reflex origin, that is, viscerosomatic or somatosomatic reflexes.

PROCEDURES In diagnosis of somatic dysfunction, it is appropriate to begin, when possible , with an overall assessment of the patient's weight-bearing mechanics. A

d ec i sion can

then be made as to what extent postural mechanics contribute to the condition being evaluated. This is followed by regional assessment of the problem area . It is here that screening for tissue texture abnormality offers an effective method for quickly identifying areas requiring more definitive examination. Once discrete somatic dysfunction is recognized, it is necessary to precisely identify asymmetry of position and all components of motion restriction (flexion and extension, side bending left and right, rotation left and r ight translation ante ,

rior and posterior and left and right, with additional motions as appropriate for assessing appendicular dysfunction). To accomplish this, it is useful to be aware of common mechanical patterns of dysfunction. S pin al somatic dysfunction is defined as type I (neutral, principle 1 of spinal physiologic motion) and type II (nonneutral, principle 2 of spinal physiologic motion).1.2 These mechanics are found between typical vertebrae, t h at is, vertebrae possessing zygapopbyseal joints and separated by intervertebral discs: the entire spine from C2 upon C3 to L5 upon 51, although the cervical spine demonstrates regionally atypical type I mechanics. In type I mechanics, a group of three or more vertebrae demonstrate

a

coupled

relationship between side bending and rotation. Under neurral circumstances (absence of spinal flexion or extension engaging the zygapophyseal articulations) when side-bending forces are applied to a group of typical vertebrae, rotation of the entire group will occur toward the side of the produced convexity. Side bending

Chapter 3 • Diag nosing Somatic Dysfunction

15

and rota tion of the entire group are coupled in opposite directions. In the cervical region, the entire group will demons t ra te coupled side bending and rotation in the same direction. The levels of transitional mechanics within and between group curves are important. The vertebrae of maximum rotation, also where rotational mechanics change direction, is designated the apex of the curve. The conjuncture of two curves, or crossover point, is where side-bending mechanics change direction. Anterior-posterior (AP) spinal mechanics are affected by type I mechanics. The presence of a g roup curve increases the existing spinal k yphosi s or lordosis. Therefore,

a

thoracic type I curve will demonstrate increased kyphosis, and a lum

bar curve will demonstrate increased lordosis. At a crossover point, the existing AP curve is decreased.

Although type II (nonneutral) somatic dysfunction may affect any two adjacent typical vertebrae, it is often found at the transitional points of group mechanics. Fryette2 noted that type II dysfunction most commonl y occurs when forces decrease the existing AP curve. The preexisting AP flattening at the crossover point therefore makes this area most vulnerable for the development of ty p e 2 mechanics. Because t h e AP curve is fla ttened at the crossover point between two type I curves, the physician would expect to find type II e x tens i on dysfunctions in the

tho r a ci c region and type II flexion dysfunction in the lumbar r egion The rotational relationship between individual vertebrae changes direction between the apical segment of a group curve and the vertebrae immediately above it. For this reason, the upper half of a group curve behaves as a series of ty p e 1I dysfunctions. Because a group curve produces an increase in the norm a l AP curve, t y p e II flexion mechanics might be expected above the apex of a type I thoracic curve and t y pe II extension mechanics above the apex of a type I lumbar curve. Atypical spinal segments, occiput on Cl, CIon C2, and the sacrum between the ilia, demonstrate dysfunctional mechanics as dic t a ted by their unique anatomy. The occiput on Cl and the sacrum between the ilia become dysfunctional with restriction of side bending and rotation coupled in opposite dire ct i o ns CIon C2 becomes dy s fu nc tional with restriction of r o t a tion The identification of spinal somatic dysfunction should lead the physician to inquire about segmentally related viscera, thereby identifying the contribution of viscerosomatic and somatovisceral reflexes to the clinical picture. Somatic dysfunc tion that is the result of a viscerosomatic reflex is pr i marily of diagnostic value. It is definitively treated by treating the causa t ive visceral pathology. Viscerosomatic reflexes are addressed in Chapter 5. Somatic dysf u nc ti on of areas other than the spine occurs as restricted motion that is dictated by the anatomy of the structures involved. It is common for artic ular motion restriction to invo lve the minor motions of the affected area. Rib dysf unc tion is often secondary to dysfunction of the respective thoracic spinal segments. Primary rib dy sf unc tio n occurs as restriction of inspiratory or expiratory excursion. When examining for appendicular dy s fu nc tion, one should begin by examining the region of complaint, followed by a thorough examination of the areas proxi mal and distal to the complaint. However, the examination is not complete until related spinal segments have been examined.3 Fi n ally, once the mechanical p a ttern of the somatic dysfunction has been diag nosed, the physician must further decide what is causing it. Is the dysfunction an articular restriction? Is the dysfun c t ion the result of tight muscles or altered fascial tension? It is certain that very few dysfunctions are purely articular, muscular, or fascial in origin. However, more times tha n no t the p hysici a n will feel that one .

.

.

,

16


component contributes significantly. Making this decision will help the physician to choose the type of OMT that can best treat the dysfunction.

Examining the Patient The diagnostic assessment of any patient begins from the focal point of the chief complaint. This allows the physician to prioritize the physical examination. That is not to say that one will necessarily skip parts of the examination, but the physi cian may emphasize some aspect in one patient and examine the same region less extensively in another. The physician must learn to do this because it is necessary to understand the significance of that component of the physical examination in the context of the patient'S condition. It would arguably be logical to perform a more extensive neurological examination upon a patient with a recent onset of seizures than an individual with me lena. The evaluation of the musculoskeletal system for somatic dysfunction as part of the complete physical examination should be performed upon every patient. However, it can be modified to conform to the diagnostic requirements of each patient. To determine how to do this, it is appropriate that the physician answer the following questions: •

Does the somatic dysfunction have a mechanical effect upon the patient? Restriction of the thoracic cage and diaphragm, while detrimental to anyone, will be particularly deleterious to a patient with chronic obstructive pulmonary disease or congestive heart failure. Similarly, does the patient have a pain com plaint that is the result of or is compounded by somatic dysfunction? Physicians o ften become so focused upon the patient's serious illness that they overlook simple problems that contribute greatly to the patient'S discomfort.

•

Is there facilitation of sympathetic (thoracolumbar) or parasympathetic (high

cervical or sacral) componenrs of the spinal cord? (See Chapter 5.) If so, how does it affect the patient? Sympathetic stimulation of the gastrointestinal tract decreases peristalsis, which predisposes the patient to constipation or the devel opmenr of an ileus. Parasympathetic stimulation increases peristalsis that can produce diarrhea and colic. •

How does venous and/or lymphatic stasis affect the patient? Impaired circula tion interferes with the body's natural defenses and with its ability to mount an effective healing process and retards the efficacy of medications. The diagnosis of somatic dysfunction is best approached in an organized fash

ion. The examination may have to be modified as dictated by the physical status of the patient. Some patients cannot stand, sit, or even move freely in bed. If physi cians keep in mind these questions, they will identify methods of modifying the physical examination to accommodate even the sickest of patients. The only rea son not to perform an examination for somatic dysfunction is an emergency that necessitates

immediate attention.

Begin with an overall screen of the patient's general body pattern.

If the patient

can stand, assess postural balance. Look for unequal leg length and pelvic and pec toral girdle unleveling. Identify type I spinal mechanics and look at regional mechanics, such as thoracic cage excursion , that will affect the clinical presenta tion. If the patient cannot stand, ileoileal mechanics and thoracic cage excursion can be assessed while the patient is supine . Examine areas where one would expect to find sympathetic and parasympathetic viscerosomatic reflexes associated with the patient'S medical problems. Having identified the overall body pattern, specif ically diagnose localized, segmental, dysfunction that is relevant to the presenta tion of the patient.


17

The following exercises are intended to demonstrate a systematic approach to d iagnosis of the spine. The discussion is limited to the diagnosis of the spine. The appropriate osteopathic texts offer descriptions of appendicular, thoracic cage, and cranial diagnosis. •

Standing structural examination

•

Supine structural.examination Regional and segmental examination

• •

Palpation for tissue texture ahnormality; layer palpation •

Cervical spine

•

Thoracic spine

•

Lumbar spine Sacrum and pelvis

•

Standing Structural Examination

The purpose of the examination is to learn as much as possi ble about the patient's general body mechanics so that findings of local somatic dysfunctio n can be placed in context. Standing behind the patient, observe for the symmetry of each of these structures (Figure

3.1).

•

Mastoid processes

•

Should er (acromion)

•

Inferior angle of scapula

•

Iliac crests Posterior superior iliac spine (PSIS)

• •

Greater trochanter of femur

TEST FOR PELVIC SIDE SHIFT (PSS)

From behind, observe the standing patient to see whether the pelvis is deviated toward one side or appears centered. Place one hand on the patient's shoulder. Place your other hand on the patient's opposite hip. Gently push the hip and pelvis medially. Switch your hands to the patient's opposite shoulder and hip and repeat the process. Compare the symmetry of motion between both sides. The pelvic side shift test is positive on the side toward which the pelvis more easily moves. OBSERVATION FOR LATERAL CURVES

From behind, observe the standing patient as the patient bends forvvard at the waist. Look for paravertebral prominence resulting from spinal rotation that occurs as one component of the type I mechanics of lateral spinal curves. In the thoracic region, the scapula will appear more posterior on the side toward which the spine is rotated. OBSERVATION OF THE AP CURVES

From the side, inspect lumbar, thoracic, and cervical AP curves for increased and flattened areas. Determine whether any such areas correspond to the observed lateral curves. Supine Structural Examination

Although the supine examination does not yield as much information about the postural mechanics of the patient as the standing examination, if this is the only position that the patient can be examined in , it is useful to do so. Assess pelvic, ileoileal, and thoracic cage mechanics by sliding your hands under the patient and palpating for paravertebral tissue texture abnormality. Screen lumbar and thoracic spinal mechanics and loo k for viscerosomatic reflexe s. Examine the cervical region as described later in the chapter.

18


Spinal Curvature Anterior / Posterior Cervical LordOSIS: ThoracIc KypnOSIS: Lumbar Lorccsls:

Latentl

(Scoliosis)

o

.�one

o

Functional

o Mild

FIGURE 3.1

I

N

o

o o o

a o o

o o o

Exam Position

Sitting

0

Standing

0

Prone/Supine

0

NO Exam

0

The recording format for the standing structural examination from the standardized osteopathic SOAP note. (See Chapter 31.)

Palpation for Tissue Texture Abnormality, Layer Palpation

Use layer palpation to gain significant information about tissue texture abnormal ity in each of the procedure descriptions that follow. Screen each region looking for tissue texture abnormality. When such abnormality is identified, perform a thorough segmental examination. Place your palpating hand on the skin and make light contact. Palpate for tem perature and texture. Next, evaluate the subcutaneous tissue. Use more palpatqry pressure. Sense how thick this area feels. The tissue texture abnormalities found in association with viscerosomatic reflexes cause distinctive changes in subcutaneous tissues that closely mirror the severity of the reflex. Introduce movement in various directions and notice the directions of loosest and tightest movement. This assesses superficial fascial tension in the region. To palpate the deep fascial layer, increase palpating pressure until you sense the deeper underlying structures. The deep fascia is generally described as a smooth,


19

firm, and continuous layer. Identify areas of thickening involving the fascia that surrounds the regional musculature. Pa lpate through the deep fascia, concentrating on the underlying muscle. Identify individual muscle fibers. Attempt to palpate the direction in which the

muscle fibers run. Pay attention to areas of increased musculature tension. Regional and Segmental Examination of the Cervical Spine (Fig.

3.2)

EXAMINATION OF THE CERVI CAL REGION

Patient position supine. Physician position: seated at the head of the examination table. This position is not always easily accomplished in the hospital setting. Palpate for tis sue texture abnormality and tenderness. After you have appropriately screened the cer vical region, with the patient remaining supine, examine the specific segments where you have identified TART findings Examination of the Occiput (CO on C1)

The major motions of this articulation are flexion and extension. The minor motions are rotation and side bending. The most commonly used test for motion is the lateral trans lation test Grasp the patient's head, placing your fingertips in contact with the occipi toatlantal (OA) junction. Identify OA side bending by introducing lateral translation to the left and right. Greater ease of lateral translation in one direction is indicative of side bending in the opposite direction. Once you have identified the side bending, you can extrapolate rotational mechanics because OA rotation and side bending are coupled in opposite directions. That is, side bending to the left of the occiput upon the atlas is associated with rotation to the right, and side bending right is associated with rotation to the left. Next, introduce OA flexion and extension and observe the symmetry of these motions. This test, along with the location of tissue texture change (and tenderness), is used to Identify anterior or posterior occiput dysfunction. If the occiput translates with greater ease to the right it indicates that the occiput is sidebent to the left side, and consequently rotated to the right upon the atlas. If the right

FIGURE 3.2

The supine position may be used for both the regional and segmental examination of the entire cervical spine.

20


OA joint will not move forward when extension is introduced and the nght OA joint has pal pable tissue texture change and is tender, the diagnosis is posterior occiput on the right If the OCCiput translates more freely to the nght it indicates that the occiput is sidebent to the left side and rotated to the right on the atlas. If the left OA joint will not move to the posterior when flexion is introduced and the left OA joint has palpable tissue texture change and is tender, the diagnosis is anterior occiput on the left Examination of the At l as ( C1 on C2)

The major motion of this articulation is rotation. This articulation is the exception that makes the rule. Atlantoaxial dysfunction involves restriction of the major motion of rota tion with little or no minor motion restriction. With the patient supine, flex the ceNical spine. This greatly reduces freedom of rota tion from C2 through (7, significantly limiting available rotation to the atlas upon (2. While palpating over the lateral masses of the atlas, rotate the head to the right and then to the left obseNing for rotational asymmetry. You may use the nose or chin as a gauge to compare available rotation. Identify the direction of greatest rotation. The dys function, posterior on the side toward which rotation occurs most freely or anterior on the side toward which rotation is restricted, is indicated by the side where palpable tis sue texture abnormality and tenderness are found. Segmental Examination of the Cervical Spine (C2 on C3 to C7 on T1)

Palpate the cervical paraspinal tissues from (2 to (7. Look for asymmetric tissue texture abnormality and tenderness and focus motion assessment on these areas. (2 to (7 demon strates type II (nonneutral) and regionally unique type I (neutral) dysfunctional mechaniCS. To test for rotation, hold the head and neck in your hands and place your fingertips posterior to the transverse processes of the cervical segment being examined. Rotate the vertebra to the right and to the left. Observe for restriction of rotation in either direc tion. Rotation is named for the direction of freer motion. Example (5 rotates more freely to the right, or left rotation is restricted. (5 is rotated right To test for side bending, employ a lateral translation test Place your fingertips over the lateral edge of the transverse processes of the cervical vertebra being tested. Translate the vertebra to the left and to the right. Translation to the left results in side bending to the right and vice versa. Side bending is also named for the direction of freer motion. Example: (5 translates more freely to the left; it is, therefore, side bent to the right. Using the informa tion gained from the rotational test, (5 is rotated right and side bent right. To test for forward bending (flexion) and backward bending (extension), introduce flex ion and extension between the vertebrae being examined. Decide whether flexion or extension demonstrates the freer motion. To confirm your findings, attempt to rotate the vertebrae being examined after introducing flexion and again after introducing extension. This is application of principle 3 of spinal physiologic motion. I In the example, (5 upon (6 is rotated and sidebent to the right (restricted rotation and side bending to the left) If a type II dysfunction is present, rotation will be more restricted in the dysfunctional compo nent of flexion and extension. That is, if (5 is flexed (restricted extension), rotation will be more restricted to the left in extension than in flexion. This dysfunction, named for the unrestricted components of motion, is recorded as (5 sidebent and rotated right flexed. REGIONAL AN D SEGMENTAL EXAMIN ATION OF THE THORACIC SPINE

Begin by palpating the paravertebral soft tissues. After identifying segmental tissue tex ture abnormality, assess for motion restriction. This is most easily accomplished from behind the seated patient. Move the patient through a complete range of motion (flexion, extension, side bending, and rotation)

Chapter 3 • Diagnosing Somatic Dysfunction Evaluation of the Upper Thoracic Region

21

(Tl-T4) Using the Head and Cervical

Region as a Lever Patient position seated. Physician position standing behind patient. Place your active hand on the patient's head and your monitoring hand on the appro priate thoracic segment

Flexion and Extension With your monitoring hand, place the pad of your middle finger in the interspinous space below the segment you wish to evaluate. Allow the index and ring fingers to con tact the interspinous spaces above and below. With your active hand, introduce forward bending from above downward until motion is sensed at the spinal level being exam ined. Note how far and how easily the spinous processes separate. Then introduce back ward bending until motion is sensed at this segment. Note how close and how easily the spinous processes approximate.

Side Bending and Rotation Place your thumb and index finger over the spinous process of the segment you wish to evaluate. Side-bend left and right from above down to the segment being examined. This process may be repeated for rotation. Note asymmetry and quality of motion. Evaluation of the Upper Thoracic Region

(Tl-T4) Using the Thumbs

to Assess Motion Patient position seated. Physician position: standing behind patient. The thumbs of both hands should contact the transverse processes of the thoracic segment being examined. This procedure is effectively used to assess rotation, flexion, and extension. It is less effective in assessing side bending.

Rotation Place your thumbs over the transverse processes of the segment to be tested. Allow your fingers to rest over the patient's shoulder area. Motion is introduced by applying pres sure anteriorly, alternately through your thumbs. Introduce rotation left and right. Note any restriction of motion. Assess quality and quantity of motion.

Flexion and Extension Place your thumbs and hands in the same position. Instruct the patient to flex the neck (you should feel flexion localize all the way down to the vertebral segment you are testing). Assess rotation in the manner already described with the patient's neck in flexion. Instruct the patient to extend the neck. Assess rotation in the same manner. Rotation will be more restricted when attempted in the dysfunctional component of flexion and extension. Example T2 rotates freely to the right upon T3. Rotation to the left is restricted. When T2 is rotated to the left, the right transverse process appears more prominent underneath your thumb; therefore, T2 is rotated right. With the neck positioned in flex Ion, T2 has increased rotation to the left (motion still restricted but improved) With the neck extended, T2 has decreased rotation to the left. Flexion results in increased rota tion. Extension results in decreased rotation. T2 is therefore rotated right and flexed. Evaluation of the Lower Thoracic Region

(T5-T12): Using the Shoulders

as a Lever Patient position seated. Physician position: standing behind the patient to the left side. Drape your left forearm (the active hand) across the patient's posterior cervicothoracic junction, so that your left elbow touches the anterior surface of the patient's left shoulder

22


and your left hand rests comfortably across the right shoulder. Place the thumb and index finger of your right (monitoring) hand on the spinous process of the thoracic segment to be examined. Side Bending and Rotation

Introduce side bending to the left by using a downward motion through your left arm while monitoring the segment Move to the patient's right side (switch hand and arm positions) and introduce right side bending. Assess the difference in side bending at that segment Return to your original assessment position at the patient's left side. Introduce rota tion by applying a posterior motion through your left elbow. Repeat this procedure from the right side and assess the difference in rotation at that segment. Once you become accustomed to this procedure, a combined side bending and rotation movement that is much more efficient can be employed. Flexion and Extension

Assess flexion and extension by placing the fingers of your monitoring hand over the lower thoracic interspinous spaces. Instruct the patient to cross the arms over the chest. Use your active hand to hold on to the patient's crossed arms. Introduce forward and backward bending from below upward by rocking the patient forward and backward on the ischial tuberosities. REGIONAL AND SEGMENTAL EXAMINATION OF THE LUMBAR SPINE

Begin by palpating the paravertebral soft tissues. After identifying segmental tissue tex ture abnormality, assess for motion restriction. This may also be accomplished with the patient seated, using the method described for the low thoracic region already described, or the patient may be examined in the supine position Patient position: prone. Physician position: stand at the patient's side. Place the pads of your thumbs over the transverse processes of a single segment Wrap the rest of your hands around the lumbar paraspinal area. Rotation

Use one hand to rotate the vertebra by directing an anterior force through your thumb over one transverse process This will rotate the vertebra to the opposite side. Repeat the process in the other direction, and compare one side with the opposite side and with the segments above and below. Side Bending

Assess side bending with your hands in the same position. Use both hands to laterally translate the vertebra to the left and right. Translating the vertebra to the right intro duces side bending to the left, and translating the vertebra to the left introduces side bending to the right Flexion and Extension

Assess flexion and extension by directing an anterior force over the spinous process with your thumb. Then allow the segment to spring back to its original position. An extended segment will easily move anteriorly and will not spring back properly. The opposite is true for a flexed segment. Flexion and Extension (Patient on Side)

The patient lies on the side facing you with the knees bent Place the fingers of your mon itoring hand over the interspinous spaces of the vertebrae being tested. Cradle the patient's legs below the knees uSing your active hand. Assess fi€xion and extension by introducing these motions through the patient's hips and pelvis up into the lumbar spine.


23

EXAMINATION OF THE SACRUM AND PELVIS Sacropelvic articular dysfunction occurs commonly as sacroiliac dysfunction. lIeoileal and global lumbosacropelvic (torsion) mechanics are given significant consideration in the muscle energy approach to pelvic dysfunction. Additionally, pubic symphysis articular dysfunction is occasionally encountered. This discussion focuses upon sacroiliac dysfunc tion. Diagnosis of sacroiliac dysfunction is a two-step process. First, determine the mechanical pattern of the dysfunction. Second, deter mine the side of the dysfunctional sacroiliac articulation. Motion Test for Sacroiliac Articular Dysfunction (Figure 3.3) Patient position prone. Physician position standing at the patient's side near hip level. Place the pads of the index and middle fingers of your monitoring hand so that one contacts the posterior superior iliac spine and the other rests in the superior portion of the sulcus of the sacroiliac joint Place the heel of your active hand in contact with the sacral inferior lateral angle (ILA) on the side opposite the monitoring fingers. With your active hand, apply downward (anterior) pressure on the apex and ILA of the sacrum, pro duce motion , and note freedom or restriction. With your monitoring hand, appreciate posterior motion of the base of the sacrum (reduction in depth of the sulcus) or absence thereof. Assess both quantity and quality of available motion. Repeat this process, exam ining the opposite sacroiliac loint, and compare the two sides. Somatic dysfunction can be named in terms of position and in terms of motion restric tion. Because anatomic structures vary in their size, shape, and symmetry in the normal pop ulation, diagnosis by defining motion restriction is considered to be the superior method. Pressure over the left ILA of the sacrum with the active hand produces right rotation about the left oblique axis. Conversely, pressure over the right ILA produces left rotation about the right oblique axis. When you palpate these motions, you will commonly note that one rotational pattern occurs with greater ease than the other. It is not readily possible to produce left rotation about the left oblique axis or right rotation about the right oblique axis since this would require directing a posterior force to the anterior surface of the sacrum.

FIGURE 3.3

Hand placement for sacroiliac motion assessment.

24

Section I • Philosophy and Principles of Patient Care Example: Pressure over the left ILA results in unrest ricted motion, while pressure over

the right ILA is met by significant resistance. Since the unrestricted sacrum can rotate both right and left about either oblique axis and decreased rotation left about the right oblique axis is identified, it is possible to extrapolate that the sacrum is rotated right on the right oblique axis. This motion pattern is consistent with the a rticular dysfunctions of either an anterior sacrum left or a posterior sacrum right The mechanical pattern of sacral motion having been identified, the next step is to identify the side of the dysfunc tional sacroiliac a rticulation. The dysfunctional side can be determined by performing the sacral flexion tests (discussed later) Additional Findings to Assist in Diagnosing an Anterior Sacrum (Upper Pole) Somatic Dysfunction Look for a deeper sacral sulcus, tissue texture abnormality, tenderness, an d decreased posterior motion at the upper pole. Also look for increased gluteal muscle tension on the somatic dysfunction side (the same side as the deep sulcus) Additional Findings to Assist in Diagnosing a Posterior Sacrum (Lower Pole) Somatic Dysfunction Look for tende rness of the lower pole and piriformis muscle tension, all on the somat ic dysfunction side (side opposite to the deep sulcus, if present). The deep sulcus

FIGURE 3.4

The standing flexion test.


25

should become less deep when movement is initiated, that is, not be stuck in a deep position. Standing Flexion Test (Figure

3.4)

Stand behind the standing patient. Place your thumbs over the PSIS. Ask the patient to bend forward. The standing flexion test is positive on the side where the thumb moves further superiorly. This occurs because in the standing position the sacrum rests in a rel atively flexed position. With further flexion of the lumbar spine, the sacrum moves with out also moving the innominate bones. However, if sacroiliac Joint restriction exists, motion of the sacrum will move the innominate bone (hip bone) on the side of the restriction. The innominate will thus move with the sacrum, and the PSIS will shift supe riorly on the restricted side. This innominate motion will cause the PSIS monitoring thumb to rise superiorly, indicating a positive standing flexion test on that side. Although usually indicative of sacroiliac joint dysfunction, a positive standing flexion test could also indicate dysfunction anywhere in the ipsilateral pelvis or lower extremity. Seated Flexion Test (Fig.

3.5)

This test is performed in a manner similar to the standing flexion test. The patient is preferably seated with the feet flat on the floor and asked to bend forward at the waist. The physician monitors for PSIS motion with the thumbs. The seated flexion test is pos itive on the side where the thumb rises more superiorly. This test is more specific for

FIGURE 3.5

The seated flexion test.

26

S e ction I • Philosophy a n d P r i n c i p l e s of P a t i e nt C a r e

sacro i l i ac J o i n t dysf u n ct i o n t h a n t h e sta n d i n g f l e x i o n test beca use t h e i n f l u e nce of l ower extrem ity dysfu nct i o n i s effectively removed by s i tt i n g d own .

Refe rences 1. E C O P. Glossary o f oste o pa t hi c term i n o l ogy. In: Wa rd RC, ed . F o u n d a t i o n s fo r Osteopa t h i c Medic i n e . 2 n d e d . P h i l a d e l p h i a : L i p p i n c o t t W i l l i a m s & W i l k i ns , 2 0 0 2 ; 1 229-1 2 5 3 . 2 . Fryette H H . Principles of Osteop a t h ic Tech n i q u e . I n d i a n a p o l i s : A m e rica n A c a d e m y o f Osteo p a t h y, 1 9 5 4 , 1 9 8 0 . 3 . S t r a c h a n W F. A p p l ied a n a r o my o f t h e pelvis a n d lower e x t re m i t i es J A m Osteo p a t h Assoc. 1 94 0 ;4 0 : 5 9-6 0 . .

