OMT review Chapters 1-6.BASICS

An impaired or altered function of related components of the somatic system: skeletal, arthroidial, and myofascial structures andrelated vascular, lymphatic and neural elements is Somatic Dysfunction (SD)Is SD named for the dysfunction (freedom) or the restriction (barrier)? Dysfunction (freedom)

The freedom is the way the joint likes to go!What does TART stand for?

T tissue texture changeA asymmetryR restrictionT tenderness

Which one of the above is most important for naming a dysfunction? R- RestrictionWhen a patient can move a joint through a full range of motion (FROM) without help, what is itcalled? Active motionWhen a doc performs the FROM for the patient, it is called passive motionWhat is the barrier reached during active range of motion by the patient? physiologic barrierWhat is the barrier reached during passive range of motion by the doctor? Anatomic barrierMovement beyond the anatomic barrier can cause what? Ligament/tendon/skeletal injuryWhich barrier is shortened when a somatic dysfunction is present in a joint? Physiologic barrierWhat is this new barrier with lack of FROM called? Restrictive/pathologic barrierIf a barrier is reset, what also must be reset? The neutral position

The next 4 questions concern ACUTE SD changes:What type of tissue texture changes will be present? Warm, swollen, boggy, increased moistureIs asymmetry present, and if so, has it been compensated for? Yes, non-compensatedIs there pain present upon movement of the joint? Yes, motion restrictedDescribe the tenderness Severe, sharp

The next 4 questions concern CHRONIC SD changes:What type of tissue texture changes will be present? Decreased or no edema, NO erythema, cool dry skin, w/ slight tension,decreased muscle tone, flaccid, ropy, fibroticIs asymmetry present, and if so, has it been compensated for? Yes, compensation present in other areas of the bodyIs motion restricted, and if so, is it painful? Yes, but little to no painDescribe the tenderness dull, achy, burningFryette’s First Law is described as:

Starts from a neutral positionSidebending precedes rotationSidebending and rotation occur to opposite sidesRotation occurs towards the convexityApplies to a group of vertebrae (>2)EX: T5-T9 N SLRR

Which Transverse Processes (TPs) are more posterior? The right side TPsFryette’s Second Law is described as:

Starting from a non-neutral position (flexed or extended)Rotation precedes sidebendingRotation and sidebending occur to the same sideRotation occurs away from the convexity, toward the concavityApplies to a single vertebraEX: T8 E RRSR or ERSR

What vertebral segments to Fryette Laws I and II apply to? Thoracic and Lumbar, NOT cervicalWhen naming the dysfunction, it is common to relate the dysfunctional segment to the segment below it.

EX: T6 is restricted in flexion, rotation and sidebending to the right in relation to T7 (so…T6 E RLSL)What does Fryette’s Third Law state? Motion introduced in one plane limits and modifies motion in the other planes

What part of the spine does this apply to? Cervical spineIn order to evaluate a SD, what is the stepwise process you must perform to name/find a SD?

First- assess rotation by placing your thumbs over the TP of each segment, the TP that is more posterior is the side thesegment is rotated to

EX: If your left thumb is more posterior than your right thumb, then the vertebra is rotated leftSecond- assess rotation while in flexion and extension, do the TPs line up while placing the segment in flexion/extension,does the already more posterior TP become MORE posterior, or does it NOT change at all

If gets better in flexion (i.e. symmetry restored)à it is a flexion dysfunction (ex: F RLSL)If gets better in extension à it is an extension dysfunction (ex: E RLSL)If the rotation remains the same whether in flexion or extension, the segment is neutral (i.e. follows Type I Fryette)

What is the orientation of SUPERIOR facets in the cervical region? BUM (backward, upward, medial)

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What is the orientation of SUPERIOR facets in the thoracic region? BUL (backward, upward, lateral)What is the orientation of SUPERIOR facets in the lumbar region? BM (backward, medial)

Next 3 questions, what spinal motion occurs in the following planes and axes:Sagittal Plane, Transverse Axis Flexion and extensionTransverse Plane, Vertical Axis Rotation Coronal Plane, AP Axis SidebendingWhat type of muscle contraction results in approximation of the muscle’s origin and insertion WITHOUT a change intension? Isotonic Contraction

Operator’s force < Patient’s forceWhat type of muscle contraction results in an INCREASE in tension WITHOUT an approximation of origin andinsertion? Isometric contraction

Operator’s force = patient’s forceWhat type of muscle contraction occurs AGAINST RESISTANCE WHILE FORCING the muscle tolengthen? Isolytic contraction

Operator’s force > patient’s forceWhat is the difference between concentric and eccentric contraction? Concentric contraction results in approximation of themuscle’s origin and insertion while eccentric contraction is lengthening of the muscle during contraction due to an external forceDirect treatment is directed TOWARDS the barrierIndirect treatment is directed AWAY from the barrierDuring active treatment the patient ASSISTSDuring passive treatment the patient RELAXESWhat types of techniques are considered only DIRECT? Chapman’s reflexes, lymphatic treatment, HVLA, and Muscle Energy(ME-rarely indirect)

Are these considered active or passive? ALL but ME are passiveMuscle energy and myofascial release are the only 2 techniques that are active

What types of techniques are considered only INDIRECT? Counterstrain and FPRAre these active or passive? Passive

What 2 techniques are both indirect AND direct? Myofascial Release and Cranial OMTCranial is passive, myofascial release can be active or passive

When is it NOT OK to use HVLA? A pt w/ advanced osteoporosis, metastatic cancer, and more often than not acute neckstrain/sprainsElderly and hospitalized pts typically respond better to indirect techniquesTypical guidelines regarding dose/frequency of OMT:

Limit OMT to key areas in sick ptsAllow time for the pt’s body to respond to the treatmentPediatric pts can be treated more frequently than geriatric ptsAcute cases should have a shorter interval bw trmts, and as the response increases, the interval can increase

Typical guidelines regarding sequence of treatment;Treat the ribs and upper thoracic spine BEFORE the cervical spineTreat T-spine BEFORE ribsTreat peripherally then move to the acute area of SDPerform cranial treatment BEFORE other OMT to help pt relaxTreat spine, sacrum and ribs BEFORE treating extremities

CERVICAL SPINEWhich cervical vertebrae are considered atypical? C1 and C2

Which one has NO spinous process or vertebral body? C1Which one has a dens that projects superiorly from its body and articulates with the segment above? C2What ligament attaches to the lateral masses of C1 to hold the dens in place? Transverse ligamentWhat 2 diseases can lead to weakening and possible rupture of the transverse ligament and cause neurologicdamage? RA and Down’s Syndrome

Are the spinous processes of C2-C6 bifid or singular? BifidWhat passes through the foramen transversarium of C1-C6? Vertebral ArteryWhat part of the vertebra do DOs use to evaluate C-spine motion? The articular pillarsThey are located to the cervical transverse processes posteriorWhere do the anterior and middle scalenes originate and insert? Origin = posterior tubercle of TPs of the cervical vertebraeand insertion= RIB 1Where does the posterior scalene originate and insert? O= posterior tubercle of the TPs of the cervical vertebrae, insertion =RIB 2What motion do the scalenes do? Unilaterally à sidebend neck to same side, bilaterally à flex the neck

How do the scalenes help in forced inhalation? Elevate the 1st and 2nd ribsSternocleidomastoid (SCM) origin mastoid process and lateral half of superior nuchal lineSCM insertion medial 1/3 of clavicle and sternumSCM unilateral contraction leads to sidebend towards, rotate awaySCM bilateral contraction flex the neck

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What does the SCM divide in the neck? The anterior and posterior trianglesShortening or restrictions w/in the SCM often result in torticollisWhich cervical motion to the joints of Luschka play the biggest role in? SidebendingThe most common cause of cervical nerve root pressure degeneration of the joints of Luschka plus hypertrophic arthritis ofthe facet jointsCervical nerve roots leave above or below their corresponding vertebra? AboveC8 exits between C7 and T1

Cervical motionOA is the motion of the occipital condyles on the atlas, C1The primary motion of the OA is flexion and extension

This accounts for % of flexion and extension of the C-spine 50%T/F…Sidebending and Rotation occur to OPPOSITE sides with either flexion or extension at OA TrueAA is the motion of C1 on C2The primary motion of the AA is Rotation (50% of C-spine)

Rotation and sidebending occur to opposite sidesT/F…Sidebending and Rotation generally occur to SAME side from C2-C7 True

C2-4 is mainly rotationC5-7 is mainly sidebending

When you translate the occiput on the atlas to the right you sidebend leftIf it is restricted in left translation, the dysfunction is sidebent leftA right deep sulcus indicates sidebent left

Why is it deep? Left occipital sidebending separates the right occipital condyle and atlas making the sulci feeldeeperIf it’s sidebent left, it must be rotated right

