2017 spring primary care update - university … spring pcu syllabus.pdfdesignates this live...

The Northwest Ohio Osteopathic Association

In Partnership with

The University of Toledo, Center for Continuing Medical

Education

P r e s e n t t h e :

Saturday, March 11, 2017

Hilton Garden Inn-Levis Commons 6165 Levis Commons Blvd Perrysburg, OH 43551

2017 SPRING PRIMARY CARE

UPDATE

NWOOA NORTHWEST OHIO

OSTEOPATHIC ASSOCIATION

Treating our families and yours

Please be sure to visit our exhibitor booths:

PLANNING COMMITTEE MEMBERS Nicholas J. Pfleghaar, D.O.

Program Director President, Northwest Ohio Osteopathic Association

Firelands Regional Medical Center Antwerp Medical Center

Nicholas G. Espinoza, D.O.

State Trustee, Northwest Ohio Osteopathic Association Dean of CORE St.Vincent’s Hosp., Toledo, OH

Med Director, The Falcon Health Center, Bowling Green, OH

Kris L. Lindbloom, D.O. President Elect, Northwest Ohio Osteopathic Association

Hospitalist, Firelands Hospital

Tracey O’Neal Hooker, D.O. Local Trustee, Northwest Ohio Osteopathic Association

Jennifer Pfleghaar, D.O.

Local Trustee, Northwest Ohio Osteopathic Association

John T. Rooney, D.O. Secretary/Treasurer, Northwest Ohio Osteopathic Association

Verde Valley Medical Center

Joy A. Studer, ED Executive Director, Northwest Ohio Osteopathic Association

Roger L. Wohlwend, D.O.

Local Trustee, Northwest Ohio Osteopathic Association

William J. Davis, D.D.S., MS Associate Dean, CME

The University of Toledo

Becky Roberts Sr. CME Coordinator

The University of Toledo

FACULTY

Mohammed S. Alo, DO General and Invasive Cardiologists Toledo Cardiology Consultants Toledo, OH Theresa A. Bonfiglio, RD/LD, CPHWC Metabolic & Bariatric Dietician Mercy Health Weight Management Center Toledo, OH Gregory R Johnston, DO Director Bariatric & Minimally Invasive Surgery Mercy Health Weight Management Center Toledo, OH

Shawn R. Kerger, DO, FAOASM Associate Professor, Dept of OMM Ohio University Health College of Medicine Dublin, OH Prak Naik, Pharm D President/Owner/Pharmacist The Drug Store of Perrysburg Jay W. Nielsen, MD Owner, Wellness Rx, LLC Perrysburg, OH Sarath K. Palakodeti, DO Attending General and Cosmetic Surgeon, Toledo Clinic, Toledo, OH Tim R. Valko, MD Director, Valko & Associates Toledo, OH

DISCLOSURES

FACULTY DISCLOSURES

Drs. Alo, Bonfiglio, Johnston, Kerger, Nielsen, Palakodeti, Valko, and Prak Naik do not

have any financial interest or other relationship with any manufacturer of commercial product or service to disclose.

PLANNERS

Drs. Davis, Espinoza, Lindbloom, Jennifer Pfleghaar, Nicholas Pfleghaar, O’Neal Hooker, Rooney, Wohlwend, Joy Studer and Becky Roberts do not have any financial interest or

other relationship with any manufacturer of commercial product or service to disclose.

ACCREDITATIONS

AOA AACCREDITATIONS The NWOOA certifies credit hours in conjunction with the OOA, directly to the AOA with the requirements and policies of the AOA. The Northwest Ohio Osteopathic Association designates this live activity for a maximum of 8.5 AOA Category 1A credits. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Toledo and Northwest Ohio Osteopathic Association. The University of Toledo is accredited by ACCME to provide continuing medical education for physicians. The University of Toledo designates this live activity for a maximum of 8.5 AMA PRA Category 1 CreditsTM. Physicians should claim only credit commensurate with the extent of their participation in the activity. Application for credit has been submitted to the American Academy of Family Physicians. Determination of credit is pending until after 3/23/17. Should you require this credit, you will need to reprint your certificate after this date to include this credit. The Ohio Board of Nursing will accept, at face value, the number of hours awarded for an educational activity that has been approved for CE, provided it was approved by a nationally accredited system of CE approval. The AAPA accepts certificates of participation for educational activities, certified for Category 1 credit from AOACCME, Prescribed credit from AAFP, and AMA PRA Category 1 CreditTM

from organizations accredited by ACCME or a recognized state medical society.

EVALUATION/CERTIFICATE

Evaluations will be readily available online daily at the start of the program. Evaluation is an important

component of continuing education programs. In addition to providing feedback to the program planners and

faculty, it provides information to improve future programs. The evaluation is an integral part of your

participation in this meeting.

TO OBTAIN YOUR CME CREDIT

Evaluations will be readily available the day of the program, and

MUST be completed in order to receive a certificate. Certificates will

be available online Monday, March 13, 2017 after 12 noon. Follow the

instructions below:

Go to website cme.utoledo.edu

Click on Direct Link to Login

Login: lastnamefirstname (no commas, no spaces)

Password: zip code (unless you have changed in our system previously)

If you have not completed your online evaluations: You will be immediately directed

to an “Online Forms Inbox”

o Click on the evaluation form for the activity,

Complete every field and hit “Submit”

o You will be directed to view/print your certificate

If you have completed your online evaluations:

o Choose “Credit Transcript” in the left side margin

o Next to the activity, will be a certificate icon, click it and print your certificate

SATURDAY, March 11, 2017 8.5 credits

7:00 a.m. -7:55 a.m. Registration/Breakfast Moderator: Nicholas J. Pfleghaar, D.O. 8:00 a.m.-9:00 a.m. The ACTION Study: Investigating Barriers in Obesity Theresa Bonfiglio, RD 9:00 a.m.-10:00 a.m. Bariatric Surgery: Treatment of Obesity as a Disease Gregory Johnston, DO 10:00-10:30 a.m. Break/View Exhibits 10:30-11:30 a.m. Biodentical Hormones:

