27 th Annual SW Conference on Medicine Westin La Paloma Spa Tucson April 27-29

Transcription

1 27 th Annual SW Conference on Medicine Westin La Paloma Spa Tucson April Edward G. Stiles, DO, FAAODist. Professor of OPP Kentucky College of Osteopathic Medicine Sturgill Distinguished Professor University of Pikeville Workshop: OMT principles & care

2 Sponsors: Tucson Osteopathic Medical Foundation Cleveland Clinic

3 Challenges for this workshop: Diversity of participants DOs: improve OPP knowledge & OMT skills MDs: provide / improve OPP knowledge & skills NP: make aware of OPP potential PA: make aware of OPP potential DO students: improve skills Goals: enable all to gain new OPP understanding and OMT skills

4 Greenman: the expert is the one who does the basics the best what makes a DO different is not OMT, but how they think / problem solve. Dispelling some OMT myths Something is not out of place : it can t completely open or close. Your not putting something back in place but restoring physiological motion, doesn t require a lot of force. OMT is not a panacea but can be dramatic when S/D is a major etiological component. One indication for OMT! presence of somatic dysfunction ( S/D ) - not pain, muscle guarding, etc. Osteopathic Joint model: vs out of place model

5 Pardigm shifts: Amount of force utilized with OMT: Mitchell stool demonstration Stiles musculo-skeletal / mesokinetic model: Tensegrity Need to find AGR / sequence: least healthy / functional area Learn principles and get them to work for you : Kimberly Spinal mechanics: facet model Direct techniques Demo the facet model for Dx and Rx ( thoracic, cervical & lumbar ) Using translation to Dx and Rx: the KEY! HV/LA thumb thrust ( Osteopathic Activator ) Thoracic MET: using a patient specific muscle corrective force T 6-11 FRS dysfunctions MET ( 2 steps ) T 12 FRS dysfunctions MET ( 2 steps ) Indirect techniques ( Laughlin - Still ) thoracic, cervical & lumbar Sacral complexity: Left sacral Flexion ( use as example ) Innominate: fine-tuning / activating only prime mover Ribs: basic Dx and Rx

6 Joint Mechanics: an Osteopathic Perspective ( Normal and abnormal - somatic dysfunction ) What is Somatic dysfunction? ( S/D )

7 Normal Joint Mechanics Active ROM Passive ROM A E P P E A Elastic & Physiological barriers: provide support & movement Hypermobility issue: hindered elastic barrier Workman s Compensation: hypomobility significance

8 Normal & Dysfunctional Joint Mechanics Active ROM Passive ROM A E P DBP N A = anatomical barrier: bony shape of the joint ( hip / shoulder ) FX / dislocation E = elastic barrier: ligaments & capsules / dislocations possible P = physiological barrier: myofascial tissues Active ROM: between the physiological barriers / restrictive barrier Passive ROM: between the elastic barriers / restrictive barrier N = neutral: position of ease DBP = dynamic balance point: dysfunctional position of ease R = Restrictive Barrier: not out of place / minimal, moderate, marked, etc. Damaged E. Barrier can account for hypermobility ( Tensegrity / prolo therapy ) R. Barrier will decrease Range of Motion ( O.M.T. ) Nothing is out of place! But functionally disorientated! GOAL OF O.M.T.: not to put something back in place but to re-establish normal range of motion. Remove the functional hindrances. P E A

9 CONSILIENCE: E. O. WILSON PhD: HARVARD BIOLOGIST A CALL FOR A UNITY OF ALL KNOWLEDGE NATURAL SYSTEMS ARE RESILIENT UNTIL WE INTRODUCE MECHANISTIC INTERFACES WITH ALL THE NECESSARY ADJUSTMENTS AND COMPENSATIONS AS A MEANS OF SUSTAINING OURSELVES. THOSE INTERFACES NOT ONLY ISOLATE US FROM NATURE BUT AT THE SAME TIME CREATE SYSTEMS THAT ARE BRITTLE AND DELICATE LOWERED RESISTANCE? INCREASED SUSCEPTIBLITY? BECOME LESS NON-LINEAR! FRAGILE BECOME DIS-EASED HOST A HARVARD DESCRIPTION OF Somatic Dysfucntion H IMPACT? NOTE: EXCHANGE THE WORDS HOST AND S/D-H

