OMM Study Guide

Frayette’s principles1. When SB from neutral position, rotation of vertebral bodies follows to opposite direction; SB precedes rotation.2. When SB is attempted from non-neutral (F/E) position rotation precedes SB to same side

Applies to a single vertebrae Rotation of vertebrae towards the concavity of the curve Traumatic origin

3. Motion in one plane limits and modifies motion in another plane Techniques (consider level of aggression for different diagnoses requiring gentle techniques)

o Myofascial release – direct is engaging soft tissue restrictive barrier with constant force until release; indirect is finding point of balance

o Counterstrain – monitor TP, find position of ease, hold for 90 seconds (120 for ribs), passively return to neutral, pain should be < 3/10.o Still technique – take joint into direction of ease (indirect) until tissues relax, add compression, guide through to barrier (direct)o FPR – add a compressive force (uses torsion in lumbar), guide joint into its direction of freedom, hold for 3-5 seconds, return to neutral. o ME (indirect ME uses reciprocal inhibition, e.g. when tricep is contracted, bicep relaxes)o Articulation (taking a joint through full ROM with focus on dysfunctional barrier)o Springing (barrier engaged repeatedly with MVMA)o Soft tissue (linear stretching and/or deep pressure to facilitate muscular and fascial relaxation)o HVLAo Inhibition o Osteopathy in cranial fieldo Lymphatic treatment (do not use pedal pump in cardiac / respiratory patient)

Chronic SD versus acute SDChronic Acute

Somato-visceral effects Minimal somato-visceral effectsDull ache or pain Acute pain, severe, cutting, sharpCool, pale, dry, scaly, itchy, blemished skin; folliculitis Warm, moist, inflamed skinRegional sympathetic vasoconstriction Local vasodilation (sympathetics cause constriction, but

bradykinins overpower, causing dilation)Decreased muscle tone; contracture; flaccid Muscle spasmLimited ROM due to contracture ROM sluggish but normalDoughy, stringy, fibrotic tissue Boggy edematous soft tissue

Chapman’s Reflex Tender Pointso Definition: predictable anterior and posterior fascial tissue texture abnormalities assumed to be reflections of visceral disease

Anterior used for diagnosis Posterior used for treatment

o Small, smooth, firm, discrete, painful nodule, approximately 2-3mm in diametero Treatment: rub in a firm circular motion for ~ 10-30 seco Myocardial

Anterior: 2nd intercostal space close to the sternum Posterior: Midway b/w the SP and the tips of the TP of T2 and T3

o Respiratory Bronchial

Anterior: 2nd intercostal space close to the sternum Posterior: Midway b/w SP and the tips of the TP at T2

Upper lung: Anterior: 3rd intercostal space close to the sternum Posterior: Midway b/w the SP and the tips of the TP of T3 and T4

Lower lung: Anterior: 4th intercostal space close to the sternum Posterior: Midway b/w the SP and the tips of the TP of T4 and T5

o Myocardium, bronchus, esophagus, and thyroid can all be found anteriorly between ribs 2 & 3 o GI & GU

Liver: 5th and 6th ICS on the right Gallbladder: 6th ICS on the right Stomach acid: 5th ICS on the left Stomach peristalsis: 6th ICS on the left

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Pancreas: Anterior: 7th ICS on the right Posterior: B/w TP of T7 and T8 right

Spleen: 7th ICS on the left Adrenal glands

Anterior: 1 inch lateral and 2 inches superior to the umbilicus ipsilaterally Posterior: Midway b/w the SP and the tips of the TP of T11 and T12 (also Chapman reflex for hypertension)

Kidneys: Anterior: 1 inch lateral and 1 inch superior to umbilicus ipsilaterally Posterior: midway b/w SP and TP tips of T12 and L1

Bladder Anterior: Umbilical area Posterior: midway b/w SP and TP tips of L1 and L2

Appendix: Tip of 12th rib on the right Colon- iliotibial band, as illustrated below Urethra: myofascial tissues along the superior margin of the pubic ramus about 2cm lateral to the symphysis Prostate: myofascial tissues along the posterior margin of the iliotibial band

