🏛️ Still's 6 Principles
"The body is a unit"
The human body does not function as separate parts — it functions as an integral unit. All parts work to benefit the organism in totality.
Structure & function interrelate
Structure governs function — abnormal structure brings dysfunction. Function modifies structure — e.g. the mastoid process develops through upright head posture via SCM.
Self-regulatory mechanisms
Neuronal reflex mechanisms constantly monitor body functions — e.g. carotid sinus baroreceptors adjust heart rate & contractility in response to BP changes.
Inherent capacity to defend & repair
First line: skin & mucous membranes. Cellular immune system protects from invaders. The body heals lacerations & fractures through its own capacity — the physician removes obstacles.
Disease from disrupted adaptability
Disease arises when environmental factors overwhelm defences, or the body cannot adapt (abnormal structure/function). The physician seeks the cause, not just the effect.
Rational treatment based on above
Still didn't mention manipulation initially (1874) — only began using it ~5 years later. Manipulation is not the only aspect of osteopathic philosophy, nor the most important.
📌 Exam Tip: Still's 4 core principles (the body as a unit, structure/function interrelationship, self-regulation, self-healing) + rational treatment. The physician's role is to remove obstacles to the body's own healing capacity.
Definition: Somatic Dysfunction vs. Osteopathic Lesion
Modern term: "Somatic dysfunction" has replaced "osteopathic lesion."
Definition (Glossary of Osteopathic Terminology): "An impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and related vascular, lymphatic and neural elements."
The modern definition takes a wider view — moving from simple manipulative therapy towards osteopathic medicine.
Three Grades of Joint Problems
| Grade | Description | Range |
|---|---|---|
| Dislocation (Luxation) | Displacement beyond anatomical range. Often with muscle tears, ligament damage. | Beyond anatomical |
| Subluxation | Partial dislocation — bone ends misaligned but still in contact. | Beyond physiological, within anatomical |
| Osteopathic Lesion | Restriction within normal physiological range — no dislocation. | Within physiological |
🦴 The T-A-R-T Criteria
Palpable changes in skin, fascia, muscle
Acute: Increased temperature, boggy texture, moist, rigid/board-like, greatest tenderness, oedema, erythema (redness lasts longer)
Chronic: Slight temp change (↑ or ↓), thin/smooth, dry, ropy/stringy, less tenderness, no oedema, blanching occurs
Bones lie in asymmetric position
E.g. spinous process lies to one side of midline, or one transverse process is more posterior than contralateral.
Restricted range of motion within physiological bounds
Physiologic barrier: point of active motion limit (passive still possible)
Anatomic barrier: passive limit — bone/ligament/tendon
Pathologic barrier: from disease/trauma (fusion, osteophytes)
Motion in the opposite direction is normal or free.
Pain with normal pressure on palpation
Subjective sensation reported by patient. Pressure that shouldn't normally cause pain will do so around a dysfunctional joint. Physician should deal with these tissues gently.
Tissue Texture Changes: Acute vs Chronic
| Feature | Acute | Chronic |
|---|---|---|
| Temperature | Increased | Slight increase or decrease (coolness) |
| Texture | Boggy, more rough | Thin, smooth |
| Moisture | Increased | Dry |
| Tension | Increased, rigid, board-like | Ropy, stringy |
| Tenderness | Greatest | Present, but less |
| Oedema | Yes | No |
| Erythema test | Redness lasts | Fades quickly or blanching |
Bogginess
Palpable sponginess in tissue — from congestion due to ↑ fluid content (acute).
Ropiness
Cord-like or rope-like feel — chronically contracted muscle (chronic).
Stringiness
Fine or string-like myofascial structures (chronic).