10 Paradigm Shift: 2018 looking at familiar data, come to new understanding & new way of explaining old observations Anatomical design OMT mechanisms Learn the principles and get them to work for you. Paul E. Kimberly, DO, FAAO

11 The Musculo-Skeletal System a 21 st. Century Perspective

12 Tensegrity structures are: Light weight Much stronger than experts had predicted Multi / Omni - directional Whole system adapts to stressors Protects the weakest link / the A.G.R. defy gravity Non-metallic materials, organized in a Tensegrity arrangement, can conduct electricity wired : keep eyes level, evenly distribute weight among all 4 quadrants. Conduct vibratory information Would it not make sense to identify, the A.G.R. ( area of greatest restriction - hindrance ) in this flexible & adaptive system?

13 MESOKINETIC SYSTEM Meso ( mesoderm ): gives rise to Connective tissues & fascia Cartilage Bone Striated and smooth muscle Myocardium and pericardium Blood and lymph vessels Kidneys and ureters Adrenal cortex Gonads Tubes, uterus and upper vagina Serous membranes lining the body cavities ( T, A & P ) GI fascial support system Spleen Kinetic: Related to movement of physical objects NOTE: S/D might impact both musculo-skeletal & visceral structures. Netter s Atlas of Human Embryology 16

14 MESOKINETIC SYSTEM Meso ( mesoderm ): gives rise to Connective tissues & fascia Cartilage Bone Striated and smooth muscle Myocardium and pericardium Blood and lymph vessels Kidneys and ureters Adrenal cortex Gonads Tubes, uterus and upper vagina Serous membranes lining the body cavities ( T, A & P ) GI fascial support system Spleen Kinetic: Related to movement of physical objects NOTE: S/D might impact both mysculo-skeletal & visceral structures. Netter s Atlas of Human Embryology 16

15 Passing on the Tradition Alan Becker, DO, FAAO 2010 Journal of AAO fall edition Dr. Still was keen on being very specific. He looked at the patient as a Totality. He looked for the Elusive Key Lesion Hindrance ( somatic dysfunction ) that people have quoted for years. That is what He looked for and when He found it, He fixed it and then left it alone. He said that once done, the body will do its own work because it is designed to do its own work. Our job is to find the Key Restriction Hindrance to homeostatic integrity, and once restored to normalcy, to rest assured that the body will take care of the rest of the work.

16 LBP patient A.G.R. ( Key somatic dysfunction ) L.B.P. Other possible A.G.R.s Cranial: dural tube U.E. L.E. Note: ever see a LBP research strategy which considered S/D in T/RC, UE, LE or cranial? ( Stiles: 100 patients ) T/RC = 60% Lumbar = 24% L.E. = 11% Total: 95% Note: Sacrum and innominates were not the #1 A.G.R.! may have been treated later in the treatment sequence

17 In light of this complexity, how do you clinically view your patients? Stiles Current Perspective complex, dynamic, inter-connected & inter-woven, multiple, simultaneously functioning systems, non-linear, autopoietic functional unit

18 OPP treatment basic principles: 2 technique components Positioning of S/D: re Restrictive Barrier Direct: HV/LA: Kimberly, should be painless and noiseless ( avoid trap of a hypermobile pop ) Muscle Energy Myofascial Indirect: Strain-Counterstrain ( S/CS ) Balanced Ligamentous Tension ( BLT ) Facilitated Positional Release ( FPR ) Still Techniques ( ST ) Functional / Laughlin ( FRT/L ) Corrective Force: Clinician introduced force: a thrust / an impulse Patient introduced force: patient specific muscle effort Intrinsic forces: self-healing forces of body