Counterstrain pointso Cervical

Posterior: C1 inion flex, C1-C7 extend and SARA, except C3 = flex and STRAW Anterior: C1 rotate away, C2-C8 flex and SARA, except C7 = flex and STRAW

o Thoracic AT1: apex of sternal notch AT2: middle of the manubrium AT3-AT6: on the sternum at the same numbered costal level AT7: under the costalchondral margin, lateral, and inferior to the xiphoid process AT8: approximately 3 cm below the xiphoid process AT9: 1-2 cm above the umbilicus, 2-3 cm lateral to the midline AT10: 1-2 cm below the umbilicus, 2-3 cm lateral to the midline AT11: 5-6 cm below the umbilicus, 2-3 cm lateral to the midline AT12: inner surface of the iliac crest at the midaxillary line Posterior thoracic TP on spinous or transverse process of corresponding vertebra

o Ribs Anterior – associated with depressed ribs

AR1: First rib where it articulates with the manubrium AR2: Second rib in the midclavicular line

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AR3-6: On corresponding rib, in the anterior axillary line Posterior – associated with elevated ribs

PR1-6: angle of corresponding rib

o Inguinal Tender point located on the lateral border of the pubic bone near the attachment of the inguinal ligament

o Iliolumbar Tender point located 1 inch superior and medial from the inferior margin of the PSIS in the iliolumbar ligament

o Piriformis Tender point located halfway from the PSIS–ILA midpoint to the greater trochanter.

Cervicalo Dysfunction

Most clinically significant SD of newborns is condylar compression Affects CN 9, 10, and 11; can cause poor feeding, swallowing, emesis, hiccups, torticollis, and perhaps pyloric stenosis

Cervical spondylosis Ankylosis of adjacent vertebral bodies Degeneration of intervertebral disc (dehydration and shrinkage) Presents as chronic neck pain, radicular pain, and decreased ROM. Affected contents of cervical canal (myelopathy and radiculopathy) present with distal motor, sensory, and proprioceptive loss.

Cervical disc herniation Painful, stiff neck BB and sidebending to side of herniation relieves pain by keeping nucleus pulposus from neural structures

Most adverse effects of OMT occur with excessive axial rotations in HVLAo Special testing

Spurling – extend and sidebend neck, add compression. Test for narrowing of foramina. Positive if pain radiates to ipsilateral arm. Underburg – extend and rotate neck in supine position. Test for vertebral insufficiency. Positive with dizziness, nausea, nystagmus.

Thoracic o Rule of 3s

T1-3 SP in the same plane as the TVP T4-6 SP ½ between the TVP above and below T7-9 SP at the plane of the TVP below T10 follows 7-9 T11 follows 4-6 T12 follows 1-3

o Motion Rotation> SB> Flexion> Extension

o Scoliosis Mild: 5-15 degrees, moderate: 20-45 degrees, severe > 50 degrees. Idiopathic origin most common. Thoraco-lumbar double curve most common. Curve is named for direction of convexity (left curve has apex on left)

Ribso Motion

Pump Handle – ribs 1-5 Inhalation: anterior aspect of the rib moves cephalad Increase in AP diameter of the thorax Motion predominantly in sagittal plane Best palpated at midclavicular line Axis of motion is costovertebral-costotransverse line (see below)

Bucket Handle – ribs 6-10 Ribs move laterally and increase transverse diameter with inhalation Motion predominantly in coronal plane Best palpated at midaxillary line Axis of motion is costovertebral-costosternal line (see below)

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Inhalation: lateral aspect of the rib moves cephalad Caliper – ribs 11-12

Ribs externally rotate with inhalation Motion predominantly in transverse plane Best palpated 3-5cm lateral to transverse process Axis of motion in vertical line (see below)

Pump handle Bucket handle Caliper

o Dysfunctions Exhalation dysfunction: likes to exhale, difficult inspiration, found in pneumonia