Viscerosomatic Reflex Dysfunctions
Chronic viscerosomatic features:
- Skin tends to be more atrophic over involved area
- Tissues display firm, dry sponginess (vs. bogginess of acute)
- Joint motion more restricted & fixed — sluggish, rigid movement. End feel = "rubbery"
- When corrected, tends to return within 24 hours
Naming Somatic Dysfunctions (Fryette's Laws)
The somatic dysfunction is always named for its freedom of motion — the directions in which the vertebra can move most easily.
| Feature | Type 1 (Neutral) | Type 2 (Non-Neutral) |
|---|---|---|
| Segments | Multiple | Single |
| Rotation / Sidebending | Opposite sides | Same side |
| Spine position | Neutral | Flexion or Extension |
| Clinical appearance | Lateral curve | Flattening / Extension of A-P curve |
| Onset | Usually gradual | Usually abrupt |
| Pain site | Either concave (contracted) or convex (stretched) | Usually over posterior facet |
Notation examples:
C3 FS[R]L = C3 flexed, side-bent left, rotated left on C4 (restricted in extension, SB right, rot right)
T7 E SrRr = T7 extended, side-bent right, rotated right on T8
Type 1 = rotation opposite sidebending (neutral) · Type 2 = rotation same as sidebending (flexion/extension)
Predisposing Factors
Habitual & Occupational
Constant gravitational force
Abnormal facets, fusion, lumbarization, sacralization
O-A, C7-T1, T12-L1, L5-S1 — especially prone
Stress, infection, reflex from other areas
Trauma → abnormal neural impulse → muscle dysfunction
⚠️ Contra-Indications to Spinal Manipulation
By Region
🦴 Cervical Spine
- ⚠️ Calcified vertebral arteries
- ⚠️ Calcified transverse ligament of C2
- ⚠️ Advanced R.A.
- ⚠️ Acute spondylosis (OA & RA)
- ⚠️ Infection — localised TB / pyogenic / cervical lymphadenitis
- ⚠️ Spina bifida
- ⚠️ Severe whiplash & fracture
- ⚠️ Metastases
🫁 Thoracic Spine
- ⚠️ Senile osteoporosis
- ⚠️ Early osteochondritis
- ⚠️ TB — Cold Abscess — Pott's disease
- ⚠️ Pyogenic osteitis — Septicaemia
- ⚠️ Metastases
- ⚠️ Paget's disease — fracture
- ⚠️ Disc herniation & prolapse (acute)
🦵 Lumbar & Sacral
Spondylolisthesis
Tuberculosis
Spina bifida / Spina bifida occulta
Ankylosing spondylitis
Osteo-arthritis
Ligamentous strain
Complete Contra-Indications & Complications Checklist
Anti-coagulant therapy
Increased bleeding risk
Atherosclerosis
Vertebral artery syndrome risk
Aortic aneurysm
Life-threatening rupture risk
Arthritis (AS, Psoriatic, Reiter's)
Recent articular trauma
Dislocation, ruptured ligaments, whiplash
Bone weakening disease
Fracture, primary/secondary malignancy
Osteomalacia / Osteoporosis / Osteomyelitis
TB (Pott's disease) / Calve's disease
Prolonged steroid therapy
Neurological: Disc prolapse, Cauda equina, Sacral root
Complications
Excessive pain, psychological intolerance, vertigo, hypermobility
Menopause
Increased osteoporosis risk
Systemic Signs & Symptoms Requiring GP Referral
Red flag mnemonic: Think CAUTION — any of these + musculoskeletal symptoms = refer before treating.
🧠 All 12 Cranial Nerves
Mnemonic (order): "On Old Olympic Towering Tops A Finn And German Viewed Some Hops"
Sensory/Motor: "Some Say Marry Money But My Brother Says Big Brains Matter More"
| # | Nerve | Type | Testing Method | Lesion Signs |
|---|---|---|---|---|
| I | Olfactory | S | Familiar scents (coffee, citrus) — block one nostril | Anosmia, hyposmia, cacosmia |
| II | Optic | S | Acuity (Snellen), Colour (Ishihara), Visual fields (wiggle finger in 4 quadrants), Reflexes (direct & consensual), Fundoscopy | Blindness, field defects, scotomata |
| III | Oculomotor | M | "Big H" tracking — follow finger, check for nystagmus, pupil constriction | Downward/outward eye deviation, ptosis, dilated pupil |
| IV | Trochlear | M | Tested with III — eye tracking (downward & lateral movement) | Vertical diplopia |
| V | Trigeminal | S+M | Sensory: Cotton wool + pin on forehead, cheek, jaw. Motor: clench teeth (masseter/temporalis), open mouth against resistance. Reflex: Jaw jerk, corneal reflex | Corneal drying, anaesthesia of forehead, decreased salivation |