19 Tell me about Fred L. Mitchell, Sr, DO, FAAO MSU-COM 1972 Picture = 1,000 words Mechanical Engineer Creative Thinker Non-linear Thinker Tensegrity thinker utilized Cybernetics Complex Adaptive Systems Thinker Phenomenologist These attributes enabled Fred to develop: the unique Mitchell Pelvic Axis Model plus a totally new OMT approach utilizing a patient generated corrective force. stressed the importance of starting your treatment at the Key S/D of the total system. 4 Tutorial participants: Greenman, Stiles, Sutton, & Ward are Legends being honored during 2018 Convocation.

20 Leon Chaitow, DO Comments about various techniques in light of data presented during the 4 th Fascia Congress: ( Sept ) Muscle Energy Techniques It is not a Post Isometric Relaxation technique ( PIR )! M.E.T. introduce movement which then decreases the pain. Leon felt my hypothesis that introduced movement stimulates the joint mechano-receptors and that inhibits the nociceptors was an appropriate expanded explanation of his statement. ( Wyke 1980 s research yrs. after 1 st M.E.T. Tutorial ) 48

21 MUSCLE ENERGY TECHNIQUES ( MUSCLE ACTIVATION ) SUMMARY 8 ESSENTIALS: also explains why it doesn't work ACCURATE DIAGNOSIS A.G.R. / SEQUENCING... Crucial for FLM,Sr. SEGMENTAL DIAGNOSIS... Specific OMT ACCURATE POSITIONING FEATHER EDGE OF RESTRICTIVE BARRIER... crucial DIRECT BALANCED LIGAMENTOUS TENSION UNYIELDING COUNTER-FORCE... Crucial A.A.O. M.E.T. - 3 VISIONS M.E.T. 3 MASTERS FRED, ED & PHIL SHOW 2005 ( FUNCTIONALLY REVERSES THE ORIGIN AND INSERTION ) APPROPRIATE MUSCLE EFFORT DIRECTION: multiple options ( Findley ) AMOUNT: least amount that produces beneficial change DURATION... Cybernetic loop key COMPLETE Rx SITE BUT DON T GIVE UP WHAT GAINED REPEAT ABOVE STEPS... remaining R. barrier, not new!, # efforts? RE-TEST... Taking money under false pretenses?, confirms Dx / Rx 21

22 Functional: Laughlin-Still basics establish a S/D diagnosis ( works best if start at A.G.R.-H / Key lesion ) start technique at Positional Diagnosis position ( take doodad where it wants to go ) ( position of ease ) ( use translation & have at apex of F/E, SB & R curves ) fine-tune dysfunctional joint so maximally relaxed ( fiddle and diddle to fine-tune positioning at D.B.P. ) ( Dynamic Balance Point ) Biodynamics language: at loose-packed position add vectored compression ( from side towards which dysfunction will initially rotate ) allow to unwind ( initially away from restricted barrier, hits a still point & then spontaneously moves into the previously restricted compartment ) recheck: know made a positive change! 2

23 POSITIONING: FUNCTIONAL TECHNIQUES SINCE AN INDIRECT TECHNIQUE POSITION AT D.B.P. WHICH IS IN THE POSITIONAL DIAGNOSIS QUADRANT ( NOT AT JOINT NEUTRAL BUT AT JOINT S/D-H NEUTRAL ) EX: DIAGNOSIS L 3 FRS L A E P THE D.B.P. WILL BE IN THE P FRS L QUADRANT R.B. E A FLEXION DBP N EXTENSION FUNCTIONAL TECHNIQUES: ALL START AT THE SAME POINT / DIFF. NAMES IF MONITOR THE DYSFUNCTIONAL FACET & TISSUE CHANGES ( FRT/L-Stiles ) [ MECHANORECEPTOR / NOCICEPTOR ROLE WITH PASSIVE UNWINDING ] IF MONITOR LIGAMENTOUS TENSION ( BLT WALES, LIPPINCOTT, BECKER & SUTHERLAND ) IF MONITOR A JONES TENDER POINT ( S/CS JONES ) IF MONITOR SUPERFICIAL OR DEEP MUSCLES ( FPR SHIOWITZ ) IF MONITOR 3 SEGMENTS ( FUNCTIONAL METHODS JOHNSTON ) IF ACTIVELY BRING THROUGH RESTRICTIVE BARRIER ( STILL VAN BUSKIRK ) ( MISINTERPRETED A.T. STILL / SHOULDER VIDEO? ) 23