The Manipulative Prescription Kenneth E. Nelson

"One must not be

a

blacksmith only, and only able to hit large bones and muscles with

a heavy hammer, but one must be able to use the most delicate instruments of the sil versmith in adjusting the deranged, displaced bones, nerves, muscles and remove all obstructions, and thereby set the machinery of life moving

To do this is to be an

osteopath"

A T Still I

As defined by

Stedman's Medical Dictionary, a prescription is "a written for

mula for the preparation and administration of any remedy."2

When writing a prescription, you must determine wh i c h therapy, how much,

how often. An example is ampicillin 500 mg every 6 hours. The same questions must be answered when deciding upon a prescription osteopathic manipulative treatment

(OMT).

for

OMT is a therapeutic inter ve n ti o n. It is the definitive treatment for somatic dys function and is employed to treat primary somatic dysfunction. It is also used to address the effect of somatic d y s f u n c t i on upon a patient'S recuperative abilities from concomitant disease processes. Because it is a therapeutic modality, its dosage must be determined and prescribed. This is defined by the diagnosis of the somatic dysfunction withi n the context of the individual patient. 27

28


DIAGNOSIS Before one ca n determine what therapy is to be used, a diagnosis must be ma de.

A

d iag no s is is a logical c o ncl usio n based upon information obtaine d from the chief S his to ry and the p h ysic al examination. The diagnosis of primary somatic dysfunction is often, a ltho ugh not always , associated with musculoskeletal pain. Somatic dysf unct io n may contribute to the patient'S illness, as in the effect of motion restriction of the thoracic cage upon the p atient with pneumonia. Consequently, somatic d y sfunction shoul d be appropri c o m pl ai n t, the p atient

'

,

ately treated, even in the absence of musculoskeletal complaint.

The diagnosis of somatic dysfunction is based upon the i dentification of one or m ore of the p hys ica l fi n ding s described as TART: tissue te x tur e abno rm a l it y, asym

metry of position, restriction of motion, and ten de r n ess. Of these, tenderness a n d tissue texture abnormality may be sought out when screening an area for significant dysfunction. Once a d y s func tion al area has been identified, one mu st specifically define (diagnose) the mechanics of the dysfunc tion. (See Chapter 3.) Define the Barrier T he ph y sici a n examines the patient and precisely identifies asymmetry of position and restriction of motion. Motion restriction is pa rt icu la rl y i m po r ta n t because the most common go al of OMT is restoration of free movement. The mechanical pattern of the motion restriction determines the mechanics of the t her ape u tic intervention.

Determine Why the Barrier Is Present Once the physician has diag no se d the mechanical pattern of the so m a ti c d y s fu nc

tion, it is necessary to ide ntif y what is causing the d ys f unc tion Is it the result of .

articular restriction? Is it due to ti g ht muscles or altere d fascial tension? Making this decision will help to determine what ty pe of OMT will be selected to treat the dysf unc t ion .

TREATING THE PATIENT If it is determined that the barrier is the result of articular dysfunction, the proce dure s h o u l d be d i rec te d at affecting articular mechanics. Such proce du res inclu de high-velocity, lo w a mplitu de (HVLA) thrust and low-velocity, moderate- to high am p l it u de articulation proce dures. If the barrier is the result of soft tissue tension, a procedure that is inte n de d to affect soft tissue is c ho s e n (muscle energy, soft tissue s tret ching , myofascial -

release).

If the dysfunction is best addressed by attempting to re duce neural reflex activity, counterstrain and facilitate d positional release may prove to be the procedures of choice.

So matic dys fu nctio n that is the result of viscerosomatic re fle x activity is specifi c ally treated by treating the underlying visceral pathology. Treatment of the visceral pathology may be facilitated (but not replaced) b y man ip ul at ing the somatic compo nent (somatovisceral reflex). Procedures chosen under these circumstances shoul d produce somatic relaxation with minimal stimulation. Once the visceral component

29

Chapter 4 • The Manipulative Prescription

has been effectively treate d, residual somatic dys funct i o n may be treated using the

logic described earlier and that discussed in the following pa ra grapbs

.

Patient Tolerance The physician at this point is almost ready to choose the procedure. There is, how e ver, one more decision-making point to consider: How much can tbe patient tol erare ? Obviously, a healthy 27 year old has greater tolerance than a health),

90 year old. A lso, a healthy 27 year old can tolerate more than tbe same individual

with pneumonia. Patient tole rance dictates the level of aggressiveness of the procedure chose n . A somewhat artificial continuum of procedures can be created based upon the rel · arive aggressiveness of the procedu res.

High-velocity, low-amplitude (HVLA), most aggressive Articulation (ART) Soft tissue (ST) Direct fascial release (DlR)

Muscle energy (ME)

Counterstrain (CS)

Facilitated positional release (FPR)

Indirect fascial release (lND)

Indirect cr L) r i g h t- s i d e d rea c t i o n

TI l to Ll , right- s i d ed react ion Ll to L3, l eft-s i d e d reactio n

Esop hagus Stomach D u o d en u m P a n c re a s ; i n c h r o n i c pa ncrea t i t i s a re a ten d s to be fixed i n exte n s i o n L i ve r G a J l b l a d der Sm a l l intestine Appe n d ix; a ssoc i a ted w i t h ten d e r n ess over the ti p of the 1 2t h rib on the ri g h t ( a nterior Cha pma n 's tender point) Cec u m a n d a scen d in g colon Desce nd ing colon

294

Section III • C l i n i c a l Co n d i t i o n s

T h e combinat ion o f C2 l e ft , T3 to T 6 right, T 5 to T I O left, and T6 to T 8 right is re ferred to as the upp er gastrointestinal pattern . The locations of the somatic manifestations of visceral dysfunction or pathology are generally predicta b l e . The i nte nsity of the tissue te xture c hange m i rrors t h e severity of the viscera l problem. Visceroso matic reflexes a d d greatly t o physical diagnosis and may also be use d to follow the clin ical progression o f

a

d isease .

N eoplastic diseases do not p roduce typical visce rosomatic reflex responses. The cord level response for th e invo l v ed visc u s will occur, but bec ause neoplasm ty p i call y deve lops wi thout i n n ervation, there is no direct source of affere nt input. Reflex activity occurs as a result of visc era l disp l a c ement and i n flammation from the presenc e of the neopl asm, not from the neoplasm itself. As s u c h , the re fle x, when encountere d , is often l ess intense than would be anticipated con s i dering the severity of the disease .

C h apma n 's re flexes , another visc erosomatic -somatov iscera l system, are a group of palpable nodular areas of tissue texture change that have diagnostic and therapeuti c sign ificance. They are considered to be a ne uroly mphatic reaction. Treatment of these points using in h ibitory pressure is repo rted to be an effective treatment of visce ral complaints. 8 The posterior re flex points in Ch apman's syste m in many instances app roximate the locations of the visce rosomat i c re flexes l isted previously. The i ntegration of the treatment of somatic dysfun ction into t h e therape utic protocol w ith OMT is indi cated for the spec ific treatment of so matic dysfu nction . A s stated previously, somatic dys func tion i s functional impai rme nt o f the neuro musculosk eletal system. Alth ough it may exist in the p rese n c e of patho l ogy, it is not in itself pathology. OMT for treatment of somatic d ysfunction is used to increase available motion, modi fy activity of the nervous syste m , or i ncrease tissu e perfusion. The integration of th e diagnos is and treatment of somatic d ysfunction into the p ractice of gastroente rology may initi ally seem superfluous. The seve rity of i llnesses en countered a n d the fact that t h e gastrointestinal syste m is consid e red to be sepa rate from the musculoskeletal system make the diagnosis of somatic dys fun ction seem inconsequential. Furthermore , OMT is not directly used for t h e t reat m e n t of gastrointestinal disease processes. Why then should one diagnose and treat somati c dysfunction in the patient with gastrointesti nal comp l ai nts an d/or patho logy ? It is b e n e ficia l , if a pati ent comp lains of a pain that resembles a gast rointesti nal probl em, to dete rmine wheth e r it is ac tually

a

pri mary m usc u loske letal pro b le m

amena ble t o OMT. If th e probl e m is gastrointe stina l , is it f unctiona l or organic ? Fu n c tiona l com plaints that res u l t from somatovisceral r e fl exes respond to the treatme n t of under ly i ng somatic dys func tion. When treating a patient w i t h an organic gastroi n test inal disease process , the physic ian can dete r m i n e how to integrate the treatment of somatic dysfunction into the th erapeutic protocol by answering the following questi ons:4 1 . How is musc u los kel etal dy sfunction affecting the patient's abil ity to re spond

to the disease p rocess? 2. What sympathetic somatovisce ral mecha nisms are present? Spinal facilitation

with resultant increased sympathetic tone i ncreases vascular tone, hence decreases tissue perfusion and nutrie nt and oxyge n supply to tissues and the reby increases any need for anaerobic glycolysis. It relaxes the ga llbladder and b i liary d u cts and decreases the glandular secre tions and pe ristalsis, produc i ng constipation or ile us.

C h a pter 20 • T h e Pat i e n t w i t h G a st r o i ntest i n a l P r o b l e m s

295

3 . W h a t parasy m pa thetic s o m a tovisceral m ec h a n i s m s a re prese n t ? S p i n a l faci l i

t a t i o n w i t h re su lta n t i n c reased p a r a s y m p a th e t ic t o n e increases t h e secret i o n of the d igestive enzymes a m y l a se and l ipase. It ca uses co n tractio n o f the gall b l a d der a nd b i l iary d ucts a n d i ncrea sed gla n d u l a r secretions a n d perista l s is , pro ducing d iarrhea . 4 . How is ci rc u l a tory stasis a ffecting the pa tie n t ? The m ec h a n ica l com p o n ent o f soma tic d ys fu ncti o n res u l ts in restrict i o n of motio n . Effic i e n t movement of the thoracic inlet, thoracic cage, a bd o m i n a l d ia p h ragm, mesen teries, and pe l vic d i a p h ragm is necessa ry for o p t i m a l low-press u re fl u i d ( lympha tic a n d ven o u s ) d y n a m ics a nd tissue perfu s i o n . Inefficiency of th is mech a n is m fu rther a d d s t o the tend ency toward tissue congestion . Viscerosoma tic reflexes ca use muscle spasm, tenderness, a n d p a i n . Part o f the d i ag nostic d i lemma is the d i fferentiation between a viscerosomatic reflex and p r i m a ry soma tic dysfu nctio n . The pe lvic d i a p luagm is i nnerva ted by the p u d enda l nerve (52-54 ) o f the pelvic sp l a nchn ic nerves. Pain i n this area may be viscerosoma tic, p e l vic pa rasym pathetic, o r simply the res u l t o f sacrope lvic somatic dysfuncti o n . Proper appl ica tion of O MT resolves p rima ry somatic dysfu nction. A l t hough viscerosomatic refl exes ca n be a ffected by OMT, the associa ted soma tic find i ngs wi l l not resolve u n t i l t h e u n derlying v iscera l cond ition is trea ted . Fa i l u re of soma tic dysfu nction t o respond to O MT should lead to the consideration of a viscerosomatic etiology. Indeed, part o f the eva luation of any somatic d ysfunction shou ld include i n q u i ry a bo u t segmenta l ly re l a ted viscera . Appen d icular complaints may result from viscerosoma tic-somatic re flexes, as in the exa m ple of l eft arm pain resu l ting fro m myoca rdia l ischemia .

C H OO S I N G A N D U S I N G TH E P R O C E D U R E H a v i n g d ecided what t o treat a n d h o w t h e tre a t m e n t is i n te n d e d to a ffect the patient, the p hysici a n m u s t d ecide u p on the m a n i p u la tive proce d u re to e m p loy. Patient to l e rance d ictates the leve l of a ggress iveness of the proced u re chose n . A somewhat a r t i fici a l conti n u u m o f proce d u re ca n b e cre a te d based u p on the relative aggressiveness o f the proced u r e . • • • • • • • • • •

High-veloci ty, low-a m p l i t u d e (HVLA )-most aggressive A rticu l a t i o n S o ft tissue D i rect fa scia I re l ease M u scle e n e rgy Cou n terstra i n Fac i l ita ted positio n a l release I n d i rect fasc i a l release I n h i bitory pres s u re Ind i rect cra n i a l-least aggressive

As stated , this l is t is q u ite a r b itrary a n d open to d e ba te , b u t the i d e a i s v a l i d . A lso, bes i d es t h e aggress iveness of t h e proced u re type, t h e t i m e req u i re d fo r a ppli c a t i o n a ffects p a t i e n t to l e r a nce. The l onger a proced ure takes, the less the patient m a y be a bl e to tolerate i t . As a r u le, the more aggress ive the p roce d u re , the less time req u i red for its a pp l ica t i o n . How m u c h O MT is e noug h ? Treat the patient u nti l a response occurs. Wha t k i n d of response? Relaxa tion o f t h e soft tissue i n t h e a rea being treated i s a good response. Altered a u tonomic tone is a lso an i n d ication o f a response. Peripheral vasod i la ti o n

296

Section III • Clin ical Cond i t i ons

res u l t i n g i n i ncre ased s k i n tempera ture or red ness a n d i ncreased s u d om o to r ( swea t i n g ) a c t i v ity i n d i c a te i t i s time to stop. Increased h e a r t o r res p i ra tory r a te a l so i n d i c a tes tha t t h e p a t i en t's l evel o f tolerance h a s b e e n reached . I f the p a t i e n t feels t h a t i n terve n t i o n i s t o o unco m forta ble, t h e physician s h o u ld s t o p a n d c h oose a n other a p p roa c h o r ret urn l a ter a n d try a ga i n .

Clinical Example: Pancreat itis The Disease

Pa n c r e a t i t i s i s c l a ssi fied a s a c u te or c h r o n i c . A c u te pa n c r e a t i t i s is m o s t freq u e n tly enco u n tered a s the res u l t o f gallstone o b s t r u c t i o n of the c o m m o n d uct ( c h oledo c h o l i th i a s i s ) . The c o n d ition resolves c l i n i c a l ly and h istologic a l l y once the o bstruc tion is e l i m i n a te d . Chron i c re l a ps i n g p a n c rea ti tis, w h ich t y p i c a l l y res u l ts from a l c o h o l a b u se , p e rs ists h is tol ogica l l y a fter cess a t i o n o f t h e e t i o l ogic c i r c u m s t a n c e . B o t h a c u te a n d c h ro n i c rel a p s i n g ( h istolog i c ) p a n c reatitis a r e m o s t o fte n enc o u n tered cJini c a l l y a s a c u te p a ncrea t i t i s . There a r e m a n y o t h e r c a uses of pa ncrea t i t i s . Choledocho l it h i a sis a n d a l co h o l i sm, however, acco u n t f o r m o s t c a s e s . 9 The p a t i e n t h a s s e v e r e c o n s t a n t u pper a b d o m i n a l p a i n a n d re fe rred p a i n t h a t r a d i a tes th r o u g h to the m i d t o l ow t h o r a c i c r eg i o n of t h e bac k . There may b e cep h a l g i a . There i s n a u s e a , v o m i t i ng, d i a p h o re s i s , t a chycard i a , a nd

s ha llow

t a c h y p n e a . The p a t i e n t's tempera ture ma y b e n o rma l o r s l i g h t l y e l eva ted . The a bd o m i n a l wa ll may be r i g i d , with r e b o u n d te n d e r n e s s . Bowel s o u n d s a re h y p oac tive. I n severe c a ses, t h e l i be r a t i o n of p a ncre a t i c e n zy m e s res u l ts in pa ncre a t i c a u t o l y s i s and s h oc k . The Pain Pa ttern

In i t i a l l y, t h e a c u tely i n fl a m e d pa ncre a s is p e r c e i v e d as

a

d eep d u l l pa i n . As the

i n fl a m m a tory p rocess i n volves the pa n c re a t i c v i s c e r a l p erito n e u m , w h i c h c o n ta i n s u n m y e l i n a te d n o c i c e p t i v e nerve e n d i ngs, the p a i n becomes s e vere . A t t h i s p o i nt, p e r i to n e a l signs d e v e l o p . Fur ther s pread of the i n fl a m m a to r y process i n v o l v e s the p a r i e t a l p e r i t o ne u m o f the a nterior a bd o m i n a l w a l l . Th i s res u l ts in the r i g i d a bd om i n a l w a l l s p l i n t i n g see n i n p a ncrea ti t i s . T h e p a ti e n t perceives referred p a i n i n t h e i ntersc a p u la r regi o n . O cc i p i t a l h ea d a c h e m a y a l s o be p rese n t . T h e ge n e r a l ized upper a b d o m i n a l p a i n a s soci a ted w i t h a c u te p a n c re a t i t i s seems e a s y to u n d ersta nd . Th e pa ncreas is an upper a bd o m i n a l m i d l i n e o rga n . T h e vis ceroso m a t i c r e fl e x fr o m p a n c rea s ma kes this p a i n d i s t r i b u t i o n even more l ogica l . T h e pa ncre a s refl e x is b i l a te r a l fr o m T 5 to T9 . T h e T5 t h r o ug h T 9 d e r m a t o m e s s u p p l y the upper a bd o m i n a l w a l l . S p ina l fa c i l i t a t i o n p r o d u ce s segm e n t a l hypera l ges i a . The b i l a te r a l i n v o l v e m e n t o f t h e p a n c re a s reflex re s u lts i n s e n s i t i z a t i o n o f t h e e n t i re u pper a bd o m i n a l w a l l . Pa n cr e a t i c r e ferred p a i n i n t h e m i d to low t h o r a c i c reg i o n i s a d i rect m a n i fes t a t i o n o f the loca t i o n o f the p a n c re a s i n a ss oc i a t i o n w i t h t h e b i la te r a l T 5 t h r o u g h T9 p a ra verte bra l tend erness o f t h e v i sceroso m a t i c refl e x . T h e occip i t a l h e a d a c h e i s a res u l t o f t h e v a g a l v isceroso m a t i c re flex t h rough t h e gre a ter a n d l e s s e r occ i p i t a l nerves t h a t origi n a te fr o m C 2 a nd C3 . The Musculoskele tal Palpa tory Findings

The s y m p a th e t ic v i scero s o m a tic reflex from t h e p a n c r e a s is fo u n d b i l a tera l l y fro m T5 to T9 . P a r a v e r te b r a l t i s s u e texture c h a nge is pa l p a b le a t these le v e l s . T h e m o re

severe the c o n d i t i o n , t h e gre a te r t h e a re a of t i s s u e text u r e c h a n g e . In l o ng s ta n d i n g c a s e s of c h r o n i c pancre a t i t i s , t h i s a rea beco mes exte n d e d , d e m o n stra t i n g fl a ttening or revers a l o f the th o r a c i c k y p h o s i s . The p a r a sympa thetic ( v a ga l ) viscerosoma tic

C h a pter 20 • T h e Pa t i e n t w i t h G a stro i n test i n a l P ro b l e m s

297

reflex is fo u n d i n t h e u p per cerv i c a l reg ion ( o c c i p u t to C2 ) . It is u ni l a tera l , w i t h a grea ter incidence on the right. T h i s reflex is p a r t i c u l a rly u s e fu l fo r m o n i t o r i ng pro gress i o n of the i l l ness beca use its su bocc ipita l loca t i o n makes i t e a s i ly access i b le i n the bed r i d d e n p a t i e n t . I f pa ncrea titis d e ve l o ps a s t h e res u l t o f cho lecystitis a n d choledochol i t h i a s i s , a ga l l b l a d d e r reflex w i l l b e presen t a t T I O right. I f i t develops i n a ssoci a t i o n w i t h a lco h o l i c hepa t i t i s , a s l i gh t l y b roa d e r rea c t i o n , T9 to TI O right, c a n be e xpected . W i t h the deve l o p ment of i le u s , a s ma l l i n testi n a le reflex wi l l be p rese nt, T8 to T I O b i l a te r a l , right greater tha n left. The u pp e r gastro i ntesti n a l irr i t a t i o n a ssocia ted w i t h t h e n a u sea a nd v o m i t i n g t h a t accompa ny p a n c re a titis pro d u ces an upper gastrointes t i n a l reflex pattern o f occ i p u t to C2 l eft ( va gu s ) , T3 to T6 right (esop h a g u s ) , T5 to no left ( s t o mach ) , a nd T6 to T8 r ight ( d u o d e n u m ) . The accompa nying perito n i tis i n v o l ves the pa rieta l a nd viscera l perito n e u m . The p a r i eta l peri to n e u m i s i n n e r v a ted by s o m a t i c nerves; therefore, pa rieta l p e r i to n i t i s p rod uces a s o m a toso m a t i c p a r a v e r te bra l refl e x w i t h pa l pable f i n d i ngs i n the low thoracic a n d m i d cervica l ( p h re n i c ) region s . T h e s o m a t i c fi n d i ngs pa raverte b r a l l y i n the upper c e r v i c a l r e g i o n a nd fro m T 5 to T9 b i l a tera ll y i n a s s o c i a t i o n with t h e signs a n d sym ptoms of pa ncre a titis a r e v e r y u s e f u l i n fo rm a ti o n . As can rea d i ly be seen, t h e m o r e c o m p lex t h e presentation and the m ore i n tense the p a t h o l ogy, the grea ter the area o f v i sceroso m a tic reflex parave rte bra l tissue texture c h a nge. In severe p a ncre a t i tis, the e n t i re cerv ica l , tho r a c i c , a n d u p per lumbar regi o n s m a y become reac t i v e . Viscerosomatic r e f l e x fi n d i ngs a re a part of the complete p hysica l exa m i n a t i o n . T hey a re not i n tended to r e p l ace exa m i na t i o n of t h e rest o f t h e p a t i e n t . O n t h e contra ry, t h e p a l p a tory s k i l l leve l necessa ry to pe rfo r m t h e osteo p a t h i c m uscu loskeleta l e x a m i n a tion has gre a t va l u e for pa l pa t i n g the a c u te a bd omen a n d else where. A com plete h i story and phys i ca l exa m i n a ti o n give the i n form a t i o n n eces s a ry to fo r m u l a te d i f fe re nt i a l d i agn oses . The more i n formation a va i l a b l e , the m o re precise t h e d iagnos i s . D i a gn oses a re c o n firmed or r u led o u t u s i ng tec h n o l ogica l m e t h o d s ( e . g . , l a bo r a tory, u l traso u n d , r a d i ography, co m p u ted tomogra p h y, mag netic res o n a nce i m a g i ng ) . The more precise t h e d i a g n oses a re, the more cost effec tive t h e use of tech no-d iagnostic p roced u res. Treatment

A c u te pancreatitis m a y v a ry in i n te n sity fro m m i ld to l i fe t h r e a te n i ng . The b a s ic tre a t m e n t is s u p po rtive, w ith speci fic trea tment d irected a t u n d erlying c o n d i t i o n s . O MT used a t t h i s t i m e is i n t e n d e d to red uce the i nte n s i ty o f the a c u te cond i t i o n . The patien t'S tolerance is red uced, a n d c a re m u s t be t a k e n not to use a p roce d u re t h a t is u n necessa r i ly st i m u l a t i ng. The s y m p a t hetic v i scerosom atic refl e x e s assoc i a ted w i t h pancre a t i tis and c o n s e q u e n t l y the a re a s t h a t a re trea ted fo r somatoviscera l e ffect a re fo u n d i n the m i d t o low t h o racic region . T h e p a r a s y m p a thetic reflexes a re fou nd in the upper cerv i c a l a n d s u bocc i p i ta l regio n . T h e i n tens ity of t h e viscera l pa thology d etermines t h e a mount of spi n a l fa c i l i ta t ion p resent. Parave rte bra l tissue te xture c h a nge is d i rectly p ropo rti o n a l to the severity of v i scera l p a t h o l ogy. The use of O M T to prod uce a somatovisceral response is not s i mp l y " p u s h ing the bu tton " a t the a n ticipated reflex l e ve l . Os teop a t h i c p h y s i c i a ns must use th e i r p a l p a tory s k i l l s to d e t e r m i n e the a reas of maxi m u m tissue texture c h a nge, then, with an appreci a t i o n for the d egree o f to l e ra nce o f t h e p a ti e n t d e c i d e upon the type of p roce d u re to use. For trea t i n g a n a c u te v i scerosoma t i c reflex for s o m a tov isceral effect, i n h i b itory press u re is usefu l . I n h i b i to ry press u re is a d i rect proce d u re t h a t may be d escri bed a s extremely l o w veloci t), a nd l o w a m p l i t u d e . Pressu re i s a pp l i e d over the a re a o f ,

298

Secti o n I I I • Cl i n ica l Cond i t i o ns

m a x i m u m t i s s u e te x t u re c h a nge using the d i sta l p h a l a n ge a l pa d of the fi nger o r t h u m b . T h e pressure i s i n c r e a s e d v e r y s l o w l y a s t h e t a r ge t t i s s u es re l a x . T h e d ev e l o p m e n t o f r e a c t i v e m u s c l e s p a s m i nd i c a tes t h a t t h e p roced u re i s too aggressive a nd s h o u l d be s t o p ped . When t o l erated , t h e press u re is a p p l ied a n d h e l d u n t i l press u r e a n esthes i a d e v e l ops in t h e trea t i n g p h y s i c i a n 's t h u m b or fi nger. ( I f p ress u re a n es thesia i s sensed by t h e tre a t i ng p hys i c i a n , it is pro b a b l e t h a t press u re a n e s t h e s i a a l s o has been prod uced i n t h e tiss ues b e i n g trea ted . ) A t t h i s t i m e , the p ress u re is very s l owly r e l e a s e d . This p r o ce d u r e may b e r e p e a ted i n 1 or 2 h o u rs d e p e n d ing upon th e p a t i e n t 's t o l e rance. It may be e m p l oyed in the t h o r a c i c reg i o n for s y m pa

th e t i c effect a n d i n the u p per cervical region fo r pa r a s y m p a t h e t i c effec t . T h e periton itis associa ted w i t h a c u te p a n crea t i t i s lim i ts d i a p h ragmatic exc u rs i o n . This pred i sposes t h e patient t o lower p u l m o n a ry a te l ecta sis a nd p n e u mon i a . G e n tl e

thoracic a n d costal m o b i l i z a tion a n d r i b ra i s i n g t o to lerance a re a pp ro p r i a te here. As the peri tonitis beg i n s to su b s i d e , myofa scia l p roced ures for the a bd o m i n a l w a l l , d i aph r a g m a t ic r e l e a s e , a n d thoracic p u mp p roce d u r e s s h o u l d be employe d . The l i mi t a t i o n of t h o ra c i c cage a n d a b d o m i na l w a ll m o b i l ity a n d decreased d i a p h ragm a tic excurs i o n seve rely l i m i ts t h e retu r n of lymph to t h e genera l c i rc u l a tion . Th i s h a s e n o r m o u s c o n s e q u e nces w h e n p a n c re a tic i n fla mma t i o n h a s s h i fted fl u i d i n to the i n ters t i t i a l s p a c e . The p resence of c e l l u l a r d e bris a n d m a c romolec u l e s i n the fl u i d exert s ign i fi c a n t o s m o t i c fo rce, m a k i n g l y m p h a t i c d r a in a ge t h e o n l y ro u te of egress. T h e p r oced u res i d ent i fi e d previously a re a l so a p propria te the r a p y h e r e . A s s o o n a s p a t i e n t tolera nce p e r m i t s , lym p h a t i c ( pe d a l p u m p a n d t h ora c i c

p u m p ) proce d u res s h o u ld b e i n i t i a ted .