| VI | Abducens | M | Lateral eye movement + lateral rectus | Eye turned medially, cannot deviate laterally |
| VII | Facial | M+S | Temporal: frown · Zygomatic: screw eyes tight · Buccal: puff cheeks · Maxillae: smile · Cervical: SCM. Taste: anterior ⅔ tongue | Partial/complete paralysis, impaired taste |
| VIII | Vestibulocochlear | S | Rinne: mastoid → ear, which louder? Weber: centre forehead, louder in which ear? Balance: walk & turn | Positional vertigo, tinnitus, hearing loss |
| IX | Glossopharyngeal | S+M | Gag reflex, touch pharyngeal arches. Taste: posterior ⅓ tongue (bitter) | Dysphagia |
| X | Vagus | S+M | Speak (voice quality), say "aah" — observe uvula central & rises evenly | Dysarthria, drooling, horse voice, choking |
| XI | Spinal Accessory | M | Trapezius: shrug shoulders against resistance. SCM: turn head against resistance | Difficulty swallowing, head movement weakness |
| XII | Hypoglossal | M | Observe tongue for wasting/fasciculations. Stick out tongue for 15-30 sec. Deviates → side of lesion | Dysphagia, dysarthria |
Key Examination Steps
CN I: Close eyes, block one nostril, smell (coffee/citrus) — altered in smokers, cold/cough, trauma
CN II: Examine pupils (equal?), shine light from side — check ipsilateral & contralateral reaction. Fundoscopy for vessels, cotton wool spots, copper wire effect. Peripheral vision: move hand/fingers from sides
CN III-IV-VI: "Big H" pattern — follow therapist's finger. Check for nystagmus
CN V: Sensory: optic, maxillae, mandette. Motor: open mouth, resist closure, move chin side to side
CN VII: Frown (temporal), screw eyes tight (zygomatic), puff cheeks (buccal), smile (maxillae), SCM (cervical)
CN VIII: Rinne — mastoid then ear (normal: ear louder). Weber — centre forehead (normal: equal). Watch lip reading. Whisper test
CN IX-X: Open mouth wide — gag reflex (serious problem if absent). Soft palate lifts evenly
CN XI: SCM — turn head left/right against resistance. Trapezius — "elevate shoulders, don't let me push down"
CN XII: Stick tongue out — leave mouth open 15-30 sec. Look for fasciculations, drifting (moves toward lesion side)
❤️ CVS Examination
History Taking
Breathlessness (Dyspnoea)
On exertion? Lying flat? Nocturnal? Cough/wheeze? DDx: HF, IHD, PE, lung disease, severe anaemia
Chest Pain
Exertional? Relieved by rest? Cold/food triggers? DDx: angina, MI, aortic stenosis, HOCM, pericarditis, pleuritic, MSK
Palpitations
Tap out rhythm. Any trigger? Caffeine/alcohol? Current meds (sympathomimetics?). DDx: extrasystoles, PSVT, thyrotoxicosis, perimenopausal
Syncope
Circumstances? Warning? Speed of recovery? Colour? DDx: epilepsy, vasovagal, micturition, postural hypotension, VBI, cardiac arrhythmias
Claudication
Leg pain on walking. More common in men + smokers. Family history important
CVS Examination Steps
1. Observation: Breathing pattern, accessory muscles, shape of chest, breathlessness
2. Hands: Clubbing (congenital heart, endocarditis, cirrhosis, IBD), splinter haemorrhages, Osler's nodes, palmar erythema, tobacco staining, cyanosis
3. Pulses: Radial — rate (60-100), rhythm, volume. Use index & middle fingers (NOT thumb). Count for 60 sec
4. JVP: Raised in right heart failure / constrictive pericarditis
5. Blood Pressure: Optimal 120/80. HTN Stage 1: 140-159/90-99, Stage 2: 160-179/100-109, Stage 3: 180+/110+
6. Precordium: Check for heaves/trills (ulnar border of hand — "bee buzzing" = valve dysfunction). Auscultate heart sounds
7. Lungs: Crepitus/wheezes. Pulmonary oedema — check sacrum & ankles for pitting oedema
Blood Pressure Measurement
Cuff placement: Lower edge ~1 inch above elbow crease, rubber bag over inner aspect of arm over brachial artery
Systolic: Raise pressure rapidly, decrease slowly — first sound heard with each heartbeat
Diastolic: Sounds become dull & muffled, then cease — point of cessation is best index
Pathological Basis of CVS Signs
| Sign | Pathology |