Treat: rib at bottom of space but top of group Inhalation dysfunction: likes to inhale, difficult exhalation, found in COPD

Treat: rib at top of space and bottom of groupo Muscles to use in rib ME

Rib 1: Anterior & Middle Scalenes Rib 2: Posterior Scalene Ribs 3-5: Pectoralis Minor Ribs 6-8: Serratus anterior Ribs 9-11: Latissimus dorsi Rib 12: Quadratus lumborum

Upper extremityo Shoulder mechanics

Scapulohumeral ratio – 2:1. For every 2 degrees of humeral abduction, scapula rotates 1.o Provocative testing

Neer – rapid flexion of shoulder with arm extended. Tests for subacromial impingement. Hawkins – rapid internal rotation of arm with shoulder/elbow flexed at 90 degrees. Tests for suprahumeral impingement. Drop arm test – drop arm at patient’s side. Tests for subacromial impingement, rotator cuff problems (mainly supraspinatus). Apply’s scratch – internal rotation and adduction to touch opposite scapula. Tests for adhesive capsulitis (mainly anteriorly) Yergason’s test – external rotation of arm with elbow flexed at 90 degrees. Tests for instability of biceps tendon in bicipital groove.

o Erb-Duchenne’s Palsy Injury to the upper part of the cord, at the root level of C5 and C6, usually associated with birth trauma. Paralysis of deltoid, external rotators, biceps, brachioradialis and supinator

o Radial nerve injury Caused by mid-shaft fracture of humerus; “Saturday night palsy” Knocks out wrist extension

o Epicondylitis Golfer’s elbow - strain of the flexor muscles near the medial epicondyle Tennis elbow - strain of the extensor muscles near the lateral epicondyle (use counterstrain in old people)

Cozen’s test (for lateral epicondylitis) - holding pronated fist out and trying to extend and internally rotate it.o Ulnar mechanics

Increased carrying angle with abducted ulna – cubitus valgus Decreased carrying angle with adducted ulna – cubitus varus Parallelogram effect:

Increased carrying angle will cause adduction of wrist Decreased carrying angle will cause abduction of wrist

o Radial mechanics Moves anterior with supination (from fall backward) Moves posterior with pronation (from fall forward)

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o TOS testing Adson’s test: neck extended, turned toward affected side

Narrows interscalene space Checks patency of ipsilateral artery passing between scalene triangle Positive with decreased/absent radial pulse

Halstead maneuver: exaggerated military posture (scapula retracted and depressed) Narrows costoclavicular space

Wright’s maneuver: shoulder external rotation, abduction beyond 90 degrees Compressed below pectoralis minor insertion

o Wrist testing Carpal tunnel tests:

Phalen’s - Wrist flexion to maximum for 60 sec. Test for CTS. Prayer’s - Reverse of Phalen’s. Test for CTS. Tinel’s - Tapping over transverse carpal ligament. Test for CTS. Provocation Test - Compress and hold over transverse carpal ligament. Test for CTS. Nerve conduction studies are the gold standard of diagnosis Hypothyroidism, pregnancy, and dialysis-associated amyloidosis can mimic CTS.

Finkelstein’s – Put thumb in palm and close fist, then ulnar-deviate wrist. Tests for DeQuervain’s tenosynovitis. Inflammation of extensor pollicis brevis and abductor pollicis longus

Lumbaro Motion

Sagittal plane orientation of the facets Allows flexion/extension>SB>rotation Ferguson’s Angle – 35 degrees (normal is 30-40)

o Pathology Anterior triangle is an area of weakness and common site of compression fracture Sacralization – L5 fuses to sacrum (batwing deformity) Lumbarization – S1 becomes 6th lumbar vertebra. Disc hernation is common due to narrow posterior longitudinal ligament

L4-L5 and L5-S1 are most common levels. Hernation at disc X will affect root X+1.

o L5/sacral rule L5 sidebends to the same side as the oblique axis L5 rotates to the opposite side of sacrum Neutral mechanics: LOL or ROR forward torsions Non-neutral mechanics: ROL or LOR backward torsions Unilateral flexion or extension produces no L5 change