Reversing Dementia, Osteoporosis, Atherosclerosis and Aging Using a Simple Approach

Jay W. Nielsen, MD 11:30 a.m.-12:30 p.m. Autism Spectrum Disorders Tim R. Valko, MD 12:30 p.m.-12:45 p.m. Lunch Buffet Line 12:45 p.m.-1:45 p.m. Review New Anticoagulants Mohammed S. Alo, DO 1:45 p.m.-2:45 p.m. Therapeutic Update to Weight Loss

Prak Naik, Pharm D

2:45 p.m.-3:15 p.m. Break /View Exhibits 3:15 p.m.-4:15 p.m. Benign Breast Disease:

Pacifying Your Patient’s Fears Sarath K. Palakodeti, DO

4:15p.m.-5:45 p.m. Osteopathic Mimics of Primary Care Complaints Shawn R. Kerger, DO, FAOASM

The ACTION Study: Investigating Barriers in Obesity

Theresa Bonfiglio, DO

Learning Objectives:

Identify results of the ACTION study, and current barriers in health care to obesity treatment.

Review methods to open a safe judgment free conversation about overweight and obesity.

Identify obesity treatments that fit the 2013 AHA/ACC/TOS model for guidelines for primary care of patients with overweight and obesity.

NOTES

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Bariatric Surgery: Treatment of Obesity as a Disease

Gregory Johnston, DO


Identify types of bariatric surgeries. Identify patient populations eligible for surgery.

Identify labs and vitamin levels that should be followed after surgery.

NOTES

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Biodentical Hormones: Reversing Dementia, Osteoporosis, Atherosclerosis and

Aging Using a Simple Approach

Jay W. Nielsen, MD


Review and discuss learning to order meaningful labs. Discuss how to interpret them.

Discuss how to interpret them, and change them safely for the better, Including endpoints of cellular effect.

NOTES

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Autism Spectrum Disorder

Tim R. Valko, MD


Discuss the ability to diagnose Autism Spectrum Disorder (ASD). Discuss the basic social/educational issues secondary to ASD.

Discuss basic management (medication/social) of ASD.

NOTES

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Review New Anticoagulants

Mohammed S. Alo, DO


Introduce all of the new anticoagulants. Discuss anti-platelet vs. anticoagulation.

Discuss mechanisms of action. Discuss elimination and reversal agents.

NOTES

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Therapeutic Update to Weight Loss

Prak Naik, PharmD


Review pharmacological agent used in weight loss management. Discuss professional and legal responsibilities of prescriber and pharmacist.

Review the latest research in weight loss management.

NOTES

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Benign Breast Disease: Pacifying Your Patient’s Fears

Sarath K. Palakodeti, DO


Identify benign breast diseases including concerning masses, common infections,

macromastia/micromastia, and Mondor’s disease. Discuss and list appropriate workup for benign vs. malignant breast disease.

Define breast screening and self breast exams.

NOTES

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Osteopathic Mimics of Primary Care Complaints

Shawn R. Kerger, DO, FAOASM


Explain benefits and limits associated with physical examinations. Explain the basic concepts of the Cyriax System of Orthopaedic Medicine.

Perform the following musculoskeletal exams: Bonnet’s, Swing Test, Lhermitte’s and Spurling’s examinations.

Recognize various knee and ankle/foot dysfunctions. Perform OMT exemplar techniques for lower extremity and cervical

dysfunctions that mimic common primary care orthopaedic conditions.

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Osteopathic Mimics of Primary Care ComplaintsOsteopathic Mimics of Primary Care Complaints

Shawn Kerger, DO, FAOASM

Associate Professor, OMM – OU‐HCOM, Dublin CampusMedical Director, Peter E. Johnston, DO, Simulation & Education Center

Shawn Kerger, DO, FAOASM

Associate Professor, OMM – OU‐HCOM, Dublin CampusMedical Director, Peter E. Johnston, DO, Simulation & Education Center

A SHORT REVIEW OF OSTEOPATHIC PRINCIPLESA SHORT REVIEW OF OSTEOPATHIC PRINCIPLES

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4 Tenets of Osteopathic Philosophy4 Tenets of Osteopathic Philosophy

• The body is a unit.

• The body possesses self‐regulatory, self‐healing, and health maintenance mechanisms.

• Structure and function are reciprocally interrelated.

• Rational therapy is based on an understanding of body unity, self‐regulatory mechanisms, and the interrelationship of structure & function.

• The body is a unit.

• The body possesses self‐regulatory, self‐healing, and health maintenance mechanisms.

• Structure and function are reciprocally interrelated.

• Rational therapy is based on an understanding of body unity, self‐regulatory mechanisms, and the interrelationship of structure & function.

Rational TreatmentRational Treatment

+ Disease =

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MDs vs. DOsMDs vs. DOs

– Site of allopathic care

– Site of osteopathic care

– Site of allopathic care

– Site of osteopathic care

Disease

Rational TreatmentRational Treatment

+ Disease =

Medical and surgical care very successful …

+ Disease =

Usual medical/surgical care unsuccessful, & OMM very beneficial & often DRAMATIC …

+ Disease =Medical care helpful, but doesn’t produce the expected clinical outcome – the

addition of OMM enables the patient to realize their “health potential”

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Indications for OMMIndications for OMM

Only ONE –

Presence of a somatic dysfunction

Only ONE –

Presence of a somatic dysfunction

Value of Physical Examination ‐ IntroductionValue of Physical Examination ‐ Introduction

The main utility for an accurate physical exam in modern medicine?– Rapid– Readily available– Rational– Results (of your treatment)– Rapport / Relationship with patient– Reasonable (in cost)– Repeatable = Reliable

The main utility for an accurate physical exam in modern medicine?– Rapid– Readily available– Rational– Results (of your treatment)– Rapport / Relationship with patient– Reasonable (in cost)– Repeatable = Reliable

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Value of Physical Exam: ACL RuptureValue of Physical Exam: ACL Rupture

Accuracy of 3 Diagnostic Tests for ACL Tears (2003) 1

• Meta‐analysis of 17 studies from potential 1090 studies

– Writings in English, French, German or Dutch were included

– From 1966 to 2003 for MEDLINE & 1980 to 2003 for EMBASE databases

• Inclusion criteria:

1. Investigation of at least one physical diagnostic test for ACL tears in the knee

2. Use of a reference standard or arthrotomy, arthroscopy, or MRI

• Tests included pivot shift, Lachman and the anterior drawer.

