Workshop #5 Internal Medicine II
Workshop #5 Internal Medicine II
Workshop #5 Internal Medicine II
Cardiovascular Disease
• You may review all or some of the included techniques as a group; however,
you will be expected to be knowledgeable of all the included techniques on the
quiz.
Case
• Chief Complaint
• A 50-year-old male with a history of MI and congestive heart failure
(CHF) presents with complaints of mild chest pressure and nausea.
What is your differential based on current
information?
• What are the most likely diagnoses?
• What are the “don’t miss” diagnoses?
• A couple other possibilities…
Differential diagnoses?
Diagnoses:
• Cardiac-STEMI , Non STEMI
• GI Related-esophagitis, GERD, gastritis
• Pulmonary-Asthma, COPD,PE
• Musculoskeletal related, somatic dysfunction ,chostochondritis, fractures
• Oncologic-primary or metastatic tumors
• Neurologic-C spine and Upper T spine HNP, Shingles,others
• Psychiatric-panic attacks
• Others
• Don’t Miss Diagnoses:
• Acute coronary syndrome
• Acute aortic dissection https://www.uptodate
• Pulmonary embolism .com/contents/evalua
• Tension pneumothorax tion-of-the-adult-with-
chest-pain-in-the-
• Pericardial tamponade
emergency-
• Mediastinitis (eg, esophageal rupture) department?
• Others source=history_widget
How to start narrowing down your
differential
• History! History! History!
• What are some of the things you would like to know? Remember,
your differential will help guide these questions.
His History
Pressure started in his chest while shoveling snow 2 week ago. The pain
then spread to his left arm and was accompanied by nausea. Initially,
the symptoms responded well to SL-NTG .Pain has become more
frequent and has not gone away with NTG. The symptoms lessen with
rest but doesn’t completely go away. The patient waited 16 hours
before presenting to the emergency room.
History
• Allergies: NKDA
• Meds: Losartan 100 mg PO daily and Simvastatin 20mg PO daily.
• Medical History: hypertension, hypercholesterolemia. MI 3 years ago , known
CHF, coronary artery disease, angina upon exertion,
• Family Medical History: Father deceased age 56, myocardial infarction;
Mother alive and well; 3 siblings, one with diabetes mellitus, hypertension; uncle
with tuberculosis
• Social History: Unemployed, Welder, Single, No religious affiliation, Tobacco:
1/2 packs of cigarettes daily for 5 years. Alcohol: occasional; denies drug use, no
exercise, sedentary, poor to fair diet/nutrition habits
ROS
• Review of Systems:
• Gen-No night sweats, no weight loss,+ malaise
• HEENT-Negative
• Neck-Negative
• Cardiac-chest pressure/pain as per HPI, mild nocturnal dyspnea, chronic extremity
swelling
• Pulm-Mild dyspnea, nonproductive cough
• Abdominal, negative
• Skin-no rash
• Neuropsych- insomnia, anxiety
• Musculoskeletal-some back and anterior chest pain, no erythema or swelling of
joints
Does he need studies?
• Does he need Imaging?
• Does he need lab?
• Any other studies acutely or chronically?
His Diagnostics
Pleural Effusion
Lobar Consolidation
Rib Fracture
Tension Pneumothorax
His Physical Exam
• Vital signs: Temperature, 99° F; Blood Pressure, 154/92: Respiratory Rate, 22;
Heart Rate,108; Height: 6’2”; Weight, 285 lbs
• General: Anxious; pale; slightly diaphoretic
• Skin: Warm, dry, no lesions or rashes; skin testing on the hand, forearm, and
• abdomen remains tented at 10 seconds
• Head: NCAT
• Eyes: PERRLA,EOMI BLT equal
• Nose: Nares without discharge; turbinates engorged; no epistaxis
• Throat: No adenopathy; thyroid non palpable and not enlarged; trachea midline
and moveable; no masses
His Physical Exam : Cont’
• Cardiac: Increased rate and regular rhythm at108 bpm; S3 gallop noted
• Lungs: Scattered rales noted
• Abdomen: bowel sounds + x 4 Q; abdomen soft, protuberant; no masses, tenderness,
or rebound,no organomegaly
• Extremity: 2+ pitting edema noted
His Structural Exam
• Patient examined in the seated and supine positions
• Head: OA FSLRR
• Neck: AA rotated left
• Chest: Left first rib elevated,T1 ERSL,T2–T4 NSRRL, with tissue texture
abnormalities in paraspinal soft tissues along T2–T4 left inclusive of rib
angles,T7−T10 NSLRR, Thoracolumbar Diaphragm motion restriction on the left,
with ribs 7−10 exhalation restriction (inhalation somatic dysfunction)
Now what is your assessment?