Sacralo Axes

Superior : Above S2, the cranial primary respiratory mechanism creates motion around this axis Middle : At S2, forward and backward bending Inferior : Below S2, rotation of the innominates

o Motion with gait Lumbar spine sidebends towards weight-bearing leg

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Anterior rotation of weight-bearing ilium; posterior rotation of leg swinging forward An oblique sacral axis is induced on side of weight-bearing leg, and rotation in same direction. Example: as left leg bears weight and right swings forward, SLRR motion occurs in lumbar spine, left innominate moves anterior, and

sacrum rotates left on its left axis.o Sacral tests

Seated flexion test: Lateralizes sacrolumbar and sacroiliac dysfunctions and eliminates lower extremity Tests motion between innominates and sacrum Positive test is side which moves first and farthest

Standing flexion test: Identifies side of iliosacral dysfunction with positive side moving farthest and longest

Iliosacral dysfunction landmarks: ASIS - assess overall position of ilium PSIS - assess overall position of ilium Pubic tubercles – higher in superior innominate and superior pubic shear Medial Malleoli - higher in posterior rotation and superior innominate Sacral sulcus – going to be deep on side of posterior rotation; narrow in outflare. Sacrotuberous ligament – lax in innominate that’s superior (ischium closer to sacrum) Knee pain / tight sartorius – posterior rotation Posterior thigh pain / tight hamstrings – anterior rotation

Sacral dysfunction landmarks: Sacral Base – assesses overall position of sacrum Inferior Lateral Angle (ILA) – assesses overall position of sacrum Sacral Sulcus – deep with anterior base Sacrotuberous ligament – tight with posterior ILA (away from ischium)

Spring test: Check if sacral base has moved posterior Positive if there is NO movement (like in a backward torsion)

Sphinx test: Check if sacral base has moved posterior Positive if thumbs on sacral base become more asymmetric when patient extends (posterior part resists moving anterior) Positive in unilateral sacral extension and backward torsions (LOR and ROL)

Lower extremityo Neuro testing

L4: foot inversion (tibialis anterior), patellar reflex, medial foot sensation L5: great toe extension (extensor hallicus longus), dorsum foot sensation, facilitates walking on heels S1: foot eversion (peroneus longus and brevis), Achilles reflex, lateral foot sensation, facilitates walking on toes Babinksi: positive if toes (or big toe) extend - UMN lesion

o Motion testing Ober’s Test - Assessment for contracture of iliotibial band or tensor fascia latae

With knee flexed, extend hip and gently allow thigh to adduct toward table Considered positive if thigh cannot adduct past midline

Straight Leg Raise Test - Assessment for sciatic nerve compression Normal straight leg raise is ≈90° Keeping knee extended, flex hip until pt reports pain Considered abnormal if cannot flex past 70°

Lasegue’s Test – differentiates between hamstring and sciatic pain in straight leg raise

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Once pain is reported, extend hip about 5° and dorsiflex foot This removes hamstring pain while adding stress onto sciatic n.

Thomas Test - Assessment for flexion contracture of hip (usually due to contralateral restricted or shortened iliopsoas muscle) Flex one thigh up to abdomen Considered positive if opposite knee lifts off table

Trendelenburg Test - Assessment of gluteus medius muscle strength Pt stands on one foot while flexing opposite knee Gluteus medius on opposite side of flexed knee should keep pelvis level Considered positive if pelvis tilts toward side of flexed knee

McMurray Test – Assessment for meniscal tears Hip and knee both flexed to 90° Medial meniscus test - external rotation of foot with valgus stress on knee, followed by extension. Lateral meniscus test - internal rotation of foot with varus stress on knee, followed by extension.