• Sensitivity, specificity and predictive values were reported.

Accuracy of 3 Diagnostic Tests for ACL Tears (2003) 1

• Meta‐analysis of 17 studies from potential 1090 studies

– Writings in English, French, German or Dutch were included

– From 1966 to 2003 for MEDLINE & 1980 to 2003 for EMBASE databases

• Inclusion criteria:

1. Investigation of at least one physical diagnostic test for ACL tears in the knee

2. Use of a reference standard or arthrotomy, arthroscopy, or MRI

• Tests included pivot shift, Lachman and the anterior drawer.

• Sensitivity, specificity and predictive values were reported.

Value of Physical Exam: ACL Rupture (cont)Value of Physical Exam: ACL Rupture (cont)

• Accuracy of 3 Diagnostic Tests for ACL Tears (2003)

– Results: (pooled together using bivariate random effects model – BREM)

• Anterior Drawer Test – inconclusive either way.

– Sensitivity = 0.2 (BREM)

– Specificity = 0.88 (BREM)

• Pivot Shift – best test for ruling in an ACL injury (highest PPV)

– Sensitivity = 0.18 – 0.48 (too low # of studies for BREM)

– Specificity = 0.97 ‐ 0.99 (too low # of studies for BREM)

• Lachman Test – best test for ruling out an ACL injury (highest NPV), & alsobest test overall.



• Accuracy of 3 Diagnostic Tests for ACL Tears (2003)

– Results: (pooled together using bivariate random effects model – BREM)

• Anterior Drawer Test – inconclusive either way.



• Pivot Shift – best test for ruling in an ACL injury (highest PPV)

– Sensitivity = 0.18 – 0.48 (too low # of studies for BREM)

– Specificity = 0.97 ‐ 0.99 (too low # of studies for BREM)

• Lachman Test – best test for ruling out an ACL injury (highest NPV), & alsobest test overall.



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What about MRI? 2What about MRI? 2


• Lachman Test –

–Sensitivity = 0.86 (BREM)

–Specificity = 0.91 (BREM)

•MRI – (BREM not done)

–Sensitivity = 0.9‐0.99

–Specificity = 0.67‐0.97

• Lachman Test –

–Sensitivity = 0.86 (BREM)

–Specificity = 0.91 (BREM)

•MRI – (BREM not done)

–Sensitivity = 0.9‐0.99

–Specificity = 0.67‐0.97

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Reliability of Physical ExaminationReliability of Physical Examination

While a single physical examination test result may not be as high as radiographic studies, the ease of repeatability (and allowing for variations…) increases the likelihood of making an accurate diagnosis.

While a single physical examination test result may not be as high as radiographic studies, the ease of repeatability (and allowing for variations…) increases the likelihood of making an accurate diagnosis.

Problems with Physical ExaminationProblems with Physical Examination• Poor performance of technique

– Incomplete or erroneous understanding of test’s purpose / MOA

– Lack of adaptation to patient or circumstances

– Poor manual ability to perform

• Inaccurate interpretation of findings

– Incomplete or erroneous understanding of test’s purpose / mechanism of action

– Pain only vs. reproduction of patient’s complaint

– Doing test too fast / not receiving the information

– Examiner bias / preconceptions

• Poor performance of technique

– Incomplete or erroneous understanding of test’s purpose / MOA

– Lack of adaptation to patient or circumstances

– Poor manual ability to perform

• Inaccurate interpretation of findings

– Incomplete or erroneous understanding of test’s purpose / mechanism of action

– Pain only vs. reproduction of patient’s complaint

– Doing test too fast / not receiving the information

– Examiner bias / preconceptions

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Cyriax System of Orthopaedic MedicineCyriax System of Orthopaedic Medicine

1. Every pain has a source.

2. Treatment much reach the source.

3. Treatment must benefit the source in order to relieve the pain.

Physical Exam:

1. Use active and resisted movements to evaluate tendons and muscles

2. Use passive movement to assess ligaments for pain, laxity or alterations in range of motion.

3. Capsular patterns indicate inflammation of the capsule/joint.

4. Non‐capsular patterns indicate intra‐ or extra‐articular tissue is inflamed.

1. Every pain has a source.

2. Treatment much reach the source.

3. Treatment must benefit the source in order to relieve the pain.

Physical Exam:

1. Use active and resisted movements to evaluate tendons and muscles

2. Use passive movement to assess ligaments for pain, laxity or alterations in range of motion.

3. Capsular patterns indicate inflammation of the capsule/joint.

4. Non‐capsular patterns indicate intra‐ or extra‐articular tissue is inflamed.

Spurling’s Manuever, & Standing/Seated Kemp’s TestSpurling’s Manuever, & Standing/Seated Kemp’s Test

Anatomy:• All these tests involve lateral nerve root compression by extension and sidebending, resulting in neuroforaminal encroachment.

• Classic tests reproduce patient’s radicular / shooting pains for nerve root compression; and local, nonradicularreproduction of patient’s pain from facet compression.

• Modified interpretations include radicular and non‐radicular pains on opposite side.

