OMT review Chapters 1-6.

BASICS An impaired or altered function of related components of the somatic system: skeletal, arthroidial, and myofascial structures and related vascular, lymphatic and neural elements is Somatic Dysfunction (SD) Is SD named for the dysfunction (freedom) or the restriction (barrier)? o The freedom is the way the joint likes to go! What does TART stand for? o T t issue texture change o A asymmetry o o R T

Dysfunction (freedom)

restriction t enderness

Which one of the above is most important for naming a dysfunction? R- Restriction When a patient can move a joint through a full range of motion (FROM) without help, what is it called? Active motion When a doc performs the FROM for the patient, it is called

p assive motion p hysiologic barrier Anatomic barrier Physiologic barrier Ligament/tendon/skeletal injury Restrictive/pathologic barrier

What is the barrier reached during active range of motion by the patient? What is the barrier reached during passive range of motion by the doctor? Movement beyond the anatomic barrier can cause what? What is this new barrier with lack of FROM called? Which barrier is shortened when a somatic dysfunction is present in a joint?

If 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 moisture Is asymmetry present, and if so, has it been compensated for? Yes, non-compensated Is there pain present upon movement of the joint? Yes, motion restricted Describe 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, fibrotic Is asymmetry present, and if so, has it been compensated for? Yes, compensation present in other areas of the body Is motion restricted, and if so, is it painful? Yes, but little to no pain Describe the tenderness d ull, achy, burning Fryettes First Law is described as: o Starts from a neutral position o Sidebending precedes rotation o Sidebending and rotation occur to opposite sides o Rotation occurs towards the convexity o Applies to a group of vertebrae (>2) o EX: T5-T9 N SLRR Which Transverse Processes (TPs) are more posterior? The right side TPs Fryettes Second Law is described as: o Starting from a non-neutral position (flexed or extended) o Rotation precedes sidebending o Rotation and sidebending occur to the same side o Rotation occurs away from the convexity, toward the concavity o Applies to a single vertebra o EX: T8 E RRSR or ERSR What vertebral segments to Fryette Laws I and II apply to? Thoracic and Lumbar, NOT cervical When naming the dysfunction, it is common to relate the dysfunctional segment to the segment below it. o EX: T6 is restricted in flexion, rotation and sidebending to the right in relation to T7 (soT6 E RLSL) What does Fryettes Third Law state? Motion introduced in one plane limits and modifies motion in the other planes o What part of the spine does this apply to? Cervical spine In order to evaluate a SD, what is the stepwise process you must perform to name/find a SD? o First- assess rotation by placing your thumbs over the TP of each segment, the TP that is more posterior is the side the segment is rotated to EX: If your left thumb is more posterior than your right thumb, then the vertebra is rotated left o Second- 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) it is a flexion dysfunction (ex: F RLSL)

If gets better in extension 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)

What is the orientation of SUPERIOR facets in the thoracic region? What is the orientation of SUPERIOR facets in the lumbar region? Next 3 questions, what spinal motion occurs in the following planes and axes: Sagittal Plane, Transverse Axis Flexion and extension Transverse Plane, Vertical Axis Rotation

BUL (backward, upward, lateral) BM (backward, medial)

Coronal Plane, AP Axis Sidebending What type of muscle contraction results in approximation of the muscles origin and insertion WITHOUT a change in tension? Isotonic Contraction o Operators force < Patients force What type of muscle contraction results in an INCREASE in tension WITHOUT an approximation of origin and insertion? Isometric contraction o Operators force = patients force What type of muscle contraction occurs AGAINST RESISTANCE WHILE FORCING the muscle to lengthen? Isolytic contraction o Operators force > patients force What is the difference between concentric and eccentric contraction? Concentric contraction results in approximation of the muscles origin and insertion while eccentric contraction is lengthening of the muscle during contraction due to an external force Direct treatment is directed TOWARDS the barrier Indirect treatment is directed During active treatment the patient During passive treatment the patient

AWAY from the barrier ASSISTS RELAXES

What types of techniques are considered only DIRECT? Chapmans reflexes, lymphatic treatment, HVLA, and Muscle Energy (ME-rarely indirect) o Are these considered active or passive? ALL but ME are passive o Muscle energy and myofascial release are the only 2 techniques that are active What types of techniques are considered only INDIRECT? Counterstrain and FPR o Are these active or passive? Passive

What 2 techniques are both indirect AND direct? Myofascial Release and Cranial OMT o Cranial 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 neck strain/sprains Elderly and hospitalized pts typically respond better to i ndirect techniques Typical guidelines regarding dose/frequency of OMT: o Limit OMT to key areas in sick pts o Allow time for the pts body to respond to the treatment o Pediatric pts can be treated more frequently than geriatric pts o Acute cases should have a shorter interval bw trmts, and as the response increases, the interval can increase Typical guidelines regarding sequence of treatment; o Treat the ribs and upper thoracic spine BEFORE the cervical spine o Treat T-spine BEFORE ribs o Treat peripherally then move to the acute area of SD o Perform cranial treatment BEFORE other OMT to help pt relax o Treat spine, sacrum and ribs BEFORE treating extremities CERVICAL SPINE Which cervical vertebrae are considered atypical? C1 and C2 o Which one has NO spinous process or vertebral body? C1 o o o Which one has a dens that projects superiorly from its body and articulates with the segment above? What ligament attaches to the lateral masses of C1 to hold the dens in place? Transverse ligament What 2 diseases can lead to weakening and possible rupture of the transverse ligament and cause neurologic damage? RA and Downs Syndrome

C2

Are the spinous processes of C2-C6 bifid or singular? What passes through the foramen transversarium of C1-C6?

Bifid Vertebral Artery The articular pillars p osterior

What part of the vertebra do DOs use to evaluate C-spine motion? They are located to the cervical transverse processes

Where do the anterior and middle scalenes originate and insert? Origin = posterior tubercle of TPs of the cervical vertebrae and insertion= RIB 1 Where does the posterior scalene originate and insert? O= posterior tubercle of the TPs of the cervical vertebrae, insertion = RIB 2 What motion do the scalenes do? Unilaterally sidebend neck to same side, bilaterally flex the neck How do the scalenes help in forced inhalation? Sternocleidomastoid (SCM) origin SCM insertion SCM unilateral contraction leads to SCM bilateral contraction

Elevate the 1 and 2 ribs

st nd

mastoid process and lateral half of superior nuchal line s idebend towards, rotate away

medial 1/3 of clavicle and sternum flex the neck

What does the SCM divide in the neck?

The anterior and posterior triangles t orticollis Sidebending

Shortening or restrictions w/in the SCM often result in

Which cervical motion to the joints of Luschka play the biggest role in?

The most common cause of cervical nerve root pressure d egeneration of the joints of Luschka plus hypertrophic arthritis of the facet joints Cervical nerve roots leave above or below their corresponding vertebra? Above

C8 exits between C7 and T1 Cervical motion OA is the motion of the occipital condyles on the

atlas, C1 5 0% True

The primary motion of the OA is flexion and extension o This accounts for % of flexion and extension of the C-spine AA is the motion of C1 on

T/FSidebending and Rotation occur to OPPOSITE sides with either flexion or extension at OA

C2 True

The primary motion of the AA is Rotation (50% of C-spine) o Rotation and sidebending occur to o pposite sides T/FSidebending and Rotation generally occur to SAME side from C2-C7 o C2-4 is mainly rotation o C5-7 is mainly

s idebending y ou sidebend left s idebent left

When you translate the occiput on the atlas to the right If it is restricted in left translation, the dysfunction is

A right deep sulcus indicates s idebent left o Why is it deep? Left occipital sidebending separates the right occipital condyle and atlas making the sulci feel deeper o If its sidebent left, it must be rotated right To test rotation at the AA joint, you must first flex the neck 45 degrees o Why? Eliminate rotation from C2-C7 To test sidebending from C2-7, you must An acute injury to the C spine is best treated with

p ush laterally on the articular pillars i ndirect fascial techniques or counterstrain first

Cervical foraminal stenosis results in n eck pain radiating into the UE, dull ache, shooting pain or paresthesias, paraspinal muscle spasm, posterior and anterior cervical tenderpoints, osteophyte formation and degenerative joint changes o Recommended OMT myofascial release, counterstrain, FPR

THORAX What is the rule of 3s? o T1-3, T12 o T4-6, T11

SP at level of corresponding TP

SP halfway bw corresponding TP and next TP o T7-9, T10 SP at NEXT TP Must know landmarks: o Spine of scapula T3 o Inferior angle of scapula T7
o o o o o Sternal notch Nipple Umbilicus Iliac crest