|---|---|
| Angina | Myocardial ischaemia (atheroma/thrombosis) |
| Murmurs | Turbulence through stenotic/incompetent valves |
| Friction rub | Pericarditis (inflammation of pericardium) |
| Raised JVP | ↑ CVP due to RHF / congestive CF |
| Oedema | Raised venous pressure (CF, venous thrombosis) |
| Dyspnoea | Pulmonary oedema (LVF or mitral stenosis) |
| Cyanosis | Excessive reduced Hb in blood — bypass of pulmonary circulation |
| Splinter haemorrhage | Microemboli from infective endocarditis |
| Purpuric rash | Microhaemorrhages from vasculitis |
| Clubbing | Congenital heart disease, endocarditis, cirrhosis, IBD |
Right vs Left Heart Failure
❤️ Left CF
Causes: Mitral/aortic valve disease, cardiomyopathy, systemic HTN
Features: Fatigue/weakness, PND, orthopnoea, dyspnoea, pulmonary congestion
🫀 Right CF
Causes: PE, rheumatic tricuspid valve, cor pulmonale, pulmonary stenosis
Features: ↑JVP, parasternal heave, hepatomegaly, ascites, ankle oedema, fatigue
🫁 4 Components: O-P-P-A
Distress? Accessory muscles (scalene, SCM)? Colour (cyanosis)? Audible sounds? Chest deformities (barrel chest, pigeon chest, kyphosis, scoliosis)? Pursed lip breathing (emphysema)?
Hands on lower lobes — thumbs to spine. Breathe in — both hands move equally. Asymmetric = pleura disease. Check tracheal deviation. Fremitus: "Ninety Nine" — vibration transmission
Resonant = normal (air-filled). Dull = fluid/consolidation. Hyper-resonant = emphysema/pneumothorax. Normal transition at lung base
Compare L & R at same levels. 4+ positions each side. Say "99" — consolidation increases vocal sound. Bronchial sounds = pneumonia/fibrosis. Crackles, wheezes, rubs
Clinical Signs & Their Meaning
| Finding | Indicates |
|---|---|
| Clubbing | Malignancy, chronic infection, fibrosis |
| Cyanosis (nail bed, tongue, lips) | Hypoxia — reduced O₂ in blood |
| Tremor (extended wrists) | CO₂ retention |
| Horner's syndrome | Pancoast tumour — ptosis, miosis, anhydrosis, enophthalmus |
| Barrel chest | Emphysema / lung hyperinflation |
| Pigeon chest | Infantile rickets (Vitamin D deficiency) |
| Consolidation | Pneumonia — ↑ fremitus, dull percussion, bronchial breath sounds |
| Pleural effusion | ↓ fremitus, stony dull percussion, absent breath sounds |
| Pneumothorax | Hyper-resonant percussion, ↓ breath sounds, tracheal deviation away |
| Pulmonary oedema | Crackles, frothy blood-streaked sputum, orthopnoea, PND |
Symptoms + Signs of Respiratory Disease
Dyspnoea Causes
Immediate: PE, pneumothorax, pulmonary oedema, asthma
Short (hrs/days): Pulmonary oedema, pneumonia, asthma, pleural effusion, anaemia
Long (wks/yrs): Chronic airways disease, fibrosing alveolitis, anaemia
Haemoptysis — Serious vs Non-Serious
Probably serious: Middle-aged/elderly, spontaneous, smoker, recurrent, large amount
Probably not serious: Young, recent infection, never smoked, single episode, small amount
Causes: Bronchial carcinoma, bronchiectasis, TB, PE & infarction
Sputum Types
White/grey: Smoking, chronic bronchitis, asthma
Yellow/green: Infection — acute/chronic bronchitis, asthma, bronchiectasis
Frothy blood-streaked: Pulmonary oedema
🫃 Abdominal Examination
9 Areas of the Abdomen
Liver, Gall Bladder, Hepatic Flexure, Right Kidney (low)
Stomach, Spleen, Pancreas, Left Kidney (high)
Ascending Colon, Caecum, Appendix (McBurney's), Small Intestine
Descending Colon, Sigmoid Colon, Small Intestine
Abdominal Exam Steps
Inspection: Masses, scars, signs of trauma, bulging flanks, jaundice, caput medusae, distension, guarding
Auscultation: Do BEFORE percussion/palpation (may disturb bowels). All 4 quadrants. Absent 3 min = peritonitis. Growling = obstruction. Liver scratch test
Palpation: Light → deep. 9 areas. Muscle tone (guarding, rigidity, rebound). Murphy's sign (gall bladder). Psoas sign, Rovsing's sign
Percussion: Start in pain-free quadrant. Liver from R iliac → R hypochondrium. Spleen from R iliac → L hypochondrium
Signs of Liver Disease
Spider Nevi