To test rotation at the AA joint, you must first flex the neck 45 degreesWhy? Eliminate rotation from C2-C7

To test sidebending from C2-7, you must push laterally on the articular pillarsAn acute injury to the C spine is best treated with indirect fascial techniques or counterstrain firstCervical foraminal stenosis results in neck pain radiating into the UE, dull ache, shooting pain or paresthesias, paraspinalmuscle spasm, posterior and anterior cervical tenderpoints, osteophyte formation and degenerative joint changes

Recommended OMT myofascial release, counterstrain, FPRTHORAX

What is the rule of 3’s?T1-3, T12 SP at level of corresponding TPT4-6, T11 SP halfway bw corresponding TP and next TPT7-9, T10 SP at NEXT TP

Must know landmarks:Spine of scapula T3Inferior angle of scapula T7Sternal notch T2Angle of Louis, sternal angle T4/5 spaceNipple T4 dermatomeUmbilicus T10 dermatome, L3/4 diskIliac crest L4

Main motion of the thoracic spine rotationLower thoracics are better at though flexion/extension

Motion is limited by ribcageThe primary muscle of inspiration diaphragmInnervation of diaphragm C3,4,5Other muscles involved in inspiration external and internal intercostals (elevate ribs and prevent retractions)

Secondary muscles Scalenes, pec minor, serratus anterior and posterior, quadratus lumborum, and LatsRIBS

What are the components of a typical rib? Tubercle, head, neck, angle, shaftHow many articulations? 3- 2 w/ corresponding vertebra and 1 w/ vertebra directly aboveWhat are the typical ribs? 3-10

True ribs 1-7False ribs 8-10Floating ribs 11,12

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What are the atypical ribs? 1,2,11,12Which one only articulates w/ its corresponding vertebra and has no angle? Rib 1Ribs w/ no tubercles and only articulates w/ corresponding vertebra? Ribs 11,12Rib has a large tuberosity on the shaft for the serratus anterior Rib 2

Upper ribs, 1-5, have primarily motion pump-handlePlane and axis sagittal plane, horizontal axis

Middle ribs, 6-10, have primarily motion bucket-handlePlane and axis coronal plane, AP axis

Lower ribs, 11 and 12, have primarily motion caliperPlane and axis horizontal plane, vertical axis

When a rib is “stuck up” in inhalation, it is an dysfunction inhalationThis is an restriction exhalationThere is pain upon exhalationThere is a narrowing of the intercostal space the dysfunctional inhaled rib ABOVEWhen there is an elevated group of ribs, you treat the bottom rib (key rib)

When a rib is ‘stuck down” in exhalation, it is an restriction inhalationThis is an dysfunction exhalationThere is pain upon inhalationThere is a narrowing of the intercostal space the dysfunctional exhaled rib BELOWWhen there is a depressed group of ribs, you treat the top rib (key rib)

Remember- BITE (bottom rib- inspiration dysfx, top rib- exhalation dysfx)Muscles of exhalation w/ their corresponding rib:

Rib 1 anterior and middle scalenesRib 2 posterior scaleneRibs 3-5 pectoralis minorRibs 6-9 serratus anteriorRibs 10-12 latissimus dorsi

LUMBAR SPINEThe posterior longitudinal ligament (PLL) begins to as it runs down the posterior aspect of the vertebralbody narrow

Due to its narrowing, the posteriolateral aspect of the intervertebral disc is weak, making the lumbar spine more susceptibleto disc herniations

L4 nerve root exits the spinal column bw L4 and L5Lumbar nerve roots become as they approach lower segments longer

This causes the nerve roots to exit just the intervertebral disc ABOVEImportant muscles erector spinae, multifidus and rotators, quadratus lumborum, and iliopsoas

Erector spinae muscles I like spaghettiIlliocostalis, spinalis, longissimus

Iliopsoas = muscle + muscle psoas major + iliacusOrigin T12-L5 vertebral bodiesInsertion lesser trochanter of femurAction 1* Hip FLEXORCommonly seen w/ iliopsoas SD pelvic side shift, positive Thomas test, and a SD of an upper lumbarsegment

Facets are aligned backwards and medial in what plane? SagittalFacet tropism causes the facets to align in what plane? Coronal

Most common anomaly in the L spine zygopophyseal/facet tropismA bony deformity in which 1 or both of the TPs of L5 articulate w/ the sacrum SacralizationFailure of fusion of S1 with the rest of the sacrum LumbarizationCongenital anomaly, defect in closure of lamina of vertebral segment (s) spina bifida

No herniation through the defect, patch of hair present spina bifida occultaHerniation of meninges through defect spina bifida meningoceleHerniation of meninges and nerve roots through defect spina bifida meninogomyelocele

Major motion of lumbar spine flexion and extensionFerguson’s angle (lumbosacral angle) is usually 25-35 degrees

Angle is formed by intersection of horizontal line and line of inclination of sacrumAcute causes of low back pain fx, disc herniation, infection, or referred painIs chronic or acute low back pain more common? CHRONIC

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A lumbar SD leads to achy pain or muscle spasms in the low back, butt, or posterior lateral thigh98% of herniations occur bw L4,L5 or L5,S1A nucleus pulposus herniation bw L3 and L4 affects what nerve root? L4OMT options initially indirect, then direct

NO HVLA!Weakness and decreased reflexes are associated w/ the affected nerve root

Psoas syndrome is caused by prolonged positions that shorten the psoas à flexion contracture of the iliopsoas

Organic causes of psoas syndrome appendicitis, sigmoid colon dysfx, ureteral calculi, ureter dysfx, metastaticcarcinoma of the prostate, salpingitisLow back pain sometimes radiates to the groinWhat are some signs present? Inc pain when standing or walking, + Thomas test, tenderpoint medial to ASIS, TypeII dysfx at L1/L2, positive pelvic shift test to contralateral side, sacral torsion, contralateral piriformis spasmOMT options ice on acute spasm, counterstrain to anterior TP, then ME or HVLA to high lumbar dysfx, don’tstretch acute spasm, only chronic!

Narrowing of the spinal canal or intervertebral foramina spinal stenosisDegenerative changes causing pressure on the nerve roots include hypertrophy of facet joints, Ca2+ deposits w/inthe ligamentum flavum and PLL, loss of intervertebral disc heightBesides OMT, what other treatments are recommended? PT, NSAIDs or low dose tapering steroids

Anterior displacement of 1 vertebrae in relation to the 1 below spondylolisthesisOften occurs at L4 or L5Usually due to fatigue fractures in the pars interarticularisSymptoms stiffed-legged, short-stride, waddling type gait, positive vertebral step-off sign (obvious forwarddisplacement while palpating the SPs)Must diagnose w/ which X-ray view? Lateral viewGoal of trmt reduce lumbar lordosis and SD (HVLA is contraindicated!)

Defect in pars interarticularis WITHOUT anterior displacement of the vertebral body SpondylolysisUpon X-ray, the fx in the pars interarticularis looks like a collar on the neck of the Scotty dogMust diagnose w/ which X-ray view? Oblique view

Degenerative changes w/in the intervertebral disc and Ankylosing of adjacent vertebral bodies spondylosisCauda equina syndrome results from pressure on the nerve roots of the cauda equina due to massive central disc herniation

Location and quality of pain Sharp low back painSymptoms saddle anesthesia, dec DTRs, dec rectal sphincter tone, and low of bowel and bladder controlT/F…Surgery is necessary to decompress the cauda equina True

SCOLIOSIS AND SHORT LEG SYNDROMELateral deviation of the spine is known as scoliosis (or rotoscoliosis)Who is more likely to get scoliosis, males or females? Females, 4:1

What % actually develops symptoms? 10%Scoliosis is named for the convexity of the curve, so sidebent left is Dextroscoliosis (dextro = right)

And if it is sidebent right Levoscoliosis (levo=left)There are 2 types of scoliotic curves:

Spinal curve that is fixed and inflexible, doesn’t correct w/ sidebending to opposite side Structural CurveSpinal curve that is flexible and partially/completely corrected w/ sidebending to opposite side, may progress to structuralcurve Functional Curve

What age group should be screened for scoliosis? 10-15 years oldWhat do you use to measure the degree of scoliosis? Cobb Angle

Draw horizontal lines from most extremely deviated vertebral bodies, and perpendicular lines from these horizontal lines,cobb angle is created at intersection of perpendicular linesMild scoliosis 5-15 degrees

Treatment PT, Konstancin exercises, and OMT à improve flexibility and strengthen trunk and abdominalmusculature

Moderate scoliosis 20-45 degreesTreatment Add brace in addition to exercises above

Severe scoliosis >50 degreesAt what angle is respiratory function compromised? >50 degreesHow about CV function? >75 degreesTreatment surgery