T2 T4/5 space T4 dermatome T10 dermatome, L3/4 disk L4 rotation

though

Angle of Louis, sternal angle

RIBS

Main motion of the thoracic spine o Lower thoracics are better at Motion is limited by Innervation of diaphragm

flexion/extension

ribcage d iaphragm C3,4,5

The primary muscle of inspiration

Other muscles involved in inspiration external and internal intercostals (elevate ribs and prevent retractions) o Secondary muscles Scalenes, pec minor, serratus anterior and posterior, quadratus lumborum, and Lats What are the components of a typical rib? Tubercle, head, neck, angle, shaft o How many articulations? 3 - 2 w/ corresponding vertebra and 1 w/ vertebra directly above o What are the typical ribs? 3 -10 True ribs False ribs Floating ribs

1 -7 8 -10 1 1,12

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

Rib 1 Ribs 11,12

Rib 2

Upper ribs, 1-5, have primarily o Plane and axis

p ump-handle b ucket-handle

s agittal plane, horizontal axis

Middle ribs, 6-10, have primarily motion o Plane and axis coronal plane, AP axis

Lower ribs, 11 and 12, have primarily motion caliper o Plane and axis h orizontal plane, vertical axis When a rib is stuck up in inhalation, it is an o This is an restriction o o o There is pain upon dysfunction

i nhalation

exhalation
the dysfunctional inhaled rib

exhalation ABOVE b ottom rib (key rib) i nhalation BELOW

There is a narrowing of the intercostal space When there is an elevated group of ribs, you treat the

When a rib is stuck down in exhalation, it is an restriction o This is an dysfunction exhalation o There is pain upon i nhalation o o There is a narrowing of the intercostal space

the dysfunctional exhaled rib

When there is a depressed group of ribs, you treat the t op rib (key rib) Remember- BITE (bottom rib- inspiration dysfx, top rib- exhalation dysfx) Muscles of exhalation w/ their corresponding rib: o Rib 1 anterior and middle scalenes o Rib 2 p osterior scalene o o Ribs 3-5

p ectoralis minor

Ribs 6-9 s erratus anterior o Ribs 10-12 l atissimus dorsi LUMBAR SPINE The posterior longitudinal ligament (PLL) begins to as it runs down the posterior aspect of the vertebral body n arrow o Due to its narrowing, the posteriolateral aspect of the intervertebral disc is weak, making the lumbar spine more susceptible to d isc herniations L4 nerve root exits the spinal column bw L4 and L5 Lumbar nerve roots become as they approach lower segments l onger o This causes the nerve roots to exit just the intervertebral disc ABOVE Important muscles erector spinae, multifidus and rotators, quadratus lumborum, and iliopsoas o Erector spinae muscles I like spaghetti Illiocostalis, spinalis, longissimus o Iliopsoas = muscle + muscle p soas major + iliacus Origin Insertion Action

T12-L5 vertebral bodies l esser trochanter of femur 1 * Hip FLEXOR p elvic side shift, positive Thomas test, and a SD of an upper lumbar Sagittal Coronal zygopophyseal/facet tropism Sacralization Lumbarization

Commonly seen w/ iliopsoas SD segment Facets are aligned backwards and medial in what plane? Facet tropism causes the facets to align in what plane? o Most common anomaly in the L spine Failure of fusion of S1 with the rest of the sacrum

A bony deformity in which 1 or both of the TPs of L5 articulate w/ the sacrum

Congenital anomaly, defect in closure of lamina of vertebral segment (s) s pina bifida o No herniation through the defect, patch of hair present s pina bifida occulta o Herniation of meninges through defect s pina bifida meningocele o Herniation of meninges and nerve roots through defect

s pina bifida meninogomyelocele

Major motion of lumbar spine

flexion and extension

Fergusons angle (lumbosacral angle) is usually 2 5-35 degrees o Angle is formed by intersection of horizontal line and line of inclination of sacrum Acute causes of low back pain fx, disc herniation, infection, or referred pain Is chronic or acute low back pain more common?

CHRONIC

A lumbar SD leads to achy pain or muscle spasms in the 98% of herniations occur bw

l ow back, butt, or posterior lateral thigh L4

L4,L5 or L5,S1

A nucleus pulposus herniation bw L3 and L4 affects what nerve root?

OMT options i nitially indirect, then direct o NO HVLA! o Weakness and decreased reflexes are associated w/ the affected nerve root Psoas syndrome is caused by p rolonged positions that shorten the psoas flexion contracture of the iliopsoas o o o Organic causes of psoas syndrome carcinoma of the prostate, salpingitis Low back pain sometimes radiates to the

appendicitis, sigmoid colon dysfx, ureteral calculi, ureter dysfx, metastatic g roin

What are some signs present? Inc pain when standing or walking, + Thomas test, tenderpoint medial to ASIS, Type II dysfx at L1/L2, positive pelvic shift test to contralateral side, sacral torsion, contralateral piriformis spasm o OMT options i ce on acute spasm, counterstrain to anterior TP, then ME or HVLA to high lumbar dysfx, dont stretch acute spasm, only chronic! Narrowing of the spinal canal or intervertebral foramina s pinal stenosis o Degenerative changes causing pressure on the nerve roots include h ypertrophy of facet joints, Ca2+ deposits w/in the ligamentum flavum and PLL, loss of intervertebral disc height o Besides OMT, what other treatments are recommended? PT, NSAIDs or low dose tapering steroids Anterior displacement of 1 vertebrae in relation to the 1 below o Often occurs at L4 or L5 o o o o Usually due to fatigue fractures in the

s pondylolisthesis

p ars interarticularis

Symptoms s tiffed-legged, short-stride, waddling type gait, positive vertebral step-off sign (obvious forward displacement while palpating the SPs) Must diagnose w/ which X-ray view? Lateral view Goal of trmt

reduce lumbar lordosis and SD (HVLA is contraindicated!) Oblique view s pondylosis p ressure on the nerve roots of the cauda equina due to massive central disc herniation Sharp low back pain

Defect in pars interarticularis WITHOUT anterior displacement of the vertebral body Spondylolysis o Upon X-ray, the fx in the pars interarticularis looks like a collar on the neck of the Scotty dog o Must diagnose w/ which X-ray view? Degenerative changes w/in the intervertebral disc and Ankylosing of adjacent vertebral bodies Cauda equina syndrome results from o Location and quality of pain o Symptoms

s addle anesthesia, dec DTRs, dec rectal sphincter tone, and low of bowel and bladder control

o T/FSurgery is necessary to decompress the cauda equina True SCOLIOSIS AND SHORT LEG SYNDROME Lateral deviation of the spine is known as s coliosis (or rotoscoliosis) Who is more likely to get scoliosis, males or females? Females, 4:1 o What % actually develops symptoms?

1 0%

Scoliosis is named for the convexity of the curve, so sidebent left is Dextroscoliosis (dextro = right) o And if it is sidebent right Levoscoliosis (levo=left) There are 2 types of scoliotic curves: o Spinal curve that is fixed and inflexible, doesnt correct w/ sidebending to opposite side Structural Curve o Spinal curve that is flexible and partially/completely corrected w/ sidebending to opposite side, may progress to structural curve Functional Curve What age group should be screened for scoliosis?

1 0-15 years old

What do you use to measure the degree of scoliosis? Cobb Angle o Draw horizontal lines from most extremely deviated vertebral bodies, and perpendicular lines from these horizontal lines, cobb angle is created at intersection of perpendicular lines o Mild scoliosis 5 -15 degrees Treatment musculature Moderate scoliosis o Treatment Severe scoliosis

PT, Konstancin exercises, and OMT improve flexibility and strengthen trunk and abdominal Add brace in addition to exercises above

2 0-45 degrees >50 degrees >50 degrees >75 degrees s urgery

At what angle is respiratory function compromised? How about CV function? Treatment

Most common cause of scoliosis i diopathic o Other causes congenital, neuromuscular weakness or spasticity, and acquired (tumor/infection/osteomalacia/psoas syndrome/short leg syndrome) An anatomical OR functional leg length discrepancy s hort leg syndrome (SLS)

Most common cause of anatomical leg length discrepancy If 1 leg only appears shorter than the other, its

h ip replacement

functional

What are some ways the body compensates? s acral base unleveling (base lowers on side of short leg), lumbar vertebra sidebend and rotate (SB away, rotate toward short leg), innominate rotation (anterior on short leg side, posterior on long leg side), and an increase in Fergusons (lumbosacral) angle by 2-3 degrees Treatment OMT to decrease SD but if doesnt work, must consider a heel lift o Rules of the heel lift apply to short leg, only lift to 50-75% of the discrepancy UNLESS the cause was acute like a hip fx or prosthesis, then do full length; o 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 outside o Max possible heel lift 1 /2 SACRUM AND INNOMINATES 3 bones fused to make up innominate i lium, ischium, and pubis S1 is referred to as the s acral promontory The most cephalad portion of the sacrum is known as the The sacral sulci are located

s acral base s acral apex

The most caudad portion of the sacrum that articulates w/ the coccyx

s uperiorly and laterally to S1 i nferiorly and laterally

The inferior lateral angles (ILAs) are located

The 3 articulations of the innominates w/ the femur at the acetabulum, the sacrum at the SI joint, and the pubic bones at the pubic symphysis True pelvic ligaments (sacroiliac ligaments) anterior, posterior, and interosseous ligaments that surround and stabilize the SI joint Accessory pelvic ligaments: o Originates at ILA and attaches to ischial tuberosity s acrotuberous ligament o Originates at sacrum and attaches to ischial spines s acrospinous ligament o o Originates at TPs of L4 and L5 and attaches to medial side of iliac crest Which ligament divides the greater and lesser sciatic foramen?