C l i n i c a l Exa m p l e : C h o l ecystitis The Disease

Ch o l e c y s t i tis is very c o m m o n i n the U n i ted S t a t e s . A p p r o x i m a t e l y 9 0 % of p a t i e nts with c h olecystitis have ga l l s t o n e s with th e potent i a l for o b s t r u c t i o n .

In

In 1 996,

3 0 m i l l i o n people were d i agnosed w i t h c h o lecy s t i t i s w i t h l i t h i a s i s a n d nea r l y 9 0 0 , 0 0 0 c h o l ecystec t o m i e s were p e r formed . T h e

re ma i n i

ng 1 0 % o f t h ese p a tients

a re described a s ha v i n g a c a l c u l o u s c h o l ecystitis, o r c h olec y s t i t i s w i t h o u t g a l l s t o ne forma t i o n . 1 1 It i s t h i s 1 0 % of cases of cho l e c y s t i t i s t h a t t h e osteopa t h i c p l1ysic i a n m a y o ften d i agnose th rough t h e u s e of v i sc e roso m a t i c refl e xes. The d iagnosis of c h o lecystitis is often d i ffi c u l t , a s i ts common sym ptoms o f belch i ng, bl o a t i ng, hea r t b u r n , fatty fo od i n tol erance, chro n i c rig h t u p per q u a d ra n t p a i n , r i g h t shoulder pain, a n d m i d epiga stric pa i n m a y a l s o be s y m ptoms of peptic u lcer d is ease, a ppend icitis, ileitis, and he patitis. A lso, c h o lecystitis may cause r i gh t l ower q u a d

r a n t p a i n, l e ft upper q u a d r a n t p a in , a n d even c hest p a i n a s at ypica l presenta t i o n s . I

1.12

Ga l l b l a d d er d i sease i s often cons i d e red only a fter the patient w ith sym ptoms o f peptic u lcer d isease is u n responsive to the use of H2 b loc kers or p ro to n p u m p i n h i b i tors.

Cho lecyst i t i s does not h a ve a ny speci fic l a b o r a t o r y m a r k e rs to h e lp with d i a gno sis. If a b i l i a ry d u ct o b s t r u c t i o n h a s been persiste n t , m i ld l y e l e v a te d transa m i nases w i th leuko cyto s i s m a y r es u l t

,

b u t a l c o h o l ic hepa titis will a lso p rod uce these

c h a nges . " Proced u res such a s h e p a t i c a nd ga l l b l a d d e r

ul

t r a s o u n d s may h e l p w i t h

t h e d i a gnosis when ga l l b l a d d er wa l l t h i c k e n i n g a n d stones a re prese n t . The p resence of g a l l stones d oes n o t necessa rily mea n the p a t ie n t h a s c l i n ica l l y s i g n i ficant d i sease .

Many p a t i e n ts have g a l l s to n e s w i t h o u t a c u te d i sease. I

I

Nuclear i maging may a l so be usefu l i n the d i a g n os i s . B i l i a ry tract i m a g i ng, hipoto i m i nod i acetic acid (HIDA ) , p a ra - i s o p ropyl aceta n i l id o - i minod i a cetic acid ( PIPIDA), or d i isopropyl i minod iacetic a c i d ( D ECID A , prono u nced d es-i-d a ) sc a ns a re u seful in d e term i n i n g o b struction of the b i l i a ry tra c t . I f c h o lecystitis i s present, the ga l l b l a d d e r

Cha pter 20 • T h e P a t i e n t w i t h G a stro i ntest i n a l P r o b l e m s

299

will not fi l l with ra d i oactive c o n tra s t by retrogra d e flow t h r o u gh t h e cys tic d u ct. The a s s u mption i s tha t the cystic d u ct wa l l i s too e d e m a to u s and i n fla med to perm it flow o f tbe ra d i o n u c l e o t i d e fro m t h e common d u ct through the cystic d uct and i n to the gall b l a d d er. W h e n used i n co n j u nction w i t h u l traso u n d fi n d i ngs o f t h ickened d u ct and ga l l b l a d d e r wa l l s , t h i s i n fo r m a t i o n c a rries a h igh proba b i l i ty that the d i agnosis of acute c h o l ecystitis i s co rrect, but i t i s n o t

a lways concl u s i ve . 1 3

Th e Musculoskele tal Palpatory Fin dings

T h e v i sce roso m a t i c r e f l e x fro m l iv e r a n d ga l l b l a d d e r h a s been i d e n t i fi e d a s r i g h t 7 s i d e d pa r a v erte b r a l t i s s u e texture c h a nge fro m TS to T I O p o s te r i o r l y. 6 , 1 4- 1 Rece n t l y, M i ll e r a n d assoc i a tes l S studied the re l a ti o n s h i p of the viscera l ga l l bl a d d e r affe rent projections i n t h e mouse t o deter m i n e t h e n e u roana to m i c a l re l a t i o n s h i p o f viscera l ga l l b l a d d e r n e u rons t o soma tic i n tercosta l n e u rons v i a t h e d o r s a l root ga n g l i o n . Fast b l u e dye w a s p l a ced i n the ga l l b l a dder o f the experi m e n t a l m ice. A second d ye , n u c l e a r y e l low, was p l aced o n severed ends of t h o racic intercosta l nerves. The

48 to 72 h o u rs, O f the expe r i m e n ta l m ice, 8 0 % revealed the p resence o f d yes

dyes tra ve l ed retrogra d e a l ong the a xons v i a a x o n a l tra nsport. A fter the m i ce were k i l led .

fro m both t h.e ga l l b l a d d er and the i ntercosta l nerves i n the d orsa l root ga ngl i a a t the

T9 to T I 2 l e vels on t h e r i g h t . The fi n d i ngs of t h i s experi ment c onfirm the presence of b i fu rcating v iscerosom atic d o rs a l root g a n g l i o n ce l l s ( b i furca t ing pe r i pheral processes fro m i n d i v i d u a l d o r s a l root ga n g l i o n ce l l s to the ga l l bl a d d e r a n d i n tercos ta l nerves ) in the mouse. Thus, M i l l e r 's fi n d i ngs d em o n s t r a te that a t least fo r m ice t h e viscerosom a t ic reflex from ga l l b l a d d er is between the levels of

T9 to T I 2 o n the right.

T h e pa l p a tory ex a m i n a t i o n d u r i n g a n a c u te episode o f c h o l ecys t i t i s will revea l tiss u e t e x t u re c h a nges i n t h e a re a s of the costotra n s v e r s e a r ti c u l a t i o n a n d t h e r i b a n g l es o n t h e r i g ht, m o s t i n tense l y a t

T 9 a n d T I O . These c h a nges i n c l u de m o i s t u re ,

p u ffi ness, te n d e r n e s s , w a r m t h , a n d red n e s s . T h e p a t i e n t m a y a l so h a ve fi n d i ngs consiste n t with t h e v i sce rosoma tic pa ttern fro m upper g a s t ro i n test i n a l i r r i t a t i o n

( C 1 -C2 l e ft , T3-T6 r i g h t , TS-T I O l e ft ) . T h e y m a y a l so d e m o n s t ra te a res tr i c t i o n

of m o t i o n o f the r i g h t h e m i d i a p h r a g m . S p i n a l c o rd segme n t fa c i l i ta t i o n t h u s a l l ows t h e tra i n e d osteopa t h i c p h y s i c i a n to d i fferentia te betwe e n d i ffe re n t d i s e a s e p rocess e s . T h i s i s parti c u l a rly u s e fu l w h e n sta n d a r d p h y s i c a l a n d l a b o r a t o ry fi n d i n g s a re i nc o nc l u s ive. Trea tmen t

I n i t i a l trea t m e n t o f the p a t i e n t w i t h c h o l ecys t i t is d e pe n d s o n t h e s e v e r i ty of the p a t i e n t's sympto m s . S y m p to m a t i c p a t i e nts who a re a m b u l a to r y a n d a fe br il e , w i t h o u t d e h y d r a t i o n o r s i g ns o f a n a c u te a bd o m e n , m a y be g i ve n d i etary res t r i ct i o n s a s t h e f i r s t l i n e o f trea t m e n t . R e d u c t i o n o f fa tty foo d s m a y p r e v e n t fu r t h e r ga l l b l a d d e r a tt a c k s , e s p e c i a l l y i n p a t i e n ts w i t h o u t s t o n e fo r m a t i o n . Tre a t me n t o f a r e a s o f s o m a t i c d y sfu n c t i o n wi l l a l s o i m p r ove n e u r a l fu nct i o n t o t h e a re a s . S o m e p a t i e n t s w it h d i s e a s e acco m p a nied by s t o n e fo r m a tion c a n b e m a i n t a i n e d w i th t h e fa tty food restr i c t i o n s , b u t o ften t he chro n i c i rr i t a t i o n o f the g a l l b l a d d e r fro m t h e stones a n d t h e cha nce o f e x p u l s i o n of s t o n e s a n d poss i b l e o bs t r u c t i on of the cy s t i c or c o m m o n d u cts rema i ns q u i t e h ig h . As a res u l t , s m a l l a m o u n ts of fa rry fo o d s m a y trigger an a tt a c k p r e c ip i t a t i n g a s u rgica l e m erge n c y with i ncre a s e d m o r b i d i t y a s opposed to a n e l ective s u rgica l i n te r ve n t i o n . S u r g i c a l r e m o v a l o f the ga l l b l a d d e r, therefore, is often recom mended t o p a t i e n t s w i t h ga l l b l a d d e r d is e a s e

and s t o n e fo rm a t i o n .

T h e d i a g n o s i s of s o m a t i c d ysfu n c t i o n i s n o t o n l y i m po rta n t i n the effective treat ment o f m u s c u l o s k e l e ta l compl a i n ts b u t a l s o Llsefu l i n d i a g n o s i ng viscera l patholo gy. Visceroso m a r i c refle xes res u l t i n somatic d y s fu n c t i o n that is res ist a n t to

OMT.

Section III • C l i n i c a l Condit i o ns

300

OMT works o n l y a fter the viscera l component is trea ted . Reocc u rring a reas of somat ic dysfunction, espec ia l l y w hen the a reas are consistent with a visceroso m a t i c reflex pa ttern should a l ert the p hys i c i a n th a t under lyi ng viscera l p a t h o l ogy may be present. ,

This is true especially with the recurre n t gastro i n testi na l pa ttern. A com pla i n t of per sistent righ t s h o u lder p a i n in the a bsence of tra u ma s ho u l d be

a

red flag to the osteo

pathic phys ic i a n and r a i se a high susp icion of u nder lying gaJ J b ladder d isease. S u rgical rem o v a l o f the d i seased g a l l b l adder m a y re move the c a use of the p a tien t's d iscomfort, b u t often some of the p a t ient's s y m p to m s rem a i n or retu rn. Care ful eva luation of the t h oracic area w i ll reve a l t he per s i sten t reflex patte r n . Tre a t ment o f t h e res id u a l v iscer o s o m a t i c reflex using O MT w i l l h elp res o l ve the pati ent'S s y m p to m s . Tre a t me n t of the reflex a reas w i l l help to reset the neu ra l i n p u t a n d norma l i ze the fa ci l i t a ted a rea s .

CONCLUSION L i t t le h a s bee n said here a bout the i m p o r t a nce o f n u tr i t i o n i n th e ca re o f t h e gas t r o i ntes t i n a l p a tien t . W h i l e this is an extrem ely i m porta nt s u bject, i ts i n c l u s i o n here wo u l d h a ve grea t l y expa nd ed the s i ze o f t h i s c h a p ter. T h i s d i sc u s s i o n stresses m u s c u loskeleta l d i a g n o s i s a n d trea tment, t h e foc u s of this c h a pter. M u s c u los keletal d i a gnosis a n d treatment m u s t be i n tegrated into the tota l d i ag nostic a nd therapeutic protocol for the p a t i e n t with gastroi ntesti n a l p a t h o l ogy. O MT is not i n tended as a repl acement thera p y. It is i n tended to e n hance thera py by fa c i l i ta ti ng the bod y 's i n herent c a p ac i ty to hea l i tself. The u se of osteo pathic d i ag n o s i s a nd trea t me n t proced ures s ho u ld red uce the m o r b i d ity a n d mo rta l i ty a ssoc i a ted w i th gastro i n tes t i n a l p a t h o logy. A l t h o u g h this ma kes sen se, t h e sta tistica l sup port for i t d oes n o t yet exi st. M u c h of w h a t has bee n prese n ted here i s a n ecd o ta l , ba sed u p o n m o re t h a n 1 0 0 years of osteop a t h i c c l i n i c a l empiric i s m . T h e c h al l enge to s u bstanti a te this d i sti n c t i ve a p p r oa ch to p a t ient ca re rests u p o n the osteopa t h ic

p r o fess i o n . It i s hoped tha t by descr i b i ng the i n tegr a t i o n of t h e d iagnos i s a n d trea t ment of s o m a tic d y sfu nction fo r p a tients w i th gastrointestinal path ology the p rofes s i o n ca n iden t i fy protoc o l s u p o n w h i c h to b a se fu t u re outcomes stud ies .

P roce d u res Plea se note : The proced u res t h a t fo l lo w a re e x a m p l es of m a n i pula t i ve treatment t h a t y o u m a y w i s h to e mploy. The a c t u a l c h o i ce of pr oced u res u sed s h o u l d be deter m i ned by the u niq ue c i rc u m s t a n ces of eac h i ndividual p a t ie n t . The fo l l o w i ng proced u res a r e usefu l w h e n treati ng t h e s o m a tic dysfu n c t i o n a s i t re l a tes to the ga stro i ntesti n a l p a t i e n t .

Thoracic Soft Tissue, Deep Articulation PATI E N T ON S I D E

See t h e p rocedure desc r i p t ion i n Cha p ter 5 a nd F i g u re 5 . 3 . T h i s p roced u re i s e mployed to d ecrea se parave rte bral mu scle s p a s m a nd s o ft t i s s u e tens i o n o f t h e t h orac i c spi ne.

Thoracic Soft Tissue Deep Articulation PATI E N T PR O N E

See t he descr i p t i o n o f the procedure i n Cha pter 5 a nd F i g u re 5 . 5 . Th i s proced u re i s e m p l o yed t o decrease p a r a ve rtebr a l m u s cle s p a s m a n d soft t i s s u e te n s i o n of the thoracic s p i ne . P a t ient p o s i ti o n : p r o n e on t h e treatment ta b l e . P h ys i c i a n p o s i t i o n : s ta nd i n g bes ide the p a tient opposite the side to be trea ted .

C h a pter 20 • T h e Pa t i e n t w i t h G a st ro i ntest i n a l P r o b l e m s

301

Rib Raising for Thoracic Cage Dy sfunction

T h i s p r oc e d u re is e mp l oyed to e n h a n ce r i b motion a n d t h o r a c i c cage com p l i a n c e . C o n s e q u e n t l y i t a ug m e n ts venous a n d l y m p h a t i c retu r n to the chest. It i s a l so t h o u g h t to a ffec t s y m p a th etic tone, i n i t i a l l y s t i m u l a ti n g regi ona l sym p a t hetic o u t p u t b u t e v e n t u a l l y r es u l t i ng i n red uced s y m p a t he tic acti v i ty from the s p i n a l levels treate d . ( See the desc r i pt i o n o f the p ro ce d u r e in Cha pter 5 a nd Fig. 5 . 6 . ) Patient Supine for Flexed or Extended Thoracic S om atic Dy sfunction, HVLA (Fig.

20. 1)

This proced ure is e m p l o y e d to treat a rticu l a r soma tic d y s fu nc t i o n , type II mechan ics, i n t h e mid to l o w t h o r a c i c spine. I t m a y be e m p l o y e d for flex ed or e x tended dysfu ncti o n s . In e i t h e r c a s e , the p h ys icia n 's h a n d p l a c e m e n t i s t h e same. T h e p a t i e n t p o s i t i o n ed with the h a n d s b e h i n d the neck works w e l l fo r a p a t i e n t wi t h l o ng a rms a nd a t h i n torso; t h is is the p o s i t i o n d e sc r i bed next. Fo l d i n g t h e a r m s a c ross t h e c h e s t w o r k s better, h o we ve r, if t he pa ti e n t i s stoc ky w i t h s ho r t a r m s . P a t i e n t posi t i o n : s u pi n e . P h y s i c i a n p os i t i o n : sta n d i n g bes i d e t h e patient, o n the s i d e toward w h i c h the dysfunct i o n i s side bent and rota ted , fac i n g the p a t i ent 'S h e a d a t a pp roxi m a tely t h e leve l of the a bd o m e n . Proced u re ( E xa m p l e : N o n n e utra l Ty pe I I A rt i c u l a r Dysfu n ct i o n of T 5 u p o n T6, F l e x e d , S i d e B e n t Left, a n d Rotated Left)

1.

Tell the patient to clasp the h a nds together behind the neck and to approximate the elbows .

2.

Stand on the patient's left side and grasp the elbows with your right forearm and ha nd. This will allow you to use the patient's pectoral girdle to introduce side bend ing a nd extension or flexion.

F I G U R E 20. 1

Patient s u pine thoracic H V LA for flexed or exte nded thoracic somatic dysfunction.

302 3.

Secti o n I I I • C l i nical Cond i t i ons R o l l the p a t i e n t 's u p p er body to the l eft so t h at o n l y the le ft s h o u l d e r is in co ntact with t h e ta b l e .

4.

R e a c h a c ross w i t h yo u r l eft a r m a n d p l ace yo u r l eft h a n d , p a l m u p , u po n t h e ta ble a t t h e level of T 6 . In this pos i t i o n , with yo u r l eft h a n d open, yo u r f i n gers s h o u l d be p o i n t i n g towa rd t h e p a t i e n t 's l eft s h o u l d e r.

5.

R o l l t h e p a t i e nt's s h o u l d ers a n d u p p e r torso b a c k onto the ta b l e a n d p o s i t i o n t h e t h e n a r e m i n e n ce of y o u r l eft h a n d so t h a t it i s i n c o n t a c t with t h e r i g h t tran sverse p rocess of T6 . T h i s asym m e t r i c p l a c e m e n t of yo u r le ft h a n d b e n ea t h the p a t i e n t wi l l i n tro d u c e ext e n s i o n a n d r i g h t rota t i o n o f T5 u p o n T6 .

6.

A d d i t i o n a l s i d e b e n d i n g m a y be i n t ro d u ced with yo u r r i g h t a r m a n d h a n d t h ro u g h t h e p a t i e n t's a r m s a n d pectoral g i r d l e .

7.

P l a c e y o u r c h est f i r m l y a g a i nst t h e p a t i e n t 's e l bows a n d p i n t h e m t o t h e ta b l e . Yo u m a y w i s h to p l a c e a p i l l ow betwe en the p a t i e n t 's e l bows a n d yo u r c h est to protect yo u r c h est .

8.

T h e f i n a l correct i v e force i s a p p l i e d as a q u i c k t h r u st down t h e s h a ft o f t h e p a t i e n t 's h u m e r u s , i n tro d u c i n g exte n s i o n a n d rot a t i o n to t h e r i g h t a n d s i d e b e n d i n g to t h e r i g h t o v e r t h e asym m e t r i ca l l y p l a ced f u l c r u m of yo u r l e ft t h e n a r e m i n e n c e .

9.

Reas sess t h e dysf u n ct i o n a l a rea . To t reat a n exte n d e d dysfu n c t i o n (T5 u po n T6 exte n d e d , s i d e b e n t l eft a n d rot ated

left) with t h i s p roc e d u re , the p o s i t i o n i n g of both the p a t i e n t and the p h ysi c i a n re m a i n s exactly t h e s a m e . T h e f i n a l co rrective force, h owever, is d e l ivered by u s i n g t h e p a t i e n t 's a r m s as levers to i n t r o d u c e f l e x i o n by b r i n g i n g t h e e l b ows c l oser to t h e chest.

Transabdominal Stimula tion

Th is proced ure is e m p l oyed to tre a t a bd o m i n a l soma t ic d y s fu n c t i o n ( I CD - 9 CM

73 9 . 9 ) . T h e proced u r e i mproves bowel fu nction by mechanica lly s t i m u l a t i n g peri sta lsis, t h u s i n crea s i ng gastro i n testi n a l moti lity a n d a l l e v i a t i n g or preven t i n g con s t i p a ti o n ( l CD-9CM 5 6 4 ) . It i s u s efu l fo r h o sp i ta l ized p a t i e n ts or o t h e r bed r i d d e n i n d i v i d u a ls . Beca use i t is m o s t effective w h e n a p p lied severa l t i m e s a d a y, t h i s pro ced u re may be t a u g h t to pa t i e n t s fo r self- a d m i n i stra t i o n i f they a re s u ffi c ie n t l y a l ert, o r i t c a n be ta u g h t t o a fa m i l y m e m ber. P a t i ent po s i ti o n : s u pi n e . P h ysici a n positi o n : st a n d ing bes i d e t h e b e d . Proced u re

1.

P l a c e t h e p a d s of the f i n g e rt i p s of o n e h a n d u po n t h e l eft l ower q u a d ra n t of t h e p a t i e n t 's a b d o m i n a l wa l l ove r t h e s i g m o i d c o l o n .

2.

Place t h e f i n g e rs o f t h e o t h e r h a n d over t h e fi rst fo r re i n force m e n t .

3.

A p p l y r h yt h m i c p ressu re w i t h t h e p a d s of t h e f i n g e rs , s l o w l y a n d d e e p l y t h ro u g h t h e a b d o m i n a l wa l l to sti m u l a te t h e co l o n .

4.

N ext a p p ly a d e e p s t ro k i n g p ress u re ce p h a l a d t o c a u d a d a l o n g t h e a ccess i b l e por tion of the s i g m o i d c o l o n .

5.

R e p e a t steps 3 a n d 4, p r o g ress i n g p roxi m a l l y a l o n g t h e l e n g t h of t h e desce n d i n g , tra n sv e rse, a n d asce n d i n g co l o n . For i n d iv i d u a l s w h o a re d e b i l itated or w h o h ave a b d o m i n a l t e n d e r n ess, t h e p roced u re

may be m o d if i e d as a n i n d i rect ma n i p u l ati o n :

1.

Be g i n n i n g i n t h e l eft lower q u a d ra n t , p l ace o n e h a n d ove r t h e ot h e r u p o n t h e a b d o m i n a l wa l l , as i n steps 1 a n d 2 .

2.

P a l pate W i t h a s m u c h p ress u re a s wi l l be t o l e rated b y t h e p a t i e n t .

3.

S e q u e n t i a l l y a p p l y a l t e r n ati n g c e p h a l a d-ca u d a d , l e ft-r i g ht, a n d c l ockwise-co u n ter c l o c k w i s e p res s u re s .

C h a pte r 20 • T h e Pat i e n t w i t h G a st r o i ntest i n a l P r o b l e m s 4.

303

M ove t h e abd o m i nal wall and und erlying abdo minal contents in t h e d i rect i o n of least resistance.

5.

H o l d u n t i l you pe rc e i ve a sense of f u rther l oo s en i ng or re l a x a t i o n i n the t i ssues beneat h your h ands.

6.

Repeat t h i s proced u re s e q u e n t i a l l y thro u g h o u t t h e abd omen, right u pper q ua d rant, left u pper q u ad rant and left lowe r q uad rant , i n that o r der. ,

Pedal Dalrymple Pump See the d e s c r i p t i o n of t h e proced u r e in C h a pter 1 0 and Figure 1 0 . 3 . T h i s p roce d u re is e mp l o y ed t o e n h a n ce ven ous a n d l y m p ha tic low-press ure re t u r n to the hea rt a n d thereby red u c e p a s s i v e co ngesti o n of t he lower extrem ities, a b d o m i n a l c o n te n ts, a n d l u ngs .

Refe re n ces 1 . R o t h s re i n R L F u n ct i o n a l g a s t ro i n tes t i n a l d i se a s e . In: N o b l e ], G reene H L , Levinson W, et a i ,

eds. Te x t b o o k o f P r i m a r y Ca re Med ici n e . 3 r d e d . S t . Lo u i s : Mos b y, 2 0 0 1 ;9 9 9 - 1 0 0 9 . 2 . A b u Fa rsa k h N A , S t i e t i e h M, A b u Fa rsa k h FA . T h e postc h o lecysrect o m y s y n d r o m e : A r o l e fo r d u o d e n o g a s t r i c r e fl u x . 3 . W i l s on

j

C l i n G a s t r o e n t e r o l 1 9 9 6 ; 2 2 : 1 97-2 0 1 .

PT, Nl i l l e r ES. I n t e rn a l m e d i c i n e : A n osteo p a t h ic a p pro a c h . O s t e o p a t h An n

1 9 79 ; 7 : 2 5 9-2 7 3 . 4 . K u c h e ra M L , K u ch e r a WA . Osteop a t h i c C o n s i d e ra t i o n s i n Syste m i c D y s fu n c t i o n s . 2 n d e d . Co l u m b u s , O H : G r e y d e n , 1 9 9 4 . 5 . Ca m i l l e r i M , Lee

]S,

V i r a m o n tes B , e t a l . I n s i g h ts i nto t h e p a thoph y s i o logy a n d mec h a n i s m s

o f c o n s t i p a t i o n , i r rita b l e b o w e l s y n d rome, a n d d ivertic u l o s i s i n o l d e r peo p l e . ] A m Geria tr Soc 2 0 0 0 ; 4 8 : 1 1 4 2 - 1 1 5 0 [rev i e w ] .

6 . Bea l !'vI C Visceroso m a t i c re fl e xe s : A review. j A m Osteopa t h Assoc 1 9 8 5 ; 8 5 : 7 8 6-8 0 1 . 7. W i l l i a m s PL, ed. G ra y's A n a tomy. 3 8 t h ed . Ed i n b u rgh: C h u rc h i l l Livi n gstone, 1 9 9 5 ; 1 2 5 1 - 1 2 5 2 . 8 . P a t r i q u i n D A . C h a p m a n 's r e f l e x e s . I n : Wa rd RC, ed . Fo u n d a t i o n s f o r Osteopa t h i c M e d i c i n e . 2 n d eel . P h i l a d e l p h i a : L i p p i n c o t t W i l l i a m s & Wi l k i n s , 2 0 0 2 ; 1 0 5 1 - 1 0 5 5 . 9 . D i M a g n o EP, S u re s h C. A c u te p a n c rea t i t i s . I n : F e l d m a n M, F r i e d m a n L S , S l e i se n g e r MH, Sc h o r sc h m i d t B F, cds. S l e i se n g e r and Ford t ra n 's G a s t ro i n testi n a l and Liver D isease. 7th ed. Ph i l a d e l p h i a : Sa u nders, 2 0 0 2 ; 9 1 3- 9 4 2 . 1 0 . Ti e r n e y L M

J r, ed .

C u rr e n t M e d i c a l D i a g n o s i s a n d Trea tment. 3 9 th e d . N e w Yo r k : L a n ge,

2000;6 8 5 .

1 1 . N o b l e j , Greene H L , Le v i n s o n W, e t a l . , e d s . Textbook o f P r i m a r y Care Me d ici n e . 3 rd ed . S t . Lo u i s : M o s b y, 2 0 0 1 ;920-9 2 7 . 1 2 . Ti n t i n a l l i .l , R u i z E, K r o m e RL Emerge n c y M e d i c i n e : A C o m p r e h e n s i v e S t u d y G u i d e . 5 t h e d .