Central red spot + radiating branches. >5 = liver disease
Fetor Hepaticus
Sweet, faecal-smelling breath
Asterixis
Flapping tremor on wrist extension
Hand Signs
Clubbing, thenar wasting, Dupuytren's, palmar erythema
Oestrogen signs
Spider nevi, testicular atrophy, gynaecomastia
Portal HTN signs
Hematochezia, haematemesis, oesophageal varices, caput medusae, ascites
Ascites
Definition: Abnormal accumulation of fluid in the abdominal cavity
Causes: Cirrhosis (↓albumin + portal HTN), hepatitis, heart/kidney failure, constrictive pericarditis, cancer, pancreatitis
Signs: Bulging flanks, shifting dullness (percussion), fluid thrill, rapid weight gain, distention, SOB, ankle oedema
Features of shifting dullness: Percuss midline (resonant due to bowel gas). Patient turns to side — fluid shifts, previously dull area becomes resonant. If border stays same → < 2L free fluid
Treatment: Bed rest + low salt, diuretics, large-volume paracentesis
🧬 Neurology
Nerve Cells
| Sensory (Afferent) | Interneuron | Motor (Efferent) | |
|---|---|---|---|
| Fibers | Long dendrites, short axon | Short dendrites, short/long axon | Short dendrites, long axon |
| Location | Cell body in dorsal root ganglion | Entirely within spinal cord/CNS | Cell body in spinal cord, axon outside |
| Function | Impulse to spinal cord | Interconnect sensory → motor | Impulse to effector (muscle/gland) |
Axons vs Dendrites
⚡ Axons
- Take info away from cell body
- Smooth surface
- Usually 1 per cell
- No ribosomes
- Can have myelin
- Branch further from cell body
🌿 Dendrites
- Bring info to cell body
- Rough surface (dendritic spines)
- Many per cell
- Have ribosomes
- No myelin insulation
- Branch near cell body
Autonomic Nervous System
| Organ | Sympathetic (Fight/Flight) | Parasympathetic (Rest/Digest) |
|---|---|---|
| Eye | Dilates pupil | Constricts pupil |
| Salivary glands | Inhibits saliva | Stimulates saliva |
| Lungs | Dilates bronchi | Constricts bronchi |
| Heart | Speeds up rate | Slows down rate |
| Gut | Inhibits peristalsis | Stimulates peristalsis |
| Liver | Stimulates glucose production | Stimulates bile production |
| Bladder | — | Stimulates urination |
UMN vs LMN Lesions
🧠 UPPER MOTOR NEURON
Path: Motor cortex → subcortical fibres → brainstem → spinal cord
- ⚠️ Increased tone (spasticity)
- "Catch" in pronators on supination
- "Clasp-knife" — resistance then sudden relaxation
- Clonus — rhythmic contractions (e.g. ankle)
- Pyramidal pattern: flexors of UL, extensors of LL
- ❌ No muscle wasting, no fasciculations
- ✅ Brisk tendon reflexes
- ✅ Extensor plantar (Babinski +ve)
🧬 LOWER MOTOR NEURON
Path: Anterior horn cell → nerve root → peripheral nerves
- ✅ Decreased tone (flaccid)
- Weakness in individual muscles & groups
- ✅ Muscle wasting (atrophy within 2-3 wks)
- ✅ Fasciculations present
- Reduced/absent tendon reflexes
- ❌ Flexor plantar (Babinski -ve)
- Nerve root lesions = myotome weakness
- Peripheral nerve = restricted distribution
Facet Lock vs Disc Herniation
| Feature | Disc Herniation | Facet Lock |
|---|---|---|
| Pain | Moderate-severe central LBP | Moderate central LBP, may be one side |
| Onset | 24-48 hrs after incident | Swift after incident |
| How | Lifting + twisting, heavy | Turning with intention, static postures |
| Radiation | Sciatic to foot/knee, paraesthesia | Vague, shifting leg pain, often absent |
| Key test | Quadrant compression away = ↑ pain | Quadrant compression towards = ↑ pain |
| SLR | +ve 30-50° | May produce leg symptoms |
| Passive mobility | No significant restrictions | Restrictions typical L4/L5/S1 |
| Diagnosis | Annular tear / possible herniation | Facet restrictions |
Common Pathological Conditions — Lumbar Spine
3 Types
Protective (temporary, pain/posture) · Functional (temporary) · Structural (permanent — short leg, hemi-vertebra, muscle weakness)
2 Types
Functional/Temporary (pregnancy, heavy loads, prolonged standing — returns to normal) · Permanent (congenital, persistent poor posture, weak muscles)