24 The scientific method of phenomenology ( Goethean Scientific Method ) is used to create a synthesis between modern orthodox embryology and a holistic view of the human being. The human embryo reveals who we are and what we are meant to be. Practitioners have found that comprehending embryological forces supports a holistic and biodynamic approach to healthcare because the same forces that formed the body are continuously at work throughout life, carrying the blueprint of health into manifestation. Jaap van der Waal, MD, PhD The Embryo in Us May A.T. Still: find S/D hindrances, effectively treat the S/D hindrances and enable the blueprint of health to emerge / to manifest. Forces we are tapping into by removing S/D hindrances.

25 Note: I am not saying AGR / sequencing is the only way to approach patients! but our data suggests it is an effective clinical strategy Sequenced OMT Stiles Data: methods Spinoscope / Gracovetsky semg evaluation Ground Reactive Force Fractal Analysis Reactive Fractal Analysis golfers Elite female runners Dynamic Athletic Research Institute ( DARI ) Jason Hunt, DO - orthopod

26 Median of 60 gait cycles ( tons of data ) Statistical & fractal significant changes Immediate changes with sequenced OMT, not with models, chasing pain or exercise. Each patient their own research project Not saying AGR / sequencing right way and other strategies are wrong, just saying we have a lot of data to support the AGR / sequencing strategy utilizing several data collection strategies Ground Reactive Force data: See similar changes 80% of time with new patients

27 Spinal Mechanics an Osteopathic Perspective

28 Spinal Mechanics Bottom line Act like a pile of blocks act like flexible ruler Type I Mechanics: Bodies in control Involves multiple vertebra SB / R occur in opposite directions Rotation is toward produced convexity Compensate for Type II, pelvic or rib cage dysfunctions Type II Mechanics: Facets in control Involves 2 vertebra SB / R occur in the same direction R toward produced concavity Associated with segmental facilitation

29 Key to establishing an accurate diagnosis and quality localization of your treatment forces X TRANSLATION Moving a segment along a line ( introduces forces from both above and below ) Have the segment being diagnosed!!! and treated!!! floating at the apex of the curve... integrates ( using Law III of Fryette s Principles to your advantage ) Minimal dysfunctions can be missed when use just flexion, extension, SB R, SB L or R R, R L ( forces introduced from only above... segment not at apex ) 29 X

30 Spinal Mechanics: Type II palpate over facets Flexion Extension X ERS L ( can t go into Flexion on left ) X FRS L ( Can t go into Extension on right ) Note: both are SB L and R L Need to use both flexion & extension to establish an accurate diagnosis

31 Unyielding Counter Force DIAGNOSIS: ERS L Rx M.E.T. Long mobilizers / restrictors Short mobilizers / restrictors Treatment procedure: Position FRS R against feather edge of R. Barrier ( D-BLT ) Do this using translation in 3 planes Dysfunctional facet pair within normal range of motion fiddle and diddle to fine tune to dysfunctional facet pair ( left ) Patient makes a gentle isometric SB L and / or R L, or both muscle effort against a gentle unyielding counter force! 2 effects occur Inhibits short restrictors ( Golgi receptor / protective role activated ): inhibited, not stretched! Long mobilizers restore some of the lost movement ( micro-isotonic response ) Facet mechano-receptors stimulated and inhibit the pain receptors ( Wyke ) Hold until cybernetic feedback loop displays movement, L. facets pair opens Have patient relax the treated area Reposition against the remaining / not new R. Barrier: take up the slack Repeat 2-3 times not Post Isometric Relaxation technique