Anatomy:• All these tests involve lateral nerve root compression by extension and sidebending, resulting in neuroforaminal encroachment.

• Classic tests reproduce patient’s radicular / shooting pains for nerve root compression; and local, nonradicularreproduction of patient’s pain from facet compression.

• Modified interpretations include radicular and non‐radicular pains on opposite side.

http://i.vimeocdn.com/video/441337202_1280x720.jpg

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• Pt usually seated.• The physician passively extends the neck and then rotates and sidebends to the same side.

• If pain hasn’t been reproduced with extension first, nor with the sidebending/rotation – then added compression axially down the cervical column along the lateral facets from the top of the head.

• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. Non‐radicular reproductive pain indicates facet.

• Pt usually seated.• The physician passively extends the neck and then rotates and sidebends to the same side.

• If pain hasn’t been reproduced with extension first, nor with the sidebending/rotation – then added compression axially down the cervical column along the lateral facets from the top of the head.

• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. Non‐radicular reproductive pain indicates facet.

Spurling’s Manuever – Mechanism of Exam

The Physician and Sportsmedicine Volume 24, Issue 10, October 1996, pages 37-46

Spurling’s ManueverSpurling’s Manuever

Common Errors in Performance:• Not using the same amount of force.• Not determining when the pain begins by palpation, or the

pain pattern (radicular vs. non‐radicular).

Mimics:• Some facet syndromes can give near‐radicular pain pattern –

but won’t follow dermatomes and pain quality is not usually electric‐shock or shooting pains

Associated / Confirmatory Testing:• Facet blocks (diagnostic – may be therapeutic)• MRI or other imaging (U/S or X‐ray), based on availability

and circumstances.

Common Errors in Performance:• Not using the same amount of force.• Not determining when the pain begins by palpation, or the

pain pattern (radicular vs. non‐radicular).

Mimics:• Some facet syndromes can give near‐radicular pain pattern –

but won’t follow dermatomes and pain quality is not usually electric‐shock or shooting pains

Associated / Confirmatory Testing:• Facet blocks (diagnostic – may be therapeutic)• MRI or other imaging (U/S or X‐ray), based on availability

and circumstances.

The Physician and Sportsmedicine Volume 24, Issue 10, October 1996, pages 37-46

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Lhermitte’s TestLhermitte’s TestAnatomy:

• This is a test of the function of the dorsal columns of the spinal cord as they move through a flexion maneuver – it can be limited due to extradural, intradural or intramedullary lesions.

• This can be a sign (pt complains of this without being tested) or a test – with flexion of the neck actively or passively, there is an electric‐shock sensation shooting down from the head and into the trunk and/or limbs.

• Caused by multiple sclerosis lesions in the C‐spine, transverse myelitis, Behçet disease, trauma, large herniated discs, space‐occupying mass in c‐spine, severe vitamin B12 deficiency, and others.

• Most recently IMRT (intensity‐modulated radiation treatment) has been added to the list for head and neck cancer pts…

Anatomy:

• This is a test of the function of the dorsal columns of the spinal cord as they move through a flexion maneuver – it can be limited due to extradural, intradural or intramedullary lesions.

• This can be a sign (pt complains of this without being tested) or a test – with flexion of the neck actively or passively, there is an electric‐shock sensation shooting down from the head and into the trunk and/or limbs.

• Caused by multiple sclerosis lesions in the C‐spine, transverse myelitis, Behçet disease, trauma, large herniated discs, space‐occupying mass in c‐spine, severe vitamin B12 deficiency, and others.

• Most recently IMRT (intensity‐modulated radiation treatment) has been added to the list for head and neck cancer pts… http://drbell.typepad.com/.a/6a01156ecadc3a970c019b01b40b28970c-pi

Mechanism of Exam:

• Pt seated and head in neutral position.

• Can either:

– Ask patient to flex the neckOr

– Physician can passively flex the neck.

• If there is an electric‐shock sensation shooting down from the head and into the trunk and/or limbs, the test is considered positive.

• Please note that I did not say if it reproduced the patient’s symptoms – if this finding is present, it deserves immediate workup and attention…you may then still have to figure out what ELSE may be creating the patient’s problem!

Mechanism of Exam:

• Pt seated and head in neutral position.

• Can either:

– Ask patient to flex the neckOr

– Physician can passively flex the neck.

• If there is an electric‐shock sensation shooting down from the head and into the trunk and/or limbs, the test is considered positive.

• Please note that I did not say if it reproduced the patient’s symptoms – if this finding is present, it deserves immediate workup and attention…you may then still have to figure out what ELSE may be creating the patient’s problem!

Lhermitte’s Test

http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig11.jpg

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Lhermitte’s TestLhermitte’s TestCommon Errors in Performance:

• Really not much – just make sure the neck is flexing and that the patient is asked to describe the pain.

Mimics:

• Some patients will report ‘pulling’ or ‘strain’ down the thorax or even into the lumbars with this motion – be sure to get clear information about the quality of the pain, not just the location/direction of the symptoms.

Associated / Confirmatory Testing:

• Other malingering tests – Axial compression, and others.

• MRI or other imaging (U/S or X‐ray), based on availability and circumstances.

Common Errors in Performance:

• Really not much – just make sure the neck is flexing and that the patient is asked to describe the pain.

Mimics:

• Some patients will report ‘pulling’ or ‘strain’ down the thorax or even into the lumbars with this motion – be sure to get clear information about the quality of the pain, not just the location/direction of the symptoms.

Associated / Confirmatory Testing:

• Other malingering tests – Axial compression, and others.

• MRI or other imaging (U/S or X‐ray), based on availability and circumstances.

http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig11.jpg

• Pt standing with physician monitoring ipsilateral lumbar spine

• The patient actively extends the lumbar region, as they rotate and sidebend to the same side.

• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminal area is more likely.