Most common cause of scoliosis idiopathicOther causes congenital, neuromuscular weakness or spasticity, and acquired (tumor/infection/osteomalacia/psoassyndrome/short leg syndrome)

An anatomical OR functional leg length discrepancy short leg syndrome (SLS)

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Most common cause of anatomical leg length discrepancy hip replacementIf 1 leg only appears shorter than the other, its functionalWhat are some ways the body compensates? sacral base unleveling (base lowers on side of short leg), lumbar vertebrasidebend and rotate (SB away, rotate toward short leg), innominate rotation (anterior on short leg side, posterior on long leg side),and an increase in Ferguson’s (lumbosacral) angle by 2-3 degreesTreatment OMT to decrease SD but if doesn’t work, must consider a heel lift

Rules of the heel lift apply to short leg, only lift to 50-75% of the discrepancy UNLESS the cause was acute like ahip fx or prosthesis, then do full length;With “fragile” pts like the elderly, begin w/ only a 1/16” increase, then proceed with 1/16” q 2 wks; with “flexible” pts,begin w/ 1/8” then increase 1/8” q 2 wks; max increase of1/4” inside the shoe, the rest must be applied outsideMax possible heel lift 1/2”

SACRUM AND INNOMINATES3 bones fused to make up innominate ilium, ischium, and pubisS1 is referred to as the sacral promontoryThe most cephalad portion of the sacrum is known as the sacral baseThe most caudad portion of the sacrum that articulates w/ the coccyx sacral apexThe sacral sulci are located superiorly and laterally to S1The inferior lateral angles (ILAs) are located inferiorly and laterallyThe 3 articulations of the innominates w/ the femur at the acetabulum, the sacrum at the SI joint, and the pubic bones at thepubic symphysisTrue pelvic ligaments (sacroiliac ligaments) anterior, posterior, and interosseous ligaments that surround and stabilize theSI jointAccessory pelvic ligaments:

Originates at ILA and attaches to ischial tuberosity sacrotuberous ligamentOriginates at sacrum and attaches to ischial spines sacrospinous ligamentOriginates at TPs of L4 and L5 and attaches to medial side of iliac crest iliolumbar ligamentWhich ligament divides the greater and lesser sciatic foramen? Sacrospinous ligament

Primary pelvic muscles levator ani and coccygeusSecondary pelvic muscles iliopsoas, obturator internus, piriformis

Piriformis innervation and action S1 and S2; external rotation, thigh extension, and abduction of thigh when hipflexedWhy important? 11% of population have sciatic nerve run through belly of piriformis, so piriformis hypertonicityleads to buttock pain that radiates down the thigh

The innominates rotate about the axis of the sacrum inferior transverseRespiratory motion occurs at the axis of the sacrum superior transverse, ~S2

During inhalation, the sacral base moves posterior (sacral extension)During exhalation, the sacral base moves anteriorDuring craniosacral flexion, the sacral base moves posteriorly or counternutatesDuring craniosacral extension, the sacral base moves anteriorly or nutates (N = Nod anteriorly)

Postural motion occurs about the axis of the sacrum middle transverseWhen person bends forward, the sacral base moves anteriorlyWhat ligament becomes taut in terminal flexion causing the base to move posteriorly? sacrotuberous ligament

Dynamic motion, that which occurs during ambulation, engages the 2 sacral axes obliqueWhile stepping forward with the R leg and still bearing weight on the L, the sacral axis isengaged? Left sacral axis

SD of the innominateThe side of the positive standing flexion test is on the side as the dysfx? SAMEThe ASIS compression test is always restricted on the dysfunctional side

Name the dysfx assuming all statistics are for the DYSFUNCTIONAL side:ASIS inferior, PSIS superior, medial malleolus inferior, longer leg ipsilaterally Anterior Innominate

Cause tight quadricepsASIS superior, PSIS inferior, medial malleolus superior, shorter leg ipsilaterally Posterior Innominate

Cause tight hamstringsASIS and PSIS superior, pubic rami superior, shorter leg ipsilaterally Superior Shear

Cause fall on ipsilateral buttock or a mis-stepASIS and PSIS inferior, pubic rami inferior, longer leg ipsilaterally Inferior ShearASIS and PSIS level, pubic bone superior Superior PUBIC shear

Cause trauma or tight rectus abdominus muscleASIS and PSIS level, pubic bone inferior Inferior PUBIC shear

Cause trauma or tight adductors

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ASIS medial, PSIS lateral, ischial tuberosity lateral, distance bw ASIS and umbilicus shortened Innominate InflareASIS lateral, PSIS medial, ischial tuberosity medial, distance bw ASIS and umbilicus longer innominate Outflare

SD of the sacrumSacral torsion is related to rotation about the sacral axes along w/ SD at L5 OBLIQUE

the axis is named for the side of the pole it runs through superiorwhen naming sacral dysfx, the 1st letter describes rotation about the vertical axis, the 2nd letter describes rotation aboutthe oblique axis

the seated flexion test is positive on the side of the oblique axis OPPOSITEBUT, it is positive on the side as a transverse axis dysfunction SAMEWhat are the possible diagnoses if there is a positive RIGHT seated flexion test?

R on L, L on L, unilateral right flexion dysfunction, and unilateral right extension dysfunctionA spring test is needed to confirm whether the torsion is forward or backward, or if it’s a flexion or extension dysfx

Positive spring test (i.e. sacrum moved posteriorly) backward torsion or extension dysfxPPP à positive, painful, posterior

Negative spring test, this means it does spring (i.e. sacrum moved anteriorly) forward torsion or flexion dysfxA lumbosacral spring test is positive if the sacral base has moved posteriorrotation in L5 is the rotation of the sacrum OPPOSITE

If L5 is rotated L, the sacrum must be R on R on R on Lsidebending at L5 is the oblique axis engaged in sacral torsion TOWARDS

if L5 is SB R, the sacrum must be either L on R or R on Rif L5 follows a Type I dysfunction, sacral torsion is more likely to be forward (L on L , R on R)if L5 follows a Type II dysfunction, sacral torsion is more likely to be backward (L on R, R on L)

EX: L5 F RRSR L on REX: L5 N RLSR R on R

If both L5 and the sacrum have a dysfx, which one do you treat first? L5Name the dysfx:

Deep right sulcus, Posterior left ILA, - spring test, + right seated flexion test L on LL5 diagnosis L5 N RRSL

Deep left sulcus, posterior right ILA, - spring test, + left seated flexion test R on RL5 diagnosis L5 N RLSR

Shallow right sulcus, posterior right ILA, + spring test, + right seated flexion test R on LL5 diagnosis L5 F/E RLSL

Shallow left sulcus, posterior left ILA, + spring test, + left seated flexion test L on RL5 diagnosis L5 F/E RRSR

Deep right and left sulci, ILA’s both shallow, springing at base present, not apex bilateral sacral flexionFALSE negative seated flexion test present b/c both SI joints are equally asymmetricBilateral sacral flexion is a common dysfunction in the post-partum pt

Shallow left and right sulci, ILA’s both deep, springing at apex, NOT base bilateral sacral extensionFALSE negative seated flexion test

Deep left sulcus, posterior left ILA, - spring test, + left seated flexion test Unilateral sacral flexion on leftShallow left sulcus, anterior left ILA, + spring test, + left seated flexion test unilateral sacral extension on leftDeep left sulcus, posterior left ILA, + spring test, + right seated flexion test unilateral sacral extension on rightShallow left sulcus, anterior left ILA, - spring test, + right seated flexion test unilateral sacral flexion on right

OMM Chapter 7 ReviewOnly bone connecting the upper extremity to axial spine? ClavicleName 4 joints of shoulder? Scapulothoracic (pseudojt)

Acromioclavicular, Sternoclavicular Glenohumeral

Name 4 rotator cuff muscles + function? Supraspinatus-ABduction Infraspinatus-Ext rotation Teres minor-Ext Rotation Subscapularis- Int Rotation

Primary shoulder flexor and ABductor? DeltoidPrimary shoulder extensors? Lat dorsi, Teres major, Post DeltoidPrimary shoulder Adductors? Pec Major, LatsPrimary shoulder Ext Rotators? Inf. Spinatus, teres minorPrimary shoulder Int Rotators? Subscapularis

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Subclavian artery passes b/t what 2 muscles? Ant/Middle scaleneWhen does Axillary artery become brachial artery? Inf. border teres minorThe radial artery eventually forms what artery of hand? Deep palmer arterial archThe ulnar artery eventually forms what artery of the hand? Superficial palmer art. ArchBrachial Plexus (BP) is derived from what nerve root levels? C5-T1Correct sequence of nerve divisions leaving BP? Roots, Trunks, Divisions, Cords, BranchesNerve root for dorsal scapular nerve? C5The first 120 deg. shoulder Abduction occurs @ what jt? GlenohumeralThe final 60 deg. Shoulder Abduction occurs @ what jt? ScapulothoracicMost common shoulder somatic dysfunction? Int +Ext Rotation RestrictionMost commonly fractured bone in the body? ClavicleAcromioclavicular jt is stabilized by what 3 ligaments? Acromioclavicular, Coracoclavicular,Coracoacromial3 structures of compressed in Thoracic Outlet Syndrome? Subclavian a., Subclavian v., Brachial PlexusName 3 places compression occurs in TOS? 1. B/t anterior and middle scalene