New Yo r k : M c G r a w H i l l , 2 0 0 0 ; 5 7 7 . L l . A d cock D . N u c l e a r m ed i c i n e . U n i v e r s i t y o f S o u t h Ca ro l i n a S c h o o l o f M e d i c i n e h o me page. Acces s i b l e a t h rtp :!lra d i o logy. me d . s c . e d u /4 n u c me d a b c . h t m . Last u p d a ted j u l y 1 1 , 2 0 0 2 . A c cessed A p r i l 1 0 , 2 0 0 5 . 1 4 . C o n l e y GJ. Th e r o l e of [he s p i n a l j o i n t l e s i o n in ga l l b l a d d e r d i s e a s e . J Am Os teo p a t h Assoc. 1 944;44: 1 2 1 - 1 2 3 .

1 5 . Ma l o n e EP. M a n i p u l a t ive t h e r a p e u tics fo r ga l l b l a d d e r d i s e a s e . I n : N o r t h u p TL, Osteopa thic Ma n i p u l a t i v e T h e r a p e u t i c a n d C l i n ica l Resea rch Assoc i a t i o n . Morristo w n ,

NJ :

American

Osteo p a r h i c Assoc i a t i o n , 1 9 4 1 ; 4 : 4 4-4 5 .

1 6 . W i l s o n PT. G a l l b l a d d e r d i s e a s e . I n : A m e r i c a n Aca d e m y o f App l i ed O s teopa t h y 1 9 4 9 Ye a rboo k . A n n A r bor, M I : Ed w a r d s Bros, 1 9 4 9 : 1 8 2- 1 8 4 . ( N o w a v a i l a b l e through t h e A m e r i c a n A ca d e m y o f Osteopa t h y, I n d i a napo l i s . ) 1 7 . Bec k e r

A R.

Conse r v a t i v e

t r e a tmen t

o f ga l l b l a d d e r

d isea s e . j

Am

Osteopath

Assoc

1 9 5 1 ;5 1 : 1 0 4- 1 0 7 . 1 8 . M i l l e r WJ, Co l l i n s G , K os i n s k i f o r v i sce roso m a r i c r e f l e x e s .

J

Rj ,

e t a l . T h e d o r s a l r o o t gangl i o n c e l l a s a pote n t i a l m o d e l

A m Osteo p a t h A s s o c 1 9 9 7 ; 9 7 : 4 8 0-E O A .

The Patient with Thyroid Disease Douglas J. Jorgensen

INTRODUCTION A key relationship in osteop at hic medicine since its inception has been systemic

pathology and somatic dysfunction, meaning subluxation or mechanical interruption of the spinal nerve supply as described in the early osteopath ic texts and literature

the osteopathic model. Still sought to achieve a health care model focused on health and the body's inherent self-regulatory and self-healing phys iologic capacities, not

simply identification andJor treatment of disease, the allopathic model. To understand health, however, intimate k no w l edge of the pathologic mechanisms and their seque

lae are paramount. Normal physiology includes a dynamic system of health respon

sive to protection andJor immune defense coupled

w it

h rudimentary housekeeping

functions. This system is orchestrated via neurophysiologic mechanisms, with the endocrine system being a primary driving force because of its ubiquitous systemic effects. Early osteopathic literature focused on the thyroid gland as a somatovisceral responder and as a viscerosomatic source of diffuse somatic dysfunctions.l•2 Modern medicine has affirmed this early observation, as the thyroid gland influences virtually every organ system in the body.

This chapter is a review of thyroid development, p h ys i o l ogy pathology, systemic ,

interactions, and pathophysiologic responses as they relate to somatic dysfunction and other tissue changes from viscerosomatic and somatovisceral relationships and to treatment approaches. An exhaustive compilation of neuroendocrine thyroid 304

Cha pter 21

• The Pat i ent w i t h Thyroid Disease

305

pa thophysi o l ogy is beyond t h e scope of t h i s chap ter, b u t basic structure a nd fu nc tion a re revi ewed as a fo u n d a ti on on w h ich the u ndersta nding o f systemic str u c tur a l c h a nges m ust b e ground ed .

Thyroid Development and Hi stology3-S Developing fro m t h e root of t h e t o n g u e by the m i d d le of t h e first trimester of feta l deve l o p ment , t h e d ista l end of the r u d i mentary thy roi d re ma i ns as the m i d a n d prox i m a l portions d issi p a te , l e a v i n g the thyroid gla n d located a n teri o r l y, para m i d lin e t o the trachea. I n the 10-w e e k - o l d fetus, t h yrotro p h i c ce l l s i n t h e a n te rior p i tu ita r y beg i n secre t i n g thy r o i d -stim u l ating h o r m o n e ( TSH), w h i c h regulates thyro id size, bi osy nthesis, and storage and re l e a se of t h y ro i d h or m ones. B y a d ulth o o d , the thyroid c a n be H sha ped to U sh aped a n d c a n exte n d a n terior l y fro m the l eve l o f Cl t o the leve l o f T l o r some where in betwe e n . It typica l l y weighs 20 to 3 0 g

(slig h tly h e a v i e r in fe m a l es) , with two l ate r a l l obes a n d a bro a d mid l i ne isthmus. Each l obe is further div i d ed i nto l obu les v i a septa d e r i v e d from the inner thy roid ca psu l e . T h e fibrous isthmus is typic a l l y 12 t o

1 5 mm i n height a n d occasi o n a l l y is asso

cia ted with a p y r a m id a l or c o n ical l obe superiorl y. The lev a tor of the thyroid , a myofascia l ele m e n t more c o m m o n on the left, m a y attach to the hy oid bone a n d crea te a d irect a n a tomic re l a t i o nship a nd be a fac tor i n so m a tic d ysf unc t i o n fro m both a viscerosoma tic a n d so m a t o v iscer a l perspec t i v e . S h o u l d ve s ti g i a l tubu l a r tis sue re m a i n , t h ere is the pote n t i a l for d eve l o p m e n t of thyr oglossa l d u c t c ysts. Ad d itiona l l y, multiple va ri a n ts fro m i n c o m plete e mbryol ogica l d escent or d e v i a tio n be y o n d norm a l a n a tomi c a l posi tion i ng c a n resu l t in the g l a n d being abnor ma l l y d isplaced , pro mpti ng workup for a susp i c i ous m ass. Histologically, the l obu l es are d i v ided i n to foll i c l es, the fu n c t i ona l u n i ts of the gla nd. The foll i cles a re c o m p ose d of spherical ce lls a n d l i n e d w i th e p i t h elium c o n sist ing of regu l a r cubo i d ce l ls e nclosi ng a c olloid-fi l l e d c a vity. There a re two types o f epi thel i a l ce l ls: pri nc i p a l ( i .e., f o ll i c u l a r ) and p a r a fo l l i c u l a r. The p r i n c ipal e p i th e l i a l cells develop collo id, w h ich c o n tains i o d o thyrogl obu l i n , the precu rsor to thy roid h o rmo nes. The p a rafo lli c u l ar ep i t h e l i a l c e l l s develop C cells, d escribed l a ter. The typica l orga ne l l es a re present, a n d fi n e m icro v i l l i exten d into the folli c u l a r c o l l oid. De nse sy mpathetic fibers, l y m p h a t i c vessels, a n d fe nest rated c a p illaries cre a te a sophi stic a t e d , ubiqu i tous, a n d highly reg ula ted n e urovascul a r p l exus for trop h i c a n d feedbac k function in t h i s fo l lic u l ar mix. Thy rogl obu l i n stores the thy r oid ho r mone, a n d the micro vi lli assist in i ts mobi liza t i o n . T h e foll i c l es are sep a r a te d by stro ma or fibrous septa . C cells, d e r i ve d from the neu roecto d e r m , are ca l c i to n i n sec reting c e l ls They pred o m i na te i n the u pp e r a n d m i d dle third o f the l a te r a l l obes. They a re loca ted in the basa l lamina a d j a ce n t to the fo l l i c l es. T h e i r p rese n c e is sig n i fi c a n t in the p a t h o logy o f hy perca l ce m i a a nd hypergastrine m i a , a n d they are p r o m i n e n t in n e o n a t a l d e v e lopme n t . The p a r a fo l l ic u l a r cel ls a re central pla yers in systemic calcium ho meostasis by v i r tue of the i r calc i to n i n producti o n .

The active thyroid hormones a re tri i odothyro n i n e (T,) a n d thyroxine (T 4 ) . They a re merely a combina tion of the a mino acid tyrosine with eithe r three or fo u r i o d i ne ato ms, respect i v e l y. The i r synthesis is controHed by a nega t i ve feedback i n h ib i tory

process mod erated by TSH (pituitary) and thy rotro pin-releasi ng hormone (TRH), secreted from the h ypotha la m us. Briefl y, the biochemistry is as fol l ows. Iod i d e is trapped with i n the fo l licu l a r thy ro i d cel ls a n d then oxid ized (io d i d e peroxidase ) to become capable

of iod inat ing tyrosi ne resid ues i n the thyroglobulin. After iod i n a ting

at the level o f the microvi l l i, monoiodotyrosi n e ( MIT) a n d diiod otyrosine ( D IT) fo rm.

306

Section III • Clinical Conditions

Coupling results in T3 or T4, depending on whether two DITs make a T4 or an MIT and a DIT make a Ty Then, by endocytosis, T3 and T4 are released from the thy

roglobulin. Roughly 80% of thyroid hormone is T4, and the balance is Ty Because

of its availability, however, the predominantly active thyroid hormone is T3. Once in

the blood, T4 is heavily protein bound (mostly to alpha-globulin), leaving little available for hormonal activi ty

.

SYSTEMIC EFFECTS FROM AN OSTEOPATHIC PERSPECTIVE In general, the osteopathic model of spinal segmental facilitation and subsequent hypersympathetic output and tone were the basis for etiologic explanations even in the early 1900s.1 Visceral abnormalities (somatovisceral reflex), in terms of hor monal response, are primarily seen as an autonomic dysfunction or in some cases a reflexive secondary et iol o gy. 7 In the thyroid gland , histopathology shows a predom

inance of sympathetic autonomic fibers, and the tenth cranial nerve, the vagus ner ve, provides the parasympathetic portion. In response to stress, the thyroid enlarges; the cuboid cells elongate to columnar cells, and the gland increases in size. If the stressor (e.g., menses, peripheral nociception of pain, trauma, ill ness) abates, the hyperplasia is transient; the cells resorb and normal histology is restored.3 Without proper osteopathic treatment of somatic dysfunction, distortion of normal innervation occurs secondary to the facilitated segment. This stressor alters

physiologic function of the thyroid, hence its response and ability to respond to endogenous or exogenous stimuli (e.g., chemotherapeutics, T3, T4, TSH). Because of the heavily sympathetically mediated modification of normal innervation sec ondary to somatic dysfunct ion, this can result in facilitated spinal segments, which cause persisting abnormal thyroid autonomic innervation. This autonomic dys

function is primarily hypersympathetic, which would follow based on the predom inance of sympathetic fibers found histologicaIly.3,8

In the allostatic model, long-term facilitation impedes hypothalamic-pituitary

adrenal (HPA) axis function via amygdala stimulation with catecholamine increases.

This establishes a feed-forward loop in which the facilitated segment remains indef initel y. The pathologic relationship, with its visceral structure, propagates further abnormal viscerosomatic stimulation. Thus, the thyroid pathology worsens the somatic dysfunction and, in turn, the somatic dysfunction continues to worsen the thyroid function, further worsening the neuroendocrine crisis and potentially mak ing it a ch ro ni c, irreversible pathologic relationship.9 Websterl described a series of experiments on humans and animals demonstrat ing the premise for somatoviscera I reflexes. Subsequentl y, Larson 10 detailed the physiologic mechanisms involved, specifically loo king at the t hyroid Research to .

prove these reflexive relationships is nearly as old as osteopathic medicine itself. Two notable figures, McConnell and Burns, who were Still's students and subse quently his colleagues, provided some of this research grossly linkin g the viscero somatic and somatovisceral relationships.

As early as 1906, C. P. McConnell experimented with an animal model creat

ing segmental lesions (spinal somatic d ysfunction) at the site of origin for visceral innervation . Vertebral and rib dysfunctions induced in healthy dogs resulted in seg

mentally related visceral pathology. Among the specifically noted induced patholo gies were goiters. Subsequent treatment of the induced dysfunctions was followed by goiter resolution, while goiter in control animals did not resolve.I•11

At the same time, Louisa Burnsl2 used both animal and human models to study viscerosomatic relationships. Using anesthetized cats, dogs, guinea pigs, and white

Chapter 21 • The Patient with Thyroid Disease

307

rats, she induced vertebral lesions with digital pressure and record ed the effects of the experimental somatic dysfunction upon segmentally related viscera . The results of the animal studies were compared to the effect of pressure a pplied to the verte bral spinous processes in human subjects and to retrosp ectively reviewed clinical

records. Of particul ar i nterest w as the observed rel ationship between somatic dy s function i nv o l v ing C4 to C7 and response obs erved in the t hyr oid .13 She observed

increased su sce pt ibilit y to infection in the affected organs. She also noted restora tion of tissue and function f o llo wing treatment of the somatic dysfunction, with symptom resolution at the target sites. I

While some of these studies did not report how long the somatic (segm en t al ) dysfunction was maintained , one could postulate that these were no t longstanding dysfunctions, for tissue restoration did occur except where frank destruct ion was noted. lacki ng the histopathologic techniques available today, this was excep tional and really timeless work, for these results have pragmatic application nearly a centu r y later.

Thyroid Function and Dysfunction Hypothalamic (medial division of paraventricular nuclei of t he median eminence) TRH stimulates release of pituitary (anterior) T SH in the face of low serum Tj and T4•

This results in stimulation of the follicular colloid with resulting increases in

T 3 and T , as described previously. In normal t h y roid physiology, this is a dynamic 4 relationship, and the inh ibitory a nd stimulatory functions are autoregulated.

Normal subjects ty pically have a T S H of 0.5 to 5.0 fLU/ml, with higher levels noted

nocturnally. TRH, in ad ditio n to T SH stimulation, causes the release o f prol actin .14

In the hypothyroid state, TRH will stimulate T SH to increase biosynt hesi s and release of thyroi d hor mone . Simultaneously, prolactin level s will increase secondary

to the hy pothalamic response to lo w thyroid hormone and its e ffect on pituitary lac totr oph . Hypothyroidism can be primary or secondary, depend ing on the etiology.

Primary Hypothyroidism (T hyroprivic or Goitrous) Primary hypothyroidism is thyroid gland failure and is the most common form of hypothyroidism, accounting for 95% of cases. The most common cause is a b lative therapy (radioactive or surgical) for Graves' disease, but thyropr ivic hypothyroidism can be congenital or id iopathic . Biosynthetic defects, iodide de fi ciency, fetal-maternal antithyroid transmission, and drug - induced, iatrogenic, and immune-mediated

causes fall into the goitrous category. I nade quate gland synthesis occurs despite max imal stimulation and can lead to second ary or compensatory thyrotrophic hypertro phy in the pituitary. This can le a d to pituitary-mediated crowding in the sella turcica

with p o s sible visual field deficits. Hyperprolactinemia may occur here too, second

ary to the process noted earlier. If medical thyroid replacement therapy resolves the

hyperprolactinemia, the diagnosis is essentially confirmed. Other pitui tary - mediated

disease (pituitary myxedema) can occur in severe primary hyperthyroidi sm, but again it is reversible with thyroid replacement therapy. Children left untreated can

develop cretinism. In iatrogenic causes, the implicated medications are amiodarone, lithium, aminosalicylic acid, and iodine.14,11

Secondary Hypothyroidism (TrophoprivicJ Secondary (central) hypothyroidism is due to hypo t h ala mic or pituitary dysfunc tion; it is suprathyroid in local etio logy. In the primary disease, T SH is elevated

before Tj or T4 declines. Moreover, simple t hy roid replacement medication will

308


not correct the scenario. TSH may be mildly elevated. Exogenous TRH stimula tion will result in TSH increases. F urther mor e , the mild TSH elevation is typically associated with a marked decrease in T4 concentration. This is the reverse effect that elevation of TSH should h ave, and this sce n ario strongly suggests central hypothyroid disease. Because of the unreliability of TSH here, T4 m u st be used to monitor this state. The euthyroid-hypothyroid pati ent typically falls into this cat egory, but eu thyroid sick syndrome can have many manifestations.14•ls Hyperthyroidism3,5,15-17

Graves' disease, the most common form of hyperthyroidism, is relatively common, with a 0.4% prevalence in the United States. It is thought to be

mu

lt i f a ctorial in

its etiology, but the exact cause is not known sav e that it is an autoimmune disor der. The result is a hype r functi oning thyroid gland that becomes diffusely hyper trophic, an associated in filtrative ophtha Imopath y, and sometimes in filtrative der mopathy. It affects women more than men (5:1 to 8:1, female to male), with incidence in the fou rth and fifth decades; it rarely occurs

a fte r

a

peak

50 years of age.

There is a strong familial predisposition with specific human leukocyte antigen

(HLA) markers noted by race. It can be preceded by Hashimoto's thyroiditis and has been associated wi th other autoimmune disorders, such as pernicious anemia, system i c lup u s erythematous, rheumatoid arthritis ,

Sjogren's

s yn d ro m e

, and

chronic hepat i t i s . It is a gamma-globulin-mediated autoimmune reaction on the plasma membrane resulting in hypertrophic thyroid tissue with increased colloidal T3 and T4 production. As with Hashimoto's thyroiditis, there is a defect in the

antigen-specific suppressor T cells. Since hyperthyroidism worsens T cell function, this process may be self-perpetuating. Diagnosis of thyrotoxicosis is not difficult, as p r oblems affect multiple systems.

We a kn ess , weight loss despite good appetite, palpitations, hyperdefecation, tremors, nervousness, sweating, and heat intolerance are all symptomatically related. These coupled with a goiter with

an u n detect a b l e TSH and elevated . If detected early or in rel a t ivel y mild cases, particularly those lacking palpable goiter or ophthal mic manifestations,

thyroid hormones make it difficult to

m i ss

suspicion must be h i gh for associated symptoms. Goiter too, which is not always uniform or symmetric in Graves' presentation, must be distinguished from other causes of thyroid masses. Symptoms can be relapsing and remitting, so index of suspicion should remain high to diagn ose and commence treatment. Treatment for Graves' disease is to address the thyroid h ypertrophy, with medical or surgical management focused on limit in g thyroid hormone production. Antiadrenergics have been used to assist in symptom control

as w ell

. Antithyroid

medications (i.e., propylthiouracil ) inhibit thyroid synthesis but work only when the medication is given. Leukopenia is the primary adverse effect of the antithyroid med ications, so serologic monitoring must be pe rfor med. Radioactive iodine is ablative but is seen as s i m p ler and more eco n omi c . It too carries risks, especially if used in chil dren, as carcinogenesis must be vigilantl y monitored. Even in adults, if rad i oactive treatment is used, the longer the life expectancy post treatment , the greater the risk of carcinoma. Surgery is a more permanent solution than nonradioactive pharmaceuti cal management, but it poses risks perioperatively. Postoperatively, indefinite thyroid replacement will be necessary, and there is the potential for inadvertent parathyroidec tomy because of the parathyroid's intimate anatomic relationship to the thyroid gland. Thyrotoxic crisis or storm used to be precipitated by surgery ( em e r gen c y) or a complicating illness (i.e., sepsis). Proper preoperative and intraoperative medical man agement and appropriate timely diagnosis can control this life-threatening associated syndrome, making death a rare outcome today.17

C h a pter 21

• The Patie n t w i t h Thyro i d D i sease

309

Pituitary (T SH-induced) hyperthy roidism is not the typical eti o l ogy for a h yper thyroid sta te. There are two types: pituitary tumors and pitu itary resistance to t hy ro i d ho rmone. T h e t u mors ( m a c r o a d enomas) a uto n o m o usly sec rete TSH o u ts i de of the normal feedb a ck i nh i bition process of the anterior pituitary, resu l ti n g i n excess t h yroid h o r m one. The resist a n ce to T3 and T 4 results i n a fa ilure to i nhi b it TSH pro duction o n ce sa t i sfactory levels o f ho rmone a re present. Thus, the pitu ita ry fa ils to shut off T S H p roduction (again not fol l o wing the negative feedback loop) and

a

hyperthyro i d state resu lts.

Thyroiditis3. 74.16. 77 Thyroi ditis, or inflammation of the thyroid , has many eti o l o gies . S u b a c u te, chronic, and Hashimo to's thyroiditis a re t h e most common fo rms. Suba c u te thyroiditis (de Querv a i n's, g i a nt cell, o r gra n u l o m a tous thyroiditis) is

viral. Typica lly, this follows an upper respi ratory in fect i o n , and the pa t i ent has marked weakness and mala ise with pain over the thyroid g l a n d. Usu a lly, these sympto ms a re present for weeks, but a cute cases, t h o u g h ra re, do occ ur. In these ra re i nstances, fever a nd thy roid pain are the primary c o m p l a i n ts, a nd the poten tial for thy rotoxicosis exists. A l t h ough thyroid p a i n is the m ost c o m m o n presenta ti on, some patients have no thyro i d pa i n despite the oth er sy m pto ms. Chronic thyroid i tis is a disorder in which self-lim ited t h yrotoxicosis occurs wit h

out prev i ous thyroid issues, a n d h istology subsequently sho ws chro n i c l ymph ocytic thyro iditis distinct from Hashimoto's thy roid itis. La bo ratory values for the erythro cyte sedimentation rate usu a l l y sta y below 50 mm/ho ur, a nd antithyr o i d antibodies have

a

low ti ter. The thyrotoxicosis typica l ly a b ates i n 2 to 5 mont hs, but some

patients ha ve recurrent episodes. T h e etio l ogy is u nclear, fa vors women, a n d ca n occur at a n y age . Postpartu m, this is the m ost com m o n fo rm o f thyroiditis. Hashimoto's thyroid itis is lymph a d eno i d g o i ter, w i t h a uto i mmu ne even ts bei n g the primary etio l ogy. A s the most c o m m o n fo r m of g oitro u s hypo thyroid ism in reg i ons with su fficient iodine, it was fi rst descri bed by Hash imoto i n 1912. It is most common i n m iddle-a ged wo men a n d i n chi ldren; it is the m ost commo n c a u se of spo r a d ic goiter. Goiter is the most pro m i nent fea ture, a f fecting the ent i re gland, t h o u g h it is not necessarily uniform or symmet r i c. The a utoi m m u ne evidence exists serologic a lly, with l ym phocytic proliferati o n a n d i m munoglobu l ins r a i sed a g a inst several components of t h y r o i d t i ssue. Ear l y l aboratory findings ma y indic a te euthy roid, but the g l a nd event u a l l y b u rns out a nd TSH increases. A c o rre l a tion with concurrence of Gra ves' disease a nd Hashi m oto's thyro iditis exists. Here a b l a tive thera py is used less often, as the a u to immune respo nse i n Hashimoto's t h y roiditis typi ca lly slo ws t h e p rogress i o n of t h e hy perthyroid state associated w ith Gra ves' disease. Py ogen i c thyroid i tis u sua lly has antecedent p y ogenic infectio n so mewhere other than the thy r oid. The patient has ten d erness and warm eryt hem a over a swo l l e n t h yroid gl and and the t y p i c a l constitu t i o n a l signs of systemic infecti o n . I t i s fortu na tely ra re but m ust be c o n sidered in i m m u noco mpromised p atients. Treatment consists of ant i b i o tics and d r a i n a ge if a fl occ u l ent a rea exi sts. The following d i s c u ssion is a breakdown o f the body systems and their relatio n shi ps t o a nd with the th y r o i d p h ysio l o gy a nd/or path ology. Some a re o bservati ons from Sti l l and his students a nd collea g u es; others a re p a th o p hysiolog i c expla na tio ns interwoven w i th longsta nd i n g osteopa thic c o n cepts. Ma n y of the early o bser vatio ns, although well doc u mented a nd repeatedly o bserved, had no q u a ntifia ble or measur a ble proof. W h ere possi ble, patho p h ysi o l og i c d a ta have been su p plied to exp l ain or el u c i d ate the l ikel y p hysi o l o g i c d y n a mics that were o bserved but l a c ked object i ve explanati ons in ea rly osteopa thic research and tea c h i ngs.

310

Section III • C l i n i ca l Condit i o n s

Co n stitut i o n a l A case study o f goiter status post tonsillectomy resulted i n sleep disturbance and a

general sense of emotiona l lability 2 Posts u rgica l treatment of the somatic dysfunc .

tions resulted in improved mood and normalization of sleep. N otable in this case was the inability of high-velocity, low-amplitude (HVLA) proced ures ro result in a fa vorable outcome. "Relaxation, movement (and) f1exibiJity"2 were the key to somatic dys f unction resolution in what would be best described today as myofas cial release. T h is patient presen ted for

care

because of the cosmetic appearance of

the goiter and the thyroid, and subsequent somatic d ysfunctions were found via history and physical examination. H ypothyroidism can result in wea kn ess , l e thargy sleepiness, fa tigue , we ight ,

gain, cold intolerance, and/or general malaise. With appropriate treatment, these symproms are poten tiall y reversible.ls

Eyes Still regarded exophthal mic goite r (exophthalmos, p roptosis) as being second ary to venous congestion. However, in d oing so he specificall y referenced the lack of knowledge at that time regarding the hypothalamic and pituitary in teraction in thyroid disease and funct ion

,

which has since been elucid a ted

.

N ever the less, he

reported cases of successful treatment of exophthalmos presumably thy ro id medi ,

ated

via d econ gesting venous

,

return to the heart whic h

proved effective.6

Proptosis, or protuberant eyes, occ u rs secondary to immunoinfl a m matory changes

that are part of the inflammation or congestion to which Still referred b u t did not histo logical l y note in his diagnosis or treatment.6 To address this, he began with the inquiry of the etio logy behind the "conges tion. Beginning at the clavicles, he moved medially to the sternocla vicular junc "

tion and then l aterally to the coracoid processes, treati ng myofasc ial structures as he found impaired t issue motion. He then moved his attention to the ri bs , with the first two being his primary focus. Focus next moved to the u pper thoracic and cer vical spine and then the occip itoatlantal j oin t hyo i d and maxillae, investing tissue, ,

,

and reI ated vascular structu res. 6 Eye involvement in thyroid disease is typica l ly thoug ht of in the hyperthyroid state, specifically Graves' disease, and is again autoi mmu nologic with histologic ,

co nfi r mation possible Proptosis, noted by Still, is the most associated feature, but .

early in the course of the disease there ma y be no apparen t ophthalmic effects. As the disease p rogresses however, periorbital soft tissue, periorbital muscl e , e ventu ,

a l ly the cornea and finally the optic nerve can all be a dverse l y affected if the diag ,

nosis is missed or tr eat men t not initiated.l7 In hypoth y roidism, there are myxedematous periorbital changes and slow muscu lar response. The face has been descri bed as cret i noid because of the associated cretinism if hypothyroidism is left unt reated indefinitely. Despite

an

ede matous look,

there are I i k e l y fine wr in kl es particular l y in p i t ui tary-base d hypothy roidis m ,

.