i liolumbar ligament Sacrospinous ligament

Primary pelvic muscles

l evator ani and coccygeus

Secondary pelvic muscles i liopsoas, obturator internus, piriformis o Piriformis innervation and action S1 and S2; external rotation, thigh extension, and abduction of thigh when hip flexed o Why important? 1 1% of population have sciatic nerve run through belly of piriformis, so piriformis hypertonicity leads to buttock pain that radiates down the thigh The innominates rotate about the axis of the sacrum i nferior transverse Respiratory motion occurs at the axis of the sacrum s uperior transverse, ~S2 o During inhalation, the sacral base moves p osterior (sacral extension) o o o During exhalation, the sacral base moves

anterior counternutates n utates (N = Nod anteriorly) middle transverse anteriorly s acrotuberous ligament

During craniosacral flexion, the sacral base moves posteriorly or During craniosacral extension, the sacral base moves anteriorly or

Postural motion occurs about the axis of the sacrum o When person bends forward, the sacral base moves o

What ligament becomes taut in terminal flexion causing the base to move posteriorly?

Dynamic motion, that which occurs during ambulation, engages the 2 sacral axes o blique sacral axis is o While stepping forward with the R leg and still bearing weight on the L, the engaged? Left sacral axis SD of the innominate The side of the positive standing flexion test is on the side as the dysfx? SAME The 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 o Cause t ight quadriceps ASIS superior, PSIS inferior, medial malleolus superior, shorter leg ipsilaterally Posterior Innominate o Cause t ight hamstrings ASIS and PSIS superior, pubic rami superior, shorter leg ipsilaterally Superior Shear o Cause

fall on ipsilateral buttock or a mis-step Inferior Shear

ASIS and PSIS inferior, pubic rami inferior, longer leg ipsilaterally ASIS and PSIS level, pubic bone superior Superior PUBIC shear o Cause t rauma or tight rectus abdominus muscle ASIS and PSIS level, pubic bone inferior Inferior PUBIC shear o Cause t rauma or tight adductors

ASIS medial, PSIS lateral, ischial tuberosity lateral, distance bw ASIS and umbilicus shortened Innominate Inflare ASIS lateral, PSIS medial, ischial tuberosity medial, distance bw ASIS and umbilicus longer i nnominate Outflare SD of the sacrum Sacral torsion is related to rotation about the sacral axes along w/ SD at L5 OBLIQUE o the axis is named for the side of the pole it runs through s uperior when naming sacral dysfx, the 1st letter describes rotation about the vertical axis, the 2 letter describes rotation about the oblique axis the seated flexion test is positive on the side of the oblique axis OPPOSITE o BUT, it is positive on the side as a transverse axis dysfunction SAME o What 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 dysfunction A spring test is needed to confirm whether the torsion is forward or backward, or if its a flexion or extension dysfx o Positive spring test (i.e. sacrum moved posteriorly) b ackward torsion or extension dysfx PPP positive, painful, posterior o Negative spring test, this means it does spring (i.e. sacrum moved anteriorly) o
nd

forward torsion or flexion dysfx

A lumbosacral spring test is positive if the sacral base has moved rotation in L5 is the rotation of the sacrum o If L5 is rotated L, the sacrum must be

p osterior

OPPOSITE R on R on R on L TOWARDS forward (L on L , R on R) b ackward (L on R, R on L)

sidebending at L5 is the oblique axis engaged in sacral torsion o if L5 is SB R, the sacrum must be either L on R or R on R o o if L5 follows a Type I dysfunction, sacral torsion is more likely to be if L5 follows a Type II dysfunction, sacral torsion is more likely to be EX: L5 F RRSR EX: L5 N RLSR

L on R

R on R If both L5 and the sacrum have a dysfx, which one do you treat first? L5 Name the dysfx: Deep right sulcus, Posterior left ILA, - spring test, + right seated flexion test o L5 diagnosis L5 N RRSL Deep left sulcus, posterior right ILA, - spring test, + left seated flexion test
o L5 diagnosis

L on L R on R R on L L on R

L5 N RLSR

Shallow right sulcus, posterior right ILA, + spring test, + right seated flexion test o L5 diagnosis L5 F/E RLSL Shallow left sulcus, posterior left ILA, + spring test, + left seated flexion test o L5 diagnosis L5 F/E RRSR

Deep right and left sulci, ILAs both shallow, springing at base present, not apex b ilateral sacral flexion o FALSE negative seated flexion test present b/c both SI joints are equally asymmetric o Bilateral sacral flexion is a common dysfunction in the p ost-partum pt Shallow left and right sulci, ILAs both deep, springing at apex, NOT base o FALSE negative seated flexion test Deep left sulcus, posterior left ILA, - spring test, + left seated flexion test Shallow left sulcus, anterior left ILA, + spring test, + left seated flexion test

b ilateral sacral extension Unilateral sacral flexion on left u nilateral sacral extension on left

Deep left sulcus, posterior left ILA, + spring test, + right seated flexion test u nilateral sacral extension on right Shallow left sulcus, anterior left ILA, - spring test, + right seated flexion test u nilateral sacral flexion on right OMM Chapter 7 Review Only bone connecting the upper extremity to axial spine? Clavicle Name 4 joints of shoulder? jt) -

Scapulothoracic (pseudo
Acromioclavicular, Sternoclavicular

Glenohumeral Supraspinatus-ABduction Infraspinatus-Ext rotation Teres minor-Ext Rotation Subscapularis- Int Rotation Deltoid Lat dorsi, Teres major, Post Deltoid Pec Major, Lats Inf. Spinatus, teres minor Subscapularis

Name 4 rotator cuff muscles + function?

Primary shoulder flexor and ABductor? Primary shoulder extensors? Primary shoulder Adductors? Primary shoulder Ext Rotators? Primary shoulder Int Rotators?

Subclavian artery passes b/t what 2 muscles? When does Axillary artery become brachial artery?

Ant/Middle scalene Inf. border teres minor Deep palmer arterial arch Superficial palmer art. Arch C5-T1 Roots, Trunks, Divisions, Cords, Branches C5 Glenohumeral Scapulothoracic Int +Ext Rotation Restriction Clavicle Acromioclavicular, Coracoclavicular, Subclavian a., Subclavian v., Brachial Plexus 1 . B/t anterior and middle scalene 2 . B/t clavicle and 1 rib
st

The radial artery eventually forms what artery of hand? The ulnar artery eventually forms what artery of the hand? Brachial Plexus (BP) is derived from what nerve root levels? Correct sequence of nerve divisions leaving BP? Nerve root for dorsal scapular nerve?

The first 120 deg. shoulder Abduction occurs @ what jt? The final 60 deg. Shoulder Abduction occurs @ what jt? Most common shoulder somatic dysfunction? Most commonly fractured bone in the body?

Acromioclavicular jt is stabilized by what 3 ligaments? Coracoacromial 3 structures of compressed in Thoracic Outlet Syndrome? Name 3 places compression occurs in TOS?

3 . B/t pec minor and upper ribs

Name 2 common causes of TOS? Test used Diagnose of TOS b/w scalenes?

Cervical rib, excess tension on scalene Adsons Supraspinatus tendonitis Bicipital tenosynovitis Supraspinatus Drop arm test Adhesive Capsulitis/Frozen Shoulder Anterior and inferior Long Thoracic n.; serratus anterior Erbs Palsy; C5-C6 Childbirth Radial nerve Radial nerve Wrist drop Crutch Palsy; Saturday Night Palsy Scaphoid, lunate, Triquetrum, pisiform, trapezium, Scaphoid Snuff box Five Medial epicondyle Flexor carpi ulnaris Lateral epicondyle Radial Nerve Biceps brachii Musculocutaneous Pronator teres, Pronator quadrates, median nerve Median nerve (except add pollicis brev) Ulnar nerve Median Ulnar Distal interphalangeal jt DIP Cubitus Valgus (ABduction ulna) Cubitus Varus (ADduction ulna) Posterior Anterior Parasthesia thumb+1 2 digits
st

Excessive tenderness at the tip of the acromion may indicate? Tenderness over bicipital groove w/ pain during flexion? Most common muscle injured in rotator cuff tear? Test used diagnose rotator cuff tear of supraspinatus? Condition caused by prolonged immobility of the shoulder? Most common shoulder dislocation?

