1. Amy Vagedes, OMS V and Sarah Watson, OMS V June 12, 2013 SCREEN, SCAN, SEGMENTAL DEFINITION

2. Goals  What is Professional Touch?  Introduce the Osteopathic Exam  Screen  Scan  Segmental Definition

3. Osteopathic Exam Is there a problem? Screen Where is the problem? Scan What is the characteristics/ nature of that problem? Segmental Definition

4. Osteopathic Exam Segmental Definition (Bullseye!) Scan Screen

5. Osteopathic Exam  Screening  2 Tissue Textures + 2 Motion Tests  Is at least 1 of each positive?  Tells you the neighborhood – Ex: Thoracic Region  Scanning  Local Deep Pressure + Confirmatory Rotation OR Sidebending  Both if you need a Tiebreaker  Tells you the exact block – Ex: T7

6. Osteopathic Exam  Segmental Definition  Tells you the specific details (the address) of the dysfunction – Ex: T7 F R r S r  ALWAYS written in ease, not resistance

7. Screen: IS there a problem? Gait Posture Look Patient Listen Superficial Muscle Tone/Gross Regional Motion Feel

8. Screen  Focusing on axial spine today  cervical spine, thoracic spine, lumbar spine  Screening consists of:  Palpation of Tissue Texture abnormalities  Gross Regional Motion Restriction of motion

9. Screen: Palpation  RESISTANCE TO PRESSURE:  Two tests in each of 8 regions (only doing axial spine today) Reproducibility & Consistency  Bilateral Structures Compare Side-to-Side  Axial Spine Compares Above with Below  Ask the question, “Is there a difference in tissue resistance from here to here?”

10. Screen: Palpation  Cervical  Upper Cervical  Lower Cervical  Thoracic  Upper Thoracic  Lower Thoracic  Lumbar  Upper Lumbar  Lower Lumbar http://www.backpain-guide.com/Chapter_Fig_folders/Ch05_Anatomy_Folder/Ch5_Images/05-4_Overall_Spine.jpg

11. Screen: Gross Regional Motion  RESISTANCE TO INITIAL MOTION INPUT :  Two tests in each of 8 regions Reproducibility & Consistency  Response of human tissue to a passive motion input (most of the time)  You are NOT using much force to generate motions

12. Screen: Gross Regional Motion  C-spine Cervical rotation Cervical sidebending  T-spine Thoracic rotation Thoracic sidebending  L-spine Lumbar lordosis** Flattening or Not Lumbar rotation** Rotates to the L or R

13. Screen: Gross Regional Motion  Lumbar lordosis  Stand behind patient and palpate lumbar lordosis  Patient *actively* flexes (bends over)  Lordosis should flatten out  Lumbar rotation  Stand behind patient and palpate lumbar lordosis  Patient *actively* flexes (bends over)  A notable prominence of left or right paraspinal tissues is abnormal These two tests can be combined in one motion for the patient.

14. Screen: Gross Regional Motion  Thoracic rotation  Have patient fold arms  While behind patient, place hands over their shoulder – palms over the head of the humerus.  Apply a slight rotary force to the L and the R  Feel for that initial resistance to motion.  Thoracic sidebending  Patient folds arms  Stand behind patient and place hand on top of the shoulder of the patient  Apply a slight downward force using your body weight as leverage

15. Screen: Gross Regional Motion  Cervical rotation  Stand behind patient and place one hand over forehead and the other hand on the back of the head  Apply a slight rotary force to the left/right  Cervical sidebending  Stand behind patient  Place one hand on the top of the head and the other at the base of the neck to stabilize the shoulders and trunk  Tell patient to let the head fall to the left/right

16. Practice  Break into partners

17. Scan: Where Is the Problem?  Thumb & index or middle finger contact paravertebral muscles that are superficial to transverse processes  Resistance (speed bump) or ease (pothole) comparing segment to segment above vs. below  This can be used in the following areas:  Cervical, Thoracic, Lumbar  Rib Cage (not doing this today)