2. B/t clavicle and 1st rib3. B/t pec minor and upper ribs

Name 2 common causes of TOS? Cervical rib, excess tension on scaleneTest used Diagnose of TOS b/w scalenes? Adson’sExcessive tenderness at the tip of the acromion may indicate? Supraspinatus tendonitisTenderness over bicipital groove w/ pain during flexion? Bicipital tenosynovitisMost common muscle injured in rotator cuff tear? SupraspinatusTest used diagnose rotator cuff tear of supraspinatus? Drop arm testCondition caused by prolonged immobility of the shoulder? Adhesive Capsulitis/”Frozen Shoulder”Most common shoulder dislocation? Anterior and inferiorWhat nerve and muscle associated with winged scapula? Long Thoracic n.; serratus anteriorMost common brachial plexus injury and its nerve roots? Erb’s Palsy; C5-C6When does the above palsy usually occur? ChildbirthNerve injured in mid-shaft humeral fracture? Radial nerveMost common BP nerve injured in trauma? Radial nerveMost common symptom of radial nerve deficit? Wrist dropName 2 other ways get radial nerve palsy’s? Crutch Palsy; Saturday Night PalsyCarpals? Scaphoid, lunate, Triquetrum, pisiform, trapezium,trapezoid, capitates, hamateMost common carpal fracture? ScaphoidWhere can scaphoid be palpated? Snuff boxHow many metacarpals are there? FiveFlexors of wrist and hand originate where? Medial epicondyleAll wrist flexors are innervated by median nerve except…? Flexor carpi ulnarisExtensors of wrist and hand originate where? Lateral epicondyleExtensors of wrist are all innervated by what nerve? Radial NervePrimary supinator of wrist? Biceps brachiiThe above muscle is innervated by what nerve? MusculocutaneousName the 2 primary muscles pronation, and innervations? Pronator teres, Pronator quadrates, median nerveMuscles of thenar eminence innervated by? Median nerve (except add pollicis brev)Muscles of hypothenar eminence innervated by? Ulnar nerveFirst and second lumbricals innervated by what? MedianThird and fourth lumbricals innervated by what? UlnarWhere does flexor digitorum profundus attach? Distal interphalangeal jt DIPElbow carrying angle > 15 degrees indicates? Cubitus Valgus (ABduction ulna)Elbow carrying angle <3 degrees indicates? Cubitus Varus (ADduction ulna)Where is head of radius in pronation? PosteriorWhere is head of radius in supination? AnteriorMajor symptom carpal tunnel? Parasthesia thumb+1st 2 digitsThree tests carpal tunnel? Tinels, Phalen, Prayer testsLateral epicondylitis? Tennis ElbowMedial epicondylitis? Golfer’s elbow

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Claw hand results from injury to what nerve? MedianApe Hand results from injury to what nerve? Median and ulnarFlexion contracture of palmar fascia? Dupuytren’s Contracture

OMM Chapter 8 ReviewName the 4 bones of knee? Femur, tibia, fibula, patellaPrimary hip extensor? Gluteus maximusPrimary hip flexor? IliopsoasPrimary knee extensor? QuadsPrimary knee flexor? Semi-membranosus, semi-tendinosusName ligament attaches head femur to acetabulum? Capitis femoris3 ligaments of ‘hip joint’? Iliofemoral, Ischiofemoral, PubofemoralHead femur glides what direction in ext. rotation? AnteriorlyHead of femur glides which direction in int. rotation? PosteriorlyLigament prevents anterior translation of tibia on femur? Anterior Cruciate LigLigament that prevents post. translation of tibia on femur? Post Cruciate LigLateral stabilizers of the knee? Medial collateral, lateral collateralWhat structure is associated with the medial collateral lig? Medial MeniscusWhat 3 motions associated with ankle pronation? Dorsi flexion, eversion, abductionWhat 3 motions associated with ankle supination? Plantar flexion, inversion, adductionFibular head glides what direction in pronation? AnteriorFibular head glides what direction in supination? PosteriorNerve root levels for femoral nerve? L2-L4Muscles innervated by femoral n.? Quads, iliacus, Sartorius and pectineusSciatic nerve courses through what foramen? Greater Sciatic ForamenSciatic nerve lies inferior to what muscle (usually)? PiriformisName 2 branches sciatic n., and muscles innervate? Tibial n. – Hamstrings (except SH Biceps)

Plantar and Toe Flexors Peroneal n. – Short head Biceps fem, Dorsi flexors & Toe Ext

Hip Angulation of neck and shaft femur? Normal = 120 – 135 degrees)Hip neck/shaft angle <120 degrees called what? Coxa varaHip neck/shaft angle >135 degrees is called what? Coxa valgaDiagnosis if patient appears “knock kneed”? Increased Q-angle (Genu Valgum)Diagnosis if patient appears “bow legged”? Decreased Q-angle (Genu Varum)Which sex has a wider Q-angle? FemaleFracture of fibular head may sever what nerve? Common fibular n.Cause of patella-femoral tracking syndrome? Muscle imbalance - Strong vastus lateralis, weakvastus medialisMCC of limp w/ hip pain in kids under 10 yo? Transient Synovitis of the hip (aka toxicsynovitis)Most common compartment affected by compartment syndrome? AnteriorO’Donahue’s triad aka “terrible triad” knee injury? MCL, ACL and medial meniscusBones of the foot? Talus, calcaneus, navicular cuboid

3 cuneiforms, 5 metatarsals, 14 phalangesThe ankle is more stable in what position? DorsiflexionBones of medial longitudinal arch? Talus, navicular, cuneiforms, 1-3 metatarsalsBones of lateral longitudinal arch? Calcaneus, cuboid, 4-5 metatarsalsMost arch dysfunction occurs which arch? Transverse Arch (navicular, cuneiforms, cuboid)Name 3 ligamentous lateral stabilizers ankle? Anterior talofibular, Calcano-fibular, posterior talofibularMost common ligament injured in foot? Anterior Talo-Fibular due to inversion/supinationMedial ankle ligament? Deltoid-prevents eversion/pronationLigament that strengthens medial longitudinal arch? “Spring Lig” – calcaneonavicular lig

OMM Chapter 9 Review

Name 5 components of the Primary Respiratory Mechanism? CNS, CSF, Dura, cranial bones and sacrumRate of the Cranial Rhythmic Impulse (CRI)? 10-14 cycles/minThree factors that decrease CRI? Stress, Depression, Chronic fatigue/

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infection Three factors that increase CRI? Exercise, Fever, Following OMTDura has what cephalad attachments? Foramen Magnum, C2, C3 and S2aka for the meninges acting as an “inelastic rope”? Reciprocal Tension MembraneSacral rocking occurs about what axis? Transverse axisArticulation of sphenoid with the occiput? Sphenobasilar SynchondrosisDuring flexion, paired cranial bones undergo what motion? External rotationFlexion has what affect on shape/size cranium? Wider, decrease AP diameterMovement at the sacrum during flexion? Counternutation (post)Name 4 “midline bones” of cranium? Sphenoid, occiput, ethmoid, vomerDuring extension, paired cranial bones undergo what motion? Internal RotationMovement at the sacrum during extension? Nutation (anterior)Extension has what affect on cranial shape/size? Narrower, increase AP diameterSphenoid rotates one direction; occiput rotates opposite on AP axis? TorsionIf left greater wing sphenoid is superior, what type torsion? Left TorsionWhen both sphenoid and occiput rotate in SAME direction with sidebending? SBRExtension lesion occurs when SBS deviates which direction? CaudadFlexion lesion occurs when SBS deviates which direction? CephaladIf sphenoid deviates superior to occiput? Superior Vertical StrainIf sphenoid deviates inferior to occiput? Inferior Vertical StrainIf sphenoid deviates to the R or L of occiput? Lateral strainOccurs when sphenoid and occiput pushed together? CompressionCompression strain SBS effects CRI how? Decreases CRIWhich cranial nerves exit through superior orbital fissure? CN III, IV, V1, VIWhich cranial nerves exit jugular foramen? CN IX, X, XIOA, AA and C2 can cause what dysfunction? Vagal dysfunctionDysfunction CN VIII can cause what? Tinnitus, Vertigo, deafnessCN dysfunction CN IX, X or XI in a newborn may cause? Suckling dysfunctionPrimary goal of CV4 ‘Bulb Decompression’? Increase amplitude CRIFinger placement during cranial vault holding? Index-Greater wing Sphenoid