Ligament testing Valgus stress - Assess stability of MCL Varus stress - Assess stability of LCL Anterior Drawer Test - Integrity assessment of ACL Posterior Drawer Test - Integrity assessment of PCL

o Dysfunctions Terrible triad

Compromise of ACL, MCL, and lateral meniscus. Commonly induced by valgus force on the knee

Fibular Head dysfunctions DEA: dorsiflexed, everted, externally rotated – anterior fibular head (distal talofibular joint posterior) PIP: plantarflexed inverted, internally rotated – posterior fibular head (distal talofibular joint anterior) Treat with opposite for direct

Ankle sprains 80% are inversion sprains; produce posterior fibular head Type I – anterior talofibular ligament Type II - anterior talofibular ligament, calcaneofibular ligament Type III - anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament

Foot dysfunctions Pes planus - Longitudinal & transverse arches fall Pes cavus - Arches rise

Psoas syndrome pelvis shift to the opposite side non-neutral dysfunction of L1 and/or L2 - flexed and rotated to same side as the spasm oblique axis sacral dysfunction - axis is same side as the spasm spasm of the opposite piriformis resulting in sciatic irritation gluteal and posterior thigh pain

Sympathetic innervationo T1-4 – head and necko T1-6 – heart and lungs, visceral pleurao T1-11 – parietal pleurao T2-8 – UE, esophaguso T5-9 – stomach, duodenum, liver, gall bladder, pancreas, spleeno T10-11 – small intestine, kidney, gonads, upper ureter, ascending and proximal 2/3 of transverse colono T11-L2 - LEo T12-L2 – lower ureter, left 1/3 of transverse, descending, and sigmoid colon, rectum, pelvic organs

Cranial boneso Paired bones – frontal, palatine, maxilla, mandible. Paired bones go into internal/external rotation.o Unpaired bones – sacrum, occiput, sphenoid, ethmoid, vomer. Unpaired bones flex and extend.

Primary respiratory mechanism (PRM): interdependent functions among five body componentso 1. Wave-like movement of CNS (supposedly due to oligodendroglia contraction)o 2. Fluctuation of CSF, with gradient for release by choroid plexus and drainage into veins produced by PRMo 3. Mobility of cranial and spinal dura responds to 1 and 2, and influences bones of cranium and sacrum.o 4. Cranial sutures allow motions

Serrate (sawtooth) – rocking motion Squamous (scale-like) – gliding motion Harmonious (edge-to-edge) – shearing motion

o 5. Involuntary rocking of sacrum between ilia, on superior transverse axis through articular pillar of S2. Cranial rhythmic impulse (CRI): fluctuation synchronous with PRM

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o Rate of 10-14/min (pt with depression would have < 10; treat with bulb decompression/CV4 technique)o Palpable in cranium and sacrumo Increased rate: fast metabolism, acute infectiono Decreased rate: slow metabolism, chronic infection, fatigueo Increased amplitude: increased ICPo Decreased amplitude: dural tension, SBS compressiono Still point: a pause in CRI

Cranial motiono Sphenobasilar junction is the reference point around which diagnostic motion patterns are describedo Midline bones follow flexion/extensiono Paired bones follow internal/external rotationo Sacrum follows the occiput o Temporals follow the occiputo Facial bones follow the sphenoido Physiologic motions that occur at SBS (PRM motion):

Flexion Midline bones flex Paired bones go through external rotation Decreased AP diameter of cranium (for some reason)

Extension Midline bones extend Paired bones go through internal rotation Increased AP diameter of cranium

o Non-pathological strains: Torsion

Sphenoid and occiput rotate in opposite directions around AP axis Named for side on which sphenoid wing is higher

Sidebending rotation Sphenoid and occiput rotate in opposite directions around individual vertical axes Both sidebend in direction of SBS deviation on single AP axis Named for direction of sidebending

o Pathological strains: Lateral strain

Sphenoid and occiput rotate in same direction around individual vertical axes Named for direction of deviation of sphenoid base (away from occiput)

Vertical strain Sphenoid and occiput rotate in same direction around individual transverse axes Named for direction of sphenoid movement (flexion = superior vertical strain)

Sphenobasilar compression Diminished CRI

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