'R

E ar, N ose, a nd Thro a t Vascular congestion o f the thyroid has been i mpl icated i n tonsillar hype rtro p h y and pain as well as dysphagia secondary to mass obstruction of the esophagus.2,6 Goiter demands serologic and/or radiograp hic work up, wit h the potential for surgi cal intervention shou ld the histopathology and/or radiographic findings warrant It.

C a u t i o n is essential in addressing an abnormal thyroid mass with osteopathic manipulation, as enh a n cing vascular and lymphatic drainage has the potential to metastasize cells. Fine-needle biopsy and/or surgical referral is paramount if tumo r is suspected.4,6

Cha pte r 21 • T h e Pat i e nt w i t h T h yro i d D i sease

311

The deep cervica l fa scia forms a s heath a ro u nd the thyroid g l a nd, fi r mly a ttach ing i t to the l a ryngos keleton. Ligamento u s a ttachme nts sti ck each lobe to the cricoid a nd thyroid cart i l a ge, a n d the posteromed i a l p o rtion a ttaches to the side of the cricoid cartilage and the first a nd second trachea l ring. Du ring s w a l lowing , these a ttac h m e n ts c reate adherent t h y roid move m e n t . The rec u rrent laryngeal nerve typically passes inferi o r to the postero l a te r a l l iga m e n t o u s a tta chme n t s . La tera l to the nerve i s a posteromed i a l portion o f the thyroid lobe tha t can be for gotten d ur i ng t hyroid s u rge ry.s Goiter is the most com m o n e a r, nose, a n d thro a t ( ENT) iss u e assoc i a ted with the thyroid g l a n d other t h a n the a n a to m y described prev i o u s l y. Goiter is s i m p l y e n l a rged t h y roid g l a n d , a nd the etiologic event is i ndeed variable. His tory, exa m i n a tio n, a nd l a boratory or ima g i n g ( wh e n wa rranted) work u p a re importa n t in d e term i ning the e t i o l ogy so that appropr i a te trea t m e n t can be rendered. Tre a tmen t i s based on u nderstand i ng the p a t h o l ogy a nd a n a tomy well e n o u g h to allow for app l ication of osteopa t h i c proced u res u n i q u e l y s u i ted for a pa rtic u lar patie n t'S malady. Card i ovascul a r The e a rliest osteopathic w r i t i ngs spea k o f Sti l l's s a y i n g that t h e "rule o f t h e artery remains supre m e . " Rega rding t h yroid vasc u l a r s u p pl y, i mpeded a rte riove n o u s f l o w i s funda mental t o t h e osteop a t h i c approach to the t h yro i d . Before t h e neu roe n d o c rino l ogy was u nderstoo d , the a n a to m i c a b norm a l i ties s poke vol umes to the base p a t h ologic mecha nism s a ffec ting the thyro id; t h a t is, congesti o n o f ve n o u s dra i n a ge o r i mpeded a r teria l s upply resulted i n abn o rm a l t h yroid tis s u e wit h sys temic e ffects. This was confirmed i n v i v o and postmo rtem by Still a nd h i s s tu dents . Thu s, keeping cervicothoracic vasc u l a r (a n d pres u m a b l y l y m pha t i c ) a n a tomy patent, pa rtic u l a r l y i n the a n te r i or neck a nd thora c i c o u tlets, was p a r a m o u nt. T h i s approac h, combi n ed wit h n o r m a l iza t i o n o f the surro u nd i ng structure a nd fu n c tion, res u l ted in d o c u m e n ted su ccess i n the trea tment of goi ter, exoph thalmos, myxede m a , a nd t h y ro iditis . A l t h o u g h only gener a l arteri ove nous n o rmaliza tion was rec o mmended for goi ter, t h y ro iditis was specifically n o ted to need un impeded flow of "blood a nd l ymph from t h e thyroid g l a n d i n to the i n te r n a l j ugula r a nd i n n o m i n ate ve i n s"19 o n to the s u peri o r vena cava a n d the right a uricle of t h e heart.6 In m yxedema , relief from o bstruction of the thyroid a nd/o r c a rotid a rteries has been associa ted w i t h symp tomatic i m proveme n t .3 The likely rea s o n for s u ccess i n these p a t i e n t s was t h a t despite not k n o w i ng t h e exa ct h i s topa thology o r ne uroe ndocrine cause be h i nd t h e symptoms, t h e trea tment allowed f o r t he imm u n e-media ted i nfl amma tion t o d ra in. In some of these m a l a d i es, the d i sease w a s self-l imited. In others, t h e thyroid tis s u e would eve n tu a l l y b u r n o u t, a l l owing the ly m p h a tic a nd vascu l a r s tructu res to flow u nimpeded , permitting rem a rka b l e s y m ptoma tic i m prove ment. For the physi cia n to do this effectively, a n u ndersta nding o f the ana tomy i s a ga i n p a ramo u nt. The spec i fic vascu lar a n a to m y of the thyroid i ncludes th ree p a i rs o f veins. Adj a c e n t to the s u p e r i o r thyroid a r tery is the s u perior thyroi d vein, which d rains i nto the internal jugula r vein . The left inferior t hyroi d vein goes to the b r a chio cepha lic ve in, a nd the righ t takes o n e of two paths. On the right, the i n ferior thy r o i d ve i n co u ld dra i n eit her to the left or r i g h t brachiocephalic veins, depend ing on its c o u rse. A n other vari a n t for both the inferior veins, however, is to j o i n a nd form the thyroid ima vei n, dra i n ing into the left bra c h i ocephalic vei n .s T he arteria l s upply to the t hyroid g land comes from the supe r i o r a n d i n fe rior t h yroid a rteries a nd occasio n a l l y the thyroid ima. Bi l a tera l colla tera l c i rc u l a ti o n i s

312


abundant here. The superior thyroid artery runs adjacent to the omohyoid and sternohyoid muscles, and typically the external branch of the recurrent laryngeal nerve runs with this artery. This artery is cut during thyroidectomy, which puts this nerve branch at risk during this procedure. Additionally, this is the arterial vessel that can be cut during an emergency cricothyroidotomy. The inferior thyroid artery is intimately related to the recurrent laryngeal nerve, but its anatomic rela tionship is highly varia ble. Furthermore, what is found on one side in terms of this relationship between nerve and artery is not necessarily the same relationship con tralaterally. A ga in surgical impairment of this nerve is possible because of its vari ,

able course. This is likely to manifest as phonation problems.5,J6 In hypothyroid disease, pulse rate, stroke volume, and cardiac output are diminished. If the disease is left untreated, pericardial effusion and hypertrophic myocardium can result. In

hyperthyroid states, dysrhythmias, cardiomegaly,

hypertension, and thyrotoxic cardiomyopathy are all p ossi b le secondary to the

hypersympathetic state that results from increased catecholamine in circulation.

Electrocardiogram, echocardiogram, and hemodynamic changes also consistent with sustained catecholamine states can be found. Some studies have suggested a marked increase in mitral valve prolapse in thyrotoxic patients. The usual cause of

death from thyroid storm is cardiac arrest.16-IS Pulmonary

The lungs provide a site for metastatic lesions of papillary thyroid adenocarci noma. Pulmonary symptoms in the face of a new thyroid mass or a thyroid nod ule of long standing warrants a chest radiograph or other pulmonary i m agi ng to rule our related pathology. Pulmonary metastasis of thyroid carcinoma worsens the overall prognosis.6 P u lmo nary arterial hypertension (PAH) has been found to be strongly associated with autoimmune thyroid disease. If a patient is diagnosed with PAH, part of the sys temic workup should include thyroid function studies to examine for occult disease.19 In the thyroid storm, respiratory distress is an important and life-threatening complication. Gastrointestinal

Thyroid effects on the gastrointestinal system in general terms are hypermobility in the hyperthyroid and hypomobility in the hypothyroid state. Hypothyroid patients have anorexia, flatus, and constipation. Gastric emptying is slow, with long intestinal transit time, decreased absorption, and occasionally ileus. Ascites may be present, as may elevated liver function test fi n dings; the gallbladder may have insufficient tone. Finally, autoimmune hypergastrinemia is associated with autoimmune thyroid

disease as much as previously mentioned autoimmune

pathologies that tend to group together. In a patient with achlorhydria, thyroid workup again is indicated.2o Genitourinary

While current literature does not emphasize the re lationship between thyroid and the genitourinary system, early osteopathic literature noted an ovarian connection. One may speculate that our osteopathic predecessors had a better understanding of the HPA axis and endocrine-related issues than we have evidence to prove or dis

prove. It has been confirmed, however, that thyroid size fluctuates with pregnancy and menses. Furthermore, early literature noted improvement of menstrual regular ity once goiter was resolved with osteopathic treatment.2-6 Struma ovarii, an ovar ian teratoma, is made up of mature thyroid tissue. Moreover, this monodermal

Chapter 21 • The Patient with Thyroid Disease

31 3

teratoma can result in hyperthyroidism. There is no evidence to suggest the case studies in the early osteopathic literatur e had such tumors or related carcinoid syn dromes; this could have been part of the differential diagnosis in addition to the affected and dysfunctional endocrine system.3 Musculoskeletal

The musculoskeletal system has been noted to be very rigid in the hyperthyroid state, with poor mobility and range of motion. At the very least, this represents autonomic dysfunction, but most of the literature suggests that the pathologic results are sym pathetically mediated. Increased musculoskeletal tone is likely secondary to the hypersympathetic stimuli associated with cyclic enhancement of somatic segmental irritation by the viscera and subsequent increased sympathetic response upon the vis cera. These two cycles, if not interrupted, continuously enhance one other in a feed forward mechanism that is a truly pathologic relationship locally and systemically. Specific findings in terms of the musculoskeletal system are found, with the sternum often twisted and with posterior displacement potentially impeding vascular f1ow.3 Another specific finding is the rotation of C2 to the left. Unlike the sympathetically mediated effects, this finding is thought to be parasympathetically mediated via cra nial nerve 10 (vagus) at the second spinal segment.6 Hypothyroidism can present as myalgia and arthralgias, and thyroid work up for nonspecific myofascial and/or joint pain is warranted in addition to the usual rheumatologic tests.3•14 Neurologic

Of anatomic importance are the relationships of the recurrent laryngeal nerve. Thyroid surgery can harm this nerve, especially when a parathyroid ecto my, intentional or not, occurs with a complete or partial thyroidectomy. Phonation problems postoperatively are often the first sign of recurrent laryngeal nerve damage. The anatomic basis for this is outlined in the section on the ENT.

While the recurrent laryngeal nerve is of anatomic interest and importance,

the primary innervation for the thyroid gland is autonomic. Cranial nerve 10 provides parasympathetic innervation, while the superior, mid dle, and infe rior ganglia of the cervical sympathetic trunk distribute the sympathetics.lO The latter are, again, the most highly concentrated histologically and are intimately related to the vascular and lymphatic supply.3 The sym pathetic nerves can be further broken d o wn into afferent and efferent supplies. The afferent supply to the thyroid is derived from cerebral and meningeal bloo d vessels, and the nerve fibers foll o w branches of the internal carotid and vertebral arteries traversing the upper cervical spinal nerves. The visceral afferents are carried along the vagus nerve or get to the sympathetic trunk via the pharyngeal plexus and then pass through the rami communicantes to C5 to C6 spinal nerves and/or the upper thoracic spina I nerves. The sympathetic efferents have three ganglia, the superior cervical, middle cer vical, and stellate. The superior cervical ganglion is the largest in the cervical sym pathetic system, with the first two spinal nerves more active than are the third and fourth. The middle cervical ganglion (fifth and sixth spinal nerves, or the thyroid nerves) create a plexus inferior to the inferior thyroid artery. The stellate ganglion is a combination of the inferior cervical and the first thoracic sympathetic ganglia . It connects via the gray rami of the sixth, seventh, and eighth cervical spinal nerves and the first two thoracic spinal nerves.1O,21 A denervated thyroid gland retains its capacity to respond to central nervous sys tem triggers. In this state, however, it is not adaptive, and the response is excessive,

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b o t h te m p o r a l l y a n d i n h o r m o n e o u t p u t . I O F u r t h e r, w it h o u t centra l regu l a t i o n , pro tein synthesis i s i nte r r u p t e d . Once i n n e r v a t i o n is restored , norma l prote i n s y n t h e s i s ret u r n s , s u ggesting a tr ophic response t o th e a u to n o m i c n e r v o u s syste m . I I I Hypot h y r o i d is m ma y pres e n t a s hyporefl e x i a , d e a fn ess, a nd/or memory i m p a i r m e n t . 1 6 H y perth yroid is m ca n be a s s o c i a ted w i t h h y p e rreflexia . Psyc h i a t r i c

A d i s t i n c t i o n s h o u l d b e m a d e between a n xiety a s i t s o w n d i sord er a n d hype r t h y

ro i d i s m . Sim i l a r ly, hypoth y r o i d i s m s h o u l d be cons i d ered a s a poss i b l e etiology o f d e p ressi o n . Th y r o i d tes t i ng s h o u l d be i n c l u d e d i n t h e wor k u p fo r e i t h e r psyc h ia tr i c c o n d i t i o n . In t h e h y p o t h y r o i d s t a t e , fa t i g u e m a y a p p e a r a n h e d o n i c ; t h u s , h y p o t h y r o i d ism m a y m a n i fest a s psy c h ia t r ic d i s e a s e t o o . D e l i r i u m i n t h y rotox icosis i s a l s o a pos s i b i l i t y a nd p a r t of an a c u te me n ta l s t a t u s c h a n ge; t h y r o i d l a b o r a tory tests a r e clea r l y i n d ic a ted. 1 4 E n d o c r i n e a n d I m m u n o l o g i c3 , 7, I O . 1 4

A k e y fe a t u re of the e n d ocrine sy stem is t h y r o i d function a n d i ts s y s temic ma n i fes ta t i on s . The t h y ro id gl a n d i ts e l f, i f s u bj e c t to m u l t i p le form s o f i m mu n e - m e d ia ted i n fla m m a tory d is e a s e s a n d thyr o i d i t i s , i s the most common p a t h o l ogic s i te assoc i a ted w i t h i m m u n e fu n c t i o n a n d d y s f u n c t i o n . I n th e i m m u n ocompro m i s e d s t a t e , StatJ h ylococcus

a u re u s ,

streptoco cci, Salm o nella, E n tero b a c te r, tu bercu los i s , a n d

fu ngi are t h e most freq u e n t ca u s es of i n fecti o u s thyro i d i t i s . These a re r a r e . Tre a t m e n t i s i n c i s i o n a l d r a i n a ge and org a n i s m -spec i fi c a n t i b i o t i c s . Vi r a l t h yroid i t i s a l s o c a n occu r a n d i s d i sc u ssed b r iefly l a te r. Th e m o s t c o m m o n a n d c l i n i ca l l y i m p o r ta n t y e t less w e l l d e fi n ed t h y r o i d itis pro b l e m s a r e the a u to i m m u n e fo r m s . Of t h e s e , Ha s h i moto's t h y ro i d i t is i s t h e b e s t k n o wn . O t h e r types i n cl u d e s u b a c u te gra n u l o m a t o u s , s u bac u te l y m p h o c y tic, a n d R i e del 's t h y r o id i t i s . T h e exact eti o l ogy of H a s h i m o to 's thyroi d itis i s u n kn o w n , b u t i t i s t h o u g h t t o be ge n e t i c a nd m e d i a te d via a n tigen -specific s u p p ressor T cel l s . S u bseq u e n t l y, t h e r e i s a n u n i mpeded a ttack o n fol l i c u l a r cel l s , w i t h res u l t i n g l y m p h o i d ce l l u l a r p ro l i fera t i o n . The co llo i d becomes a tr o p h i c a n d sparse, d ec re a s i n g fa c i l i ta t ion of T3, T4 , or th yrogl o b u l i n pro d u c t i o n . Th us, typ ic a l l y i t is assoc i a ted w i t h a h y p o t h y r o i d state. Yet a l t h o u g h most l o ng-term s u fferers deve l op a h y pothyro i d s t a te, some become t h yrotoxic (hash i-toxicos i s ) i n m i d cou rse. Aga i n , the e t i ology h e re i s u n c l e a r. H a s h i m oto's th yroi d i tis is the m o s t c o m m o n e t i o l ogy of go i t r o u s h y p o t h y roid i s m i n regi o n s with i o d ine d e fi ciency and a m a j o r c a u s e of non e n d e m i c go i t e r i n c h i l d r e n . Fe m a le to m a l e p r e d i lection is 1 0 : 1 , a n d it typ ica l l y occ u rs between

3 0 and 5 0 years o f age. The genetic rela ti o n s h i p is a s socia ted with h u m a n l e u k o c y te a n t i gen D R S , a n d t h e r e is a s t r o n g c o r r e l a t i o n a m o n g these p a t i e n ts i n t h a t they a re l i k e l y to h a ve other a u to i m m u n e d i s o rd ers a s well. Of the

other

t h y r oid i ti s

s u btypes,

s u b a c u te gra n u l o m a t o u s

t h y roid itis is

th o u g h t ro be seco n d a ry to specific v i r a l i n fecti o n s with res u l t i ng pa infu l go i t e r. Fe m a l e ro m a l e p red i l e c t i o n is 3 : 1 , w i t h pre v a l e n c e in the seco n d to fift h d eca d e s . S u b a c u te l y m p h o c y t i c th y r o i d i t i s is d i ffer e n t i n h i sto logy, a n d i t i s p a i n less c o m pa red to t h e gra n u l o m a t o u s for m . T h e s e m a y be p r e s e n t f o r months, b u t eventu a l l y nor m a l i z a t i o n of the thyroid re t u r n s . Asp i r i n a l o n e s u ffi ces fo r m i l d cases; however, i n severe fo r m s , ora l s t e ro i d s may be n ec e s s a r y. A beta - bloc k e r a l so m a y be i n d ic a ted t o pre v e n t t h y r o i d sto r m . T 4 a n d r a d i o a ctive iod i ne t r e a t m e n t s h o u l d

be m o n i tored, a n d o n c e n o r m a l i zed , the rapy c a n be s top ped .

Rie d e l 's thyro i d i t i s is ra re b u t i mp o r ta n t in t h a t i t m u s t be i n t h e d iffe re n ti a l wit h thy roid carci noma when a h a rd thyroid mass o r gland i s fou n d . I t is

a

fi brosing

C h a pte r 2 1 • The Pati e n t wit h Thyroid Dise a s e

31 5

rea c t i o n t h a t esse n t i a l l y destroys the t h y r o i d gl a n d a nd some o f the s u r ro u n d ing s o ft tissue. It e x h i b i ts t h e same 3 : 1 fem a l e- to - m a le pred i lection but occurs in the fo urth to seventh d eca d e s of l i fe . As w i t h the other a u toi m mu n e t h yro i d i ti s pro b l e m s , its e t i o l ogy i s u nknow n . Osteo p a t h ic trea tment c a n hel p t o exp e d i te hea l i ng a n d n o r m a lize thyroid e n d oc r i ne fu nctio n . In one s t u d y, u n i l a tera l e l ectri c a l st i m u l a ti o n of cervica l sym pa thetic gangl i a res u l ted in TS H - i nd uced t h yr o i d horm o n e p rod ucti o n . Th i s was seco n d a ry to i p s i l a teral v a s oconstriction, w i t h s u bseq u e n t parasympa thetica l l y co n t r o l l ed e n h a nced fo l l i c u l a r s e n siti v i ty t o t h e T S H i tself. 1 0 Th u s , s ym p a t h e tico to n i a fro m s o m a ti c d ys function c o u l d res u l t i n a s i m i l a r p hy s i o logic res p o n s e . Fu rthermore , i t w o u l d s u ggest tha t oste o p a t h i c m a n i p u l a tive tre a t m e n t ( O MT) c a n s h o rten cou rses o f t h y r o i d d i s e a s e . T h i s was fo u n d by S t i l l , a s noted e a r l i er, in a d d i t i o n to others. H a sh i m o t o 's t h y ro i d i t i s speci fical l y responded w i t h a shortened cou rse of i l l n e s s . A h igh i ndex of s u s p i c i o n fo r thyroid disease must be p resent when other a u toi m m u n e d isease i s pres e n t . H e m atolog i c a l a n d Lym phatic

Sti l l based most o f his trea t m e n t in this a rea o n the p a l p a tory find i ng of co nges tion in the t h y r o i d a nd s u rro u n d i n g t i s s u e s . P r o x i m i t y to p a r a thyro i d m a kes this a rea p a r t i c u l a r l y v u l ne r a b l e to meta s t a t i c or i n f l a m m a t o r y d i s s e m i n a t i o n . 3 T h y r o i d l y mp h a t i c d ra i n a ge i s e x te n s i v e a n d m u l t i d i recti o n a l . T h e i m me d i a te d ra i na ge fo l lo w s a l o ng the rec urrent la ryngea l nerve v i a the perigla n d u l a r, pretra c heal, p r e l a ry ngea l , and pa ra trachea l nodes o n to t h e m e d i a s t i n a l nodes. Meta static s p read ty p i cally moves c e p h a l a d a l o n g the i n tern a l j u g u l a r v e i n due to para g l a n d u l a r o bs t r u c tion b l o ck i ng i n fe r i o r d r a i n a ge. D e r m atolog i c 3, 7 , 1 4, 1 7

I n s u ffi c i e n t t h y ro i d h o r m o n e c a n res u l t in h y po t h y ro i d i s m o r myxed e m a . Treatment i s focused on t h y roid re p l a c e ment. Myxe d e m a is a l oc a l t h i c k e n i n g o v e r t h e l a tera l d i sta l l o wer extre m i ty s u p e r i o r to the a nk le. I t i s typica l l y b i l a tera l , w i t h the s u r fa ce us u a l l y s h i n y, b u t i t ma y be sca l y o r even p u c k e r e d , l i k e t h e s k i n of a n o r a nge. T h e l egs ap pea r e d e m a t o u s b u t d o not have p i t t i n g e d e m a . M y x e d e m a c a n a l so occu r o n t h e d o r s u m o f t h e fee t or p h a l a nges a n d r a r e l y t h e stomach . Pret i b i a l d e r m o p a th y w i t h G r a v e s ' d i sease occ u rs i n a p p rox i m a te l y 1 0 to 1 5 % o f cases . I t is i n s i d i o u s i n p resenta t i o n , b u t o nce i t i s e v i d e n t , da mage is irrevers i b l e . Alon g w i t h s k i n fi n d i ngs, t here i s evidence f o r cogn i t ive d e l a y. I n c h i ld ren, cretinism m a n i fests a s p h y s ica l a n d mental s l o w i n g, both of w h i c h c a n be a v o i d e d w i th v igila n t scree n i ng a n d trea tme nt. Iodine-deficient c o m m u n ities a re m o s t a t ri s k . There c a n b e spora d i c c a s e s w i t h o u t i o d i n e d efic i e n c y ; howev er, t h ese ca ses typ i c a l ly a re the re s u l t o f a genetic d i sease a ffec ting thyroi d h o r m o n e synthesis, S i nce thyroid d is ease c a n a cco m pa n y o t h e r p a t h ology, part i c u l a r l y a u to i m m u ne, p a t i e n ts with sar c o i d m a y h a v e t h y ro i d i nv o l ve m e n t a s we l l . Manipulative Treatment o f Thyroid Disease StatesU•8, 10 Th e use of OMT is intended to address s o m a tic dysfu n c tion that is fo u n d in asso ciation with thyro id disease. [t is in tended to augment and n o t to replace s tandard medical therap ies.

Trea t m e n t a s descri bed b y Sti l l was focused on o p e n i ng a rte r i o v e n o u s , nerv o u s , a n d l y m p h a t i c flow. It i s wel l d e s c r i b e d i n h i s e n c o u nters w i t h exop h tha l m o s . T h i s w a s desc r i b ed b y h i m a s trea t m e n t u n der eye-re l a te d t h y r o i d d i se a s e , a s eye m a n i festa tions w e r e l i ke l y t he f i r s t presenting s y mptoms o ther tha n a go i ter. Without

31 6

Secti o n I I I • C l i n i ca l C o n d i t i ons

t he c u r r e n t se rologic, histop a t h o l ogic, a n d i m a g i ng a d v a n ce m e n ts, the histor i c a l t r e a t m e n t was nevertheless re m a r k a b l y a c c u r a te. To d a y the m a i n trea tment, h o w ever, s h o u l d b e to reso lve the u n d e rl y i ng p a thologic m e c h a n ism . T h is w i l l a l l ow str u c ture a n d fu n c t i o n to retu r n to the i r norma l i n te rp l a y. Oste o p a thic m a n i p u l a t i o n d o es ha v e a p o t e n t i a l l y significa n t r o l e in t h is a re n a . However, c a u t i o n must be exercised to m a tc h the d osage of the m a n i pulative i n terv e n t i o n to t h e d isease p rocess, so tha t no h a r m is d o n e . ( See C h a pter 4 . ) I n t h e h yp e r t h y r o i d sta te , m a n i p u l a tive procedures m ust n o t b e a ggressive o r sti m u l a to r y. F u r thermore, t h e m o r e a cute t h e i l l n ess, the more l i m i te d the p roce d u re sho u l d be, a nd a pprop r i a te m e d i c a l prop h y l a xis ( e . g . , beta - b l oc k e rs ) should be presc r i bed . I n t h e case o f hyp erth yroid i s m , l iterature d i rects us to C4 to C 6 , w i t h the l ik e l i h o o d of a s i n g l e -seg m e n t d ysfu nctio n be i n g fo u n d . A myofasc ial release, faci l i ta te d positio n a l release, a n d/or Sti l l tec h n i que may be effective; a r tic ul a tory o r h ig h - v e locity proced ures are contra i n d i c a ted . Tre a t m e n t interva l s can be a s fre q u e n t as two to three ti mes a day a s n e e d e d . I n the chro n ic t h y r o i d state, tre a t m e n t is a g a i n a i m e d at reso l v i ng the u nd e rly i n g h o r m o n a l , i m m u n e , o r i n fectious etiol ogy. S i m u l ta n eous i n i t i a ti o n o f osteo p a t h i c proce dures as deemed appropr i a te sh ou l d be i m p l e m e n te d . The upper tho r a x is pre d o m i n a n t l y i n volved here, w i th a flex ion d ysfunc t i o n o f T2 b e i ng m ost c o m m o n l y noted . 6 Freq u e n c y and i n tensity of trea tment are i n d i v i d ua l i zed u n t i l reso lut i o n of t h e c h ro nic s y m p to m s a n dlor d isease state. Wh i l e loc a l tre a t m e n t i s a ppropr i a te , the t h y ro i d is a m a j o r e n d o c r i n e o rga n . As suc h , cra n i a l d ysfu nction and trea t m e n t m ust be a d d ressed bec a u se o f the p i tuita r y 's p r o x imity to t he sphe n obas i l a r sy n c h o n d rosis a n d the co nsequen t effec t o f the c ra n i a l mec h a n ism o n the HPA a x is. A ga i n , oste o p a t h i c tre a t m ent sho u l d include a com p r e h e nsive tre a t m e n t of t h e u n d e r l y i n g pa tho logy a nd the asso c i a ted sym ptoms. Thyroid ma l ignancy (pri m a r y or metasta t i c ) s h ould n o t be a d d ressed w i t h osteop a t h i c trea tment because o f the risk o f metastases. Pyoge n ic i n fect i o n s h o u l d be add resse d o n a case - b y -case basis, but s i m ila r caut i o n shou l d b e noted , as m ost cases of pyogen ic thyro i d d isease a re in i m m u n o c o m p r o m ised i n d i v i dua ls, and sys temic d isse m i n a tion c a n resul t in sepsis a n dlor m u l t i o rga n i n v o l v e m e n t . 7 C o m m o n si tes of t h y r o i d -related so ma tic d ys fun c t i o n are l isted i n Ta b l e 2 1 . 1 .