18. Scan Mark the identified segment We will come back to this point to do motion testing

19. Scan: Confirmatory Motion Scans  Passive motion test  Rotation, sidebending, flexion/extension  Increased accuracy (reliable and reproducible)  Active motion is too variable  Immediate response, not the end feel!  Listening and Motor Hands

20. Scan: The Hands  Listening  Contacts dysfunctional segment and “senses” response to motion: restriction  No motion input  Motor  Consistent introduction of motion  Rotation, Sidebending, Flexion/Extension, (pick two of these motions)

21. Scan: Rotatory Scan  Physician:  Standing behind & to the Side of the patient  Patient Seated:  Arms Crossed  Contact the location being scanned with the finger and thumb of the listening hand  Feeling for immediate ease or resistance upon initiation of the motion  The ‘motor hand’ contacts the patient’s. elbow  Introduces ipsilateral rotation (rotation to the same side) Lumbars shown here.

22. Scan: Cervical Sidebending Scan  Physician:  Standing behind & to the Side of the patient  Patient Seated:  Arms Crossed  Contact the location being scanned with the finger and thumb of the listening hand  Feeling for immediate ease or resistance upon initiation of the motion  The ‘motor hand’ contacts the patient’s. head in the same way cervical sidebending screening was performed  Introduces ipsilateral sidebending

23. Scan  What if the two scans do not agree?  Use a 3 rd Scan to Break the Tie.

24. Practice  Break into Partners

25. Segmental Definition: What is the Problem?  We have now identified where the problem is.  Next, we have to identify what the nature of the problem  A.k.A. How do we describe the dysfunctional segment in relation to specific motions?  Ex: T7 F RrSr (written in ease, not resistance)  Resistance may be easier to feel, but all diagnoses in OMM are written in ease

26. Segmental Definition  Rotatory  Flexion/extension  Sidebending (right/left)  Rotation (right/left)  Translation  Cephalad/caudad  Right/left  Anterior/posterior  Respiration  Today, we will focus on the rotatory motions

27. Segmental Definition  Active motion:  Motion which is accomplished by the patient  Passive motion:  Motion which is generated by the physician  We will be using passive motion today

28. Segmental Definition: Rotation of Thoracic Spine  Physician:  Standing behind & to the Side of the patient  Patient Seated:  Arms Crossed  Contact the identified segment with the finger and thumb of the listening hand  Feeling for immediate ease or resistance upon initiation of the motion  The ‘motor hand’ contacts the patient’s. elbow  Introduces ipsilateral rotation (rotation to the same side) No need to compare above and below since we have already identified the dysfunctional segment

29. Segmental Definition: Flex/Ext of the Thoracic Spine  Physician:  Stands to the side of the patient  Patient Seated:  Arms Crossed  Contact the identified vertebra with the finger and thumb of the listening hand  Feeling for immediate ease or resistance upon initiation of the motion  The ‘motor hand’ contacts the patient’s ribcage opposite the side the physician is standing  Introduces flexion by slumping patient’s shoulders forward or extension by arching the patient’s back

30. Segmental Definition: Sidebending of the Thoracic Spine  Physician:  Standing behind & to the Side of the patient  Patient Seated:  Arms Crossed  Contact the identified vertebra with the finger and thumb of the listening hand  Feeling for immediate ease or resistance upon initiation of the motion  The ‘motor hand’ contacts the patient’s shoulder  Introduces ipsilateral sidebending

31. Segmental Definition  Lumbar spine can be segmentally defined in the seated position as well as prone  Cervical spine can be segmentally defined in the seated or supine position using the head to input the motion  There is less gravitational pull to contend with when the patient is in the supine position

32. Putting it all together Screen, Scan and Segmental Definition: Demo

33. Review of Osteopathic Exam Screen Scan Segmental Definition Questions?? Summary

34. References  Johnston WL, Friedman HD, Eland DC. Functional Methods: A Manual for Palpatory Development in Osteopathic Examination and Manipulation of Motor Function. 2 nd ed. 2005; Indianapolis, IN. American Academy of Osteopathy: 17-79.  Foundations of Osteopathic Medicine, 3 rd Ed.