Middle-temporalRing- mastoid temporalLittle-sq. occiput

Name some indications for craniosacral Tx? After childbirth, trauma, DentistryAbsolute contraindication for craniosacral Tx? Skull Fx, Intracranial bleed, increased cranialpressureRelative contraindications for craniosacral Tx? TBI, Hx seizures or dystonia

OMM Chapter 10 Review**20% OMT Board questions from Fig. 10.4 and Table 10.2

Pool of neurons in state of sub-threshold excitation? FacilitationFacilitation at an individual spinal level? Segmental facilitation3 components of Spinal Reflex? Afferent limb, central (spinal) limb, efferentlimbSpinal cord segment can receive input from what 3 areas? Higher brain centers, Viscera, Somatic AfferentsA facilitated segment can lead to what? TARTTwo most common types facilitation reflex? Viscero-somatic and Somato-visceral

*Review Table 10.1 on pg. 102 for autonomic function review*Affect of parasympathetics on respiratory epithelium? DEC goblet cells, enhance thin secretionAffect of sympathetic on respiratory epithelium? INC goblet cells, produce thick secretionAffect of parasympathetics on lens of eye? Contracts for near visionAffect of sympathetics on lens of eye? Relaxes for far vision

*Review Table 10.2 on pg. 104 for sympathetic review*All parasympathetics for viscera above diaphragm innervated by what? VagusParasympathetics for ascending and transverse colon? VagusParasympathetics do descending and rectosigmoid colon? Pelvic SplanchnicOvaries and testes get parasympathetics from where? VagusAll other reproductive structures get parasympathetics from where? Pelvic SplanchnicRoots of sympathetic nervous system? T1-L2

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Sympathetics to head and neck? T1-T4Sympathetics to heart? T1-T5Sympathetics to lungs? T2-T7Sympathetics to entire GI? T5-L2What landmark divides the duodenum to jejunum? Ligament of TreitzWhat landmark divides the transverse colon from descending? Splenic flexureSympathetic innervations above ligament of Treitz? T5-T9Sympathetic innervations b/t lig. Treitz and splenic flexure? T10-T11Sympathetic innervations after splenic flexure? T12-L2Sympathetics to upper extremities? T2-T8Name 3 purposes of rib raising? 1. Normalize (decrease) sympathetic activity

2. Improve lymph return3. Improves inhalation for more effectivethoracic pressure

Contraindications for rib raising? Spinal/rib fracture; recent spinal surgeryPurpose of inhibition of Celiac, Sup mesenteric, Inf. Mesenteric ganglion? Reduce hypersympathetic activityContraindication for abdominal inhibition techniques? Abd. aneurysm, open surgical woundCranial Nerves with parasympathetics? III, VII, IX, XPurpose of condylar decompression? Free parasympathetic responses CN IX, X byopening jugular foramenCondylar compression causes what problem in newborns? Suckling problemsName two purposes of sacral inhibition? Normalize hyperparasympathetic Lcolon/pelvis; reduce labor pain due to cervical dilationContraindication for sacral inhibition? Local infections or incisions

OMM Chapter 11 ReviewPosteriorly, Chapman’s points generally located where? B/t spinous and transverse processesChapman’s pts generally reflect what type reflex? Viscera-somatic reflexWhere is Chapman’s pt appendix? Tip R 12th ribWhere are Ant & Post Chapman’s pt (CP) adrenals? Ant- 2” sup, 1” lateral umbilicus

Post – B/t SP &TP of T11-T12Where are Ant & Post CP kidneys? Ant- 1” sup, 1” lateral umbilicus

Post- B/t SP & TP of T12-L1Where is CP for Bladder? Periumbilical regionWhere is CP for Colon? Lateral thigh within Iliotibial band (seefigure)Chapman’s Points: Colon Chapman’s Points: Adrenals, Kidney, Bladder…

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On exam, a trigger point will elicit pain where? At site compressed AND may refer painelsewhere Trigger points may represent what types of reflex? Viscero-somatic, somato-visceral and or somato-somaticDifference b/t Trigger point and Tenderpoint? Tender pts do NOT refer pain

OMM Chapter 12 Review

T/F - Myofascial release can be direct, indirect or passive? TrueWhich type of treatment does physician move tissue into restrictive barrier? Direct

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Which type of treatment does physician move tissue away restrictive barrier? IndirectTwo forces physician may use to “fine tune” myofascial release? ‘Twisting’ or transverse forcesName 3 “enhancers” used to help induce release during myofascial release? Respiration, eye movement or musclecontractionFive steps of Myofascial Release? 1. Palpate Restriction

2. Apply Compression3. Add twisting or transverse force4. Use enhancers5. Await Release

Name 2 goals myofascial release? Restore functional balance andImprove lymphatic flowOf the 4 diaphragms in body, which is most important in terms of lymph flow? Abdominal diaphragmName 2 Diaphragm release techniques? Thoracic Inlet & Thoracoabdominaldiaphragm releaseName 4 locations of Common Compensatory Patterns? OA junction, Cervicothoracic jnx,thoracocolumbar jnx and lumbosacral jnxDescribe the common Compensatory Pattern in 80% individuals? OA-Left

Cervicothoracic- RightThoracocolumbar-LeftLumbosacral-Right

OMM Chapter 13 ReviewLymph from heart and lobes of lungs (except upper L lobe) drains into what? Right DuctThoracic duct traverses through what fascia of the thoracic inlet? Sibson’s FasciaRight (Minor) duct drains into what? R brachiocephalic v.Left (Main) duct drains into what? Junction b/t L Internal Carotidand Subclavian v.The thoracic duct travels through which diaphragmatic opening? Aortic hiatusAt what level is the cistern chili? L2The main cells found in lymph? LymphocytesLymphatics are primarily innervated by what? SympatheticsName 5 extrinsic forces affect lymph flow? OMT, exercise, Contraction ofmuscles, Pulsation adjacent arteries, respiratory motionName2 intrinsic forces affect lymph flow? Smooth muscle contraction,interstitial fluid pressureLymphatic Dysfunction may exhibit fullness/bogginess in what areas? -Supraclavicular

- Posterior Axillary Fold-Epigastric Area- Inguinal Area- Popliteal area & Achilles area

List 10 techniques listed in book used Tx lymphatic dysfunction? Chapman’s Reflexes; Thoracic andPedal Pump; Cranial Techniques- Dura sinuses; ME Sibson’s fascia; Rib Raising; Splenic/Liver Pump; Facial Sinus pressure;Anterior Cervical mobilization; Extremity PumpLymphatic Tx of the Thoracic Inlet acts on what tissue structure? Sibson’s FasciaHow does rib raising help lymph flow? Improves respiration; normalizeshypersympatheticsHow does redoming the diaphragm help lymph flow? Optimizes thoracoabdominalpressure gradientsList some common illness indications for lymphatic treatments? URI, Bronchitis, pneumonia,GI disorders, cirrhosis, hepatitis…Relative contraindications lymph Tx? Osseous Fx, Bacterial infections withfever, Abscess or localized infection, Certain Carcinomas

OMT REVIEW CH 14- 18

CH 14: COUNTERSTRAIN and FPRCOUNTERSTRAIN

passive indirect technique in which the tissue is positioned at a point of balance or ease away from the restrictive barrierJONESEliminates TENDERPOINTS

Small tense edematous areas of tenderness about the size of a fingertipTypical locations – bony attachments of tendons, ligaments or belly of muscleDO NOT radiate pain (trigger points do)

Basic stepsLocate Tenderpoint (TP)

Can be at the area of CC or can be induced from elsewhere

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Ex- psoas spasm (tenderpoint found here) causes low back pain (CC)Palpate the TP

To determine if significant compare to other sideIf multiple areas – treat most tender first

Place patient in position of comfortMAINTAIN light contact, shorten the muscle being treatedREAPPLY firm pressure to check reduction of tenderness

Fine tune til 70% reducedMAVERICK POINT - 5% of TPs, will not improve with tx, these are treated by positioning pt into position oppositeof what is typically used

Most in cervical spinePt completely relaxed, maintain position of comfort for 90 secondsSlow return to neutral - First few degrees are most importantRECHECK with firm pressure

No more than 30% of tenderness should remainTECHNIQUES

CERVICAL spineAnterior TPs

Slightly anterior to or on the most lateral aspect of the lateral massesTx position – Flex - SARA – sidebend away and rotate awayMAVERICK point – C7

2-3 cm lateral to medial end of clavicle at lateral attachment of SCM muscleTx position – Flex STRAw – sidebend towards and rotate away