• Non‐radicular reproductive pain indicates facet, & is usually “late” in motion.

• Pt standing with physician monitoring ipsilateral lumbar spine

• The patient actively extends the lumbar region, as they rotate and sidebend to the same side.

• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminal area is more likely.


Standing Kemp’s Test – Mechanism of Exam

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139762/bin/jcca_58_3_258f2b.jpg

BAD technique here –pt extending at knee, not lumbar spine!

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• Pt seated with physician monitoring ipsilateral lumbar spine

• The physician passively extends patient’s lumbar region, adding rotating and sidebending to the same side.

• Interpreted the same as standing!• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminalarea is more likely.


• Pt seated with physician monitoring ipsilateral lumbar spine

• The physician passively extends patient’s lumbar region, adding rotating and sidebending to the same side.

• Interpreted the same as standing!• Radicular pain that is reproductive is a classic positive test & indicates nerve compression. If pain is “early” in motion (before tension is palpated in the lumbar spine), then a disc is more likely the cause – if “late”, then degenerative changes in the neural foraminalarea is more likely.


Seated Kemp’s Test – Mechanism of Exam

https://o.quizlet.com/JD4rc43QxDeCcUlPt0pHJQ_m.png

Standing/Seated Kemp’s TestStanding/Seated Kemp’s TestCommon Errors in Performance:• Not using the same amount of force.• Allowing knees to bend instead of lumbar extension (St Kemp’s).• Not determining when the pain begins by palpation, or the pain pattern

(radicular vs. non‐radicular).

Mimics:• Some facet syndromes can give near‐radicular pain pattern – but won’t

follow dermatomes and pain quality is not usually electric‐shock or shooting pains

Associated / Confirmatory Testing:• Facet blocks (diagnostic – may be therapeutic)• MRI or other imaging (U/S or X‐ray), based on availability and

circumstances.

Common Errors in Performance:• Not using the same amount of force.• Allowing knees to bend instead of lumbar extension (St Kemp’s).• Not determining when the pain begins by palpation, or the pain pattern

(radicular vs. non‐radicular).

Mimics:• Some facet syndromes can give near‐radicular pain pattern – but won’t

follow dermatomes and pain quality is not usually electric‐shock or shooting pains

Associated / Confirmatory Testing:• Facet blocks (diagnostic – may be therapeutic)• MRI or other imaging (U/S or X‐ray), based on availability and

circumstances.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4139762/bin/jcca_58_3_258f2b.jpg

https://o.quizlet.com/JD4rc43QxDeCcUlPt0pHJQ_m.png

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http://www.anatomyatlases.org/AnatomicVariants/NervousSystem/Images/70.jpg

Bonnet’s TestBonnet’s TestAnatomy:

• This test uses the external rotation mechanics of the piriformis at less than 60° of hip flexion to determine if piriformis tension has a role in the patient’s pain.

• Note – this does NOT mean that there’s not another factor in the patient’s pathophysiology, but rather that the piriformis does have some role in the pathology…and so addressing the piriformis might be of benefit.

Anatomy:

• This test uses the external rotation mechanics of the piriformis at less than 60° of hip flexion to determine if piriformis tension has a role in the patient’s pain.

• Note – this does NOT mean that there’s not another factor in the patient’s pathophysiology, but rather that the piriformis does have some role in the pathology…and so addressing the piriformis might be of benefit.

Mechanism of Exam:

• Physician performs a routine SLR, careful to stop at the reproduction of pt’s radicular pain.

• Physician then very slightly returns the leg toward the table until just the point where the patient’s pain reduces / goes away, and stops there.

• At this level of hip flexion, the physician then internally rotates the leg which puts tension on the piriformis.

• If the pain is reproduced w/ the internal rotation, the piriformis has a role in the patient’s pain and should be addressed.

Mechanism of Exam:

• Physician performs a routine SLR, careful to stop at the reproduction of pt’s radicular pain.

• Physician then very slightly returns the leg toward the table until just the point where the patient’s pain reduces / goes away, and stops there.

• At this level of hip flexion, the physician then internally rotates the leg which puts tension on the piriformis.

• If the pain is reproduced w/ the internal rotation, the piriformis has a role in the patient’s pain and should be addressed.

Bonnet’s Test

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Bonnet’s TestBonnet’s TestCommon Errors in Performance:• Not having a positive SLR first!• Moving too far into flexion past the patient’s pain threshold

point, or not far enough back to a reduced or pain‐free location.

• Not internally rotating the leg enough.• Not paying attention to if this maneuver reproduces the

patient’s pain!Mimics:• Intraarticular process of the hip – shouldn’t cause radicular

pain with SLR, though.Associated / Confirmatory Testing:• Other hip tests (Fabere’s / Patrick’s, Yeoman’s, Hibbs,

Gaenslen’s, etc.).• MRI or other imaging (U/S or X‐ray), based on availability

and circumstances.

Common Errors in Performance:• Not having a positive SLR first!• Moving too far into flexion past the patient’s pain threshold

point, or not far enough back to a reduced or pain‐free location.

• Not internally rotating the leg enough.• Not paying attention to if this maneuver reproduces the

patient’s pain!Mimics:• Intraarticular process of the hip – shouldn’t cause radicular

pain with SLR, though.Associated / Confirmatory Testing:• Other hip tests (Fabere’s / Patrick’s, Yeoman’s, Hibbs,

Gaenslen’s, etc.).• MRI or other imaging (U/S or X‐ray), based on availability

and circumstances.

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Force Distribution Through the Bony PelvisForce Distribution Through the Bony Pelvis

• Sacroiliac & Pubic Joints are key components in the integrity of force distribution from above and below.

• This is the ‘Foundation’ for trunk function.

• Sacroiliac & Pubic Joints are key components in the integrity of force distribution from above and below.

• This is the ‘Foundation’ for trunk function.