Assessment
• MI
• CHF
• HTN
• Hyperlipidemia
• Obesity
• Tobacco abuse
• Somatic Dysfunction of
• Cranium
• Cervical
• Thoracic
• Rib
• Diaphragm
Plan
Urgent or emergent medical management consistent with his diagnosis
prior to initiating OMT
Anatomy and Physiology Pertinent
to Structural Evaluation and
Treatment of the Cardiopulmonary
System
Configuration of the Thorax
Neurologic Model
Neurologic Model
“The preferred homeostatic state
of the cardiovascular system is
under parasympathetic
dominance. In decompensated
Heart Failure and many chronic
cases of heart failure, there are
increased levels of catecholamines
and hypersympatheticotonia.”
https://qph.fs.quoracdn.net/main-qimg-b0fc70386036e07cef74b9e2cf6233c7-c
Autonomic Irritation/Activity
Sympathetic Parasympathetic
• Increased catecholamines • Decreased inotropy
• Increased inotropy • Decreased chronotropy
• Increased chronotropy • Decreased BP
• Increased BP • Increased CBF
• Increased O2 demand • Improved lymph drainage
• Decreased CBF • Myocardial stabilizing
• Decreased time for diastole
• Cardiac remodeling
• Impaired lymph drainage
Parasympathetic Nervous System
Ipsilateral CN X - Vagus
Heart
Bronchial Tree
Right Vagus innervates Esophagus (lower 2/3rds)
Small Intestine
heart through the SA node Liver
Gallbladder
Hyperactivity Pancrease
predisposes to Sinus Kidney & upper ureter
Ovaries & Testes
bradyarrythmias Ascending and transverse colon
ACUTE CHRONIC
• Increase in skin temp and • Trophic changes in skin –
moisture cool, dry
• Cutaneous hyperesthesia • Increased thickening of skin
• Red reflex and subq tissues (boggy
turns fibrotic)
• Increased subq fluid (boggy)
• Localized mm contraction
• Increased mm contraction involving 2 or more
• Motion testing may feel like a segments
hard rubber band – “firm • Motion testing feels like
springiness” hard barrier
Spinal Facilitation
• Self-sustaining loop beginning with sensory afferent
originating in periphery, spinal cord interneurons, and
ventral horn motorneurons/or to sympathetic chain ganglia
via white rami communicantes
• Atria
• When atria involved usually in T4-5 dermatomal distribution
• Inferior and post wall MI show more consistent C2 dysfunction felt to be vagal mediated
Somatic Findings
• Tacchyarrythmias:
• Postural
• Nutritional
• Systemic Diseases
• Psychological Disease
• Infections
From Travell
Respiratory-Circulatory Model
Lymphatics
• Extrapleural lymphatics
drain to intercostal
vessels, to axillary
nodes and then to the
right or left lymphatic
duct
• Pleural sac and lung
tissues drain through
the pretracheal nodes
and then to the right
lymphatic duct.
Evaluate for Chapman’s Reflexes:
Cardiac , Kidney , and Adrenal areas
Anterior Posterior
Heart Heart
2nd ICS near Cardiac T3 sup facet
sternum Adrenal
Adrenal Midway between
2-2.5” superior tip of transverse
and 1” lateral and spinous
to umbilicus processes at
intertransverse
Kidney space between
1” superior and T11-T12
1” lateral to Adrenal Kidney
umbilicus Kidney Midway between
tip of transverse
and spinous
processes at
intertransverse
space between
Plan
Once medically managed and stable would consider OMT to address
patient from
Neurologic model
Respiratory-circulatory model
Structural /mechanical model
Energy efficiency model
OMT Treatment Approaches
For MI-Initial Treatment- Assumes patient is medically managed and relatively
stable
Area Treatment Approach Anatomic/Physiologic Basis?Model
OA,AA Paraspinal inhibition ,BLT, FPR, Reduce pain(and associated anxiety), Reduces detrimental somatic
Upper Thoracics Suboccipital release, Rib raising influence to the facilitated segment and the heart (somatovisceral
(gentle) reflexes)
to reduce viscero-somatic chest pain.
