OMM I Exam 2 LGT

October 14, 2009

Timothy Dinh
 Differential Diagnosis for Low Back
Pain
Muscular/ligamentous
Fracture
strain/sprain
Tumor metastasis
Facet joint hypertrophy
Osteomyelitis
Degenerative disk
Somatic Dysfunction
disease
Disc herniation Adhesive arachnoiditis
Spondylolisthesis Epidural abscess
Spondylosis Pagets disease
Spondylolysis Postural back pain
Scoliosis Colitis
Spinal claudication Diverticulitis
Nephrolithiasis Prostatitis
Uterosacral ligament Psychiatric disease
traction
The Superior articular facets of the
lumbar spine face in what direction?
A. Backwards, Upward, Lateral
B. Forwards, Downward, Medial
C. Backwards, Downward, Medial
D. Backwards, Upward, Medial
E. Forwards, Upward, Lateral
 Osteology
Sagittal plane orientation of facets
Superior Articular facet faces
Posteromedially (BuM)

Allows good BB/moderate FB

Discourages Rotation & SB
Which position provides the most
stress on the spine
A. Laying Supine
B. Sitting slouched over in a chair
C. Laying lateral recumbent
D. Standing straight up and down
E. Sitting upright
 Disc Load and Positioning
Sitting with
poor posture
applies the
greatest load
possible
Load on third
lumbar
vertebrae of
a 70kg
persons in
kilograms
with postural decompensation as they are
affected by sacral innominate changes. Where
do they often refer pain?
A. Inguinal area
B. Lower Back
C. Gluteus Maximus
D. Thoracic Spine
E. Down the ipsilateral leg
 Lumbar Anatomy: Ligaments
Iliolumbar Ligaments
Attachment at L4 and
L5 transverse process
Increases stability at
the lumbosacral
junction These are often the first
structures to be involved with
Commonly strained in
postural decompensation as
traumatic injuries they are affected by sacral and
Refers pain often to innominate changes

inguinal area
Increased Sympathetic Tone in the
Lumbar area can lead to all of the
following EXCEPT?
A. Abdominal pain
B. Flatulence
C. Distension
D. Vomiting
E. Constipation
Somatovisceral/Viscerosomatic
Effects
Increased Sympathetics
Ileus
Constipation
Abdominal pain
Flatulence
Distension

Increased

Parasympathetics
Colitis
Crohns
IBS (both inc.)
Diarrhea
Vomiting
You are performing a lumbar/lower extremity exam on a
patient in your office. You have the patient perform a
hip drop test and find it positive on the left side. This
means:
A. The right leg is weight bearing, and the
left hip drops less than 20 degrees.
B. The left leg is weight bearing, and the left
hip drops less than 30 degrees
C. The left leg is weight bearing, and the
right hip drops less than 20 degrees
D. The right leg is weight bearing, and the
right hip drops less than 25 degrees
E. The left leg is weight bearing, and the left
knee does not bend
Hip Drop Test: Interpretation
Positive = the plane of the iliac crests drops
less than 20 degrees and/or the lumbar and
thoracolumbar spine does not side bend with
a smooth lateral curve; named to the side
that is weight bearing (eg. L leg bends and L
I.C. does not drop: Positive R hip drop
Positive test suggests that T-L and/or lumbar
spine has difficulty SB toward the weight
bearing side.
 Trendelenburg Test
Assessment of gluteus
medius muscle strength
Pt stands on one foot
while flexing opposite
knee
Gluteus medius m. on
opposite side of flexed
knee should abduct leg,
keeping pelvis level
Considered positive if
pelvis tilts toward side of Not to be confused with hip-
drop test, which assesses
flexed knee ability of lumbar vertebrae to
sidebend
Your patient was playing soccer and hurt her leg. You
diagnose her with a Grade 1 Sprain. This means:
A. Her ankle is broken
B. She has complete disruption with no tensile
strength, sloppy end feel with gapping and
indentation
C. She has slight pain and gapping upon
stress
D. She has generally intact tensile strength
with no gapping.
E. Her leg is fine, and you can send her home
without treatment
Classification of Sprains/Strains
Grade I: generally intact
tensile strength (no
gapping), TTP.
Grade III: complete
disruption with no
tensile strength, sloppy
end-feel with
gapping/indentation.
Grade II: in between,
with pain and slight
gapping upon stress
A runner presents to your office after
completing a marathon. Which test is most
likely to be positive?
A. Patrick Test
B. Thomas Test
C. Lasegues Test
D. Braggards Test
E. Obers Test
 Thomas Test
Assessment for contralateral restricted or
shortened iliopsoas muscle
Flex one thigh up to abdomen
Considered positive if opposite knee lifts off table
Can be active or passive
 ROM-Patricks Test
Assessment for gross hip motion
Differentiate between hip joint pathology and sacroiliac
SD (pain is either deep in the hip joint or toward the
back)
FABERE
Flexion
ABduction
External Rotation
Extension
 Straight Leg Raise Test
Assessment for sciatic nerve compression/irritation
Sciatic pain vs. hamstring pain
Normal straight leg raise 90 without pain/symptoms
Keeping knee extended, Dr flexes hip until pt reports
pain
Lasegues Test
Tests for pain specific to sciatic n. origin
Once pain is reported, Dr extends hip about 5 and
flexes knee. At new endpoint Dr. extends knee
This removes hamstring pain while adding stress
onto sciatic n.
Considered abnormal if pt reports return of pain,
especially if pain radiates past knee
Braggards Test
 Obers Test
Assessment for contracture of
iliotibial band or tensor fascia
latae
Dr stabilizes hip and knee
With knee flexed, extend hip
Gently allow thigh to adduct
toward table
Considered positive if thigh
cannot adduct past midline
Which is not a point in the sagittal
plane used when evaluating Posture?
A. External Auditory Canal
B. Angle of the third rib
C. Greater Trochanter
D. Lateral Condyle of the Knee
E. Just anterior to the Lateral Malleolus
Postural screen