Thieme 2007, pp.364-365

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Sacropelvic FunctionSacropelvic Function

• Three Joints:

–2 Sacroiliac Joints

–Pubic Joint

• Important for ‘Shock Absorption’

• Three Joints:

–2 Sacroiliac Joints

–Pubic Joint

• Important for ‘Shock Absorption’

Primal Pictures 2003

Piriformis

Iliacus

QuadratusLumborum

IMPORTANT Muscular Players in LBP:

Two ways to address these elements:1.Treat these muscles,

and / or

2.use these muscles to engage the restricted joints.

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Facilitated Positional Release ApproachFacilitated Positional Release Approach

History of FPRHistory of FPR

• Described by Stanley Schiowitz, DO, FAAO, in conjunction with his teaching fellows at the time (DiGiovanna & Dowling) in the 80s & 90s.

• The fellows referred to the technique as “IO” in their notes – short for “Instant Osteopathy”.

• The paper describing his technique was published in 1990, and it was titled then as “Facilitated Positional Release”.

• Described by Stanley Schiowitz, DO, FAAO, in conjunction with his teaching fellows at the time (DiGiovanna & Dowling) in the 80s & 90s.

• The fellows referred to the technique as “IO” in their notes – short for “Instant Osteopathy”.

• The paper describing his technique was published in 1990, and it was titled then as “Facilitated Positional Release”.

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Facilitated Positional Release (FPR)Facilitated Positional Release (FPR)

• Flatten any A‐P curves.•Apply compressive, torsional, or traction force through area affected. (can also be done after neutral positioning)

• Position lesioned area into a neutral position.

• Hold for 3‐4 seconds & return to neutral position passively (on pt’s part). Recheck.

• Flatten any A‐P curves.•Apply compressive, torsional, or traction force through area affected. (can also be done after neutral positioning)

• Position lesioned area into a neutral position.

• Hold for 3‐4 seconds & return to neutral position passively (on pt’s part). Recheck.

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Diagnosis and TreatmentDiagnosis and Treatment

• Requires different diagnosis technique altogether – and might not align with diagnosis in other models/approaches

• Benefits of FPR approach:– Pt remains prone, no need to switch positions– Very well tolerated, requires minimal patient effort (guided breaths at most)

– Diagnostic path is shorter/cleaner – right side vs. left side is all…

• Downsides of FPR approach:– Pt remains prone – there are lateral recumbent variations, but those are technically difficult to perform…

– Usually need 2 pillows – one for abdomen and one for leg. Can adapt with additional patient effort and physician adaptation, though…

• Requires different diagnosis technique altogether – and might not align with diagnosis in other models/approaches

• Benefits of FPR approach:– Pt remains prone, no need to switch positions– Very well tolerated, requires minimal patient effort (guided breaths at most)

– Diagnostic path is shorter/cleaner – right side vs. left side is all…

• Downsides of FPR approach:– Pt remains prone – there are lateral recumbent variations, but those are technically difficult to perform…

– Usually need 2 pillows – one for abdomen and one for leg. Can adapt with additional patient effort and physician adaptation, though…

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Sacral Diagnosis for FPRSacral Diagnosis for FPR• Pt prone with pillow under abdomen to flatten the lumbar curve (and thereby, the sacrum…)

• Place heels of both hands inferior to the ILAs

• Direct a cephalad force in either an alternating fashion or simultaneously through the ILAs

• Compare sides of the sacrum for freedom/restriction

• Restricted side is dysfunctional

• Pt prone with pillow under abdomen to flatten the lumbar curve (and thereby, the sacrum…)

• Place heels of both hands inferior to the ILAs

• Direct a cephalad force in either an alternating fashion or simultaneously through the ILAs

• Compare sides of the sacrum for freedom/restriction

• Restricted side is dysfunctionalDiGiovanna, An Osteopathic Approach to Diagnosis and Treatment, 3rd Edition : Facilitated Positional Release.

Sacral RestrictionSacral Restriction• Pt prone with a pillow under abdomen, &

another under thigh below hip joint

• Physician monitors affected SI joint with finger, and rest of hand on sacrum

• With other hand, abduct thigh until motion is felt at SI (can add IR to leg if needed/beneficial)

• Push leg down toward floor until motion is again felt

• Pt performs a deep inhalation & exhalation while physician pushes cephalad against ILA

• Release and recheck

• Pt prone with a pillow under abdomen, & another under thigh below hip joint

• Physician monitors affected SI joint with finger, and rest of hand on sacrum

• With other hand, abduct thigh until motion is felt at SI (can add IR to leg if needed/beneficial)

• Push leg down toward floor until motion is again felt

• Pt performs a deep inhalation & exhalation while physician pushes cephalad against ILA

• Release and recheck DiGiovanna, An Osteopathic Approach to Diagnosis and Treatment, 3rd Edition : Facilitated Positional Release.

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History of Still TechniqueHistory of Still Technique• It shares quite a bit of technical similarity to a different technique described in 1996 by Richard van Buskirk, DO, FAAO, which he titled “Still Technique”, but there are a few differences:

– Still technique’s position of ease is usually more exaggerated than FPR’s.

– Still technique requires the practitioner to move from the position of ease through neutral and into the barriers – FPR does not, although many FPR practitioners do so as well.

• It shares quite a bit of technical similarity to a different technique described in 1996 by Richard van Buskirk, DO, FAAO, which he titled “Still Technique”, but there are a few differences:

– Still technique’s position of ease is usually more exaggerated than FPR’s.

– Still technique requires the practitioner to move from the position of ease through neutral and into the barriers – FPR does not, although many FPR practitioners do so as well.

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Cervical Technique – AA (C1‐C2): Rotated LeftCervical Technique – AA (C1‐C2): Rotated Left

• Pt supine, w/ physician sitting or standing at the head of table.

• Physician places hands over the parietotemporalregions, palpating Lt C1 trans process.