Neurologic Model
OA,AA Paraspinal inhibition ,BLT, FPR, Reduces detrimental somatic influence to the facilitated segment
Cervical Suboccipital inhibition, Rib raising and the heart. (particular attention to these areas associated with
Upper thoracic (gentle) Arrythmia) Neurologic Model and Biomechanical Model
Rib
Upper thoracic somatic dysfunctions These areas are Paraspinal inhibition ,BLT, FPR, Reduces detrimental somatic influence to the facilitated segment that
usually located at T1–T2 and their corresponding Suboccipital inhibition, encourage inappropriate sympathetic outflow to the heart. (particular
ribs. attention to these areas associated with Tacchyarrythmias)
Neurologic Model
For Pectoralis consider inhibition or For Pectotoralis major TP Reduces detrimental somatic influence to the
Right Pectoralis major trigger point counterstrain facilitated segment and the heart (somatovisceral reflexes)
OA/AA and cervical region somatic dysfunctions. Suboccipital inhibition, Reduces detrimental somatic influence to the facilitated segment
FPR,BLT,Indirect MFR and the heart (normalize the vagal response).Particular attention to
these areas associated with Bradyarrhythmias and heart block
Neurologic Model
OMT Treatment Approaches
For MI-Long Term Treatment
Area Treatment Approach Anatomic/Physiologic Basis?Model
Upper thoracic region ME, Still, FPR. Particular attention Sympathetic and Parasympathetic balance
to Type II dysfunctions
Perform this type of Neurologic Model
treatment once the patient is
ambulatory.
Thoracic Inlet Soft tissue, Technique selection may Diaphragm mechanics; reduce pain
Abdominal Diaphragm involve direct or indirect methods; Lymphatic drainage; respiratory mechanics
myofascial release; thoraco-
abdominal diaphragm release using
indirect methods. Respiratory –Circulatory Model
Neurologic Model
Respiratory –Circulatory Model
Biomechanical Model
Thoracic Inlet and Thoracoabdominal diaphragm Soft tissue, Technique selection may Diaphragm mechanics; reduce pain
involve direct or indirect methods; Treat as necessary to maintain proper diaphragmatic function
myofascial release; and thoraco-
abdominal diaphragm release using Respiratory –Circulatory Model
indirect methods.
Suboccipital and mid cervical Articular/ME,BLT,FPR,MFR(indirect SNS ganglia stimulation; respiratory mechanics
or direct), Neurologic Model
Cervical spine suboccipital Respiratory –Circulatory Model
inhibition. Biomechanical Model
Chapman’s 2nd ICS near sternum,periumbilical Chapman’s Reflex Neurolymphatic reflex (diagnosis & treatment)
Adrenal and Kidney reflexes; and superior T3 facet Neurologic Model
,interspace ½ way between TP and SP of ribs 11- Respiratory –Circulatory Model
12,T12-L1 -posteriorly
Cautions and Contraindications with OMT
and cardiac patients
1. Do not treat the patient in the supine position or treatment positions that restrict respiratory
efforts.
2. Do not treat with forceful direct method treatments.
3. Do not over treat .
4. Note that liver pump, liver flip, and classic thoracic pumps are all too vigorous. Avoid undue
sudden compression or decompression changes in abdomen or undue abdominal pressure as
the liver and spleen may be friable,
5. Continue to treat the patient to provide optimal lymphatic flow to reduce the amount of
scarring from the healing process.
6.Care and monitor not to overload a decompensated heart with overt pump techniques
Foundations, pp. 1015–1024.
Todays lab
1. OMT portion of the Lab is to
2. Practice diagnosis from seated position and comparing to supine
diagnosis
3. Practice FPR for the cervicals from a seated and supine position
4. Practice ME for the cervicals from the seated or supine position
5. If time allows the student can practice treating with FPR and with no
change in hand position switching the treatment to ME
For example
Treating C2 ERSR.