What nerve and muscle associated with winged scapula? Most common brachial plexus injury and its nerve roots? When does the above palsy usually occur? Nerve injured in mid-shaft humeral fracture? Most common BP nerve injured in trauma? Most common symptom of radial nerve deficit? Name 2 other ways get radial nerve palsys? Carpals? trapezoid, capitates, hamate Most common carpal fracture? Where can scaphoid be palpated? How many metacarpals are there?

Flexors of wrist and hand originate where? Extensors of wrist and hand originate where? Extensors of wrist are all innervated by what nerve? Primary supinator of wrist?

All wrist flexors are innervated by median nerve except?

The above muscle is innervated by what nerve? Muscles of thenar eminence innervated by? Muscles of hypothenar eminence innervated by? First and second lumbricals innervated by what? Third and fourth lumbricals innervated by what? Where does flexor digitorum profundus attach? Elbow carrying angle > 15 degrees indicates? Elbow carrying angle <3 degrees indicates? Where is head of radius in pronation? Where is head of radius in supination? Major symptom carpal tunnel? Three tests carpal tunnel? Lateral epicondylitis? Medial epicondylitis?

Name the 2 primary muscles pronation, and innervations?

Tinels, Phalen, Prayer tests Tennis Elbow Golfers elbow

Claw hand results from injury to what nerve? Ape Hand results from injury to what nerve?

Median Median and ulnar Dupuytrens Contracture Femur, tibia, fibula, patella Gluteus maximus Iliopsoas Quads Semi-membranosus, semi-tendinosus Capitis femoris Iliofemoral, Ischiofemoral, Pubofemoral Anteriorly Posteriorly Anterior Cruciate Lig Post Cruciate Lig Medial collateral, lateral collateral Medial Meniscus Dorsi flexion, eversion, abduction Plantar flexion, inversion, adduction Anterior Posterior L2-L4 Quads, iliacus, Sartorius and pectineus

Flexion contracture of palmar fascia? OMM Chapter 8 Review Name the 4 bones of knee? Primary hip extensor? Primary hip flexor? Primary knee extensor? Primary knee flexor? 3 ligaments of hip joint?

Name ligament attaches head femur to acetabulum? Head femur glides what direction in ext. rotation? Head of femur glides which direction in int. rotation? Ligament prevents anterior translation of tibia on femur? Ligament that prevents post. translation of tibia on femur? Lateral stabilizers of the knee?

What structure is associated with the medial collateral lig? What 3 motions associated with ankle pronation? What 3 motions associated with ankle supination? Fibular head glides what direction in pronation? Fibular head glides what direction in supination? Nerve root levels for femoral nerve? Muscles innervated by femoral n.?

Sciatic nerve courses through what foramen? Sciatic nerve lies inferior to what muscle (usually)? Name 2 branches sciatic n., and muscles innervate?

Greater Sciatic Foramen Piriformis Tibial n. Hamstrings (except SH Biceps) Plantar and Toe Flexors Peroneal n. Short head Biceps fem, Dorsi flexors & Toe Ext Normal = 120 135 degrees) Coxa vara Coxa valga Increased Q-angle (Genu Valgum) Decreased Q-angle (Genu Varum) Female Common fibular n. Muscle imbalance - Strong vastus lateralis, weak Anterior MCL, ACL and medial meniscus Talus, calcaneus, navicular cuboid 3 cuneiforms, 5 metatarsals, 14 phalanges Dorsiflexion Talus, navicular, cuneiforms, 1-3 metatarsals Calcaneus, cuboid, 4-5 metatarsals Transverse Arch (navicular, cuneiforms, cuboid) Anterior talofibular, Calcano-fibular, posterior talofibular Anterior Talo-Fibular due to inversion/supination Deltoid-prevents eversion/pronation Spring Lig calcaneonavicular lig CNS, CSF, Dura, cranial bones and sacrum 1 0-14 cycles/min Transient Synovitis of the hip (aka toxic

Hip Angulation of neck and shaft femur? Hip neck/shaft angle <120 degrees called what?

Hip neck/shaft angle >135 degrees is called what? Diagnosis if patient appears knock kneed? Diagnosis if patient appears bow legged? Which sex has a wider Q-angle?

Fracture of fibular head may sever what nerve?

Cause of patella-femoral tracking syndrome? vastus medialis MCC of limp w/ hip pain in kids under 10 yo? synovitis) Most common compartment affected by compartment syndrome? ODonahues triad aka terrible triad knee injury? Bones of the foot?

The ankle is more stable in what position? Bones of medial longitudinal arch? Bones of lateral longitudinal arch? Most arch dysfunction occurs which arch? Name 3 ligamentous lateral stabilizers ankle? Most common ligament injured in foot? Medial ankle ligament?

Ligament that strengthens medial longitudinal arch?

OMM Chapter 9 Review Name 5 components of the Primary Respiratory Mechanism? Rate of the Cranial Rhythmic Impulse (CRI)? Three factors that decrease CRI?

Stress, Depression, Chronic fatigue/

infection -

Exercise, Fever, Following OMT Foramen Magnum, C2, C3 and S2 Reciprocal Tension Membrane Transverse axis Sphenobasilar Synchondrosis External rotation Wider, decrease AP diameter Counternutation (post) Sphenoid, occiput, ethmoid, vomer Internal Rotation Nutation (anterior) Narrower, increase AP diameter Torsion Left Torsion SBR Caudad Cephalad Superior Vertical Strain Inferior Vertical Strain Lateral strain Compression Decreases CRI CN III, IV, V1, VI CN IX, X, XI Vagal dysfunction Tinnitus, Vertigo, deafness Suckling dysfunction Increase amplitude CRI Index-Greater wing Sphenoid Middle-temporal Ring- mastoid temporal Little-sq. occiput

Three factors that increase CRI? Dura has what cephalad attachments? Sacral rocking occurs about what axis?

aka for the meninges acting as an inelastic rope? Articulation of sphenoid with the occiput? Flexion has what affect on shape/size cranium? Movement at the sacrum during flexion? Name 4 midline bones of cranium? Movement at the sacrum during extension? Extension has what affect on cranial shape/size?

During flexion, paired cranial bones undergo what motion?

During extension, paired cranial bones undergo what motion?

Sphenoid rotates one direction; occiput rotates opposite on AP axis? If left greater wing sphenoid is superior, what type torsion? Extension lesion occurs when SBS deviates which direction? Flexion lesion occurs when SBS deviates which direction? If sphenoid deviates superior to occiput? If sphenoid deviates inferior to occiput? If sphenoid deviates to the R or L of occiput? Occurs when sphenoid and occiput pushed together? Compression strain SBS effects CRI how? Which cranial nerves exit jugular foramen? OA, AA and C2 can cause what dysfunction? Dysfunction CN VIII can cause what? Primary goal of CV4 Bulb Decompression? Finger placement during cranial vault holding? Which cranial nerves exit through superior orbital fissure? When both sphenoid and occiput rotate in SAME direction with sidebending?

CN dysfunction CN IX, X or XI in a newborn may cause?

Name some indications for craniosacral Tx?

After childbirth, trauma, Dentistry Skull Fx, Intracranial bleed, increased cranial TBI, Hx seizures or dystonia Facilitation Segmental facilitation Afferent limb, central (spinal) limb, efferent Higher brain centers, Viscera, Somatic Afferents TART Viscero-somatic and Somato-visceral DEC goblet cells, enhance thin secretion INC goblet cells, produce thick secretion Contracts for near vision Relaxes for far vision Vagus Vagus Pelvic Splanchnic Vagus Pelvic Splanchnic T1-L2

Absolute contraindication for craniosacral Tx? pressure Relative contraindications for craniosacral Tx? 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? Facilitation at an individual spinal level?

3 components of Spinal Reflex? limb Spinal cord segment can receive input from what 3 areas? A facilitated segment can lead to what?

Two most common types facilitation reflex? *Review Table 10.1 on pg. 102 for autonomic function review* Affect of parasympathetics on respiratory epithelium? Affect of sympathetic on respiratory epithelium? Affect of parasympathetics on lens of eye?

Affect of sympathetics on lens of eye? *Review Table 10.2 on pg. 104 for sympathetic review* All parasympathetics for viscera above diaphragm innervated by what? Parasympathetics for ascending and transverse colon? Parasympathetics do descending and rectosigmoid colon? Ovaries and testes get parasympathetics from where? Roots of sympathetic nervous system?

All other reproductive structures get parasympathetics from where?