32 Unyielding Counter Force DIAGNOSIS: FRS L Rx - M.E.T. X Long mobilizers / restrictors Short mobilizers / restrictors ( timing gear problem ) Treatment procedure: Position ERS R against feather edge of R. Barrier ( D-BLT ) Do this using translation in 3 planes Dysfunctional facet pair within normal range of motion fiddle and diddle to fine tune to dysfunctional facet pair ( right ) Patient makes a gentle isometric SB L and / or R L, or both muscle effort against a gentle unyielding counter force! 2 effects occur Using the left long mobilizers activates the law of reciprocal innervation, inhibits contralateral short restrictors... Doesn t stretch short restrictors, inhibits them. Then long mobilizers restore some of the lost movement ( micro-isotonic response ) As closes, stimulates mechano-receptors which then inhibit pain receptors. ( Wyke ) Hold until cybernetic feedback loop displays movement... SB R &R R closes R. facet pair Have patient relax the treated area Reposition against the remaining / not new R. Barrier: take up the slack Repeat 2-3 times not Post Isometric Relaxation technique

33 CNS RESPONSE: A VIRUS IN THE SOFT-WARE PROGRAM OF THE C.N.S. ( AN ANALOGY ) DYSFUNCTIONS PLUS ADAPTIVE PATTERNS ARE PRESENT IN THE MESOKINETIC SYSTEM BUT MAINTAINED IN THE C.N.S.? NEUROPHYSIOLOGICAL ROLE Our Eugene & Golf data support this concept 33 X X

34 virus in software analogy OKC 1994 Bob Foreman, PhD Ch: Physiology OUMed S/D-H pattern maintained in cerebellum? Cerebellum enables total body adaptations to occur to: Keep eyes level Evenly distribute weight in all 4 quadrants Why finding KEY is important! Treating Pr. or Sec. S/D? AFTER 2008: Engineering Biomechanics of Human Motion Robert L. Williams, PhD Ohio University willar4@ohio.edu

35 T 7 ERS L : Functional Position: instruct patient to Sit up and push stomach forward You then translate T 7/8 area to right These 2 movements close the left facet pair ( taking doodad where wants to go ) ( fiddle & diddle to fine tune & add rotation ) Add vectored compression toward dysfunctional facet pair Allow to unwind in both directions maintain compression during whole treatment ends up at FRS R, may be neutral. Recheck: realize self healing potential Palpate where? 6

36 T 7 FRS L Functional Positioning: instruct patient to Slump forward / apex of F/E curve You then add translation T 7/8 to right so at apex of both flexion & SB L curves. These 2 movements open the right facet pair ( taking doodad where it wants to go ) ( fiddle & diddle to fine tune & add R ) Add vectored compression toward dysfunctional facet pair Allow to unwind in both directions Maintain compression throughout treatment usually ends up at ERS R, or may be neutral. Palpate where? 7

37 ESSENTIALS: ANT. LUMBAR IS LOOKING LEFT ( SIDE LOAD I.T. ) RIGHT FACET PR. IS DYSFUNCTIONAL ( SIDE FLOAT ) FASCIAL LOAD TOWARD R. FACET PAIR POSITION: L 3 FRS L USING TRANSLATION FLOAT R. FACET PAIR LOAD OR BEAR WEIGHT ON L. I/T AS SLOWLY ADD COMPRESSION TOWARD RIGHT FACET PAIR, THE BODY WILL AUTOMATICALLY ROTATE LEFT HIT A STILL POINT THEN SPONTANEOUSLY ROTATES TO RIGHT TOWARD RESOLVED RESTRICTED BARRIER LUMBAR DYSFUNCTION: L 3 FRS L Functional 37