Evaluate your patient in the sagittal plane:

External auditory canal
Humeral head
(L3)
(anterior 1/3 sacral base)
Greater Trochanter
Lateral condyle of Knee
(just cl. Anterior) to lateral malleolus

Is the lumbar curve present? Increased? As

expected?
Rotation of the vertebra occurs
around which plane and in what axis?
A. Coronal Plane about an A/P Axis
B. Sagittal Plane about a Transverse Axis
C. Sagittal Plane about a Vertical Axis
D. Horizontal Plane about a Vertical Axis
E. Horizontal Plane about an Transverse Axis
Remember
:
Take into account
all 3 planes of
motion:
1. coronal
(sidebending)
2. horizontal
(rotation)
You are palpating a patients back when you notice a gap between the L2 and
L3 vertebrae. You palpate the interspaces between L1-L4. When you put the
patient into Extension, the gap between L2 and L3 remains pronounced and
the patient does not seem to be able to extend fully. What is your diagnosis?

A. L3 is stuck in Extension
B. L2 is stuck in Extension
C. L3 is stuck in Flexion
D. L2 is stuck in Flexion
E. L1 is non neutral
Lumbar Spine Sagittal Plane-
Forward Bending
Common Findings
Slight separation from spinous process of
segment below
Slight approximation to spinous process of
segment above
Tenderness of supraspinous ligament
Bilateral restriction of rotation
Restriction of sidebending
Backward bending restriction - Forward
bending ease
Lumbar Spine Sagittal Plane
Backward Bending

Common Findings
Slight approximation of spinous process to
segment below
Slight separation of spinous process from
segment above
Tenderness of supraspinous ligament
Bilateral restriction of rotation
Sidebending may be restricted
Forward bending restriction
You decide to treat the patient in the supine
position. Which describes the proper technique
to perform this treatment?
A. Flex the knees up to the chest. Physicians hands on
either side of the transverse process of the lesioned
segment. Have patient push knees up against physicians
chest
B. Physician on side of table with hands on spinous process
of the lesioned segment. Physcian instructs patient to
flatten back against resistance. Physician then instructs
patient to relax, while following the fingers up to the new
barrier.
C. Physician on side of table and contacts the spinous
process, while inducing sidebending toward the physician.
Physician grasps the ankles and instructs the patient to
attempt to pull the legs back to midline while maintain
pressure on the spinous process
D. Physician on side of table and contacts the opposite
transverse process. Physician pushes on the transverse
A. This is for Extension somatic dysfunction

C. This is supine muscle energy for neutral

lumbar somatic dysfunction

D. This is supine indirect technique for neutral

somatic dysfunction
Fryettes Principles
Law I: When the spine is in neutral,
sidebending to one side will be accompanied
by horizontal rotation to the opposite side.
Law II: When the spine is flexed or extended
(non-neutral), sidebending to one side will be
accompanied by rotation to the same side.
Law III: When motion is introduced in one
plane it will modify (reduce) motion in the
other two planes.
 The lumbar spine normally flexes 40 degrees
and extends 30 degrees. Non neutral type II
motion is more likely to occur in the lumbar
and thoracic spine when the spine is in a
straightened configuration.
Therefore, non neutral dysfunction (Type II
mechanics) in the lumbar spine is MORE
LIKELY to occur when the spine is flexed.
Foundations page 738
A patient presents to your office with lower back pain. You feel his L5 vertebrae
and notice that the left transverse process is more prominent on the left. You
push on the spinous process and notice that it is difficult to translate to the right.
It does not get better in flexion or extension. What is your diagnosis?