Sympathetics to head and neck? Sympathetics to heart? Sympathetics to lungs? Sympathetics to entire GI?

T1-T4 T1-T5 T2-T7 T5-L2 Ligament of Treitz Splenic flexure T5-T9 T10-T11 T12-L2 T2-T8 1 . Normalize (decrease) sympathetic activity 2 . Improve lymph return 3. Improves inhalation for more effective thoracic pressure Spinal/rib fracture; recent spinal surgery Reduce hypersympathetic activity Abd. aneurysm, open surgical wound III, VII, IX, X Free parasympathetic responses CN IX, X by

What landmark divides the duodenum to jejunum? Sympathetic innervations above ligament of Treitz?

What landmark divides the transverse colon from descending?

Sympathetic innervations b/t lig. Treitz and splenic flexure? Sympathetic innervations after splenic flexure? Sympathetics to upper extremities? Name 3 purposes of rib raising?

Contraindications for rib raising?

Anterior:

Purpose of inhibition of Celiac, Sup mesenteric, Inf. Mesenteric ganglion? Contraindication for abdominal inhibition techniques? Cranial Nerves with parasympathetics?

Purpose of condylar decompression? opening jugular foramen Condylar compression causes what problem in newborns?

Suckling problems Normalize hyperparasympathetic L Local infections or incisions B/t spinous and transverse processes Viscera-somatic reflex Tip R 12 rib
th

Name two purposes of sacral inhibition? colon/pelvis; reduce labor pain due to cervical dilation Contraindication for sacral inhibition? OMM Chapter 11 Review Posteriorly, Chapmans points generally located where? Chapmans pts generally reflect what type reflex? Where is Chapmans pt appendix?

Where are Ant & Post Chapmans pt (CP) adrenals?

Ant- 2 sup, 1 lateral umbilicus Post B/t SP &TP of T11-T12 Ant- 1 sup, 1 lateral umbilicus Post- B/t SP & TP of T12-L1 Periumbilical region Lateral thigh within Iliotibial band (see

Where are Ant & Post CP kidneys? Where is CP for Bladder? Where is CP for Colon? figure) Chapmans Points: Colon

Chapmans Points: Adrenals, Kidney, Bladder

Posterior:

On exam, a trigger point will elicit pain where? elsewhere

At site compressed AND may refer pain Viscero-somatic, somato-visceral and or somatoTender pts do NOT refer pain True Direct

Trigger points may represent what types of reflex? somatic Difference b/t Trigger point and Tenderpoint?

OMM Chapter 12 Review T/F - Myofascial release can be direct, indirect or passive? -

Which type of treatment does physician move tissue into restrictive barrier?

Which type of treatment does physician move tissue away restrictive barrier? Two forces physician may use to fine tune myofascial release?

Indirect Twisting or transverse forces Respiration, eye movement or muscle 1 . Palpate Restriction 2 . Apply Compression 3 . Add twisting or transverse force 4 . Use enhancers 5 . Await Release

Name 3 enhancers used to help induce release during myofascial release? contraction Five steps of Myofascial Release?

Name 2 goals myofascial release? Improve lymphatic flow Of the 4 diaphragms in body, which is most important in terms of lymph flow? Name 2 Diaphragm release techniques? diaphragm release Name 4 locations of Common Compensatory Patterns? thoracocolumbar jnx and lumbosacral jnx Describe the common Compensatory Pattern in 80% individuals?

Restore functional balance and Abdominal diaphragm Thoracic Inlet & Thoracoabdominal OA junction, Cervicothoracic jnx,

OA-Left Cervicothoracic- Right Thoracocolumbar-Left Lumbosacral-Right

OMM Chapter 13 Review Lymph from heart and lobes of lungs (except upper L lobe) drains into what?

Right Duct Sibsons Fascia R brachiocephalic v. J unction b/t L Internal Carotid Aortic hiatus L2 Lymphocytes Sympathetics OMT, exercise, Contraction of Smooth muscle contraction, -Supraclavicular - Posterior Axillary Fold -Epigastric Area - Inguinal Area - Popliteal area & Achilles area

Thoracic duct traverses through what fascia of the thoracic inlet? Right (Minor) duct drains into what?

Left (Main) duct drains into what? and Subclavian v. The thoracic duct travels through which diaphragmatic opening? At what level is the cistern chili? The main cells found in lymph?

Lymphatics are primarily innervated by what?

Name 5 extrinsic forces affect lymph flow? muscles, Pulsation adjacent arteries, respiratory motion Name2 intrinsic forces affect lymph flow? interstitial fluid pressure Lymphatic Dysfunction may exhibit fullness/bogginess in what areas?

List 10 techniques listed in book used Tx lymphatic dysfunction? Chapmans Reflexes; Thoracic and Pedal Pump; Cranial Techniques- Dura sinuses; ME Sibsons fascia; Rib Raising; Splenic/Liver Pump; Facial Sinus pressure; Anterior Cervical mobilization; Extremity Pump Lymphatic Tx of the Thoracic Inlet acts on what tissue structure? Sibsons Fascia

How does rib raising help lymph flow? hypersympathetics How does redoming the diaphragm help lymph flow? pressure gradients List some common illness indications for lymphatic treatments? GI disorders, cirrhosis, hepatitis Relative contraindications lymph Tx? fever, Abscess or localized infection, Certain Carcinomas OMT REVIEW CH 14- 18

Improves respiration; normalizes Optimizes thoracoabdominal URI, Bronchitis, pneumonia, Osseous Fx, Bacterial infections with

CH 14: COUNTERSTRAIN and FPR COUNTERSTRAIN passive indirect technique in which the tissue is positioned at a point of balance or ease away from the restrictive barrier JONES Eliminates TENDERPOINTS o Small tense edematous areas of tenderness about the size of a fingertip o Typical locations bony attachments of tendons, ligaments or belly of muscle o DO NOT radiate pain (trigger points do) Basic steps 1. Locate Tenderpoint (TP) b. Can be at the area of CC or can be induced from elsewhere

i. Ex- psoas spasm (tenderpoint found here) causes low back pain (CC) Palpate the TP a. To determine if significant compare to other side b. If multiple areas treat most tender first 3. Place patient in position of comfort a. MAINTAIN light contact, shorten the muscle being treated b. REAPPLY firm pressure to check reduction of tenderness i. Fine tune til 70% reduced c. MAVERICK POINT - 5% of TPs, will not improve with tx, these are treated by positioning pt into position opposite of what is typically used i. Most in cervical spine 4. Pt completely relaxed, maintain position of comfort for 90 seconds 5. Slow return to neutral - First few degrees are most important 6. RECHECK with firm pressure a. No more than 30% of tenderness should remain TECHNIQUES o CERVICAL spine 1. Anterior TPs 1. Slightly anterior to or on the most lateral aspect of the lateral masses 2. Tx position Flex - SARA sidebend away and rotate away 3. MAVERICK point C7 o 2-3 cm lateral to medial end of clavicle at lateral attachment of SCM muscle o Tx position Flex STRAw sidebend towards and rotate away 4. C-spine has greatest number of Maverick points 2. Posterior TPs 1. At tip of spinous process or on lateral sides of SPs 2. Tx position Extend SARA o C3 flexion and STRAw 3. MAVERICK point Inion o At inion or just below o Tx position Marked flexion o THORACIC spine 1. Anterior 1. T1-6 at midline of sternum at attachment of corresponding ribs 2. T7-12 in rectus abdominus muscle 1 inch lateral to midline on right or left 3. Tx position Flex and some SARA 2. Posterior 1. On either side of SP or on transverse process 2. Tx position Extend SARA o RIBS 1. *TX- MAINTAIN FOR 120 SECONDS 2. Anterior 1. Associated with depressed ribs (exhalation SD or inhalation restriction) 2. Rib 1 just below medial end of clavicle 3. Rib 2 6-8 cm lateral to sternum on rib 2 4. Ribs 3-6 along mid-axillary line on corresponding rib 5. Tx position o Rib 1 and 2 Flex head, SB and R towards o Ribs 3-6 SB and R thorax towards, slight flexion 3. Posterior 1. Associated with elevated ribs (inhalation SD or exhalation restriction) 2. Angle of corresponding rib 3. Tx position SARA, minimal flexion o LUMBAR spine 1. Anterior 1. L1 medial to ASIS 2. L2-4 on ASIS 3. **L5- 1 cm lateral to pubic Symphysis on superior ramus 4. Tx position pt supine, hips and knees flexed and markedly rotated away 2. Posterior 1. On either side of SP or on transverse process o L3-4 can be on iliac crest o L5 can be on PSIS 2. Tx position pt prone, extended SB away (R can be either to or away) 3. MAVERICK point o LOWER POLE 5 TH LUMBAR Caudad to PSIS as much as one cm Tx pt prone, hip and knee flexed, leg internally rotated and adducted o PELVIS 1. Many of them, most important 1. Iliacus o 7cm medial to ASIS o Tx- pt supine with hip flexed and externally rotated 2. MAVERICK point o Piriformis In piriformis, 7 cm medial to and slightly cephalad to greater trochanter Tx pt prone, hip and knees flexed, thigh abducted and externally rotated 2.