38 Cervical Region During extension: using fingertip translation, facets should close. If facets don t close, test both sides for resistance using diagonal translation. During flexion: using lateral translation, facets should open, test both sides for resistance Treatment: either direct ( MET or HV/LA) indirect: at position of ease

39 FUNCTIONAL TECHNIQUES cervical area SCREENING EXAMINATION PATIENT IS SEATED OPERATOR STANDS NEXT TO THE PATIENT WITH ONE HAND ON THE PATIENT S HEAD THE OTHER HAND PALPATES ALONG THE ARTICULAR COLUMN UTILIZING THE DISTAL PAD THE THUMB ( OVER THE FACETS ) THUMB SLIDES CEPHLAD OVER ARTICULAR COLUMN AS THE NECK IS ROTATED... USE COMPRESSION LOOK FOR SPEED-BUMPS PASSIVELY Dx... FINDING D.B.P. / POSITION OF EASE 39

40 FUNCTIONAL TECHNIQUES lower cervical area DIAGNOSIS: FRS R PATIENT IS SITTING PASSIVELY POSITION THE DYSFUNCTIONAL DBP OF FRS R THEN FIDDLE & DIDDLE TO FINE-TUNE ADD GENTLE CAUDAD COMPRESSION TOWARD SEGMENT ( DYSFUNCTIONAL FACET PAIR ) ALLOW IT TO UNWIND TO THE RIGHT, HITS A STILL POINT AND THEN SPONTANEOUSLY ROTATES & SIDEBENDS LEFT AND EXTENDS NOTE: VAN BUSKIRK DOES ACTIVELY & STOOD IN FRONT OF PATIENT RETEST... TO SEE IF CORRECTED! FEW MEDICAL RESPONSES OCCUR THIS QUICKLY 40

41 Rib Cage Mechanics an Osteopathic Perspective

42 Rib Cage Mechanics Pump-Handle Bucket-Handle Exhaled Inhaled Clinical Application: pseudo-angina Waterville Data Impact ( Medicare codes)

43 MUSCLES: CLINICAL USE ( EXPIRED DYSFUNCTIONS ) X X X TREATMENT PRINCIPLES: EXHALED vs EXPIRED STABILIZES SCAPULA ALTERNATIVE METHOD 43

44 MUSCLES: CLINICAL USE ( INSPIRED DYSFUNCTIONS ) LOWER RIBS: BUCKET-HANDLE WANT TO USE SIDE-BENDING THEN STRETCH OUT FASCIA UPPER RIBS: PUMP-HANDLE WANT TO USE FLEXION POSTERIOR M.E.T. EFFORT AT END ( GLIDES POSTERIOR END CEPHLAD ) 44

45 Stiles Pelvic model: an evolving model

46 PELVIC REGION AN EVOLVING PERSPECTIVE 1960 s VIEW 1970 MITCHELL s 2013

47 TENSEGRITY & FRACTAL GEOMETRY: SI/J UNIQUE SIDE TO SIDE FRACTAL / ROUGH & NON-LINEAR PROVIDES A PROTECTIVE DESIGN! WHY DENSE POST. S/I LIGAMENTS? ( HOLDING TWO SURFACES APART? ) ENABLE COMPLEX SACRAL MOVEMENT? FLOATING COMPRESSION PLUS 6 FUNCTIONAL AXES... QUANTUM # ( INTERSECTING ITA AND OA s ) NOTE: STA IS ANTERIOR TO ITA... ROLE? IF TENSEGRITY IS FUNCTIONING DO WE NEED FORM / FORCE CLOSURE? IS THAT A BACKUP SYSTEM? HAS SIGNIFICANCE OF ROUGHNESS BEEN MISINTERPRETED? ( OCCURS DURING 2d & 3d DECADES ) MITCHELL- TENSEGRITY DESIGN ENABLE COMPLEX MOVEMENT PATTERNS AND PREVENT WEAR & TEAR? 47

