Osteopathic Ten Step Exam

by Tyler Cymet, DO, FACOFP

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    00:01 This is the osteopathic 10-step exam.

    00:04 Please always remember and never forget the osteopathic 10-step exam.

    00:08 This is what you need to know. This is what you need to do.

    00:11 And while we broaden it to 10 steps, you are able to go off of this and focus on the area of discomfort or area of pain.

    00:19 Step #1 is a postural analysis screen, and this is static—standing still, do they look comfortable? Are they symmetrical? And you can evaluate and palpate major landmarks, the ASIS and the shoulders, and see and make sure they’re even.

    00:33 Step #2 is watch them walk. Gait analysis.

    00:37 I like having fun and I will often do a 30-second stand here or a duck walk.

    00:44 At 55 years of age, people lose the ability to squat and walk.

    00:48 They tend to have lost the nervous system balance muscle communication and they tend to fall off and need to support themselves more.

    00:57 Step #3 is dynamic trunk testing. It is sidebending and you can do this while you have the patient standing.

    01:03 Step #4 is a standing flexion test.

    01:05 You put your fingers on the PSIS, the posterior superior iliac spine, and have them bend over and you check the motion to make sure its equal on both sides.

    01:15 Step #5 is the Stork test which we will go over later.

    01:18 Step #6 is the seating flexion test which puts the bone down on the seat and then you measure again to see if the posterior superior iliac spine moves equally or asymmetrically.

    01:30 Step #7 is screening of the upper extremities.

    01:33 We tend to forget the arms and legs.

    01:35 Don’t forget the arms and legs.

    01:37 It’s part of the whole musculoskeletal exam.

    01:39 Step #8 is trunk motility which is rotating and sidebending, and you do that seated.

    01:47 Step #9 is head and neck mobility.

    01:50 We check the cervical spine often but we don’t often check head mobility and other motions besides just touching the cervical spine.

    02:00 And #10 is the total body screen palpation and motion testing where you get the whole body and make sure you understand the musculoskeletal system and the functioning of the whole body.

    02:11 You could do arms, Patrick’s FABERE and other musculoskeletal tests to check for motion.

    02:18 So this is the 10-step exam that you must always remember and never forget.

    02:21 And while you are going to focus off and go into the area of pain and the area directed by the chief complaint, since osteopathic medicine is a holistic philosophy, it’s important to do the whole musculoskeletal exam and see where you may need to focus where the patient may benefit from care later on.

    02:39 The musculoskeletal exam is a more nuanced exam than other exams in that you’re doing multiple things in the same area.

    02:48 So when you palpate a muscle, you’re gonna palpate it with 2 to 3 pounds of pressure to feel the muscle.

    02:54 Then you’re going to try and give 5 to 7 pounds of pressure to feel the skin drag and to feel the fascial system.

    03:01 And then you go a little bit deeper to feel the muscle, to feel the bogginess, to feel the texture of the muscle.

    03:07 So starting with skin drag, when you put your hand over the muscle, and you lightly move it, does it move easily and does it move fluidly? And does the skin come together along the Langer lines so that you can see how the skin bends and how it folds and how comfortable it is.

    03:26 So increased drag when it’s slower can be caused by moisture, it can be caused by dryness, and dehydration.

    03:34 These are going to change the drag and we always look for tinting and turgor of the skin.

    03:40 Drag is when you look at tinting and turgor with motion and you put them together.

    03:46 So a lot of times, this will change acutely and the skin drag is something that can change from morning to night and is not as easily reproducible at each visit, but if you notice a problem when you’re doing the exam, it helps you understand where you are.

    04:02 Faster drag occurs with older people with dry skin or atrophy, slower drag in younger people with better connections and stronger connections.

    04:13 And one thing we always warn students about is if you’re doing this skin-to-skin and you get sweat on you or oil on you, best thing where you don’t want to wash with just an alcohol based wash.

    04:25 You need to wash with soap and water or you need to consider wearing gloves.

    04:29 You don’t want to be doing palpation with someone who’s sweating or wet without either gloves or protecting yourself by washing afterwards.

    04:38 That’s the skin drag.

    04:40 The other thing I do with most of my patients is examine the red reflex.

    04:44 No, not the red reflex in the eye.

    04:46 This is the 32nd red reflex you get when you go across the big muscle groups, mostly in the back or the neck and you rub down 3 times with about 10 to 12 pounds of pressure, and you give it about 30 seconds. In 15 to 30 seconds you’ll notice a redness come out in the muscle area and the superficial skin and that will give you a good sense of what the evenness is.

    05:10 If you have an area where there’s not good blood flow or a chronic problem, you won’t have as red a response.

    05:18 So you look at whether there are compensatory changes, whether there’s redness here and here, or if it looks the same on both sides.

    05:25 It’s a good test for symmetry and a good test of how the muscles are going to exhibit, and basically, if we’re saying muscles are an endocrine system and they release hormones, this is telling you what the vascular release is like and how it’s going to communicate with the rest of the body.

    05:44 So the red reflex is an exam, I think, is very important to look for the whiteness, to look for the redness, and to look for asymmetry and to note how long it takes for the red reflex to come out.

    05:56 If it comes out quickly and it comes out quickly all the time, that it could be the person’s normal pattern.

    06:01 If it’s 15 to 20 seconds, it’s a good lag time, it’s a good response time, and it looks healthy, that’s good but it gives you information and it’s easy and quick to do.

    06:11 Areas of somatic dysfunction that are acute tend to be redder and come out quicker.

    06:16 Issues of somatic dysfunction that are chronic and longstanding tend to have less vasculature, less blood flow, and they tend to be whiter and have less of a response.

    06:27 So it’s a good, quick differentiator to see how long the complaint is and to put some validity to what the patient is saying or to question what the patient is saying.

    06:37 So these are some easy exam techniques you can use when evaluating the musculoskeletal system in a patient.

    About the Lecture

    The lecture Osteopathic Ten Step Exam by Tyler Cymet, DO, FACOFP is from the course Osteopathic Principles and Tenets. It contains the following chapters:

    • Osteopathic Ten Step Exam
    • Skin Drag
    • Red Reflex

    Included Quiz Questions

    1. Static postural analysis
    2. Dynamic trunk sidebending
    3. Seated flexion test
    4. Standing flexion test
    5. Gait analysis
    1. Gait analysis
    2. Stork test
    3. Trunk mobility test
    4. Postural analysis
    5. Flexion test
    1. Standing flexion test
    2. Postural analysis
    3. Gait analysis
    4. Trunk mobility testing
    5. Stork test
    1. Red reflex
    2. Skin drag
    3. Skin tenting
    4. Skin turgor
    5. Palpation

    Author of lecture Osteopathic Ten Step Exam

     Tyler Cymet, DO, FACOFP

    Tyler Cymet, DO, FACOFP

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