FPR (FACILITATED POSITIONAL RELEASE) Indirect myofascial release treatment SCHIOWITZ Used to treat : o Superficial muscles o Deep intervertebral muscles to influence vertebral motion Basic Steps o Superficial Muscle Tx 1. Pt in neutral - doc straightens AP curvature of spine 2. Doc applies facilitating force compression or traction 3. Doc shortens muscle to be treated 4. Hold for 3-4 secs 5. Release and reevaluate o Deep intervertebral muscle Tx Dx C5 E SRRR 1. Pt supine, head beyond edge of table resting on pillow in docs lap 2. Pt in neutral straighten cervical lordosis by flexing head slightly 3. Doc applies facilitating force 4. Doc places C5 into E SRRR 5. Hold for 3-4 secs 6. Release and reevaluate

Ch 15: MUSCLE ENERGY Pt actively uses muscles on request, from a precisely controlled position in a specific direction, against a distinctly executed counterforce Can be active direct or active indirect technique (indirect rare) Types of ME o Postisometric relaxation (direct tech) 1. Place pt into restriction ( into barrier) = opposite the diagnosis 2. Then pt contracts against counterforce of doc = isometric contraction 1. Distance bw origin and insertion of muscle stays the same! stretches the internal connective tissues 3. Golgi tendon organ sense this tension in muscle tendons and causes a reflex relaxation of agonist muscle fibers allows doc to stretch to a new barrier 4. EX- biceps is in spasm extend elbow to restriction, have pt flex against resistance for 3-5 sec, relax, repeat o Reciprocal inhibition 1. Contracts antagonist muscles! 1. Sends signals to spinal cord and thru reciprocal inhibition reflex arc the agonist is forced to relax 2. CAN BE DONE DIRECTLY OR INDIRECTLY 3. Direct 1. EX- biceps spasm extend elbow to restriction, have pt contract TRICEPS against resistance 4. Indirect 1. EX- biceps spasm flex elbow away from barrier, have pt contract TRICEPS against resistance o Joint mobilization using muscle force 1. Helps restore normal ROM in a joint using muscle contraction 2. EX contract hip flexors helps pull innominate anterior in a posterior innominate SD o Oculocephalogyric reflex 1. Uses extraocular muscle contraction to effect cervical and truncal muscles o Respiratory assistance 1. Uses pts voluntary respiratory motion 2. Most Rib inhalation SD are treated this way o Crossed extensor reflex 1. Typically used in extremities that are so severely injured or not accessible that direct manipulation is impossible 2. EX- contraction of right biceps produces relaxation of left biceps and contraction of left triceps Typical steps 1. Position joint or bone into the barrier in all planes of motion 2. Tell pt to reverse direction 3. Pt contracts to move joint away from barrier 4. Doc maintains counterforce for 3-5 secs til contraction is perceived at critical articulation (isometric contraction) 5. Doc tells pt to relax, and doc relaxes as well (post isometric relaxation phase) 1. During relaxation Doc takes up slack in joint (passive lengthening) 6. Repeat 3-5 times and recheck Localization o More important than intensity of force Contraindications o Post surgical pts, intensive care pts TECHNIQUES 1. CERVICAL spine pt supine 1. OA R and SB are to OPPOSITE SIDES 2. AA ONLY ROTATION 3. C2-7 R and SB are to SAME SIDE 2. THORACIC spine pt seated 1. UPPER THORACIC (T1-4) ONLY HEAD AND NECK ARE USED 2. LOWER THORACIC (T5-12) OSTEOPATHIC SALUTE 1. Pt places hand behind head on side of ROTATION 3. RIBS pt supine o BITE = Tx bottom rib inhalation SD, Tx top rib in exhalation SD 1. INHALATION SD 1. Place 1 hand on anterior aspect of key rib

4. 5.

Flex pt for pump handle (PH) dysfunction, Sidebend for bucket handle (BH) dysfunction On the dysfunctional rib, push down so tension taken off rib Pt inhales then exhales deeply o For BH dysfunction, pt reaches for knee ON AFFECTED side 5. Pt holds breath at end-expiratory phase for 3-5 sec during which physician adjusts flexion to new restrictive barrier 6. On inhalation, physicians RESISTS inhalation motion of rib (REPEAT 3x) 7. RECHECK! 2. EXHALATION SD 1. Pt places forearm ON affected side across forehead w/ palm up 2. Doc grasps key rib posteriorly at rib angle 3. Pt inhales deeply while doc applies an inferior traction on rib angle 4. Pt needs to hold breath at full inhalation while performing one of the following isometric contractions for 3-5 sec (Repeat 3-5x): o Rib 1: pt raises head directly toward ceiling Anterior and middle scalenes o Rib 2: pt turns head 30 degrees away from dysfunctional side and lifts head toward ceiling Posterior scalene o Ribs 3-5: pt pushes elbow of affected side toward opposite ASIS Pectoralis minor o Ribs 6-9: push arm anterior Serratus anterior o Ribs 10-12: pt adducts arm Latissimus dorsi 12 also quadratus lumborum LUMBAR spine 1. Same steps as lower thoracic spine = osteopathic salute SACRUM 1. Unilateral sacral flexion 1. stuck in exhalation so resistance is during inhalation 2. Pt prone, doc standing on ipsilateral side (side of dysfunction) 3. Caudad hand holds pts leg above knee, slightly internally rotate and abduct it 4. Cephalad hypothenar eminence on pts posterior ILA 5. Ask pt to inhale and hold breath, while doc push anterior on ILA (soresist) 6. Hold 3-5 sec 7. Direct pt to exhale while you resist any posterior inferior movement of sacrum 2. Unilateral sacral extension 1. stuck in inhalation so resistance is during exhalation 2. 3. 4. 5. 6. 7. 3. Pt prone, physician standing on ipsilateral side (side of dysfunction) Caudad hand holds patients leg above knee in internal rotation and slight abduction Cephalad hypothenar eminence on the patients 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

2. 3. 4.

6.

Sacral torsions 1. Forward torsion = LoL or RoR o Pt lies lateral recumbent with side of axis down (second letter) o Have pt rotate down towards the table and hug the table while keeping the hips straight (FORWARD torsion = FACE down) o Flex the hips until you feel motion at the sacral sulci o Bring legs off the table toward you (induces sidebending and engages the axis) o Have pt push UP as you push DOWN o Follow ME protocol 2. Backward torsion = LoR or RoL o Pt lies lateral recumbent with side of axis down (second letter) For LoR lie on Right side, for RoL lie on Left side o Flex hips until feel motion at sacral sulci o Grasp pts bottom arm and pull thru to rotate torso backwards and have them grab table (BACKWARD torsion = BACK down) o Bring both legs off the table towards you (induces SB and engages axis) o Pt pushes UP against you while you push DOWN o Follow ME protocol INNOMINATES 1. Anterior 1. Pt. supine & D.O. on side of dysfunction. 2. Flex lower extremity on side of dysfunction at knee and hip. 3. Put shoulder against pts leg & cup ASIS with cephalad hand & ischial tuberosity with caudad hand. 4. Push knee against my chest. 5. Follow ME protocol 2. Posterior 1. Pt. supine & D.O. on side of S.D. 2. Pt. on edge of table allowing ischial tuberosity on side of dysfunction to fall off edge. - leg hangs freely

7.

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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. 6. Follow ME protocol 3. Pubic shears 1. Superior o Pt. supine and D.O. on dysfunctional side between table and leg. o Stabilize opposite ASIS. o Have pt. scoot laterally until ischial tuberosity at edge of table (dysfunctional side leg hangs off) o Abduct knee to gap symphysis. o Bring knee to opposite ASIS (this will extend and ADDuct) 2. Inferior o Pt. supine and D.O. on side of dysfunction. o Flex lower extremity at knee and hip an ABduct thigh to gap pubic symphysis. o Place knee against chest, cup cephalad hand against ASIS, grasp ischial tuberosity with other hand. o Push knee to opposite foot (this will extend and ADDuct) o Follow ME protocol UPPER EXTREMITIES 1. Posterior radial head = pronation SD, supination restriction 1. Pt seated, and dr standing in front of pt 2. Dr applies a handshake grip or grab wrist on the side to be treated, and places index finger over anterior surface of distal radius 3. Doc applies anterior pressure on the radial head with the pad of the thumb 4. Dr extends elbow within a few degrees of full extension and supinates the pts hand to the restriction 5. Pt is told to pronate their hand (turn hand over) 6. Follow ME protocol 2. Anterior radial head = Supination SD, pronation restriction 1. Dr grasps pts wrist with the hand opposite the dysfx and pronates the arm 2. With other hand apply posterior pressure on radial head 3. Pt is told to supinate their hand (turn it over) while dr resists 4. Follow ME protocol LOWER EXTREMITIES (p143 is wrong) 1. Anterior fibular head 1. Pt prone or supine with knee flexed, place hand on lateral side of pts foot, cupping ankle 2. Plantar flex and invert pts foot to barrier 3. internally rotate tibia 4. Tell pt to dorsiflex, push foot laterally 5. Follow ME protocol 2. Posterior fibular head 1. Pt prone or supine and knee flexed, place hand on lateral side of pts foot, cupping ankle 2. Dorsiflex and evert foot to barrier 3. Externally rotate tibia 4. Tell pt to plantarflex, push foot medially 5. Follow ME protocol 3. 4. 5.