48 FLOATING COMPRESSION DESCRIBES A CLOSED STRUCTURAL SYSTEM COMPOSED OF A SET OF THREE OR MORE ELONGATED COMPRESSION STRUTS WITHIN A NETWORK OF TENSION TISSUES, THE COMBINED PARTS ARE MUTUALLY SUPPORTIVE IN SUCH A WAY THAT THE STRUTS DO NOT TOUCH EACH OTHER, BUT PRESS OUTWARD AGAINST NODAL POINTS IN THE TENSION NETWORK TO FORM A FIRM, TRIANGULATED, PRESTRESSED TENSION AND COMPRESSION UNIT BEFORE AFTER

49 PALPATING THE SACRAL BASE ( 1970 TUTORIAL ) Locate the P.S.I.S. Glide thumbs medial & anterior to sacrum ( sulcus ) Then glide thumbs superior to sacral base I.L.A.: palpate sacral hiatus Palpate inferior lateral to I.L.A. 49

50 Biomechanical Complexity: anatomical ( Mitchell, Sr. always stressed this principle for every anatomical area ) adduction-abduction int. / ext. rotation Key to fine-tuning Key: modify technique to patient uniqueness!!! ( mastery rather than competency )

51 L. SACRAL FLEXION: Rx MET PATIENT IS PRONE Greenman: technique description ( ABD 15 0 & I/R ) ABD /ADDUCT THE L.. LEG TO LOOSE-PACK THE LEFT S/I JOINT ( ALSO INT./EXT. ROTATE LEG ) LOCATE THE MTA OPERATOR DETERMINES THE MOST EFFICIENT VECTOR DIRECTION WITH THEIR R. HAND ON LEFT ILA USE RESPIRATORY ASSIST: RE-TEST INSPIRATION MISTAKES: NOT REALIZING ABOVE TASKS / ASSUME ALL SI/Js ARE THE SAME... SKILLS DEVELOP RAPIDLY WITH THIS APPROACH! TEXT: GREENMAN 2d & 4 th EDITIONS ABD / ADDUCT TO APPROX INT. ROTATE THIGH TO OPEN S/IJ BUT.... VECTOR 51 MONITOR

52 LEFT SACRAL FLEXION ( functional ) FASCIAL LOAD ( SLOWLY ADD COMPRESSION TOWARD DYSFUNCTIONAL JOINT ) + A/D R L P/N FLOAT LEFT S/IJ ( AS SIDEBEND TO RIGHT ) MTA ( LOCATE WITH A/P TRANSLATION ) LOAD OR BEAR WEIGHT ON R. I/T ( BY SIDEBENDING TRUNK TO RIGHT ) THE I/T SACRUM LOOKING AT FOOD FOR THOUGHT: LOADED RIGHT I/T, LOOSE PACKED LEFT S/IJ & FIND MTA THIS LOCATES THE DBP FOR THE DYSFUNCTIONAL S/IJ ADDED COMPRESSION TO ACTIVATE TENSEGRITY IT WILL UNWIND AWAY FROM RESTRICTIVE BARRIER AFTER THE STILL POINT, THE BODY AUTOMATICALLY GOES TOWARD THE PREVIOUS RESTRICTED BARRIER FINDS THE NEW DBP & AXIS AUTOMATICALLY!!! ILLUSTRATE THE RAPID AND DYNAMIC PLASTICITY OF THE CNS? BUOYANCY AND RESILIENCY POTENTIAL! I/P 52