• Rotate pt’s head to the left ease barrier, & introduce gentle compression toward C1 until softening is perceived.– FPR – hold this position for 3‐5 secs and return to neutral passively

– Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to right restrictive barrier.

• Recheck.


• Physician places hands over the parietotemporalregions, palpating Lt C1 trans process.

• Rotate pt’s head to the left ease barrier, & introduce gentle compression toward C1 until softening is perceived.– FPR – hold this position for 3‐5 secs and return to neutral passively

– Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to right restrictive barrier.

• Recheck.

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Anterior Talar DysfxnAnterior Talar Dysfxn• Commonly anteriorly displaced, or impacted/’jammed’.

• Usually secondary to a traumatic inversion of ankle, but also be d/t chronically tight post. calf muscles.

• Frequently associated w/ plantar fasciitis.

• Pt complains of ant. talar pain w/ attempted dorsiflexion, & possibly of reduced calf stretch when attempted.

• Commonly anteriorly displaced, or impacted/’jammed’.

• Usually secondary to a traumatic inversion of ankle, but also be d/t chronically tight post. calf muscles.

• Frequently associated w/ plantar fasciitis.


Evaluation for Anterior / “Impacted” Talus – Swing TestEvaluation for Anterior / “Impacted” Talus – Swing Test


• Swing Test – with foot passively dorsiflexed, posteriorly glide the talus under the mortise joint –evaluate for range & ‘endfeel’ of motion, compared with unaffected side.


• Swing Test – with foot passively dorsiflexed, posteriorly glide the talus under the mortise joint –evaluate for range & ‘endfeel’ of motion, compared with unaffected side.

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Articular TechniquesArticular Techniques

• HVLA –

–High velocity, low amplitude

–Short, but quick motion at barrier

• LVHA –

–Low velocity, high amplitude

–Slow, long motion into and through barrier

• HVLA –

–High velocity, low amplitude

–Short, but quick motion at barrier

• LVHA –

–Low velocity, high amplitude

–Slow, long motion into and through barrier

Articular TechniquesArticular TechniquesHVLA Technique• Define the lesion.• Take up the slack toward the barrier, ideally in all three planes.

• Have patient relax fully.•Move joint in a planar fashion through the barrier with a quick, directed thrust.

• Recheck your findings.

HVLA Technique• Define the lesion.• Take up the slack toward the barrier, ideally in all three planes.

• Have patient relax fully.•Move joint in a planar fashion through the barrier with a quick, directed thrust.


LVHA Technique• Define the lesion.• Take up the slack toward the barrier, ideally in all three planes.

• Have patient relax fully.•Move joint in a planar fashion through the barrier with a gentle, steady motion.


LVHA Technique• Define the lesion.• Take up the slack toward the barrier, ideally in all three planes.

• Have patient relax fully.•Move joint in a planar fashion through the barrier with a gentle, steady motion.


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Talar ReleaseTalar Release• Pt supine w/ knee & hip flexed to 90° & hip slightly abducted, nestle your elbow against the mid‐hamstring area while forming a “ring” with your thumbs & forefingers around the talus.

• Slowly, but firmly, flex the hip while maintaining the ring around the talus. You should feel a traction force building.

• Maintaining the tension, either exert a quick thrust with the talus or gently rock the talus into dorsiflexion with a little inversion/eversion until you feel a release, pop, or clunk.

• Recheck for improved ROM or deeper calf muscle stretch.

• Pt supine w/ knee & hip flexed to 90° & hip slightly abducted, nestle your elbow against the mid‐hamstring area while forming a “ring” with your thumbs & forefingers around the talus.

• Slowly, but firmly, flex the hip while maintaining the ring around the talus. You should feel a traction force building.

• Maintaining the tension, either exert a quick thrust with the talus or gently rock the talus into dorsiflexion with a little inversion/eversion until you feel a release, pop, or clunk.

• Recheck for improved ROM or deeper calf muscle stretch.

Articular Techniques for TalusArticular Techniques for Talus• Place ipsilateral middle or ring finger over superior aspect of talus, below tib‐fib joint.

• Dorsiflex ankle to barrier, while cradling calcaneus w/ contralateral hand. May fine tune w/ inversion & eversion to maximize dorsiflexion.

• With the patient relaxed, either:

– tug the foot quickly w/ moderate force in a caudal direction, (High‐velocity / low‐amplitude = HVLA)

– or w/ traction force caudally, rock calcaneus & talus as a unit in an inversion/eversion plane. (Low‐velocity / high‐amplitude = LVHA)

• Place ipsilateral middle or ring finger over superior aspect of talus, below tib‐fib joint.

• Dorsiflex ankle to barrier, while cradling calcaneus w/ contralateral hand. May fine tune w/ inversion & eversion to maximize dorsiflexion.

• With the patient relaxed, either:

– tug the foot quickly w/ moderate force in a caudal direction, (High‐velocity / low‐amplitude = HVLA)

– or w/ traction force caudally, rock calcaneus & talus as a unit in an inversion/eversion plane. (Low‐velocity / high‐amplitude = LVHA)

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Talar Tug (HVLA) – Alternate HoldTalar Tug (HVLA) – Alternate Hold

•Need to engage barrier, then rapidly pull & dorsiflex at the same time – makes a ‘sleeping J’ pattern movement when viewed this way

• Need to engage barrier, then rapidly pull & dorsiflex at the same time – makes a ‘sleeping J’ pattern movement when viewed this way

Alternative Techniques for TalusAlternative Techniques for Talus

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ConclusionConclusion

•“Education is what you

remember after you have

forgotten what you studied

for the test."

‐ Emerson

•“Education is what you

remember after you have

forgotten what you studied

for the test."

‐ Emerson

ReferencesReferences

1. Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta‐analysis. J Fam Pract.2003;52:689–694

2. Hoyt M, Goodemote P, Morton J. How accurate is an MRI at diagnosing injured knee ligaments? J Fam Pract. 2010;59(2):118–120.