C-spine has greatest number of Maverick pointsPosterior TPs

At tip of spinous process or on lateral sides of SPsTx position – Extend – SARA

C3 – flexion and STRAwMAVERICK point – Inion

At inion or just belowTx position – Marked flexion

THORACIC spineAnterior

T1-6 – at midline of sternum at attachment of corresponding ribsT7-12 – in rectus abdominus muscle – 1 inch lateral to midline on right or leftTx position – Flex and some SARA

PosteriorOn either side of SP or on transverse processTx position – Extend SARA

RIBS*TX- MAINTAIN FOR 120 SECONDSAnterior

Associated with depressed ribs (exhalation SD or inhalation restriction)Rib 1 – just below medial end of clavicleRib 2 – 6-8 cm lateral to sternum on rib 2Ribs 3-6 – along mid-axillary line on corresponding ribTx position

Rib 1 and 2 – Flex head, SB and R towardsRibs 3-6 – SB and R thorax towards, slight flexion

PosteriorAssociated with elevated ribs (inhalation SD or exhalation restriction)Angle of corresponding ribTx position – SARA, minimal flexion

LUMBAR spineAnterior

L1 – medial to ASISL2-4 – on ASIS**L5- 1 cm lateral to pubic Symphysis on superior ramusTx position – pt supine, hips and knees flexed and markedly rotated away

PosteriorOn either side of SP or on transverse process

L3-4 can be on iliac crestL5 – can be on PSIS

Tx position – pt prone, extended SB away (R can be either to or away)MAVERICK point

LOWER POLE 5TH LUMBARCaudad to PSIS as much as one cmTx – pt prone, hip and knee flexed, leg internally rotated and adducted

PELVISMany of them, most important

Iliacus7cm medial to ASISTx- pt supine with hip flexed and externally rotated

MAVERICK pointPiriformis

In piriformis, 7 cm medial to and slightly cephalad to greater trochanterTx – pt prone, hip and knees flexed, thigh abducted and externally rotated

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FPR (FACILITATED POSITIONAL RELEASE)Indirect myofascial release treatmentSCHIOWITZUsed to treat :

Superficial musclesDeep intervertebral muscles to influence vertebral motion

Basic StepsSuperficial Muscle Tx

Pt in neutral - doc straightens AP curvature of spineDoc applies facilitating force – compression or tractionDoc shortens muscle to be treatedHold for 3-4 secsRelease and reevaluate

Deep intervertebral muscle TxDx – C5 E SRRR

Pt supine, head beyond edge of table resting on pillow in docs lapPt in neutral – straighten cervical lordosis by flexing head slightlyDoc applies facilitating forceDoc places C5 into E SRRRHold for 3-4 secsRelease and reevaluate

Ch 15: MUSCLE ENERGY

Pt actively uses muscles on request, “from a precisely controlled position in a specific direction, against a distinctly executedcounterforce”Can be active direct or active indirect technique (indirect rare)Types of ME

Postisometric relaxation (direct tech)Place pt into restriction ( into barrier) = opposite the diagnosisThen pt contracts against counterforce of doc = isometric contraction

Distance bw origin and insertion of muscle stays the same! – stretches the internal connective tissuesGolgi tendon organ sense this tension in muscle tendons and causes a reflex relaxation of agonist muscle fibers –allows doc to stretch to a new barrierEX- biceps is in spasm – extend elbow to restriction, have pt flex against resistance for 3-5 sec, relax, repeat

Reciprocal inhibitionContracts antagonist muscles!

Sends signals to spinal cord and thru reciprocal inhibition reflex arc the agonist is forced to relaxCAN BE DONE DIRECTLY OR INDIRECTLYDirect

EX- biceps spasm – extend elbow to restriction, have pt contract TRICEPS against resistanceIndirect

EX- biceps spasm – flex elbow away from barrier, have pt contract TRICEPS against resistanceJoint mobilization using muscle force

Helps restore normal ROM in a joint using muscle contractionEX – contract hip flexors helps pull innominate anterior in a posterior innominate SD

Oculocephalogyric reflexUses extraocular muscle contraction to effect cervical and truncal muscles

Respiratory assistanceUses pts voluntary respiratory motionMost Rib inhalation SD are treated this way

Crossed extensor reflexTypically used in extremities that are so severely injured or not accessible that direct manipulation is impossibleEX- contraction of right biceps produces relaxation of left biceps and contraction of left triceps

Typical stepsPosition joint or bone into the barrier in all planes of motionTell pt to reverse directionPt contracts to move joint away from barrierDoc maintains counterforce for 3-5 secs til contraction is perceived at critical articulation (isometric contraction)Doc tells pt to relax, and doc relaxes as well (post isometric relaxation phase)

During relaxation Doc takes up slack in joint (passive lengthening)Repeat 3-5 times and recheck

LocalizationMore important than intensity of force

ContraindicationsPost surgical pts, intensive care pts

TECHNIQUESCERVICAL spine – pt supine

OA – R and SB are to OPPOSITE SIDESAA – ONLY ROTATIONC2-7 – R and SB are to SAME SIDE

THORACIC spine – pt seatedUPPER THORACIC (T1-4) – ONLY HEAD AND NECK ARE USEDLOWER THORACIC (T5-12) – OSTEOPATHIC SALUTE

Pt places hand behind head on side of ROTATIONRIBS – pt supine

BITE = Tx bottom rib inhalation SD, Tx top rib in exhalation SDINHALATION SD

Place 1 hand on anterior aspect of key rib

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Flex pt for pump handle (PH) dysfunction, Sidebend for bucket handle (BH) dysfunctionOn the dysfunctional rib, push down so tension taken off ribPt inhales then exhales deeply

For BH dysfunction, pt reaches for knee ON AFFECTED sidePt holds breath at end-expiratory phase for 3-5 sec during which physician adjusts flexion to newrestrictive barrierOn inhalation, physicians RESISTS inhalation motion of rib (REPEAT 3x)RECHECK!

EXHALATION SDPt places forearm ON affected side across forehead w/ palm upDoc grasps key rib posteriorly at rib anglePt inhales deeply while doc applies an inferior traction on rib anglePt needs to hold breath at full inhalation while performing one of the following isometric contractionsfor 3-5 sec (Repeat 3-5x):

Rib 1: pt raises head directly toward ceilingAnterior and middle scalenes

Rib 2: pt turns head 30 degrees away from dysfunctional side and lifts head toward ceilingPosterior scalene

Ribs 3-5: pt pushes elbow of affected side toward opposite ASISPectoralis minor

Ribs 6-9: push arm anteriorSerratus anterior

Ribs 10-12: pt adducts armLatissimus dorsi12 also – quadratus lumborum

LUMBAR spineSame steps as lower thoracic spine = osteopathic salute

SACRUMUnilateral sacral flexion

“stuck in exhalation” so resistance is during inhalationPt prone, doc standing on ipsilateral side (side of dysfunction)Caudad hand holds pt’s leg above knee, slightly internally rotate and abduct itCephalad hypothenar eminence on pt’s posterior ILAAsk pt to inhale and hold breath, while doc push anterior on ILA (so…resist)Hold 3-5 secDirect pt to exhale while you resist any posterior inferior movement of sacrum

Unilateral sacral extension“stuck in inhalation” so resistance is during exhalation

Pt prone, physician standing on ipsilateral side (side of dysfunction)

Caudad hand holds patient’s leg above knee in internal rotation and slight abduction

Cephalad hypothenar eminence on the patient’s shallow sacral sulcus

Ask the pt to exhale and hold breath, while you push anterior and caudad on the superior sulcus

Hold for 3-5 seconds

Direct the pt to inhale while you resist any anterior superior movement of the sacrum

Sacral torsionsForward torsion = LoL or RoR

Pt lies lateral recumbent with side of axis down (second letter)Have pt rotate down towards the table and hug the table while keeping the hips straight(FORWARD torsion = FACE down)Flex the hips until you feel motion at the sacral sulciBring legs off the table toward you (induces sidebending and engages the axis)Have pt push UP as you push DOWNFollow ME protocol

Backward torsion = LoR or RoLPt lies lateral recumbent with side of axis down (second letter)

For LoR – lie on Right side, for RoL – lie on Left sideFlex hips until feel motion at sacral sulciGrasp pts bottom arm and pull thru to rotate torso backwards and have them grab table(BACKWARD torsion = BACK down)Bring both legs off the table towards you (induces SB and engages axis)Pt pushes UP against you while you push DOWNFollow ME protocol

INNOMINATESAnterior

Pt. supine & D.O. on side of dysfunction.Flex lower extremity on side of dysfunction at knee and hip.Put shoulder against pt’s leg & cup ASIS with cephalad hand & ischial tuberosity with caudad hand.“Push knee against my chest.”Follow ME protocol

PosteriorPt. supine & D.O. on side of S.D.Pt. on edge of table allowing ischial tuberosity on side of dysfunction to fall off edge. - leg hangs freely