Common S ites of Thyro i d - Related Somat i c Dysfu n ction Maxil lae6 Occ i p itoat lantal j o i nt2.6 Atlantoaxi a l joi n t2 Hyoid6 C e rvical spine (C 2 rotated left)6 C e rvicothoracic (CT) j u n ction2 C lavicles2.6 Ribs 1 a n d 2 6 T 1 - T4 (myxedema)6

T 1 -T8 (goiter)6 Sacro i l i ac j o i n t2

Cha pter 21 • T h e Pat i e n t w i t h Thyro i d D i sease

31 7

Proce d u res P lease note: The proced u res that fo llow a re exa mp l es of m a n i pul a t i ve trea tment th a t you m a y w i sh to em ploy. The a ctual choice of p roced u res used s ho uld be dete r m i ned by the uni que c i rcumstances of each i n d i vidual patient . T he use of O MT to treat t h e som a t i c com ponent for patients w i t h t h y roid d i s ease s hou ld , therefo re, logica lly inc l u d e t h e fol lowing : •

U p pe r thor a c i c HVLA

•

Tho racic i nlet release

•

Ribs 1 a n d 2

•

Dee p cervi cal fasc i a , musc u l a r and l i g a mentous atta chments to the h yo i d and ,

cricoi d , and thyro i d ca rti l a ges •

C4 to C6

•

Occipitoa tla nt a l myof a sc i a l release

m yofasc i a

l release

Upper Thoracic on Side, Extended: HVLA and Articulatory Treatment (Fig. 2 1 . 1) T h is p rocedure is e m p loyed to trea t type II a r ticular soma tic d y s function of the u p per thoracic s p ine . In lea rni ng to d o this procedure, it is o ften eas ier to e m p loy it genera l l y to i n t roduce a r t ic u la r range o f m otio n . ( For d i a gnos is, see C h a pter 3 . ) Pat ient pos i t ion: l y ing o n the s i de . Physic i a n posi tion : stan d ing at the level o f the p atie nt'S shou lders , fac ing the patien t .

P rocedure ( E xa m p l e : T2 o n T3 E xte n d e d , S i d e B e nt Left, a n d R o t a t e d Left) 1.

The p a t i e n t l i es on the l eft s i d e so that the re l at i v e l y poste r i o r t r a n sverse p rocess of T2 i s down .

2.

C ra d l e t h e l eft s i d e of t h e p a t i e n t 's h e a d i n t h e p a l m of yo u r r i g h t h a n d .

3.

W i t h yo u r l eft h a n d , fi r m l y g ra s p t h e s p i n o u s p rocess o f 1 3 betwe e n yo u r t h u m b a n d i n dex f i n g e r. Yo u r l eft h a n d m u st re m a i n t i g h t l y i n c o n ta ct w i t h T 3 t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re to e n s u re t h a t fo rces i n t ro d u ced with yo u r r i g h t h a n d a re l o ca l i zed betwee n T2 a n d 13 .

FIG U R E 2 1 . 1

P a t i e n t o n s i d e , u p p e r t h o ra c i c type I I , ext e n d e d , h i g h -v e l o c i ty, low a m p l itude.

318 4.

Sect i o n I I I • C l i n i ca l Cond it i o n s R o l l t h e p a t i e n t s l i g h t l y towa rd y o u a n d l e a n f o rwa rd , p i n n i n g t h e p a t i e n t 's u p per torso to the t a b l e b y p l a c i n g you r c h est a g a i nst t h e p a t i e n t 's right s h o u l d e r. Yo u may wish to p l ace a s m a l l p i l l ow between yo u r c h est and the s h o u l d e r.

5.

W h i l e cra d l i n g t h e p a t i e n t's h e a d w i t h y o u r l eft h a n d (step 2 ) I n trod u ce r i g h t s i d e b e n d i n g b y l i fti n g t h e h e a d a w a y f r o m t h e t a b l e u n t i l you fee l r i g h t s i d e be n d i n g

6.

occ u rri n g between T 2 a n d

13 .

Tra n s l ate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e a n t e r i o r l y with y o u r r i g h t h a n d u n t i l w i t h yo u r l eft h a n d y o u f e e l f l ex i o n betwe e n T2 a n d

7.

13 .

Rotate t h e p a t i e n t 's h e a d a n d c e rv i c a l s p i n e to t h e ri g h t with yo u r r i g h t h a n d u n t i l w i t h you r l eft h a n d you f e e l r i g h t rota t i o n between T2 a n d n . I t i s I m p o rta n t t h a t you c o n s c i o u s l y m a i n ta i n t h e r i g h t s i d e be n d i n g d e s c r i b e d i n s t e p 5 a b ove d u r i n g t h i s p a rt o f t h e p roced u re .

8.

A p p l y t h e f i n a l c o r rect i ve force t h ro u g h yo u r r i g h t h a n d as an H V LA i n crease of flex i o n , r i g h t s i d e be n d i n g , and r i g h t rotat i o n of T2 a g a i n st the h o l d i n g fo rce of yo u r l eft h a n d u po n n .

9.

R e a ssess t h e m o t i o n betwe e n T2 a n d

13 .

Upper Thoracic on Side, Flexed: H VLA and Articulatory Treatmen t (Fig. 2 1.2) a r t i c u l a r som a t i c dysfu n c t i o n of t h e to d o t h i s proced u re, it i s o f t e n e a s i e r to e m p l oy

Th i s p roce d u r e is employed to tre a t t y p e II u p p e r t h o racic sp i n e . I n l e a rn i n g

i t genera l ly to i n t rod u c e arti c u l a r ra nge of m o ti o n . ( F o r d i a g n o s i s , see C h a pter 3 . )

P a ti e n t p o s i t i o n : lying o n t h e s i d e . P h ys i ci a n pos i t io n : sta n d i ng

at

t h e l e v e l of

t h e p a t i e n t 's s h o u l d e rs , fa cing t h e p a t i e n r . P roced u r e ( E x a m p l e : T 2 on T 3 F l exed, S i d e B e n t R i g ht, a nd Rotated R i g ht)

1.

The patient l i e s o n t h e l eft side so t h a t t h e re l a t i v e l y poste r i o r tra n sverse p rocess of T2 i s u p .

2.

C ra d l e t h e l eft s i d e o f t h e p a ti e n t 's h e a d i n t h e p a l m o f you r r i g h t h a n d .

FI G U R E 2 1 . 2

Pat i e nt o n s i d e, u p p e r t h o r a c i c ty p e I I . flexed. h i g h -v e l o c ity. low-a m p l it u d e .

C h a pt e r 2 1

3.

• T h e Pati e n t wit h Thyroid Disease

W i t h yo u r l e ft h a n d , f i r m l y g ra s p t h e s p i n o u s p rocess of

13

31 9

between yo u r t h u m b

a n d i n d ex f i n g e r. Yo u r l eft h a n d m u st rem a i n t i g h t l y i n c o n ta ct w i t h 13 t h ro u g h o u t t h e re m a i n d e r o f t h e p roce d u re t o e n s u re t h a t f o rces i nt r o d u c e d w i t h yo u r r i g h t h a n d a re loca l i zed betwe e n T 2 a n d 13 .

4.

R o l l the pati e n t s l i g h t l y towa rd you a n d l e a n forwa rd , p i n n i n g t h e p a t i e n t 's u p p e r torso to t h e ta b l e by p l a c i n g yo u r c h est a g a i n s t t h e r i g h t s h o u l d e r. Yo u m a y w i s h t o p l a ce a s m a l l p i l l o w betwe e n yo u r c h est a n d t h e s h o u l d e r.

5.

W h i l e c ra d l i n g t h e p a t i e n t 's h e a d (step 2 ) , a l l ow t h e d o rs u m of yo u r r i g h t h a n d to rest on t h e trea t m e n t t a b l e . T h i s i n t ro d u ces s i d e b e n d i n g to t h e l eft. It is i m p o rt a n t t o k e e p yo u r r i g h t h a n d a s c l ose to t h e ta b l e a s poss i b l e t h ro u g h o u t t h e re m a i n d e r of t h e p roced u re to e n s u re t h a t t h e s i d e ben d i n g i s c o r rect l y a p p l i e d .

6.

Tra n s l ate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e poste r i o r l y w i t h yo u r r i g ht h a n d u n t i l w i t h y o u r left h a n d y o u fee l exte n s i o n betwe e n T2 a n d

13 .

I t is i m p o rta n t t h a t t h i s

move m e n t be a p p l i e d a s a stra i g h t poste r i o r t ra n s l a t i o n t o p reve nt h y p e rexte n s i o n o f t h e l o w cervi ca l s p i n e .

7.

Rotate t h e p a t i e n t 's h e a d a n d cerv i c a l s p i n e to t h e l eft w i t h yo u r r i g h t h a n d u n t i l w i t h y o u r l eft h a n d y o u fee l l eft rota t i o n betwe e n T 2 a n d 13 . I t i s i m p o rt a n t t h a t y o u c o n sc i o u s l y m a i n ta i n t h e l eft s i d e be n d i n g d e s c r i b e d i n s t e p 5 d u r i n g t h i s pa rt of t h e p roce d u re . A l so , for p ra ct i t i o n ers w i t h re l a t i v e l y s h o rt forea r m s , it is i m p or t a n t not to com p ress t h e p a t i e n t 's face betwe e n yo u r f o re a r m and u p p e r a rm .

8.

A p p l y t h e f i n a l correct i ve fo rce t h ro u g h yo u r ri g h t h a n d a s a n HVLA i n c rease of exte n s i o n a n d left rota t i o n of T2 a g a i n st t h e h o l d i n g force of yo u r l eft hand u p o n B .

9.

Rea ssess t h e m o t i o n between T 2 a n d B .

Thoracic Inlet Myofascial Release

See the p roced u r e d escrip t i o n in Cha pte r 1 9 a n d F i g u re 1 9 . 2 . Th i s p roced u re i s em ployed to release restric t i o n s of t h e t h o r a c i c i n l e t a n d t h e r e b y p ro d uce symmetric m o v e ment of t h e t ra n s v erse fa sc i a l t i s s u e s . It m a y be p e r fo r m e d e i t h e r a s a d i rect or in d irect proced u re. Upper Rib Diagnosis and Trea tmen t D I A G N O S I S O F E L EVAT E D F I RST A N D S E C O N D R I B S

The u p per ribs, 1 a n d 2, ten d to d e m o n s trate restr i c ted b u c ket h a n d le m o t i o n as t h e i r d y sfu n c t io n a l m ec h a n ic s . T h a t i s , th e i r a n te r i o r sternocosta l a rtic u la ti o n a n d th e i r posterior costove rte bra l a rticu l a ti o n s re m a i n re l a t i vely fi x e d , w h i l e t h e l a t era l portion o f t h e r i b bod y moves u p a n d d ow n l i ke a b u c k e t h a n d l e . U p p e r ri b d y s fu n ct i o n s are o ften p os i ti o n e d a s e le v a ted b u c ke t h a n dle mech a n i c s . The pos tero l a tera l a s pect o f the d y s fu nc t i o n a l ri b is i n a s l ightly cepha l a d pos i t i o n a n d resi sts d ow n ward press u re. It m a y b e d iagnosed a s fo l l ows: P a t i ent pos i t i o n : sea ted . P h y s i c i a n p os i t i o n : stand ing behind t h e p a t i e n t . Proced u re

1.

B e g i n by exa m i n i n g t h e u p per t h o racic s p i n e fo r somatic dysf u n ct i o n . (See C h a pter

3)

Seg menta l ly re l ated s p i n a l dysfu n c t i o n s h o u l d be treated before r i b dysfu n c t i o n 2.

Pal pate t h e sca l e n e m u s c l e s l a tera l l y at t h e b a s e of t h e n e c k i n t h e t r i a n g u l a r s p a c e su p e r i o r to t h e c l a v i c l e , poste r i o r to t h e s t e r n o c l e i d o m asto i d , a n d a n t e r i o r to t h e trapezi u s . S p a s m of t h e a n te r i o r a n d m i d d l e sca l e n e s w i l l e l evate t h e f i rst ri b . The sca l e n es s h o u l d b e stret c h e d before you treat a n e l evated f i rst o r seco n d ri b .

3.

Pa l pate t h e l a tera l a s p ect o f t h e f i rst rib a t t h e base o f t h e n ec k . A p p l y d ownwa rd force to t h e r i b . An e l evated fi rst r i b resists t h i s m o ti o n .

320


FIGURE 21.3

First rib facilitated positional release to reduce muscle tension associated with

4.

a

dysfunctional first rib.

Palpate the angle of the second rib just above the superior border of the scapula. Again, apply downward force over the angle of the second rib. An elevated second rib resists this motion.

FIRST RIB, FACILITATED POSITIONAL R EL EAS E (FIG 21.3)

This procedure is employed to reduce muscle tension associated with a d y s func

tional first rib. Patient position: supine. Physician pos ition: standing beside the treatment table on the side of the dysfunctional rib and facing the pa tie nt S head. '

Procedure (Example: Elevated First Rib on the Right)

1.

Standing on the patient's right side, position the patient in such a way that the right shoulder is slightly flexed and adducted and the right elbow is flexed so that the right hand lies upon the anterior chest near the left shoulder.

2.

Place your right hand upon the patient's right shoulder with your index finger touching the area of tissue texture change over the angle of the first rib on the right. Maintain your hand in this position throughout the remainder of the proce dure to monitor the fi rst rib.

3. 4.

With your left hand, grasp the flexed right elbow. Flex the patient's right shoulder until the right forearm is brought into contact with your right forearm.

5.

With your left hand, apply a compressive force to the patient's right elbow through the humerus until with your right index finger you feel decreased tension in the soft tissue over the first rib. This compressive force should be maintained throughout steps 6 and 7.

6.

Slowly further extend the patient's right shoulder, bringing the right forearm firmly into contact with your right forearm, thereby introducing internal rotation of the right shoulder.

C h a pter 2 1

7.

• T h e Pat i ent w i t h Thyro i d D i sease

321

Exte n d t h e p a t i e n t 's s h o u l d er a s m u c h a s poss i b l e a n d t h e n a b d uct i t , m o v i n g t h e r i g ht e l bow i n a n a rc of c i rc u m d u ct i o n , f i rst cep h a l a d , t h e n l a t e r a l l y, a n d f i n a l l y ret u r n i n g to t h e p o s i t i o n of step 1 .

8.

Reassess ava i l a b l e f i rst r i b m ot i o n .

F I RST R I B , H V LA

See F ig u r e 1 6 . 2 . T h i s proced u r e i s e m p l oyed to restore n o r m a l resp i r a to r y exc u r s i o n o f the fi rst rib to esta blish physiol ogic r a n ge of m o t i o n to the costoverte bra l j o int between T 1 a n d r ib 1 . Patie nt po s i t i on : seated . Phys icia n p os i t i o n : s ta n d i ng beh ind the p a t i e n t . Proc ed ure ( E xa m p l e : E l evated F i rst R i b o n t h e R i g ht) T h e postero l atera l portion of the r i b I S e l evated and res i sts d ownwa rd m ot i o n , w i t h s u r ro u n d i n g t i ss u e textu re c h a n g e a n d te n d e r ness .

1.

P u t yo u r l eft foot u p o n t h e ta b l e j u st to t h e l eft of t h e p a t i e n t's p e l v i s .

2.

R e s t t h e p a t i e n t 's l eft a rm u p o n yo u r k n e e . Yo u m ay w i s h to p l a c e a p i l l ow between t h e p a t i e n t 's axi l l a and you r k n e e .

3.

P l a ce yo u r r i g h t h a n d at t h e b a s e of t h e p at i e nt's n e c k o n t h e r i g h t ove r t h e e l e vated f i rst r i b so t h a t yo u r i n d e x f i n g e r is d i rected a n teri o r l y a n d y o u r t h u m b i s d i rected post e r i o r l y.

4.

P l a c e y o u r l eft fo rea r m a n d h a n d a g a i n st t h e l eft s i d e of t h e p at i e n t 's h e a d a n d n e c k to s p l i n t t h e cerv i c a l s p i n e

5.

W i t h yo u r l eft h a n d , u s e t h e p a t i e n t 's h e a d a n d n e c k a s a l ever t o rotate a n d s i d e

6.

W i t h yo u r r i g h t h a n d , a p p l y d ownwa rd p ress u re t o r i b 1 o n t h e r i g h t .

b e n d t h e c e rvica l s p i n e to t h e r i g h t d ow n to t h e l ev e l of T 1 a n d t h e f i rst r i b .

7.

H o l d i n g t h e p a t i e n t 's c h est between yo u r r i g h t h a n d a n d l eft k n ee, t r a n s late t h e to rso to t h e l eft t o i n c rease r i g h t s i d e b e n d i n g of t h e c e rv i coth o ra c i c j u n ct i o n .

8.

I n st r u ct t h e p a t i e n t to i n h a l e d e e p l y a n d exh a l e , a n d i n c re a s e t h e d ow n w a rd p res s u re over t h e fi rst r i b w i t h yo u r r i g h t h a n d d u r i n g t h e e x h a l a t i o n .

9.

A p p l y a n H V LA t h rust dow n wa rd , m ed i a l l y, a n d a n t e r i o r l y t h ro u g h yo u r r i g ht h a n d a g a i n st t h e dysfu n cti o n a l fi rst r i b .

1 0 . Reassess ava i la b l e fi rst r i b moti o n . S E CO N D R I B , H V LA

See F i g u r e 1 6 . 3 .

Second r i b H V L A i s e m ployed t o restore no r m a l respira tory exc u r s i o n o f the seco n d rib to esta b l i sh p h ysiologic ra nge o f motion to the costotr a n s v erse j o i n t . Patient pos i t i o n : sea ted u p o n t h e trea tment ta b le . Physic i a n p os i t i o n : s t a n d i n g beh i n d t h e p a t i e n t . P roced u r e ( E xa m p l e : Second R i b on t h e R i g ht) T h e re i s t i s s u e text u re c h a n g e su rro u n d i n g the a n g l e of r i b 2 o n the r i g h t , w h i c h is h i g h e r t h a n rib 2 on t h e l e f t .

1.

Put you r l e f t foot u p o n t h e ta b l e J u st to t h e l eft of t h e p a t i e n t 's p e l v i s .

2.

R e s t t h e p a t i e n t's l eft a rm u po n yo u r k n e e . Yo u m a y w i s h t o p l a ce a p i l low betwe e n t h e p a t i e nt's axi l l a a n d yo u r k n e e .

3.

Pl ace y o u r r i g h t h a n d over t h e patie nt's r i g h t s h o u l de r, w i t h y o u r t h u m b contact i n g the a n g l e of r i b 2. Yo u may find i t easi e r to do this jf you p u l l t h e p a t i e n t 's right arm to the l eft across t h e c h est . T h i s p rotracts t h e s h o u l d e r a n d d raws the sca p u l a l atera l ly.

4.

Place yo u r l e ft e l bow i n fro n t of t h e pat i e n t 's l eft s h o u l d e r, w i t h y o u r fo re a r m t o u c h i n g t h e l eft s i d e of t h e n e c k a n d f a c e . Yo u r l eft h a n d s h o u l d be h o l d i n g t h e t o p of

322

Section III • C l i n i c a l C o n d i t i o n s t h e h e a d . T h i s a r m a n d h a n d p l a ce m e n t a l l ows y o u to s p l i n t t h e p a t i e n t 's cerv i c a l s p i n e with y o u r l eft fo rea r m .

5.

W i t h yo u r l eft h a n d , s l owly rota te t h e p a t i e n t 's h e a d a n d n e c k to t h e l eft, d i s e n g a g

6.

W i t h yo u r l eft h a n d a n d fo rea r m , s i d e - b e n d t h e pat i e n t 's n e c k to t h e r i g h t d own to

7.

W i t h yo u r r i g h t h a n d , a p p ly a d ow n wa rd d i rected p ress u re to t h e a n g l e of r i b 2 .

8.

W i t h yo u r l eft h a n d , i n trod uce s l i g h t l y m o re l eft rot a t i o n of t h e p a t i e n t 's h e a d a n d

i n g t h e r i b h e a d f ro m t h e h e m ifacet a s T 1 rotates a w a y fro m i t the level of rib 2 .

n e c k w h i l e exe rt i n g s i m u l ta n e o u s d ownwa rd p ress u re o n t h e 2 n d r i b w i t h yo u r r i g h t h a n d . T h i s f u rt h e r d i se n g a g e s t h e r i b h e a d from t h e h e m i f a cets . Stop t h e rota t i o n w h e n you s e n s e t h a t the rib ex h i b i t s less res i sta n ce to the d ownward p ressu re f r o m yo u r r i g h t h a n d .

9.

I n st r u ct t h e pat i e n t t o i n h a l e d e e p l y a n d ex h a l e , a n d i n c rease t h e d ownwa rd p res s u re over the f i rst rib with yo u r r i g h t h a n d d u r i n g t h e ex h a l a t i o n .

10

T h e f i n a l c o r rective f o rce is a n H V LA t h rust d i rected d ownwa rd , m ed i a l l y a n d a n te r i o rly t h ro u g h yo u r ri g h t h a n d a g a i n st t h e a n g l e of the dysfu ncti o n a l seco n d r i b .

1 1 .

R e a ssess ava i l a b l e seco n d r i b m ot i o n .

An terior Neck Soft Tissue (Lymphatic) Procedure

See the description of the proced u re in C h a pter 1 6 a nd Figure 1 6 . 1 8 . T h i s p roced u re i s e m pl oyed t o reduce co n gest i o n of t h e soft tissues a nd e n h a nce lym p h a tic dra i nage o f the neck . The fa s c i a o f the neck m a y be c o n s i d e red as a n external cylinder tha t sp l its t o enc lose t h e sternoc l e id o m a s to id a n d tra pez i u s m u s cles and s u rr o u nd s t h e d e e p fascia tha t i n vests the deeper s t r u c t u re s of t h e n eck a nd fil l s the s p a c e betwe e n them . The s u pe r fi c i a l l ymph a tic drain a ge of the head l i e s o u tsid e the exter n a l fa scial c y l i n d er a nd m u s t p a ss throu g h i t to d ra i n i n to the deep cerv i c a l l y m p h a t i c v e sse l s The first p a r t o f t h i s proce d u re is d i rected a t mov ing l y mp h fro m t h e s u p e r f i ci a l to the deep l y m p h a t i c vesse ls. The second part o f t h i s p r o c edure i s d i rected a t the deep s t r u c t u res a nd m a y a lso be e m p l oyed t o decrease te n s i o n in t h e s u pra h y o i d a nd i n fra h y o id m u sc le s . .

Cervical. Indirect Balancing

See the d escrip tion of the proced u re i n C h a p ter 1 6 a nd Fig u re 1 6 . 6 . T h is p r o c ed u r e i s employed to decrease cerv ica l tiss ue te nsion a nd enhance the s y m m e tric a l ra nge of m o t i o n of the cervica l sp i n e . Occipitoatlantal Direct Myofascial Release

See the descripti o n of the p r o c edu r e in C h a p t e r 1 6 a nd Figure 1 6 . 1 2 . T h i s proced u re i s e m p l oyed t o trea t gene ra l a rt i c u l a r a n d soft t i ss u e , myofa s c i a l , s o m a t i c d y s fu n c t i o n o f t h e o cc i p u t rela tive t o C 1 , the a t l a s , to red u c e m y o fa s c i a l ten s i o n , and to esta b l i s h s y m m e t r i c m o t i o n between the occipu t a nd the a t l a s .

Refere n ces 1 . We bste r G W. Concer n i ng O s teop a t h y. Revised ed . N o r w o o d , M A : P l i m pton, 1 9 1 7; 1 02- 1 04 , 1 3 6- 1 4 2 .

2 . U n v e r ferth E C . G o i te r : A c a s e re port. A p p l ied A c a d e m y o f Osteopa t h y 1 9 4 0 Yea r book. 1 9 4 0 .

Vo l 3 ; 1 02-1. 0 8 . ( Now a v a i l a b l e th rough t h e Amer ica n Aca d e m y o f O s te o pa thy, I n d i a na po l is . )

3 . Rob b i n s

S L , K u m a r V, Corra n R S . R o b b i n s P a t h o l o g i c B a s i s o f D i s e a s e . 4 th e d . P h i l a de l p h i a :

S a u nders, 1 9 8 9 ; 1 2 1 4- 1 2 4 2 .

Cha pter 21

• T h e P a t i e n t w i t h Thyro i d D i sease

323

4 . N o r m a n E n d o c r i n e S urge ry C l i n i c . H o w YO U ( T h y r o i d Wo r k s . Ava i l a b le a t h r r p :llw ww. e n d o c ri ne lVc b .comlr h yfu ll c tion . h t m l . Accessed Ma y 2 8 , 2 0 0 5 . 5. La m a i re D, D o r i o n D. T h y r o i d d n a to m y. h c r p :ll w w w. e m e d i ci ne . c o mienr/ro p i c 5 3 2 . h tm ; l a s t u pd a ted M a y 3 , 2 0 0 5 . A ccessed M a y 2 8 , 2 0 0 5 .

6 , S t i l l A T. Resea rch a n d P r a c t i c e . K i r k s v i l le , M O : A m h o r, 1 9 1 0 ; 8 2-8 3 , 1 0 6-1 1 5 .

7 , K u c h e ra M , K u c h e ra W. O s teop a t h i c Cons i d e r a t i o n s i n S y s te m i c D ys f u n c ti o n . 2 n d e d . Co l u m b u s , O H : G r e y d e n , J 9 9 4 ;4-6, 11 , 1 7 , 1 8 7 , 1 9 2 .