3. Thieme, Atlas of Anatomy, 2nd Edition.4. Nicholas & Nicholas, Atlas of Osteopathic Techniques, 3rd edition,

Chapter 13.

Special thanks to Nicole Alexander, OMS‐IV & Abby Huck, OMS‐IV for their help with some of these photos.

1. Scholten RJPM, Opstelten W, van der Plas CG, Bijl D, Deville WLJM, Bouter LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta‐analysis. J Fam Pract.2003;52:689–694

2. Hoyt M, Goodemote P, Morton J. How accurate is an MRI at diagnosing injured knee ligaments? J Fam Pract. 2010;59(2):118–120.

3. Thieme, Atlas of Anatomy, 2nd Edition.4. Nicholas & Nicholas, Atlas of Osteopathic Techniques, 3rd edition,

Chapter 13.

Special thanks to Nicole Alexander, OMS‐IV & Abby Huck, OMS‐IV for their help with some of these photos.

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APPENDIXAPPENDIX

Cervical Still Technique – C2‐7: C4ESRRRCervical Still Technique – C2‐7: C4ESRRR• Pt supine, w/ physician sitting or standing at the head

of table.

• Physician places hands so that one is palpating Rt C4articular process & the other can control pts head.

• Extend pt’s head until C4 is engaged, & then rotate & SB head Rt until C4 softening is perceived.

– FPR – hold this position for 3‐5 secs and return to neutral passively

– Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to left restrictive barrier.

• Recheck.



• Extend pt’s head until C4 is engaged, & then rotate & SB head Rt until C4 softening is perceived.

– FPR – hold this position for 3‐5 secs and return to neutral passively

– Still’s – w/ moderate acceleration and maintaining the same amount of compression, rotate head through neutral to left restrictive barrier.

• Recheck.

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Cervical Still Technique – OA (C0‐C1): C0ESRRLCervical Still Technique – OA (C0‐C1): C0ESRRL• Pt supine, w/ physician sitting or standing at the head

of table. • Physician places hands so that one is palpating Rt C4

articular process & the other can control pts head.• Extend pt’s head until C4 is engaged, & then rotate & SB

head Rt so that C4 softening is perceived.– FPR – hold this position for 3‐5 secs and WHILE ADDING TRACTION (only time you do this) return to neutral passively

– Still’s – maintain compression force axially toward C4& w/ moderate acceleration, SB head to Lt (as you rotate Rt) through neutral while simultaneously adding graduated flexion.

• Recheck.



• Extend pt’s head until C4 is engaged, & then rotate & SB head Rt so that C4 softening is perceived.– FPR – hold this position for 3‐5 secs and WHILE ADDING TRACTION (only time you do this) return to neutral passively

– Still’s – maintain compression force axially toward C4& w/ moderate acceleration, SB head to Lt (as you rotate Rt) through neutral while simultaneously adding graduated flexion.

• Recheck.

Fibular Head DysfunctionFibular Head Dysfunction

• Goal of all the following

treatments are for the return

of anterior glide of the

proximal fibular head & to

allow external rotation of

tibia.

• Goal of all the following

treatments are for the return

of anterior glide of the

proximal fibular head & to

allow external rotation of

tibia.

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Articular Technique ‐ Fibular HeadArticular Technique ‐ Fibular Head

• Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus

• Externally rotate tibia to barrier

• Place ipsilateral 2nd MCP joint behind fibular head

• Flex knee up to barrier

• Either quickly flex knee about the 2nd

MCP joint, or smoothly continue flexion. Recheck.

• Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus

• Externally rotate tibia to barrier

• Place ipsilateral 2nd MCP joint behind fibular head

• Flex knee up to barrier

• Either quickly flex knee about the 2nd

MCP joint, or smoothly continue flexion. Recheck.

Articular Technique - Fibular HeadArticular Technique - Fibular Head

• Another view• Note the use of the

operator’s left wrist/forearm to maintain external rotation of tibia prior to knee flexion

• Another view• Note the use of the

operator’s left wrist/forearm to maintain external rotation of tibia prior to knee flexion

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Articular Technique ‐ Fibular Head (Prone)Articular Technique ‐ Fibular Head (Prone)

• Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus & stabilize

• You may externally rotate tibia to barrier, or not

• Place heel of hand behind fibular head

• Either quickly exert an anterior impulse or smoothly apply pressure anteriorly

• Grasp affected extremity with contralateral hand at either distal tib/fib junction or at the calcaneus & stabilize

• You may externally rotate tibia to barrier, or not

• Place heel of hand behind fibular head

• Either quickly exert an anterior impulse or smoothly apply pressure anteriorly

Peroneal Muscles – Soft Tissue TechniquePeroneal Muscles – Soft Tissue Technique

• Goal here is to reduce pain & tension, & promote fluid evacuation from distal ankle

• Can also serve as a prep for another technique for ankle or leg

• Gently massage or apply perpendicular traction to affected tendons & muscles

• As with any fluid model, start proximally & work distally

• Goal here is to reduce pain & tension, & promote fluid evacuation from distal ankle

• Can also serve as a prep for another technique for ankle or leg

• Gently massage or apply perpendicular traction to affected tendons & muscles

• As with any fluid model, start proximally & work distally

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Popliteal ReleasePopliteal Release• Relaxes popliteal fossa tissues & promote drainage from lower leg

• Exert an anterior force with fingers in midline of fossa

• While patient extends knee (maintaining heel on table), exert a firm, spreading force with fingertips

• This can be uncomfortable, but should not be painful

• Relaxes popliteal fossa tissues & promote drainage from lower leg

• Exert an anterior force with fingers in midline of fossa

• While patient extends knee (maintaining heel on table), exert a firm, spreading force with fingertips

• This can be uncomfortable, but should not be painful

NOTES ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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