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off table.Cephalad hand reaches across & stabilizes opposite ASIS.Tension applied to anterior thigh rotating innominate anterior to new restrictive barrier“Pull your knee up to the ceiling.” Follow ME protocol

Pubic shearsSuperior

Pt. supine and D.O. on dysfunctional side between table and leg.Stabilize opposite ASIS.Have pt. scoot laterally until ischial tuberosity at edge of table (dysfunctional side leg hangsoff)Abduct knee to gap symphysis.“Bring knee to opposite ASIS” (this will extend and ADDuct)

InferiorPt. supine and D.O. on side of dysfunction.Flex lower extremity at knee and hip an ABduct thigh to gap pubic symphysis.Place knee against chest, cup cephalad hand against ASIS, grasp ischial tuberosity with otherhand.“Push knee to opposite foot” (this will extend and ADDuct)Follow ME protocol

UPPER EXTREMITIESPosterior radial head = pronation SD, supination restriction

Pt seated, and dr standing in front of ptDr applies a “handshake grip” or grab wrist on the side to be treated, and places index finger overanterior surface of distal radiusDoc applies anterior pressure on the radial head with the pad of the thumbDr extends elbow within a few degrees of full extension and supinates the pts hand to the restrictionPt is told to pronate their hand (“turn hand over”)Follow ME protocol

Anterior radial head = Supination SD, pronation restrictionDr grasps pts wrist with the hand opposite the dysfx and pronates the armWith other hand apply posterior pressure on radial headPt is told to supinate their hand (turn it over) while dr resistsFollow ME protocol

LOWER EXTREMITIES (p143 is wrong)Anterior fibular head

Pt prone or supine with knee flexed, place hand on lateral side of pts foot, cupping anklePlantar flex and invert pts foot to barrierinternally rotate tibiaTell pt to dorsiflex, push foot laterallyFollow ME protocol

Posterior fibular headPt prone or supine and knee flexed, place hand on lateral side of pts foot, cupping ankleDorsiflex and evert foot to barrierExternally rotate tibiaTell pt to plantarflex, push foot mediallyFollow ME protocol

CH 16 – HIGH VELOCITY – LOW AMPLITUDE (HVLA)

Passive, direct techniquePosition restricted joint against its restrictive barrier a short (low amp) quick (high velocity) thrust is directed to move the jointpast the restrictive barrierAka thrust tech, mobilization with impulse txNeurophysiologic mechanism

Theory 1 – thrust forcefully stretches a contracted muscle producing a barrage of afferent impulses from muscle spindles toCNS. CNS sends inhibitory impulses back to muscleTheory 2 - thrust forcefully stretches a contracted muscle pulling on its tendon activating the golgi tendon receptors àreflexive relaxation

General procedureMove segment to be treated towards its restrictive barrierPt told to relax – usually works best during exhalation phaseDoc uses short quick thrust to move thru barrier – pop or click may be heard

DO NOT back off of restrictive barrier before applying thrust (do not brace yourself)Recheck

IndicationsTreat motion loss in SD (not for pathologic loss)

**ContraindicationsAbsolute

OsteoporosisOsteomyelitis (and Potts disease)FracturesBone metastasisSevere RA – esp cervical – transverse ligament of dens ruptureDown’s syndrome – same as RA

RelativeAcute whiplash, pregnancy, post surgery, herniated disc, pts on anticoagulants or with hemophilia, vertebralartery ischemia (positive Wallenberg’s test)

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ComplicationsMinor – soreness or symptom exacerbationMajor

MC – vertebral artery injury in neck extensionMC low back – cauda equina syndrome

TECHNIQUESCERVICAL

OAPt supine, doc at head of tableMCP at base of occiputSet the pt up opposite the SDThrust toward the pts opposite eyeRecheck

AAOnly rotationThumb on fulcrum hand contacts the pts zygomatic processPt is asked to inhale and exhale, then rotational thrust is applied

C2-7Can be treated using a SB or rotatory thrustRotational thrust

If rotated right, use right hand as fulcrumIf rotated left, use left handThen SB into your handThe thrust is directed towards opposite eye

SB thrustIf SB right, use left hand as fulcrumIf SB left, use right hand as fulcrumRotate the opposite wayThrust directed toward pts opposite shoulder

THORACICS AND RIBSTHORACIC

Kirksville krunchIn general – doc stands opposite side of rotation with pt supinePt crosses arms – opposite over adjacent

Type II –flexed – thrust is toward the floorextended – thrust is directed at the vertebrae below the dysfx and aimed 45 degrees cephalad

Type ISame as flexed, except SB pt away from you

RIB 1 – Inhalation SDRib stuck upis the exception – on the side that is stuck up, SB toward and rotate away (similar to a cervical hvla)

all the other ribs – Inhalation or Exhalation SDlike Kirksville except thenar eminence goes under posterior rib angle of key rib (BITE)flex torso and slightly SB away, thrust down towards hand

LUMBAR (roll)Used for T10 – L5Pt can be treated with the TP facing up or down

Ex – rotated right – can treat in left lateral recumbent (TP up) or right lateral (TP down)Basic set up

Flex pts leg until palpate motion at joint, straighten bottom legHook top leg in lower legs popliteal fossa

TYPE IITRANSVERSE PROCESS UP à pull pts inferior arm downTP DOWN à pull pts inferior arm up

TYPE ITP UP à pull pts inferior arm upTP DOWN à pull pts inferior arm down

With one arm in pts axilla and the other on iliac crest, apply thrust forward and toward table

Ch 17 – ARTICULATORY TECHNIQUESAka springing techniques or low velocity/moderate amplitude (good if don’t like hvla)Direct , increase ROM in a restricted joint using repetitive forces (respiratory coop, and ME can be added)Indications

Limited or lost articular motionNeed to increase frequency or amplitude of motion of a body regionNormalize sympathetic activity (rib raising)

ContraindicationsRepeated hyperrotation of cervical spine in extension may cause vertebral artery damageAcutely inflamed joint – esp if from infection or fracture

Typical procedureMove affected joint to the limit of all ROM, once barrier is reached slowly and firmly continue to apply gentle force againstitNow can add resp coop or ME to increase stretchReturn to neutralRepeat several times until no further response is achieved

TECHNIQUES

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RIB RAISINGPurpose –

Increase chest wall motion (useful in viral pneumonia)Normalize sympathetic (ganglia lie anterior to rib heads)Improve lymphatic return

Procedure – can be supine or seatedPt supine, doc seated on one sideDoc places fingers under pts thorax with pads of fingers on rib angleApply gentle tractionRaise ribs by pushing upwards with fingertips (use forearm as lever)

Spencer’s (this is DiGiovannas version, different than what is in OMT review)For ppl who have fibrosis and restriction during a period of inactivity (adhesive capsulitis) after an injury

Stage 1Shoulder extension with elbow flexed

Stage 2Shoulder flexion with elbow extended

Stage 3Circumduction with slight compression and elbow flexed

Clockwise and counterclockwiseStage 4

Circumduction with traction and elbow extendedClockwise and counterclockwise

Stage 5Abduction with elbow flexedAdduction and external rotation with elbow flexed

Stage 6Internal rotation with arm abducted, hand behind back

Stage 7Distraction, stretching tissues, and enhancing fluid drainage with arm extended

Fingers interlaced just distal to the acromion processME- have pt push hand down on your shoulder

CH 18 - SPECIAL TESTS

CERVICAL SPINESpurling test (compression test)

What it does – narrows the neural foramina à nerve root compression à referred painPt seated, doc extends and SB the C-spine to the side being testedThen pushes down on top of headPositive if pain radiates into ipsilateral arm (distribution can localize nerve root)

Wallenberg’s testWhat it does – tests vertebral artery insufficiencyPt supine, doc flexes neck and holds it for 10 secsThen extends neck and holds it for 10 secsDo the same thing for rotation to left and right, and rotation to left and right with extension

And in any position the doc would attempt to mobilize the c-spinePositive – if pt complains of dizziness, visual changes, lightheadedness, eye nystagmusVariation = Underberg’s test

Neck is backward bent and head fully rotated to either sideIf develops vascular or neuro symptoms – HVLA contraindicated!