8 . W i l l a rd F H , M o k l e r

DJ,

M o rgane PJ . N e u r o e n d o c r i n e - i m m u n e s y s t e m a n d h o m eo s ta s i s . I n :

Wa rd R C , e d . Fo u n d a t i o n s fo r O s teo p a t h i c Med i c i n e , Ba l t i m o r e : Wi l l i a m s & Wi l k i n s ,

1 9 9 7 ; j 0 7- 1 3 5 . 9 , W i l l a rd F H , M o k l e r DJ , M o rga ne PJ . N e u ro e n d o c r i ne - i m m u ne s ystem a n d h o m e o s ra s i s , I n : Wa rd R C , e d . F o u n d a t i o n s for O s teo p a t h i c Medici n e , Ba l t i more: W i l l i a m s & W i l k i ns , 1 997; 1 26-1 3 1 . 1 0 . La r s o n

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1 1 . Furrher p r o o f o f the osteo p a th i c t h e o r y : D r. M c C o n n e l l 's exp e r i m e n r s . J O s te o p a t h y [ 9 0 6 ; 1 3 : 1 60-1 6 1 , ] 2 . B u r n s L . V i s c e ro-s o m a t i c a n d S o m lCo.�cHo."Opoo..:ModI.:... FIGURE 31.1

(e) Page 3, physical examination. (Continued)

complaint, or the problem24), as well as functional assessments, such as the Rand

SF-36.27 Analysis of outcomes and incorporation into the clinical setting leads to the practice of evidence-based medicine. Over the past several years, there has been an increasing emphasis on outcome measures in the practice of medicine. Medical outcomes research investigates how a process used in providing health care services affects the outcome of the patient'S dis ease or health status. This type of research does not look at mechanisms or causes of the change in outcome, but only the end result of the procedure. Outcomes can include physical data, treatment results, practice encounter characteristics, types and

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( 8 ) Pa g e 2, a r e a s designa ted to record the diag nostics and tre a tm e nt of somatic dysfu nction, a ssessm ent, treatme n t plan, a nd dete r m i nati on of E & M l evel.

In the present med ical environme n t , it is esse n t i al that the medical professions be able to conduct outcomes research , To enable med i c a l professions to investigate and va l i d a te the i r treatment, diagnostic, and prevention modalities, methods of clinical data col lection in practi ce- based settings must be developed and validated , This process has begun using the Outpatient Osteopathic SOAP Note Form ro col l ect and report incidences o f d i f ferent disease e ntities within a famil y practice. 3 1

500

Sect i o n IV • Pract i c e I s s u e s

P R E A M B LE T O AN E LE CTRONIC M E DICAL R E CORD : T H E VAL I DAT E D SOAP NOT E FO R M

The l o n g-term goal o f L B O R C's progress n o te wor k , d e fined a t the i nau gural mee t i n g in 1 9 9 6 , has been t h e c reation of an electronic ve rsion o f the O utpatient Osteopathic S O AP Note Form for use by all family pra ctitione rs, American Acad emy of Family Physicians ( AA F P ) as we l l as A C O FP. Since that meeti ng, the fede ral gove r n m e n t has man d ate d that within a d ecade near l y a l l A m e r i ca ns must have an e lectronic med ical record . Recognizin g t he impend i n g c h ange , t h e L B O R C , i n a sso ciati o n w i th I n s titu tional Co m p u ting at Des Moines University u n d e r t h e leadersh ip of B rya n La rse n , set o u t to create an o n l ine versio n of the osteo pat hic SOAP n o te fo rm. Named e S O A P, this p r o totypical o n l i n e d ata co llection for m incorpo rates an attract ive We b in t e r face t hat resem b l e s the paper SOAP note fo rm b u t e xists o n th e Wor l d Wide We b . The system a l lows users to log on to a We b site and have a b lan k S O A P note that can be completed wit h d eid entified p a t i e n t d a ta. T h i s el ectronic n o te is avai lab l e fo r use by i n te rested investigators. l2t The original p u rpose of deve l o p i n g e S O A P was to al low the creation o f a natio nal osteopathic data base t hat co u l d p rovid e i n fo r mation on p r a ctice pat terns and efficacy of the diagnostic and the rapeutic measures e m p loyed by physicians practicing manual m e d icine . The current d esign, however i s much m o re flexib le, i n that ad d i tional m o d u l es may be i n corporated as needed fo r specifi c p rojects o r applications. 32:j: This fl exibility permits t h e capabilities of e S O A P to b e en hanced . From the research perspective, the cu rrent system has s u ccessfu l l y co m p l eted beta test trials and i s consid e red sci e n tifical ly val i d ated . 3 6 Beca use t h e p u rpose o f e S O A P was primari l y research, n ot med ial record kee p ing, i t was deci ded to e lim i nate private health informatio n ( PHI) fro m t h e database , s i n ce the i n cl usion of PHI w o u l d n ecessitate specific au thorization from each patient represented in this d atabase . The Health I n s u rance Portability and Acco u n tabi l ity A ct ( H I PAA ) req u i res that speci fic authorization to use PHI for research must be o btained from research participants . Because i t was n o t certain that s uch authorization wou ld be col l ected in every i nstance, the database was con str u cted w i t h o u t t h e inclusion o f PHI. eSOAP retai ns u t i l ity fo r p racticing p h ys i cians a s a chart n o t e , since the physician can , upon co m pletion o f the reco r d , p rin t it and affi x the p a tie nt's i d e n ti fying in formation to it fo r i nclusion in the ch art. W h i le the We b- based eSOAP was functional and attractive, its one key d raw back was that physician s cou l d not read i ly co m p lete the eSOAP wh i l e see i ng patients , since d ata input req u ired being onlin e . Th us, for most p racti ces, a separate session to input data wo u l d be needed . It was concl u d e d t hat t h i s wou l d red uce p a r ticipati on, a conside ration that s u ggested a new version o f eSOAP was needed . In view of t h e forego i ng, L B O R CIIT ( De s Moines) began development of a stand -alone perso n a l co m p u te r ( P C ) version o f the e S O AP. This has been i m ple m e nted on a tab l et com p uter that can be used in t b e e xam i nation room during an o ffice v isit. The inte r face for this stan d -a l o n e e S O AP prod u ct has been redesigned so that m a n y p u l l -d own m e n u s and check boxes a re e m p loyed to keep the use r from h aving t o scro l l d ow n l o n g pages o f informatio n . T h e record can con ta i n PHI, since t h e reco r d \-v i l l reside o n the ph ysician 's com p uter. A hard co py can be printed to go i nto the patien t 's permane n t reco r d . The inaugural d e m o nstrat i o n of

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• T h e Sta n d a rd i z ed M e d i ca l R e c o rd

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" S ta nd - a l o n e e S O A P " h a s been a n n o u n ced fo r the Fa l l 2 0 0 6 A O A C o n v e n ti o n i n L a s Vega s , N e v a d a . In t h e c o u rse o f develo p m e n t o f t h e sta n d - a l o n e eSO AP, i t bec a m e a p p a r e n t th a t t h i s i n s t r u m e n t cou l d b e used t o d oc u ment items needed fo r t h e A O Ns Clinica l Assess m e n t Progra m ( C A P ) . As

a

res u lt, a d di t i o n a l fi e l d s have been i n corporated

i n to t h e la test v e rs i o n o f the s ta nd - a l o n e eSOAP that w i l l s u pport CAP. As develop m e n t c o nti n u es, i t w i l l he poss i b le to add i ncrea s i n g levels o f fu nctiona l i ty a s fu t u re v e rsi ons of eSOAP a re d e v e l oped . U l t i m a te l y,

an

i n terfa ce w i l l be a va i l a b l e for the

stand-alone eSOAP t h a t w i l l a llow u p l oa d o f d e id e nt i fied d a ta to the n a t i o n a l osteo pa t h ic d a ta base for m a j o r i n ter i n s ti t u t i o n a l s t u d i e s of e ffica c y and practice patte r n s . W i t h i n t h e c l i n i c , p h y s i c i a n s c a n u s e c o mp u te r progress n otes l i n k e d to d ec i s i o n s u pp o r t s ystems to mo d i fy t h e i r p r a c t i c e p a tterns i n respo nse to a q u i c k l y c h a ng ing e n v i r o n m e n t . 1 U 4 Th i r d - p a rry p a yers a c t u a l l y pre fe r el ectro n i c recor d s o v e r h a n d w r i tte n n o tes or e v e n pa per S O A P notes. Keeping el ectronic med i c a l record s ( E M R s ) is n e a r ly e ffo r t l e s s . T h e y tend to be c o m plete, provid i n g t h o r o u g h d oc u m e n ta t i o n fo r t h e med i c a l practice wi th few e r re s u b m i s s i on s , l e s s h a ss l e , a n d grea ter re i m b u rse m e n t : t h e perfect remed y for r i s i n g p ra c t i c e c o s t s . O n e o f t h e p r i nc i p a l a d v a n ta ges o f u s i n g m u ltisite c o m p ut e r p a t i e n t record s i s t h e c a p a b i l i t y o f record i ng l a rge q u a ntities of d a ta w i t h i n a centr a l reposi tory o v e r a re l a t i v e l y s h o r t t i me. W i t h H I PA A -c o m p l i a n t o v e r s i ght, t h e s e d a ta m a y b e a n a I yzed i n c I i n i c a l resea rc h s t u d i e s , v a s t ! y i ncrea s i ng effi c i e n c y o v er c o n v e n t i o n a I

( a n a l og ) m e t h o d s . T h e a d v a n t ages to osteopa t l1 i c p o s tgra d u a te t r a i n i n g i ns t i t u t i o ns a n d fa m i l y m e d ic i ne res i d e n c y progra m s a re en o r m o u s . St u d i es a l re a d y co m pl eted ha ve shown s u bsta ntial economic a d v a n ta ges. A s

a

gro u p , no ma tte r w h ether paper n o tes or e lectro n i c med i a , fa m i l y p h ys i c i a ns ha bitu a l l y u nd e rcode. I n one s m a l l s t u d y ca rr i ed out in 2002,

a

p r i v a te physici a n switched

practice record i n g to use o f the S O A P notes, and the esti m a ted ye a r l y revenue i n c rease a m o unted to $ 1 2,000. The incre ased reve nue was d u e p r i m a r i l y to a SO 'Yo increase in the use of level 3 codes over leve l 2 (Ta ble 3 1 . 1 ) . Ad d computer a i d s a nd rem inders to this m i x to fa c i l ita te acc u ra te cod i ng, a n d re i m b urse m e n t can o n l y go u p . I n a d d i t i o n to prov i d i n g econ o m ic a d v a n tages, in t h e c o n text o f o u tcomes

resea r c h , EMRs p ro v i d e

a

fo r m id a b l e d a ta -h a n d l i n g i n s tru m e n t . It is expected th a t

E sti mated Ye a r l y Rev e n u e I n crease Fo l l owi ng U s e of t h e S O A P N ote Form i n a Pri vate Fa m i ly P ractice Ave r a g e

Yea r ly Breakdown

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63

38

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33

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$ 1 2,000-1 4,000

502

Section IV • Pract i ce I s s u e s

t h e u s e o f c o m p u ter rec o r d s w i l l gre a t l y fa ci l i ta te t h e a v a i l a b i l i ty o f l a rge a mo u n ts of sta n d a r d ized , c e n tr a l ized d a ta , a d d re s s i n g the need for o u tcomes rese a rc h m ore e ffi c i e n tl y w h i l e effec t i v e l y pro d u c i ng v a l id a te d practice g u i d e l i nes for osteo p a t h i c fa m i l y practice.

T h e Pa p e r S O A P Note F o r m s The o r i g i n a l SOAP n o te for m, the O u tp a t i e n t Osteo p a t h i c S O A P Note Form, was crea ted and v a l i d a ted w i th the i n te n t th a t t h e note w o u ld be a s fo l l o w s : 1 . A standa rd ized record i n g i n strume n t 2 . Used by physici a n s world w i d e 3 . E a s y to u s e a s we l l a s u sefu l i n t h e cl i n i c a l setti n g

3 . U s e d t o s t a n d ard ize e d u c a t io n a n d t h e t r a c k i n g of tra i n i n g ; for d i ffere n t rese a r c h top i c s

5 . A b l e to be mod i fi e d

6 . C a p a b l e o f c o l l e c t i n g re l ia b l e rese a rc h d a ta q u i c k l y To d a te , t h e S O AP notes a re sta n d a r d i ze d , u s e d by p h ys i c i a n s w o r l d w i d e , a n d

h a v e bee n s h o w n t o be e a s y to use a n d u sefu l i n t h e c li n i ca l setting . Rece n t retro spec t i v e s t u d ies have s h o w n t h e note's a b i l i ty to c o l lect re l ia b l e research d a ta q u ickly on many topics a nd to track t h e tra i n i ng o f resi d e n ts . 35,]6 Imagine trying to get 14 oste o p a t h i c p h y s i c i a n s to agree o n the p e r fect n o te fo r everyon e . D iffi c u l t ? I n d eed yes. I m possi ble ? We l l , n o t rea l l y. To fa c i l i ta te conse n

s u s prior to t h e a c t u a l crea tion o f t h e S O A P note, th ree b r o a d a re a s o f n e e d were iden ti fied : c I i n ical practice, ed u c a t i o o , and resea rc h . •

Pro fess i o n a l a n d c l i ni c a l oeed s i n v o l v e prov i d i ng i m proved q u a l i t y p a t i e n t ca re, d e v e l o p i n g pra c t ice g u i d e l i n e s a n d pro v i d i n g j u s t i fica t i o n for re i m b u rseme n t i n ,

a n e a s y - t o - use eifi c i e n t fo r m a t . •

Ed u ca t i o n a l n e e d s i n vo l ve tra c k i n g c a p tu red e x p e r ie nces, e n s u r i n g t h a t d is t i n c t i vely osteo p a t h ic ed u c a tiona l requ irements f o r a cc re d i t a t i o n a n d gr a d u a t i o n a r e m e t , a n d provi d i n g a tra i n i ng t o o l fo r d oc u m e n t a t i o n and cod i n g

•

.

Rese a r c h ne e d s i n v o l v e g a t h e r i n g la rge a m o u n ts o f q u a l i ty resea rc h d a ta i n a sta n d a rd ized for m a t by physic i a n s worl d w i d e u s i n g va l i d a ted i n s t r u m e n ts, w i t h a fra m e w o r k e a s i ly m o d i fi e d fo r a v a rie ty o f topics a n d types of rese a rc h designs ( e . g . , retrospec t i v e , prospective ) .

Advantages o f U s i n g the O u tpati e nt Osteo pat h i c SOAP Note Forms Why use a fo r m r a t h e r t h a n s c r i b b l i n g on a b l a n k piece of pa p e r ? A fo r m is s i m p l e r a n d fa ster t o u s e , sta n d a rd i zed , a n d i t p r o v i d e s u n a m b i g u o u s h a rd c o p y p roo f of w h a t w a s d on e . F u r t h er, i t sa ves the practice a gre a t d ea l of m o n e y t h ro u g h c o d iog re m i n d ers a n d by prov i d i n g p r o p e r, e a s i ly reviewed d oc u m e n ta t i o n . O u tl i ned next a re other a d v a n ta ges.

Educa tional Adva n tages •

Provides tr a c k i ng of p a t i e n t encou nters for p h ys i c i a n s , students, i n terns, a n d res i d e n ts , inc l u d i n g d ia g n oses, treatments, a n d proced ure s . Pa t i e n t e n co u n ters usi ng the S O A P n o te for m s a r e b e i n g a n a l yzed fo r e d u ca t i o n a l tra c k i ng pu rposes . J 5 The use of t h e s e fo rms i n tra i n i ng i ns t i t u ti o n s w i l l i m prove q u a l i ty by c l a r i fy i n g t h e a cc r ed i ta t ion and gra d u a ti o n p rocess.

Chapte r 31

• T h e Sta n d a rd i z ed M e d i c a l Record

503

•

Documents w h ether competency req uirements a re bei ng met. The series i s rec ommended for use by Americ a n Association of Colleges of OsteDpa thic

•

Provides training and reminders with regard to documentation. Studen ts, interns, and residents who have used the initial SOAP note form found it easy to use and

•

Provides tra ining i n coding. Phys i c i a n s i n tra ining who ha ve used the form i n

Medic ine ( A ACOM ) .

helpful in reminding them of items they were forgetting during patient encounters . 1 t h e past now request to use it because o f its tra i n i n g va lue. •

Reminds the aut hor th at there may be a musc u l os keleta l component to consider.

•

Provides for a u n i form education a l tra cking in fra structure.

Research Advantages • •

Fac i l i tates retros pective c ha rt rev iew36 Faci l i tates outcomes research 3 1 , 3 5 , 3 6

•

Ada pts ea s i ly for use in prospective studies

•

Accepts addition al study-spec i fic modu les a s req u ired

•

A l l ows data to be arc h i ved in a n a tionw ide d a ta ba se for access by i n vestigators addres s i n g other research question s . Such an a rchive a l s o may provide the n a t ura l history of a disea se or a ssist in finding anomalous regional hea l th pattern s useful in fig hting the war on b i oterrorism.

•

Provides

•

Has been va lida ted in publis hed studies funded by the AOA i ,35-37

a

un i form researc h i n frastructure a mong cooperating grou ps

Pro fession Advantages •

Un i form notes m a k e auditing and peer rev iew easier on the revi ewer.

•

C l ear coding j usti fication promotes reimbursement.

•

The conden sed note format promotes doc umen ting more of what occurred dur

•

It mi nim izes lack of reimbursement or c l a i m rej ection due to u n c lear n otes .

•

It yields payme nt when charges look suspic ious for d i a gnoses used, suc h a s with

•

It renders obvious how many and what body regions a re treated.

ing the patient encounter, l eadin g to higher coding levels.

Medicare, prol onged visits, and counsel ing. •

It eases credentia l ing of hos pita l s , schools, and progr a m s , especia lly w i th regard to the musculoskeletal c omponen t .

•

I t provides trac k i n g o f patient en counters for i mproved c l i n ical pra ctice.

•

CME credit is a va i l a ble for training i n th e use of the form .

•

A va riety of forms are a va i l able for speci fic k in ds of patient vi sits .

•

It is time effic ient.

•

It a ll ow s for less th i n king about reporting for m at, hence more thi n k i ng abo u t

t h e patien t . Patient A dvan tages •

Promotes easy trac king of p a t i ents' p rogress overa l l and progress w i th respect to pain management through the pain a n a l og scale

•

Fa c i l i tates c l i n ic a l guidel ine development

•

Identifies fi n d ings that a re out of the ordina ry to prompt early intervention

•

Fa cil ita tes q u a l ity assura nce by peer revi ew

•

M a k es items in the n ote, suc h as diagnoses, trea tment, and procedures, easy to

•

Aids i n iden tifi c a tion of procedu res that are help ing o r n o t helping t h e patient

find from visit to v i s i t and th at s hou ld be conti nued or disconti n ued

Sect i o n IV • Practice I ss u e s

504

T h e S O A P n o t e fo rms a re effective d a t a -g a t hering i n s t r u m e n ts fo r a nswering o u tcomes q u e s t i o n s fa c i ng osteo p a t h ic med icine tod a y. I n p u b l ished o u tcomes a n a lyses,3 1 ,35,36 q u e s t i o n s were a n swered based o n freq u e n c ies, averages, corre l a t i o n s , a n d c o m p a r i s o n s . A l l q u estions a s k e d co u l d be a ns w e red u s ing d a ta from the S O A P n o te fo r m s . For exa m p l e , the severity o f s o m a tic d y sfu nction, the n u m b e r o f regi o n s trea ted w i t h O MT, proced u res u s e d , a n d responses t o trea t m e n t c o u l d a l l be e x p l o r e d . Q u e s t i o n s on a verages, such a s age, d u r a tion o f visit, a nd fo l l ow- u p t i m e , were a n swered . Q u e s t i o n s on correlations between d i sease e n t ities and spec i fi c OMT proced u res u sed and between severity o f som a t i c d ys f u n c t i o n a n d O MT tre a t m e n t response were a n swered . Q u e s t i o n s on d i fferen ces a m ong d octors, such a s the top fo u r d ia g n oses o f each

a tte n d i n g p h y s i c i a n , were

a d dresse d . In a d d i t i o n to answe r i ng t h ese k i n d s of o u tcomes q u estions, the S O A P n o tes p r o v i d e d t h e fo l l ow ing fu n c t i o n s : postd octora l a n d p red octo r a l t r a ck i n g , a d d i t i on a l o u tcomes research i nto t h e efficacy of osteopa t h i c in terv e n tion , medica l science rese a rc h , a u to n o m i c c o r re l a t i o n with d i s e a s e en t i ti e s , d o c u m e n t a t i o n o n t h e n a t u ra l h i story o f m u scu loske l e t a l d y s f u n c t i o n , a n d

bi l l ing i n fo r m a t i o n .

F u r t h e r, t h e d a ta p e r m itted i n te r n a l comp a r i s o n s a m o ng osteopa thic p h y s ic i a n s .

The Forms Gen eral

B a s i c informa tion nee d ed for e d u c a tiona I a n d research p u r poses for tra c k i n g a n d d a t a ga t h e r i ng a s d e t e r m i ned by LBORC a n d c o n firmed b y a retrospec t i ve stu d y3 6 i n c l u d es the fo l l o wing: 1. First and l a s t n a m e and d a te o f v i s i t o n eac h p a ge 2. Age 3 . P a t i e n t 's p a i n a n a l og sca l e 4 . C h i e f c om p l a i n t 5 . M u s c u l o s k e l e ta l ta b l e ( s ) to incl u d e e ither chec k i n g a b o x t h a t sta tes " a l l n o t

d o n e " o r some c o m b i n a tion of methods u s e d fo r exa m i n a tion or exa m i na t i o n m e t h o d u s e d ( ti s s u e texture c h a nge, asymmetry, ra nge o f m o t i o n , a nd ten d er ness [TART] ) , severity of som a t i c dysfu n c t i o n , description o f s o m a t i c d ys fu n c tion fi n d i ngs, whe t h e r OMT wa s performed, what OMT proced ures were used , a n d respon se to tre a t m e n t 6 . P h y s ic i a n 's e v a l u a ti o n of t h e p a t i e n t p r i o r to treatment ( fi rst v i s i t o r reso lved

or i m proved or u n c h a nged or wo rse ) 7. Prior i t i zed d i agnoses, written o u t a n d r C D - 9 CM-coded 8. M i n u tes spen t w i t h the p a t i e n t 9 . Follow- u p rec o m m e n d ed i n n u m be r o f d a y s , week s , m o n t h s , years o r a s

needed 1 0 . N u m be r o f a re a s o n which OMT w a s pe r formed 11 . O ther proced u res p e r formed , i n c l u d i ng C u rrent Proced u r a l

Ter m i n o l o gy

( CPT ) code and written d e s c r i p t i o n 1 2 . E & M cod e 1 3 . Sig n a tures of exa m i ne r a n d tra n scri b e r ( i f o n e is used ) at t h e bottom of e a c h

p a ge T h i s b a s ic i n forma t i o n i nc l u d e s on Iy i n fo r m a t i o n perti n e n t to the chief com p l a i n t a n d excl u d e s the com p lete genera l h i story, s u c h a s the past med ica.1 h i story, hea l t h m a i n tena nce i n fo r m a t i o n , a n d other d a ta t h a t are not needed for every fo l l ow up vis i t .

Cha pter 31

• T h e Sta n d a rd i z e d M e d i c a l Record

505

Th ree vers i o n s of the SOAP n ote fo r m a re recommended for u s e a nd can be d ownloa d ed from t h e ACOFP and AAO We b site s : 25 1 . O u tp a t i e n t Osteop a t h i c SOAP Note Form

( 1 9 9 8 ) , o n e page

2 . O u tp a t i e n t Osteop a t h i c SOAP Note-Fo l l o w - u p Form ( revised

2 0 0 2 ) , two pages ( Fig. 3 1 . 2 ) 3 . O u tp a t i e n t Osteop a t h i c S O A P N o t e F o r m Series ( re v i sed 2002 ) , th ree or fo u r pages ( Fi g . 3 1 . 1 ) Specialty Forms Developed fro m the Origina l SOAP Note Forms

1 . O u t p a t i e n t Osteo path ic Single Orga n System Muscu loskeleta l Form Series 2. O u t p a t i e n t O s teopa t h i c Cra n i a l SOAP Note Fo r m §

3. Osteopa t h i c M u s c u l osk e le t a l Exam i n a ti o n o f the Hos p i ta l ized Patient, a o n e

page i n patient form for o n ly t h e exa m i n a ti o n porri on of a p a t i e n t e n co u n ter '· * A l l of the S O A P notes d e v e l o ped since 1 9 9 6 a re recom m e n d e d for use by t h e A O A , A A C O M , ACO FP, a n d A A O . The orig i n a l o n e -p a ge n o t e , O u tp a ti e n t Osteopa t h i c S O A P Note For m , w a s v a l i d a ted i n 1 99 7 , with t h e copyri g h t secured i n 1 9 9 8 and the v a l i d a t i o n study p u b l i s h e d i n 1 9 9 9 . A l t hough i t w a s a d eq u a te a t t h e ti me, 2 years l a ter a revision p rocess bega n . This exp a n d e d t h e form t o two p a ges a nd beca me the O u tp a t i e n t Osteo p a th i c S O A P Note Follow- u p Form, copy righ t sec u red in 2002. Through interaction a n d fee d b a c k from the osteop a t h i c comm u n i ty, i t was dete r m i n ed t h a t severa l n o tes w e r e needed . A n i n i t i a l - v i s i t for m w a s d eemed necessa ry, a n d t h e for m was fu r t h er expa nded to become t he fou r page O u t p a ti e n t O s teopa t h i c SOAP Note Form Series . The Outpatient Osteopathic SOAP Note Form Series is i ntended for use in p r i m a r y ca re p ractice and m a nipu l a ti ve med icine spec i a l ty practices o t h e r t h a n osteopa t h i c practices. The O u tpatient Osteopathic Single Organ System Musculoskeleta l Form Series ( S O S ) was va l id a ted in 2 0 0 4 . 3 1 This series i s intended fo r use in osteop a t h i c ma n i p u l a t i v e med i c i n e spec i a l ty pra ctices o r w h e never a comp lete m u sc u l os k e l et a l e xa m i n a ti o n i s need e d , such a s d u r i n g a n i n i t i a l h istory a n d p h ysica l . T h e m a i n d i f fe rence between the S O A P note series a n d the SOS is t h e exa mina tion fo r m . I n the SOS, the exa m i na t ion fo r m is d e ta i l e d to i nc l u d e i te m s needed for a compre h e n sive exa m i n a t i o n fo r c o d i n g . In a d d i tion, i t s u ggests i t e m s t h a t the physician m a y want t o t r a c k or t h a t a re u s e fu l i n osteop a t h i c trea tme n t . T h e O u t p a t i e n t Osteopa th i c C ra n i a l S O A P N o t e F o r m D i s des igned s pec i fica l ly fo r os teo p a t h i c p h ys i cia ns who primari l y u s e c r a n i a l osteopa thy or fo r p a t i e nts w h o h a v e a h e a d d i sorder or dysfu nc t i o n . A l l of t h e s e for m s c a n be u sed together o r s e p a r a te l y i n a n o u t p a ti e n t o ffice i n a n y m a n n e r t h e practitioner c h ooses. F o r exa mp le, o n a n initi a l vis i t o n e c o u l d u s e th e O u tp a t i e n t Osteopa t h i c S O A P N o t e Form Series. At t h e f i r s t v is i t , t h e physi cian fi nds tha t the patient h a s low back p a i n, a n d o n a ret u r n v i sit, a c o m p lete m u sc u l oskeletal e x a m i n a t i o n i s g i ve n . For this rer u m v i s it, one co u l d u s e the O u tp a t i e n t Osteop a t h i c S i ngl e Organ System Muscu l os k e leta l Form Series. For s u bs e q u e n t fo l l o w - u p v i s i ts for OMT, the O u t p a t i e n t Oste o p a th i c S O A P Note-Fo l l o w- u p Form w i l l w o r k we l l fo r record i n g t h e encounters . A l l of these fo rms co n ta i n the basic i nfor m a t i o n needed fo r c l i n i c a l , ed u c a t i onal, and research p u rpose s . The origi na l O u tp a t i e n t Osteopa t h i c SOAP Note Form was designed so

SSpearheaded by L B O R C m e m be r

Mills. Michael K uchera.

