Omm Review Sheet

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OMM Study Guide 

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Frayette’s principles 1. 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 HVLA o Inhibition o Osteopathy in cranial field o Lymphatic treatment (do not use pedal pump in cardiac / respiratory patient) Chronic SD versus acute SD Chronic Acute Somato-visceral effects Minimal somato-visceral effects Dull ache or pain Acute pain, severe, cutting, sharp Cool, pale, dry, scaly, itchy, blemished skin; folliculitis Warm, moist, inflamed skin Regional sympathetic vasoconstriction Local vasodilation (sympathetics cause constriction, but bradykinins overpower, causing dilation) Decreased muscle tone; contracture; flaccid Muscle spasm Limited ROM due to contracture ROM sluggish but normal Doughy, stringy, fibrotic tissue Boggy edematous soft tissue Chapman’s Reflex Tender Points o 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 diameter o Treatment: rub in a firm circular motion for ~ 10-30 sec o 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

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 Posterior: Midway b/w the SP and the tips of the TP of T4 and T5 Myocardium, bronchus, esophagus, and thyroid can all be found anteriorly between ribs 2 & 3 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  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 points o 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

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Thoracic  AT1: apex of sternal notch

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 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 Ribs  Anterior – associated with depressed ribs  AR1: First rib where it articulates with the manubrium  AR2: Second rib in the midclavicular line  AR3-6: On corresponding rib, in the anterior axillary line  Posterior – associated with elevated ribs  PR1-6: angle of corresponding rib

Inguinal  Tender point located on the lateral border of the pubic bone near the attachment of the inguinal ligament Iliolumbar  Tender point located 1 inch superior and medial from the inferior margin of the PSIS in the iliolumbar ligament Piriformis  Tender point located halfway from the PSIS–ILA midpoint to the greater trochanter.

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Cervical o 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 HVLA o 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.

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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

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 T12  follows 1-3 Motion  Rotation> SB> Flexion> Extension 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)

Ribs o 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)  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

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Bucket handle

Caliper

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 group 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 extremity o 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.

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 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. 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 Radial nerve injury  Caused by mid-shaft fracture of humerus; “Saturday night palsy”  Knocks out wrist extension 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. 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 Radial mechanics  Moves anterior with supination (from fall backward)  Moves posterior with pronation (from fall forward)

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 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.

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6  Inflammation of extensor pollicis brevis and abductor pollicis longus 

Lumbar o 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

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Sacral o 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  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

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 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 extremity o 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  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

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 Posterior Drawer Test - Integrity assessment of PCL 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 innervation o T1-4 – head and neck o T1-6 – heart and lungs, visceral pleura o T1-11 – parietal pleura o T2-8 – UE, esophagus o T5-9 – stomach, duodenum, liver, gall bladder, pancreas, spleen o T10-11 – small intestine, kidney, gonads, upper ureter, ascending and proximal 2/3 of transverse colon o T11-L2 - LE o T12-L2 – lower ureter, left 1/3 of transverse, descending, and sigmoid colon, rectum, pelvic organs Cranial bones o 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 components o 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 PRM o 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 o Rate of 10-14/min (pt with depression would have < 10; treat with bulb decompression/CV4 technique) o Palpable in cranium and sacrum o Increased rate: fast metabolism, acute infection o Decreased rate: slow metabolism, chronic infection, fatigue o Increased amplitude: increased ICP o Decreased amplitude: dural tension, SBS compression o Still point: a pause in CRI Cranial motion

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Sphenobasilar junction is the reference point around which diagnostic motion patterns are described Midline bones follow flexion/extension Paired bones follow internal/external rotation Sacrum follows the occiput Temporals follow the occiput Facial bones follow the sphenoid 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 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 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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