📝 Structured Clinical History
Key History Questions
1. How can I help you today? When did the problem arise? Sudden or gradual? Injury or unusual activity?
⚠️ Insidious onset unrelated to injury = view with suspicion (neoplasm, degenerative, tissue fatigue)
2. What aggravates/relieves the pain? Better/worse AM or PM?
⚠️ Bilateral referred pain = vertebral canal lesion. Pain not aggravated by activity or relieved by rest = pathological. Morning pain = inflammatory arthritis. Morning stiffness = DJD/chronic arthritis. Night pain = serious (keeps patient awake)
3. Had this before? How resolved? Treatment? Same this time?
4. Other symptoms? (grinding, popping, giving way, numbness, tingling, weakness, dizziness, nausea)
5. Current/previous treatment? Medications? Pain meds/anti-inflammatories/muscle relaxants may mask signs.
⚠️ Long-term corticosteroids → osteoporosis, proximal muscle weakness, ↑ pain threshold
6. General health? Disease processes influencing treatment?
7. Patient's own ideas about the problem?
8. Past MSK history — symptoms, treatments, response
9. Current medical history (2 yrs) — accidents, illnesses, hospitalisations, fractures, operations, X-rays, bowels/micturition, births, menstrual, allergies
10. Medication — full name, amount, helping?, daily dose (BDS/TDS/QDS), when started/finished, reactions
Mechanical vs Non-Mechanical Pain
🔧 Mechanical Pain
- ✅ Specific onset (injury/activity)
- Intermittent or constant
- Aggravated/relieved by position/activity
- Facet locks: pain constant, aggravated by certain movements
- Muscle: pain only when using affected muscle
- Nerve: intermittent/constant, radicular, shooting/stabbing/hot/cold/numb
🚨 Non-Mechanical (Red Flags)
- ❌ No reason/insidious onset
- ❌ Night pain / night sweats
- ❌ Unremitting pain
- ❌ Medication doesn't help
- ❌ Position/activity doesn't affect pain
- ❌ Loss of appetite / weight loss
- ❌ Passing blood / can't pass urine/stool
- ❌ Sudden violent headaches + vomiting
- ❌ Patient looks unwell
- ❌ Bilateral symptoms
- 📞 REFER TO GP
Joint Pain: Articular (Inflammatory) vs Mechanical (Degenerative)
🔥 Inflammatory (Articular)
- Warmth, redness
- Joint swelling (soft tissue)
- Pain/stiffness at rest
- Morning stiffness
- Polyarticular = RA, viruses, infection
- Monarticular = OA
🔧 Mechanical (Degenerative)
- Activity-related pain
- Improvement with rest
- "Locking", "catching", "giving way", "crepitus"
- No soft tissue swelling/warmth/redness
Example Lesions
Erb's Palsy (C5-C6) — Upper plexus injury → loss of shoulder abduction / elbow flexion
Klumpke's Palsy (C8-T1) — Lower plexus injury → loss of intrinsic hand muscles + long flexors/extensors of fingers
Median nerve lesion — Carpal tunnel compression
Common peroneal nerve — Trauma involving fibula head
🎯 Exam Quiz
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