Flatten the spine
Place C2 in ERSR position
Compress gently to C2
After 3-5 seconds return C2 to neutral
If a restriction is still present take C2 into FRSL position and carryout ME with isometric contraction
Todays lab
• Screen
• OA,AA,(vagal influence by and on Cardia)
• Cervical (C3-5 can affect diaphragm)
• Thoracic (upper T spine with sympathetic influence on and from
Cardia))(T1-2 particularly with lymphatic concerns and thoracic
outlet)
• Ribs(upper 4 ribs with sympathetic influence on and from Cardia)
(Upper 4 ribsparticularly with lymphatic concerns and thoracic outlet)
• Lower Ribs and T spine due to Kidney and adrenal areas of posterior
Chapman’s as well as Thoracoabdominal diaphragm)
Todays lab
• Diagnose
• OA, AA, Cervicals from a seated position
1. Superficial
Normalization of palpable
(superficial) abnormal tissue texture
2. Deep
Deep muscle involved in joint mobility
62
FPR
Generally
• Straighten out any A-P curves
• Take the dysfunctional segment to position of ease
• Facilitating force applied either before or after segmental motion*
• Wait 3-5 seconds & return patient to the neutral position passively
• Take affected area past neutral into the “Feathered edge “ of the
direct barrier
63
Superficial FPR
Primary Myofascial Dysfunction
66
Hand placement for Seated Cervical FPR
One hand on vertex to control compression and somewhat rotation and sidebending.
Using “pincer grip “ with thumb and 1or2 fingers to monitor
as well as to encourage spinal sidebending.
68
C2-C4 Dysfunction Example C4FRRSR
1.The patient lies supine, and the physician sits at the head of the
table.
2.The physician gently supports the cervical region with the right hand
3.With the left hand on the patients head , the physician neutralizes
the cervical spine by gently flattening the anteroposterior
curve(slight flexion)
4.An activating force(arrow) in the form of gentle (1 lb or less)axial
compression is added with the left hand
5.While maintaining compression, the physician gently positions the
patient’s head towards flexion and right sidebending and
rotation(arrows) until maximum reduction of muscle and tissue
tension is achieved(figs 12.3 and 12.4)
6.The physician holds this position for 3-5 seconds and then slowly
releases the compression while taking the area towards its position
of ease and then towards the restrictive barrier, then to neutral
7.If tissue relaxation is not noted within a few seconds ,axial
compression should be released and procedure should be repeated
8.Reassess Nicholas AS ,Nicholas EA, Atlas of osteopathic Techniques,2 nd
Ed, Lippincott
69
Williams and Williams,2012,(p.335)
Contraindications
• Contraindications
• Inability to relax
• Herniated disc where the positioning could exacerbate the
condition
• Moderate to severe intervertebral foraminal stenosis, especially in
the presence of radicular symptoms at the level to be treated if the
positioning could cause exacerbation of the symptoms by further
narrowing the foramen
• Severe sprains and strains where the positioning may exacerbate
the injury
7
Muscle Energy to Typical Cervical
Vertebrae
Position the patient at the restricted barrier by
• Gently sidebending towards the barrier until motion is just felt at
the involved segment.
• Maintaining the sidebending component, rotate the patient’s
head towards the barrier until again motion is felt.
• Now engage the flexion/extension barrier by flexing the neck to
the involved segment, or if restricted in flexion, extending the
segment by pushing anteriorly on the inferior vertebrae.
Muscle Energy to Typical Cervical
Vertebrae, cont.
• Holding the patient gently but firmly against the barrier, the patient is then
instructed to gently rotate their head in the opposite direction to produce
an isometric force. This position is maintained for 3 seconds.
• The patient completely relaxes their effort following muscle contraction
for another 3 seconds, while the physician maintains the joint position.
• The physician then repositions the restrictive barriers in all planes while
always palpably monitoring the joint. This is typically a small adjustment.
• Repeat one or two times.
• Always recheck the findings to make certain the dysfunction is corrected
Muscle Energy- example C5 F RSL
• Extension is induced at the • Rotate & sidebend to the • Pt. actively sidebends to the
segment with the fingers right until motion is felt at left while the DO resists
the involved segment
If Time allows or just for fun
• The physician compresses down on the patient's elbow with the force directed
toward his monitoring fingers