A. L5 N SRRL
B. L5 NN SLRR
C. L5 E SRRL
D. L5 F RRSR
E. L5 N SLRR
You decide to treat the patient with an HVLA technique
in which the patient is lying on his side. In what
position is the patient?
A. Prone
B. Left lateral recumbent
C. With the Rotation side down
D. Right lateral recumbent
E. Supine
In what direction is your thrust?
A. Inferior, Posterior, Lateral
B. Lateral Only
C. Superior, Anterior, Medial
D. Anterior only
E. Superior, Posterior, Medial
You are performing the seated muscle energy technique for neutral lumbar
dysfunction. After 3-5 complete rounds of muscle energy, you decide to
finish the technique with an HVLA thrust. In what direction is your thrust?

A. Anterior
B. Inferior and Anterior
C. Superior and Anterior
D. Inferior
E. Superior and Medial
What type of technique is the
Sphinx technique?
A. HVLA
B. Articulatory
C. Still Technique
D. Muscle Energy
E. Springing
Your patients left transverse process of L3 is deeper than the right. You also
find that the vertebral segments translate more easily to the right. You
decide to treat the patient with a seated indirect technique. Which answer
discusses the correct hand placement of the proper hand?

A. The Right Thumb pad contacts the right

transverse process of L4
B. The Left Thumb pad contacts the right
transverse process of L4
C. The Right Thumb pad contacts the right
transverse process of L3
D. The Left Thumb pad contacts the left
transverse process of L2
E. The Left Thumb pad contacts the left
transverse process of L4
Multiple Plane - Type I
Mechanics - Treatment. NSLRR
Sitting, indirect, pt coop, resp force.
Kimberly Manual 4421.D

Pt sitting straddling end of table

Operator contacts ipsilateral TP of segment
below the rotated side
Operator contacts Contralateral TP on
lesioned segment
Pt is instructed to drop arm to induce further
SB to float segment
Pt is instructed to BB to float the segment
Pt instructed in respiratory force
(hold breath)
recheck
The patient cannot tolerate the technique, so
you decide to perform a direct supine muscle
energy technique. On what side do you sit?
A. On the left side of the table
B. At the head of the table
C. On the right side of the table
D. At the foot of the table
E. Go check on another patient
Multiple Plane - Type I Mechanics
Treatment. Supine, direct, ME
Kimberly Manual 4421.11F p109
D.O. sits on side of
rotation
Operated gently pulls
spinous process
encouraging left
rotation N SLRR
Maintaining contacts
pt is instructed in ME
to attempt to return
 Hand Placement:
DO on side of
rotation

Operator hand on
contralateral TP

By raising this TP
(move it anteriorly),
rotation occurs to
opposite side.

Traction here induces

SB

Multiple Plane-Type 1 Mechanics

Supine Indirect, pt coop, resp force
L3 N SLRR Kimberly Manual 4421.G p111
Your patient presents to the office with lower back pain. When
diagnosing the patient, you note that the L5 Transverse process
moves more easily in rotation on the left side. When you push on
the spinous process, it translates more easily to the left. It seems to
get better when the patient leans forward.

You decide to treat the patient with a seated muscle energy

technique. What describes proper hand placement?
A. Your right arm goes under the left arm and over the right arm to
induce further sidebending and rotation
B. Your left arm goes under the left arm and over the right arm of the
patient to induce sidebending and rotation away from the somatic
dysfunction
C. Your left arm goes over the left and right arm of the patient to
induce sidebending and rotation away from the somatic dysfunction
D. Your right hand goes over the right and left arm of the patient to
induce sidebending and rotation away from the somatic dysfunction
E. Your left arm goes under the left and right arm of the patient to
induce further sidebending and rotation
A patient presents to your office with low back. She reports a
history of bending over all weekend and pulling weeds out of her
garden. Which of the following is a likely diagnosis for this patient?

A. L3 ESRRL
B. L2 NSRRL
C. L4 FRRSR
D. L3 ERLSL
E. L5 NSRRL
You decide to treat the patient using an articulatory
technique. Which answer describes proper starting
position of the patient?
A. Left Lateral Recumbent
B. Right Lateral Recumbent
C. Rotation Side Down
D. Supine
E. Prone
Which of Fryettes Prinicples defines the reason behind
the Sacrificial Lamb of lumbar somatic dysfunction?
A. Law I: When the spine is in neutral,
sidebending to one side will be accompanied
by horizontal rotation to the opposite side.
B. Law II: When the spine is flexed or
extended (non-neutral), sidebending to one
side will be accompanied by rotation to the
same side.
C. Law III: When motion is introduced in one
plane it will modify (reduce) motion in the
other two planes.
Which is not a TART Change?
A. Tissue Texture Change
B. Assymmetry
C. Restriction in motion/Red Reflex
D. Tenderness
E. All of these are TART changes
What is the definition of Somatic
Dysfunction?
QUESTIONS??????