Miriam

" S p e a r h e a d e d by L B O R C m e m b e r

Section IV • Pract i ce I s s u e s

506

t h a t physicia n s c o u l d m a k e u p their own e x p a nd e d vers i o n s fo r c l i n i ca l or research p urposes so a s l o n g a s they conta i ne d t h e basic re q u i re d i n fo r m a t i o n and a p p e a red i n the same ge nera l form a t o f the origi n a l note. The basic i n for m a t i o n a nd fo r m a t t i n g a r e i m p o rta n t for ease of d a ta extractio n . In

1998,

for

the

inpatient

a re n a ,

the

Osteopa thic

Muscu loskel eta l

Exa m i n a tion-Hos p i t a l F o r m a n d I n s tr u c t i o n Ma n u a l w a s deve l o p e d . S h o r t l y therea fte r, the A O A H o u s e o f Delegates reco m m e n d e d t he form fo r u s e b y osteopathic s tu d e n ts a n d r es i d e n ts i n t h e hosp i ta l s e tti n g . 3 8 T h e p r i n c i p l e s a n d b a s i c i n fo r m a t i o n o f t h e O u t p a t i e n t Osteopa thic S O A P Note F o r m were p u t t o yet a n o ther u s e . T h e s a l i e n t fea ture o f a l l of t hese forms i s t h e u n i q u e l y osteopa t h i c m u sc u l os k e le tal ta b l e . Th is t a b l e i n c l udes TART for regi o n s examined, presence and severity of s o m a tic d ysfu n c t i on, a n d somet i mes, depend i n g o n the fo rm, whether O MT was done, what m od a l ities were u s e d , and what t h e response to trea tme n t was. The Forms: Detail

T h e o r igi na l O u tp a t ie n t Osteopathic S O A P N o te For m , n o w o bsolete, was

a

one

page n o t e . I t w a s the s i mplest p a p e r version and was e a s y to li se i n c l i n i ca l prac tice but was l i m ited i n t h e a mo u n t o f s p ace a v a i l a b l e fo r cha rting. I t w a s designed for u se i n the ou tpa tient setti ng, u s u a l J y fo r a fo l l o w - u p o r re t u r n v i s i t . From the research p e rspective, i t a l re a d y h a s been applied s u ccessfu lly to o u tcomes resea rc h in fa m i l y practice . 3 l However, it collected m i n i m a l d a t a a n d w a s ve r y d e ficient i n g a i n ing u sefu l i n for m a t i o n a bo u t d i agnoses. I t a l so h a s been u s e d fo r e d u c a tio n a l tra c k i n g . l ,3 l The revised O u tp a t i e n t O s t e o p a thic S O A P No te-Fo l l o w - u p Form , t h e p re ferred e s t a b l i s h e d - p a t i e n t n o te fo r priva te practice, is a tw o-page note25 ( F ig. 3 1. 2 ) . T h i s form is a n expa n d e d version o f the origi n a l S O AP note fo rm tha t p rov i d es a d d i tion a l space for h a n dwritten n o tes in t h e s u bjective a n d o b j ec t i v e sec t i o n s a n d a more structured a n d d e t a i l e d w a y of l isti ng d i a g n o s i s . In a d d i t i o n , t h e re

IS

consid

era b l y g r e a t e r d e t a i l w i t h r e g a r d t o cod i ng, p a r t i cu l a r l y i n t h e s u bj ective, a ssess m e n t, a n d p l a n secti o n s of the form . When copied fro n t to back, the fo rm may be p l a c e d on a s i ngle sheet o f p a p er, m a k i n g it e a s i e r to m a n i p u la te d u ring the p a t i e n t enco u n ter w h i l e red uci ng p a g e s i n t h e patien t'S c h a r t , t w o fe a t u res t h a t a r e rea d i l y a pprecia ted i n b u s y practices . The revised O u tp a t i e n t Osteop a t h ic S O AP Note F o r m Series, the p re ferred n o te for a new p a t i e n t v i s i t a n d p h ys i ci a n s i n train i n g , is a three- to fo u r- p a ge note25 (Fig. 3 1 . 1 ) . This s e r i e s i n c l u d e s an o u tpatient hea l t h s u m m a r y ( fi l l ed i n most ly d u r i n g the first v i s i t ) a n d th ree pages for t h e p rogress note, t h e history fo rm, e xa m i n a t i o n fo r m , a n d a s sessment a n d p l a n fo rm. I t co n ta i n s more i n fo r m a t i o n b u t i s s t i l l s i m p l e a n d e a s y t o u s e once o n e i s fa m i l i a r w i t h i ts form a t . I t h a s m o re room to write s u b j ective and o bj e c t i v e fin d i n gs and an i ncrease in cod i n g tra i n i n g i n for m a t i o n . Beca use of this it i s d esigned fo r u s e in t h e o u t p a t i e n t setti ng, u s u a l J y fo r a n e w p a t i e n t . With more cod ing g u i d e l i n e s i nc l u d e d , this is the i d e a l note fo r p h ys ici a ns i n tra i n i ng to u s e w i th n e w - p a t i en t a nd fo l l ow- u p visits . From t h e e d u c a t i o n a l track i ng a nd resea rch perspectives, these n o tes a re c o n s i d e red equa l l y competent, a s they b o t h c o n t a i n t h e essen t i a l i n fo rm a t i o n d e emed necessa ry by the LBORC. T h e S O S form is a three- t o fo u r-page note ( w i t h s u m mary page ) d esigned t o c o m p lement the SOAP n ote for m . 25•37,39 I t s u s e a t the i n it i a l v i s i t a l lows t h e other SOAP note fo rms to be used most effectively as fo l low- up fo r m s . In a d d i tion to the

C h a pter 3 1

• T h e Sta n d a rd i z e d M e d i c a l R e c o r d

507

i nfo rmation i n the muscu loskeletal ta b l e , the SOS for m includes such i tems a s gait a n d station, spina l curves, exa m i n a ti o n positi o n s , leg l engths, leve l ness o f l a nd ma rk s , reflexes, and motor eva l u a tion t h a t i s required i n a comprehen sive exa m i n a t i o n of the muscu loskeleta l syste m . O t h e r areas o f the for m incl u d e the gen e ra l a ppea rance, ca rd i ovasc u l a r, l y m p h a tic, skin a n d n e u r o l ogi c/psyc h i a tric examinations. These s pe c i fic a reas were i n c l u d ed fo r cod i n g p u r poses and are l isted in box form for ea s y u s e . The SOS form is s t ructured so t h a t if a l l a r e a s a nd boxes a re fil led, the p h ysic i a n wi l l have met a l l cod i ng criteria for re i m b u rsem e n t for a level 5 c o m preh e n s i v e exam i n a tion a s s e t forth b y the May 1 99 7 Hea l t h Ca re Fina ncing A d m i n istra tion . T h e O u tpa t i e n t Osteopa t h ic Cra n i a l S O A P Note Form is a specia l ty for m for u s e w i t h o u t p a ti e nts w h o h a v e sign i fica n t cra n i a l dysfuncti o n . It s i mp l i fies d o c u mentat i o n of c ra n i a l fi nd ings a n d the res u l ts of trea t m e n t . 2 5 T h e Osteo p a t h ic M u scu los ke leta l Exa m i n a t i o n of the H o s p ita l ized P a t i e n t is the i n p a t i e n t fo rm reco m m e n d ed by th e A O A for the stan d a r d i zed hos p i ta l struc t u r a l e x a m i n a t ion in a l l osteop a thic hosp i t a l s . 2 5 ,38 It is a o n e - page form with a n o p ti o n a l w o r k s h e e t t h a t h a s m a ny o f t h e fea t u re s o f t h e SOAP note series form , most no ta b l y t h e p resence o f th e muscu l o s k e l etal s o m a t i c d y s fu nction ta b l e . T h i s fo rm i s l i m ited i n th a t i t contains the e xa m i n a ti o n p o r t i o n b u t n o h i story, assess ment, p l a n , o r trea t m e n t g i ven d u ring a p a t i e n t enco u nter. Outp a tient Os teopa thic SOAP Note Form Series: Form Pages

Of t h e t h ree S O A P n o te fo rms a v a il a b l e , t h i s v e r s i o n i s t h e m o s t co m p re h e n s i ve . I t i n c l u d e s t h e O u tp a t i e n t Hea l t h S u mm a ry F o r m , t h e O u tpa t i en t O s teo p a th i c S O A P N o te H i s to r y F o r m ( pa ge 1 o f 3 ) , t h e O u t p a t i e n t O s teopa t h i c S O AP Note Ex a m i n a t i o n F o r m ( p a ge 2 o f 3 ) , a n d t h e O u tp a t i e n t O s t e o pa t hic A s se s s m e n t a n d P l a n F o r m ( pa g e 3 of 3 ) ( Fi g . 3 1 . 1 , A-D ) . O n t h e s e fo r m s , bo l d b l a c k boxes a re p r o v i ded fo r m a n y o f the e n t r i e s t h a t i n d i c a te t h e d a t a c r i t i c a l t o resea r c h a n d re q u i r e d to be fil led in. Th e fo r m a t o f these fo r m s w a s d e s i g n e d so t h a t d a ta cou l d ea s i l y be c o l lected a n d a n a l y zed by c o m p u te r a nd s o t h a t a d d i t i ons t o t h e fo rm c o u l d be m a d e wi t h o u t d i s r u p t i o n o f b a s i c d a ta g a t h e r i ng . A l l d e fi n i ti o n s a re o b ta i n e d fr om t h e s ta n d a rd C P T a n d I C D - 9 C M b o o k s a n d t h e G l o s s a ry of O s te o p a t h i c Term i n o l ogy. 4 0 This va l i d , sta n da r d i ze d , a n d easy-to-use fo rm i s our best recom m e n d a ti o n fo r resea rch a nd tra ining i n osteop a t h i c med ic i n e . O u tp a t i e n t H e a l t h S u mm a r y i s t h e fro n t left- h a n d p a ge o f a two-sec t i o n ch art system or rhe fro n t page of a one-section chart (Fig. 3 1 . 1 A ) . T h is page i s reviewed a t eac h patient v i s i t, a n d all sect ions a re kept c u rre n t . It i s d i vided i n to six sec t i o n s : l . I d e n t i fica tion a nd d i spositio n 1 1 . S oc i a l a n d fa m i l y h i s tory

I I I . P a s t med i ca l h i story I V. Hea l t h m a i n te n a n c e

V. Past s u r g i c a I h i s t o ry

V1 . Con s u l ta n ts

At each p a t i e n t v i s i t , t h i s sec t i o n provi d e s r a p i d retrieva l of past med ic a l , s u rgi ca l , s oc i a l , fa m i l y, a l l e rgy and med i c a ti o n h i s tory and a l i s t of co n s u l ta n ts, r o u t i n e scree n i ng d a tes, a n d i m m u n i za ti o n s . Th i s form a l so c o n t a i n s ge nera l d e mogra phic i n fo r m a t i o n , i nc l u d i n g d a te o f b i rth , sex, m a r i t a l sta tu s , s ign i fica n t o t hers, re li g i o n , d a te and u pd a te s , p h o n e n u m bers, d o- n o t - re s u scita te s ta t u s , a nd whom a n d h o w t o ca l l i n c a se of a n e m ergen c y. ,

508

Sect i o n IV • Practice I s s u e s

The o u t p a t i e n t history fo r m , p a g e 1 of 3 , p r o v i d e s t h e s u b j ec t i ve por t i o n o f a SOAP n o te fo r an o u t p a t i e n t v i s i t ( F i g . 3 1 . 1 B ) . It is d iv i d e d i n to t w o sec t i o n s : 1 . P a t i ent's n a m e , date, a g e , p a i n a n a l og sca l e , a n d c h i e f co m p l a i n t I I . H i s tory o f p rese n t i l lness, review o f s y s t e m s , a n d p a s t m e d i c a l , fa m i l y, a n d

s oc i a l h i s to r y T h e seco n d sec t i o n i s d e s i g n e d t o m a k e the cOll n t i n g o f e l e m ents e a s y fo r b i l l ing p u rposes. O nce i te m s i n e a c h s e c t i o n a re co u n te d , the p h y s i c i a n ca n c h oose r h e a pp r o p r i a te leve l o f c o d i n g s im p l y b y l o o k i ng to t h e l e ft of e a c h secti o n . A t t h e bot t o m o f the page, the three sections a b ove a re c o l l a ted to c o m p u t e a fi n a l h i s t o r y level to b e used o n t h e l a s t p a g e to d e te r m i n e t h e E & M s e r v ice c o d e . O u tp a t i e n t O s teop a t h i c S O AP N o t e Ex a m Fo r m , p a g e 2 o f 3 , p r o v i d es s p a c e for t h e o bj ective, or p h y s ic a l exa m i n a ti o n , fi n d i n gs secti o n o f t h e S O AP n o t e ( F i g . 3 1.1 C) . It is d i v i d e d i n to fo u r sec t i o n s : I . T h e p a t i e n t 'S n a m e , d a te , s e x , a n d v i t a l s ig n s I I . O b j ec t i ve secti o n ( c on t i n u e d ) I l l . H o r i z o n ta l planes a n d l e v e l of gene ra l m u l t i s y s t e m exa m i n a ti o n IV. M usc u l oskele t a I ta ble

Phys ica l fi nd i n gs fo r any a re a s or s y s tems o f the genera l m u l t isys tem e xa m i n a t i o n a re rec o r d e d i n t h e o bj e cti v e sec t i o n . A d i a g ra m i s u s e d o n th i s p a g e to i n d i ca te leve l n ess o f l a n d m a r ks . T h e d i a g r a m i s p laced for r h e con v e n ie n c e o f t h e reco r d e r a nd can b e u s e d i n a ny w a y t h e recorder w i s h es . It is n o t esse n t i a l t o c o l l e e r b a seli ne re s e a r c h d a ta . Sta rred a r e a s o n th i s page a re fo r c o d i n g a s s i s ta nce . K e y p o i nts to r e me m b e r a re t h a t e a c h e x tremity i s c o u nted i n d i v id u a l l y fo r ele m e n ts in t h e e xa m i n a tion section but a r e g ro u p e d in t h e trea t m e n t sec t i o n and th a t t h e s p i n e ( th o r a c i c , ri b s , l u m b a r, s a cr u mJpe l v i s , p e l visli n n o m . , a b d .lo t h e r ) i s g ro u ped i n t h e e x a m i n a t i o n sec t i o n b u t c o u n ted sepa ra te l y i n t h e t re a tm e nt sec t i o n . Each TA RT criterion for each e x a m i n a ti o n region is c o u n ted as one e l e m e n t . A n exa m i n a t i o n c o n d ucted i n the u s u a l o s teopa t h i c mann e r w o u l d t h e n p r o v i d e fo u r e l e m e n ts p e r s pe c i fi e d re g i o n . T h e a l l o w ed regio ns-( 1 ) h e a d , face, a n d n ec k ;

( 2 ) s p i n e ; ( 3 ) r i g fl t u p p er e x t remity; ( 4 ) l e ft u p p er extrem i ty ; ( 5 ) r ig h t l o w e r e x tre m i t y ; ( 6 ) l e ft l o w e r e x t r e m i ty-are gro u ped a nd sta r re d o n t h e fo r m fo r e a s y rem e m bra n c e . A c o d i n g gu i d e f o r t h e fi n a l exa m i n a ti o n l e v e l i s pres e n t o n t h e fo r m . T h e fi na l exa m i n a t i o n c o d e c a n t h e n be tra ns fe rred t o t h e t h i rd p a ge fo r c o m p u t i n g t h e fi n a l l e v e l of t h e E & M service c o d e fo r the v i s i t . O u t pa t i e n t Osteopa t h i c S O A P Note Assess m e n t a n d P l a n Form, p a ge 3 o f 3 , i s d i v i d ed in to s i x s e c t i o n s beg i n n i ng w i t h the a s sess m e n t se cti o n o f t h e S O A P n o te ( F ig. 3 1 . 1 D ) . I . Pa t i e n t 's n a m e a n d d a te I I . D i a g n o s i s a n d e v a l ua ti o n p r i o r to t r e a t m e n t

I I I . P l a n : som a t i c d ys f u n c t i o n regio n , O M T d o ne , t r e a tm e n t m e t h o d ( s ) used , a n d response t o O MT I V. O t h e r t re a tme n t m e t h o d s used V. Cod i n g V I . M i n u te s s pe n t w i t h t h e pa tient, fo l l o w - u p , u n i ts , O M T pe rfo r m e d a s a b ove

( n u m be r of a re a s ) , o t h e r proced ures perfo r m e d , a n d E&M codes The newest fo rms provide fo r priori t i z a t i o n o f d i a g n oses a n d space fo r b o t h w r i tt e n d i agn oses a n d their associa ted I C D - 9 CM codes. Space i s pro v i d ed fo r o t h e r t re a t m e n t meth o d s , s u c h a s m e d i c a m e n t s , exerc i s e , n u t r i t i o n , p h y s ica l t h e ra p y, a n d

Chapter 3 1

• T h e Standardized M ed i c a l R e c o rd

509

a ny th ing el se that a phys i c i a n m i ght o r d e r. The cod i ng sect i o n i ncl u d es n i teri a for both cod i ng by com ponents and cod ing by tim e , w h ichever the p h ys i c i a n ma y n eed fo r a pa rticu l a r v i s i t . Area s w he re OMT c a n be perfo r m e d inc l u d e h e a d and fa ce, nec k , t h o r a c i c , r i bs , l u m ba r, sacru m , pel v is, a bd o m e n/other, upper extremity, a n d lower ex trem i t y. T h i s p a ge a lso i n c l u d e s t h e ta b l e for fi guring t h e fin a l l e v e l o f serv i ce E & lvl code, the aggrega te o f each fin a l level o f service for the h i sto r y, exa min a t i o n , a nd med ica l dec i s i o n m a k i n g . A l l o t h e r v e r s i o n s o f the S O A P for m s a r e v a r i a tions o n these form s . T h e y a l l h a ve t h e basic esse n tia l i n fo r m a t i o n for research a n d trac k i n g p u rposes b u t h a v e m o r e o r l e s s in fo r m a ti o n i n speci fic a re a s .

U s a g e G u i d es, M ate ria ls, a n d Cou rses Ava i l a b l e P u b l i s h ed a n d b o u n d u s a ge g u i d es ( s ec u red b y c o p y ri g h t ) fo r th ree o f t h e S O AP notes, each o f w h i c h conta i ns b l a n k fu l l - p a ge copies of the forms, m a y be o b ta ined in 11 a rd c o p y versions, w i t h o u t c h a rge, fro m the Ameri c a n A c a d e my of Osteopathy ( 3 5 0 0 De Pauw B l v d . , S u i te 1 0 8 0 , In d i a n a po l i s , I N 4 6 2 3 6- 1 1 3 6 ) . The forms are titled O u tp a t i e n t Osteo p a t h i c S O A P Note Form S e r i e s , O u tp a t i e n t Osteopa thic SOAP Note Follo w-Up Form, a n d O u t p a ti e n t O s te o p a t h i c S i n g l e O rgan System M u sc u l os k e l et a l Form Series. I n a d d i ti o n , e a c h for m , i n c l ud i ng t h e O u t p a ti e n t Osteopa t h i c C ra n i a l S O A P N o t e F o r m , m a y be d o w n l oa d ed fro m th e A A O 's We b si te25 or the We b s i te o f the ACOFP. 2s T h e Osteop a t h ic M u s c u loskele t a l Ex a mi n a ti o n o f the Hospita l i zed Patient is a v a i l a b l e t h ro u g h the We b s i te o f t h e A C O F P.25 An i n s t r u cto r's kit fo r tra i n i n g u sers to be cenified ( for q u a lity a ss u ra nce ) a l s o i s a v a i l a b l e u p on request from t h e LBORC c h a i r. t t Partic i p a n t k i ts i d e ntical to t h a t u s ed i n t h e c o n v e n t i o n s ' certi fic a t i o n cou rse a r e a va i l a b l e t h ro u g h the A A O . T h e tra i n i n g k i t c o n ta i n s t h e fo l l ow i n g mod u l e s :

of t h e O ut p a t i e n t O s teo p a t h ic S i n g l e Orga n System ( S O S ) a nd S OA P N o t e F o r m S e r i e s P h y s i ci a n De mogra p h ic/Pa rticip a t i o n Form Tra i n i ng o u tl i nes fo r the O u t p a t i e n t Osteopa t h i c S O S M u sc u l oske leta l Exa m Form Series a n d O u tp a tient Osteopa t h i c S O A P N o te Form Series C u r re n t a p p l i c a t i o n s Tra i n ing o b j ectives fo r t h e O u tp a t i e n t Osteopa t h ic SOS a nd S O A P N o t e Forms U s a ge gu i d es, w i t h b l a n k fo rms, fo r the O u tp a t i e n t O s teopa th i c SOAP Note Form Series, the S O A P Note Form ( s h o rt fo r m ) , the Fo l l ow-up Form , a nd t h e SOS M u s c u l os k e l e t a l F o r m Ser ies D o c u m e n t a t i o n g u i d e l ines a n d cod i ng, i n c l u d i ng E&M c o d ing and d oc u m e n t a t i o n g u i d e l i nes, 1 9 9 5 , 1 9 9 7 Ad d itiona l d a ta s u rvey tools ( R a n d 3 6 -Item Hea l t h S u rvey 1 . 0 [SF3 6 ] , R a n d Hea l t h Sciences Progra m; Muscu l o s k e l e ta l O u tco mes D a t a Eva l u a ti o n a nd Ma nagement System; Consumer Satisfaction S u rvey, 2 n d edition, GHAAlDavjes & Wa re; S peci a l ized Osteopa t h i c Questionna i re, LBORC, A O A for Osteopa t h ic Ma n i pu lative Med i c i n e Patient Sati sfaction ) Ce rti fica t i o n process, i n c l u d ing i n s tr u c t i ons, case stud ies, a nd b l a n k fo rms

1 . P a rti c i pa nt L i s t F o r m for ceni fica t i o n 2.

3. 4. 5.

6.

7.

8.

9.

" ConraC[ rhe L B O R C ch a i r, now M i c h a e l A. Se ffi nge r, Depa r t m e n t of O S l l'o p J t h i c IVb n i p u l ,l ti v e Med i c i n e , Col kge o f OSleoparh i c Medicine o f rhe P a c i fic, We,rern U n i versity o f Hc 4 5 -3 4 7

R i b ren cI e r poi n ts , c o u n re r s r r a i n proce d u res, 355 -3 5 9 , 3 5 5 f, 3 5 6 £, 3 5 8 f

refl exes from, 4 5 (SARS), 243

Severe

S h o r r l eb

b a l a nc e , 1 6 2 , 1 65 ,

4 0 8 -4 0 9 , 4 25-426 assess m e n t , 4 2 2-42 5 , 4 2 2 f, 4 2 3 f

R I C EM mn e m o n ic , 1 46 , 1 4 8

p h y s ic a l e xa m i na t i o n , 4 1 4-4 1 9 , 4 1 5 f, 4 1 6 f, 4 1 7 f,

R o t a t i o n a nd r i b r a i s i n g , 2 5 0-2 5 1 , 2 5 0 f

prese n t a t i o n o f the p a t i e n t, 4 0 9 , 4 0 9 f, 4 1 Of,

R i ed e l 's r h y r o i d i tis , 3 1 4-3 1 5

R o r a r o r c u ff ten d o n i t i s , 1 4 6-] 4 7

4 1 8 f, 4 1 9 f, 4 2 0 f, 4 2 J f 4 1 1 -4 1 4 , 4 1 1 1, 4 1 2 f, 4 1 3 f

I n d ex

530

r e s p i r,Hory i n fection

Somatic Dysfunction in Osteopathic Family Medicine

Careers in osteopathic medicine

Foundations of Osteopathic Medicine

Osteopathic Medicine Recall

Foundations for Osteopathic Medicine

Counterstrain Approaches in Osteopathic Manipulative Medicine

The DOs: Osteopathic Medicine in America

Pediatric Manual Medicine: An Osteopathic Approach

Textbook of Family Medicine

Family Medicine Certification Review

Case Files Family Medicine

Family Medicine 2006: Family Medicine (Current Clinical Strategies)

Deja Review Family Medicine

Myofascial and Fascial-Ligamentous Approaches in Osteopathic Manipulative Medicine

Essentials of Family Medicine (Sloane, Essentials of Family Medicine)

Current Diagnosis and Treatment in Family Medicine

Family Violence in Primary Care (Medicine)

CURRENT Diagnosis & Treatment in Family Medicine

Somatic Cell Nuclear Transfer

Blueprints Family Medicine (Blueprints Series)

Family Medicine Obstetrics (Third Edition)

Bratton's Family Medicine Board Review

Family Health Guide: New Medicine

Osteopathic Diagnosis

Erectile Dysfunction

Fang dysfunction

Mitochondrial Dysfunction in Neurodegenerative Disorders

Voiding dysfunction

Manual of Osteopathic Technique

Atlas of Osteopathic Techniques

Somatic Dysfunction in Osteopathic Family Medicine

Careers in osteopathic medicine

Foundations of Osteopathic Medicine

Osteopathic Medicine Recall

Foundations for Osteopathic Medicine

Counterstrain Approaches in Osteopathic Manipulative Medicine

The DOs: Osteopathic Medicine in America

Pediatric Manual Medicine: An Osteopathic Approach

Textbook of Family Medicine

Family Medicine Certification Review

Case Files Family Medicine

Family Medicine 2006: Family Medicine (Current Clinical Strategies)

Deja Review Family Medicine

Myofascial and Fascial-Ligamentous Approaches in Osteopathic Manipulative Medicine

Essentials of Family Medicine (Sloane, Essentials of Family Medicine)

Current Diagnosis and Treatment in Family Medicine

Family Violence in Primary Care (Medicine)

CURRENT Diagnosis & Treatment in Family Medicine

Somatic Cell Nuclear Transfer

Blueprints Family Medicine (Blueprints Series)

Family Medicine Obstetrics (Third Edition)

Bratton's Family Medicine Board Review

Family Health Guide: New Medicine

Osteopathic Diagnosis

Erectile Dysfunction

Fang dysfunction

Mitochondrial Dysfunction in Neurodegenerative Disorders

Voiding dysfunction

Manual of Osteopathic Technique

Atlas of Osteopathic Techniques

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