CH 16 HIGH VELOCITY LOW AMPLITUDE (HVLA) Passive, direct technique Position restricted joint against its restrictive barrier a short (low amp) quick (high velocity) thrust is directed to move the joint past the restrictive barrier Aka thrust tech, mobilization with impulse tx Neurophysiologic mechanism 1. Theory 1 thrust forcefully stretches a contracted muscle producing a barrage of afferent impulses from muscle spindles to CNS. CNS sends inhibitory impulses back to muscle 2. Theory 2 - thrust forcefully stretches a contracted muscle pulling on its tendon activating the golgi tendon receptors reflexive relaxation General procedure 1. Move segment to be treated towards its restrictive barrier 2. Pt told to relax usually works best during exhalation phase 3. Doc uses short quick thrust to move thru barrier pop or click may be heard 1. DO NOT back off of restrictive barrier before applying thrust (do not brace yourself) 4. Recheck Indications 1. Treat motion loss in SD (not for pathologic loss) **Contraindications 1. Absolute 1. Osteoporosis 2. Osteomyelitis (and Potts disease) 3. Fractures 4. Bone metastasis 5. Severe RA esp cervical transverse ligament of dens rupture 6. Downs syndrome same as RA 2. Relative 1. Acute whiplash, pregnancy, post surgery, herniated disc, pts on anticoagulants or with hemophilia, vertebral artery ischemia (positive Wallenbergs test)

Complications 1. Minor soreness or symptom exacerbation 2. Major 1. MC vertebral artery injury in neck extension 2. MC low back cauda equina syndrome TECHNIQUES 1. CERVICAL 1. OA 1. Pt supine, doc at head of table 2. MCP at base of occiput 3. Set the pt up opposite the SD 4. Thrust toward the pts opposite eye 5. Recheck 2. AA 1. Only rotation 2. Thumb on fulcrum hand contacts the pts zygomatic process 3. Pt is asked to inhale and exhale, then rotational thrust is applied 3. C2-7 1. Can be treated using a SB or rotatory thrust 2. Rotational thrust o If rotated right, use right hand as fulcrum o If rotated left, use left hand o Then SB into your hand o The thrust is directed towards opposite eye 3. SB thrust o If SB right, use left hand as fulcrum o If SB left, use right hand as fulcrum o Rotate the opposite way o Thrust directed toward pts opposite shoulder 2. THORACICS AND RIBS 1. THORACIC 1. Kirksville krunch o In general doc stands opposite side of rotation with pt supine o Pt crosses arms opposite over adjacent 2. Type II o flexed thrust is toward the floor o extended thrust is directed at the vertebrae below the dysfx and aimed 45 degrees cephalad 3. Type I o Same as flexed, except SB pt away from you 2. RIB 1 Inhalation SD 1. Rib stuck up 2. is the exception on the side that is stuck up, SB toward and rotate away (similar to a cervical hvla) 3. all the other ribs Inhalation or Exhalation SD 1. like Kirksville except thenar eminence goes under posterior rib angle of key rib (BITE) 2. flex torso and slightly SB away, thrust down towards hand 3. LUMBAR (roll) o Used for T10 L5 o Pt can be treated with the TP facing up or down o Ex rotated right can treat in left lateral recumbent (TP up) or right lateral (TP down) o Basic set up o Flex pts leg until palpate motion at joint, straighten bottom leg o Hook top leg in lower legs popliteal fossa 1. TYPE II 1. TRANSVERSE PROCESS UP pull pts inferior arm down 2. TP DOWN pull pts inferior arm up 2. TYPE I 1. TP UP pull pts inferior arm up 2. TP DOWN 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 TECHNIQUES Aka springing techniques or low velocity/moderate amplitude (good if dont like hvla) Direct , increase ROM in a restricted joint using repetitive forces (respiratory coop, and ME can be added) Indications 1. Limited or lost articular motion 2. Need to increase frequency or amplitude of motion of a body region 3. Normalize sympathetic activity (rib raising) Contraindications 1. Repeated hyperrotation of cervical spine in extension may cause vertebral artery damage 2. Acutely inflamed joint esp if from infection or fracture Typical procedure 1. Move affected joint to the limit of all ROM, once barrier is reached slowly and firmly continue to apply gentle force against it 2. Now can add resp coop or ME to increase stretch 3. Return to neutral 4. Repeat several times until no further response is achieved TECHNIQUES -

1.

2.

RIB RAISING 1. Purpose 1. Increase chest wall motion (useful in viral pneumonia) 2. Normalize sympathetic (ganglia lie anterior to rib heads) 3. Improve lymphatic return 2. Procedure can be supine or seated 1. Pt supine, doc seated on one side 2. Doc places fingers under pts thorax with pads of fingers on rib angle 3. Apply gentle traction 4. Raise ribs by pushing upwards with fingertips (use forearm as lever) Spencers (this is DiGiovannas version, different than what is in OMT review) 1. For ppl who have fibrosis and restriction during a period of inactivity (adhesive capsulitis) after an injury 1. Stage 1 o Shoulder extension with elbow flexed 2. Stage 2 o Shoulder flexion with elbow extended 3. Stage 3 o Circumduction with slight compression and elbow flexed Clockwise and counterclockwise 4. Stage 4 o Circumduction with traction and elbow extended Clockwise and counterclockwise 5. Stage 5 o Abduction with elbow flexed o Adduction and external rotation with elbow flexed 6. Stage 6 o Internal rotation with arm abducted, hand behind back 7. Stage 7 o Distraction, stretching tissues, and enhancing fluid drainage with arm extended Fingers interlaced just distal to the acromion process ME- have pt push hand down on your shoulder

CH 18 - SPECIAL TESTS CERVICAL SPINE 1. Spurling test (compression test) 1. What it does narrows the neural foramina nerve root compression referred pain 2. Pt seated, doc extends and SB the C-spine to the side being tested 3. Then pushes down on top of head 4. Positive if pain radiates into ipsilateral arm (distribution can localize nerve root) 2. Wallenbergs test 1. What it does tests vertebral artery insufficiency 2. Pt supine, doc flexes neck and holds it for 10 secs 3. Then extends neck and holds it for 10 secs 4. Do the same thing for rotation to left and right, and rotation to left and right with extension 1. And in any position the doc would attempt to mobilize the c-spine 5. Positive if pt complains of dizziness, visual changes, lightheadedness, eye nystagmus 6. Variation = Underbergs test 1. Neck is backward bent and head fully rotated to either side 2. If develops vascular or neuro symptoms HVLA contraindicated! SHOULDER 1. TOS Tests 1. Adsons test 1. What it does checks for tight scalenes 2. Monitor pts pulse 3. Arm extended at elbow, at shoulder extend, externally rotate, and slightly abduct 4. Pt is told to take a deep breath and turn head toward ipsilateral arm 5. Positive if decreased or absent radial pulse 2. Wrights (aka arm hyperextension test) 1. What it does checks compromise under pec minor at coracoid process 2. Hyperabduct arm above head, with some extension 3. Positive if decreased or absent radial pulse 3. Costoclavicular syndrome test (aka Military posture test) 1. Checks for compromise bw clavicle and first rib 2. Depress and extend the shoulder 3. Positive if decreased or absent radial pulse 2. Apleys scratch test 1. What it does evaluate ROM of shoulder 2. Abduction and external rotation pt reaches behind head and touch opposite shoulder 3. Adduction and internal rotation pt reaches in front of head and touch opposite shoulder 4. Further eval of internal and add pt reaches behind back and touch inferior angle of opposite scapula 3. Drop arm test 1. What it does detects rotator cuff tears 2. Pts abducts shoulder to 90 degrees 3. Told to slowly lower arm 4. Positive pt cant lower arm smoothly, or arm drops to side from 90 4. Speeds test 1. What it does assesses biceps tendon in bicipital groove 2. Pt fully extends elbow and flexes shoulder and supinates forearm