SHOULDERTOS Tests

Adson’s testWhat it does – checks for tight scalenesMonitor pts pulseArm extended at elbow, at shoulder – extend, externally rotate, and slightly abductPt is told to take a deep breath and turn head toward ipsilateral armPositive – if decreased or absent radial pulse

Wright’s (aka arm hyperextension test)What it does – checks compromise under pec minor at coracoid processHyperabduct arm above head, with some extensionPositive – if decreased or absent radial pulse

Costoclavicular syndrome test (aka Military posture test)Checks for compromise bw clavicle and first ribDepress and extend the shoulderPositive – if decreased or absent radial pulse

Apley’s scratch testWhat it does – evaluate ROM of shoulderAbduction and external rotation – pt reaches behind head and touch opposite shoulderAdduction and internal rotation – pt reaches in front of head and touch opposite shoulderFurther eval of internal and add – pt reaches behind back and touch inferior angle of opposite scapula

Drop arm testWhat it does – detects rotator cuff tearsPts abducts shoulder to 90 degreesTold to slowly lower armPositive – pt cant lower arm smoothly, or arm drops to side from 90

Speeds testWhat it does – assesses biceps tendon in bicipital groovePt fully extends elbow and flexes shoulder and supinates forearm

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Doc resists flexionPositive – tenderness in bicipital groove

Yergasons testWhat it does – determines stability of biceps tendon in bicipital groovePt flexes elbow to 90 while doc grasps elbow with one hand and wrist with otherDoc pulls down on pts elbow and externally rotates the forearm as the pt resists motionPositive – pain elicited as biceps tendons pops out of the groove

WRISTAllens

What it does – assesses adequacy of blood supply to hand by radial and ulnar arteriesPt opens and closes hand several times, and makes a tight fistDoc occludes radial and ulnar aa at wristPt opens hand – which should be paleDoc releases on artery and assesses flushing of handIf flushes slowly or not at all – the released artery is not adequately supplying the handRepeat for other artery

FinkelsteinWhat it does – test for tenosynovitis in abductor pollicis longus and extensor pollicis brevis at wrist (DeQuervain’s disease)Pt makes fist with thumb tucked inside fingersDoc stabilizes forearm and deviates wrist ulnarlyPositive – pt feels pain over tendons at wrist

Phalen’sWhat it does – aids dx of carpal tunnel syndromeDoc flexes wrist and holds this position for one minutePositive – tingling felt in thumb, index and middle finger and lateral part of ring finger

Reverse Phalen’s (Prayer)Pt extends wrist while gripping docs hand, hold for one minutePositive – tingling felt in thumb, index and middle finger and lateral part of ring finger

Tinel’sWhat it does – aids dx of carpal tunnelDoc taps over volar aspect of pts transverse carpal ligamentPositive – same as aboveAlso can be used to dx neuropathies of ulnar nerve at elbow, peroneal nerve at fibular head, and posterior tibialnerve at ankle

LUMBAR SPINEHip –drop

What it does – assesses SB of lumbar spine and thoracolumbar junctionPt standing, doc locates superior and lateral aspect of iliac crestPt is told to bend one knee without lifting heel from floorPositive – anything less than a smooth convexity in the l-spine of the ipsilateral side, or a drop of the crest lessthan 20-25 degrees

Straight leg raise (Laseques)What it does – evals sciatic nerve compressionPt supine, doc grasps leg to be tested under the heel and places other hand on anterior knee to keep it extendedDoc lifts leg up – flexing the hip until pt feels discomfort (normal = 70-80 degrees)Once pt feels pain- doc lower leg a little and dorsiflexes the foot (Braggard’s test)

This stretches the sciatic nerveIf no pain = negative test, problem is a tight hamstringIf pain spreads all the way down leg = positive – sciatic origin

SACRUM AND INNOMINATESSeated flexion

What it does – tests sacroiliac motionPt seated with both feet flat on floorDoc locates PSIS and places thumbs on inferior notchPt bends forward, doc assess PSIS levelPositive – PSISs are not level, SD on side of superior PSIS

Standing flexionWhat it does – tests iliosacral motionSame as seated, except pt is standing

ASIS compressionWhat it does – helps determine side of SI dysfx (sacrum, innominate or pubes)Pt supine, doc contacts ASISs and applies posterior compression to each, while stabilizing the otherPositive – on the side where there is resistance (no “resiliency)’

Pelvic side shiftWhat it does – determines if sacrum is midlinePt standingdoc stabilizes right shoulder with right hand, and pushes pelvis to right with left handdoc stabilizes left shoulder with left hand, and pushes pelvis left with right handpositive – on side with freer translation of pelvis – indicates pelvis is shifted to that side

Often seen in flexion contracture of psoasFlexion contracture of right psoas will cause a pos pelvic shift to the left

Trendelenberg’sWhat it does – assesses gluteus medius muscle strengthDoc stands behind ptPt picks one leg up off the floorPositive – pelvis falls on the same side the leg is lifted = opposite gluteus medius is weak

Lumbosacral springWhat it does – assesses if sacral base is tilted posterior

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Pt prone, doc place heel of hand over lumbosacral junctionDoc applies gentle and rapid springing over junctionPositive = posterior sacral base, little or no springing

Backward bending (sphinx)What it does –determines if sacral base has moved posterior or anteriorPt prone, doc places thumbs on superior sulci – will be asymmetricHave pt prop up onto elbows – causes base to move anterior

If thumbs become more symmetric – part of base moved anteriorIf thumbs become more asymmetric – part of base moved posterior

Positive – if sacral base is posteriorHIPS

Ober’sWhat it does – detects tight tensor fascia lata and iliotibial bandPt lies on side opposite iliotibial band being testedDoc stands behind pt and flexes knee to 90, abducts hip as far as possible and slight extends hip, whilestabilizing pelvis to keep pt from rollingDoc allows thigh to fall towards tablePositive – thigh remains in abducted position = tight band

Patrick’s (FABERE)What it does – assesses pathology of sacroiliac and hip joint – esp OA of hipPts hip is Flexed, ABducted, Externally Rotated and Extended into a figure 4 positionPositive = pain in or around the hip joint,

accentuated pain (due to arthritic changes) when doc places one hand on opposite ASIS and other onbended knee and applies pressure on both

ThomasWhat it does – assesses possibility of flexion contracture of hip (usually due to iliopsoas)Pt supine, doc checks for exaggerated lumbar lordosis (common in flexion contracture)Doc flexes one hip and knee so that knee and anterior thigh touch pts abdomenPositive – if opposite leg lifts off table

KNEEAnterior and posterior drawer test

What it does – assess anterior and posterior cruciate ligamentsPt supine with hip flexed to 45 and knee flexed to 90Doc sits on pts foot, wraps hands around behind tibia, and places onethumb on medial and lateral joint linesACL – tibia is pulled anteriorly

Positive ACL tear – if slides forwardPCL – tibia is pushed posteriorly

Positive PCL tear – if slides backMust compare both knees

Bounce homeWhat it does – evals problems with full knee extension – usually bc of meniscal tears or joint effusionsPt supine, doc grasps heelKnee is flexed completely, then is allowed to drop into full extensionPositive – if extension is incomplete or there is a “rubbery” feel to end point extension

Apley’s compression and distractionWhat it does – evals meniscus and ligamentous structures of kneePt prone, knee flexed to 90Compression – doc presses straight down on heel and internally and externally rotates the tibia

Positive = pain = meniscal tearDistraction – doc pulls up on foot and internally and externally rotates tibia

Positive = pain = ligamentous injury (usually medial/lateral collateral ligs)Lachman’s

What it does – assess stability of ACL (more accurate than draw test)Pt supine, doc grasps proximal tibia with one hand and distal femur with otherKnee flexed to 30 and tibia is pulled forward with handPositive – tibia excessively moves forward from under femur

McMurray’sWhat it does – detects tears in posterior aspect of menisciMedial meniscus

Pts knee is fully flexedTibia is externally rotated and valgus stress is placed onthe kneeMaintain this position and slowly extend the kneePositive = palpable or audible “click” = posterior tear ofmedial meniscus

Lateral meniscusSame, except internally rotate and varus stress is applied

Patellar grindWhat it does – assess posterior articular surfaces of patella andpossible chondromalacia patellaePt supine with knees extended and relaxedDoc pushes patella distally and asks pt to contract quads

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Positive = pain, bc roughness of surface will grind and be palpable and painful withcontraction and mvmt of patella

Valgus (pic to the left) and varus (pic to the right) stressWhat it does – assess stability of collateral ligamentsPt supine or sittingKnee flexed, doc stabilizes ankle while pushes against knee medially, then laterallyValgus stress test = lateral force, knee goes medially, tibia goes out (valgus)

Tests medial collateral ligamentVarus stress test = medial force, knee goes laterally, tibia goes in (varus)

Tests lateral collateral ligamentPositive – if there is any gapping on the opposite side of the force, that ligament is torn

ANKLEAnterior draw

What it does – assess medial and lateral ligs of ankle – mainly talofibular lig, but also superficial and deepdeltoidPt supine, doc grasps distal tibia/fibula with one hand and pulls foot forward with other hand – graspingposterior aspect of calcaneus

Foot should be held in 20 degrees of dorsiflexion the whole timePositive – excessive mvmt of talus under tibia/fibula (bilateral injury)

If deviates to one side – ligament on opposite side is damaged

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