53 RIGHT ANTERIOR INNOMINATE: Rx MET PATIENT IS SUPINE OPERATOR FLEXES R. HIP UNTIL THE ITA IS LOCATED THE R. S/I JOINT IS THEN LOOSE- PACKED UTILIZING ABD/ ADDUCTION AND I/R & E/R TO FLOAT AGAINST RESTRICTIVE BARRIER... Only prime movers activate PATIENT ATTEMPTS TO EXTEND THE HIP vs YOUR COUNTER-FORCE MISTAKES: NOT REALIZE ABOVE TASKS.. SYNERGISTS AND ANTAGONISTS ACTIVATED WITH MET EFFORT. NOT CLEAN M.E.T. RESPONSE ALTERNATIVES: LATERAL AND PRONE 53

54 ESSENTIALS: ANT. PELVIS IS LOOKING LEFT ( SIDE LOAD ) RIGHT I/SJ IS DYSFUNCTIONAL ( SIDE FLOAT ) R N LEVEL S + FASCIAL LOAD LOAD OR BEAR WEIGHT ON L. I/T LEVEL FLOAT RIGHT S/IJ ( WHERE PALPATE ) LOCATE ITA RIGHT ANTERIOR INNOMINATE: Functional 54

55 SACRAL FINDINGS: ANTERIOR SACRAL BASE L. SACRAL FLEXION R. SACRAL EXTENSION L/L SACRAL TORSION L/R SACRAL TORSION LEFT LEFT RIGHT RIGHT SULCUS LEFT DEEP RIGHT NORMAL LEFT NORMAL RIGHT SHALLOW RIGHT DEEP LEFT NORMAL RIGHT NORMAL LEFT SHALLOW SITTING F.B.T. LEFT RIGHT RIGHT LEFT L 5 ROTATION R L R L R R R R LORDOSIS POST / INF. I.L.A. SL. INCREASED SL. DECREASED SL. INCREASED DECREASED FLAT LEFT LEFT LEFT LEFT AXIS INVOLVED M.T.A. M.T.A. L.O.A. R.O.A. SPHINX TEST NEGATIVE POSITIVE NEGATIVE POSITIVE L. LEG LENGTH ( MECHANICS ) L. LONG L. LONG R. SHORT L. SHORT R. LONG L. SHORT

56 Clinical Application: Host + Disease = Illness ( clinical presentation ) host + DISEASE = Illness HOST + disease = Illness HOST + DISEASE = Illness Additional mechanisms: for explaining OMT outcomes Cybernetics ( dynamic feedback loops ) Gen. Adaptive systems ( 1 system ) Complex systems ( multiple systems ) Fractal Geometry ( distribution issues ) Fractal / Chaos Physiology ( homeo-dynamics ) Autopoiesis ( dynamic S/F changes ) Multi-agent Modeling Network of Networks Emergent Properties S/D can impact: 1, all, any combo of arms 7 Competencies: ( P/P mirror strategy ) Osteopathic integration Medical Knowledge Patient Care Interpersonal Communications Professionalism Practice-Based Care System-Based Care

57 Complexity & Family Practice: Systems & Complex Thinking Annals of Family Medicine Vol 12 no 1 Jan / Feb 2014 THE NEW CONCEPTS AND LANGUAGE AVAILABLE TO OSTEOPATHY CYBERNETICS: BILL JOHNSTON AND CHARLES BOWLES FUNCTIONAL METHODS AUTOPOESIS: COMPLEX & DYNAMIC STRUCTURE - FUNCTIONAL RELATIONSHIPS ( TERM NOW IN LITERATURE ) 21 CENTURY MECHANISMS AVAILABLE TO EXPLAIN O.P.P. OUTCOMES BODY IS A COMPLEX FUNCTIONAL UNIT OF INTERCONNECTED SYSTEMS

58 A.C.G.M.E. Educational Model Experiential Educational Model ( utilizing a patho-physiological mirror strategy ) Action / Experience / cc. / symptom / sign Reflection / gather data / develop hypothesis Abstraction treat / test hypothesis / develop theory ( establish a final diagnosis ) Application / old, new or other BOTTOM LINE Educational Phenomenology

59 What is that all about? I have a better understanding now! Osteopathic Management