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3. Doc resists flexion 4. Positive tenderness in bicipital groove Yergasons test 1. What it does determines stability of biceps tendon in bicipital groove 2. Pt flexes elbow to 90 while doc grasps elbow with one hand and wrist with other 3. Doc pulls down on pts elbow and externally rotates the forearm as the pt resists motion 4. Positive pain elicited as biceps tendons pops out of the groove

WRIST 1. Allens 1. What it does assesses adequacy of blood supply to hand by radial and ulnar arteries 2. Pt opens and closes hand several times, and makes a tight fist 3. Doc occludes radial and ulnar aa at wrist 4. Pt opens hand which should be pale 5. Doc releases on artery and assesses flushing of hand 6. If flushes slowly or not at all the released artery is not adequately supplying the hand 7. Repeat for other artery 2. Finkelstein 1. What it does test for tenosynovitis in abductor pollicis longus and extensor pollicis brevis at wrist (De Quervains disease) 2. Pt makes fist with thumb tucked inside fingers 3. Doc stabilizes forearm and deviates wrist ulnarly 4. Positive pt feels pain over tendons at wrist 3. Phalens 1. What it does aids dx of carpal tunnel syndrome 2. Doc flexes wrist and holds this position for one minute 3. Positive tingling felt in thumb, index and middle finger and lateral part of ring finger 4. Reverse Phalens (Prayer) 1. Pt extends wrist while gripping docs hand, hold for one minute 2. Positive tingling felt in thumb, index and middle finger and lateral part of ring finger 5. Tinels 1. What it does aids dx of carpal tunnel 2. Doc taps over volar aspect of pts transverse carpal ligament 3. Positive same as above 4. Also can be used to dx neuropathies of ulnar nerve at elbow, peroneal nerve at fibular head, and posterior tibial nerve at ankle LUMBAR SPINE 1. Hip drop 1. What it does assesses SB of lumbar spine and thoracolumbar junction 2. Pt standing, doc locates superior and lateral aspect of iliac crest 3. Pt is told to bend one knee without lifting heel from floor 4. Positive anything less than a smooth convexity in the l-spine of the ipsilateral side, or a drop of the crest less than 20-25 degrees 2. Straight leg raise (Laseques) 1. What it does evals sciatic nerve compression 2. Pt supine, doc grasps leg to be tested under the heel and places other hand on anterior knee to keep it extended 3. Doc lifts leg up flexing the hip until pt feels discomfort (normal = 70-80 degrees) 4. Once pt feels pain- doc lower leg a little and dorsiflexes the foot (Braggards test) 1. This stretches the sciatic nerve 5. If no pain = negative test, problem is a tight hamstring 6. If pain spreads all the way down leg = positive sciatic origin SACRUM AND INNOMINATES 1. Seated flexion 1. What it does tests sacroiliac motion 2. Pt seated with both feet flat on floor 3. Doc locates PSIS and places thumbs on inferior notch 4. Pt bends forward, doc assess PSIS level 5. Positive PSISs are not level, SD on side of superior PSIS 2. Standing flexion 1. What it does tests iliosacral motion 2. Same as seated, except pt is standing 3. ASIS compression 1. What it does helps determine side of SI dysfx (sacrum, innominate or pubes) 2. Pt supine, doc contacts ASISs and applies posterior compression to each, while stabilizing the other 3. Positive on the side where there is resistance (no resiliency) 4. Pelvic side shift 1. What it does determines if sacrum is midline 2. Pt standing 3. doc stabilizes right shoulder with right hand, and pushes pelvis to right with left hand 4. doc stabilizes left shoulder with left hand, and pushes pelvis left with right hand 5. positive on side with freer translation of pelvis indicates pelvis is shifted to that side 1. Often seen in flexion contracture of psoas o Flexion contracture of right psoas will cause a pos pelvic shift to the left 5. Trendelenbergs 1. What it does assesses gluteus medius muscle strength 2. Doc stands behind pt 3. Pt picks one leg up off the floor 4. Positive pelvis falls on the same side the leg is lifted = opposite gluteus medius is weak 6. Lumbosacral spring 1. What it does assesses if sacral base is tilted posterior

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2. Pt prone, doc place heel of hand over lumbosacral junction 3. Doc applies gentle and rapid springing over junction 4. Positive = posterior sacral base, little or no springing Backward bending (sphinx) 1. What it does determines if sacral base has moved posterior or anterior 2. Pt prone, doc places thumbs on superior sulci will be asymmetric 3. Have pt prop up onto elbows causes base to move anterior 1. If thumbs become more symmetric part of base moved anterior 2. If thumbs become more asymmetric part of base moved posterior 4. Positive if sacral base is posterior Obers 1. 2. 3. What it does detects tight tensor fascia lata and iliotibial band Pt lies on side opposite iliotibial band being tested Doc stands behind pt and flexes knee to 90, abducts hip as far as possible and slight extends hip, while stabilizing pelvis to keep pt from rolling 4. Doc allows thigh to fall towards table 5. Positive thigh remains in abducted position = tight band Patricks (FABERE) 1. What it does assesses pathology of sacroiliac and hip joint esp OA of hip 2. Pts hip is Flexed, ABducted, Externally Rotated and Extended into a figure 4 position 3. Positive = pain in or around the hip joint, 1. accentuated pain (due to arthritic changes) when doc places one hand on opposite ASIS and other on bended knee and applies pressure on both Thomas 1. What it does assesses possibility of flexion contracture of hip (usually due to iliopsoas) 2. Pt supine, doc checks for exaggerated lumbar lordosis (common in flexion contracture) 3. Doc flexes one hip and knee so that knee and anterior thigh touch pts abdomen 4. Positive if opposite leg lifts off table Anterior and posterior drawer test 1. What it does assess anterior and posterior cruciate ligaments 2. Pt supine with hip flexed to 45 and knee flexed to 90 3. Doc sits on pts foot, wraps hands around behind tibia, and places one thumb on medial and lateral joint lines 4. ACL tibia is pulled anteriorly 1. Positive ACL tear if slides forward 5. PCL tibia is pushed posteriorly 1. Positive PCL tear if slides back 6. Must compare both knees Bounce home 1. What it does evals problems with full knee extension usually bc of meniscal tears or joint effusions 2. Pt supine, doc grasps heel 3. Knee is flexed completely, then is allowed to drop into full extension 4. Positive if extension is incomplete or there is a rubbery feel to end point extension Apleys compression and distraction 1. What it does evals meniscus and ligamentous structures of knee 2. Pt prone, knee flexed to 90 3. Compression doc presses straight down on heel and internally and externally rotates the tibia 1. Positive = pain = meniscal tear 4. Distraction doc pulls up on foot and internally and externally rotates tibia 1. Positive = pain = ligamentous injury (usually medial/lateral collateral ligs) Lachmans 1. What it does assess stability of ACL (more accurate than draw test) 2. Pt supine, doc grasps proximal tibia with one hand and distal femur with other 3. Knee flexed to 30 and tibia is pulled forward with hand 4. Positive tibia excessively moves forward from under femur McMurrays 1. What it does detects tears in posterior aspect of menisci 2. Medial meniscus 1. Pts knee is fully flexed 2. Tibia is externally rotated and valgus stress is placed on the knee 3. Maintain this position and slowly extend the knee 4. Positive = palpable or audible click = posterior tear of medial meniscus 3. Lateral meniscus 1. Same, except internally rotate and varus stress is applied Patellar grind 1. What it does assess posterior articular surfaces of patella and possible chondromalacia patellae 2. Pt supine with knees extended and relaxed 3. Doc pushes patella distally and asks pt to contract quads 4.

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Positive = pain, bc roughness of surface will grind and be palpable and painful with contraction and mvmt of patella Valgus (pic to the left) and varus (pic to the right) stress 1. What it does assess stability of collateral ligaments 2. Pt supine or sitting 3. Knee flexed, doc stabilizes ankle while pushes against knee medially, then laterally 4. Valgus stress test = lateral force, knee goes medially, tibia goes out (valgus) 1. Tests medial collateral ligament 5. Varus stress test = medial force, knee goes laterally, tibia goes in (varus) 1. Tests lateral collateral ligament 6. Positive if there is any gapping on the opposite side of the force, that ligament is torn

ANKLE 1. Anterior draw 1. What it does assess medial and lateral ligs of ankle mainly talofibular lig, but also superficial and deep deltoid 2. Pt supine, doc grasps distal tibia/fibula with one hand and pulls foot forward with other hand grasping posterior aspect of calcaneus 1. Foot should be held in 20 degrees of dorsiflexion the whole time 3. Positive excessive mvmt of talus under tibia/fibula (bilateral injury) 1. If deviates to one side ligament on opposite side is damaged