Omt Review

COMLEX

OMM

Chapman’s Reflex Points

Chapman Reflex Points STRUCTURE

ANTERIOR POINT

POSTERIOR POINT

CNS retina, conjunctiva cerebellum ENT sinuses middle ear pharynx tonsils tongue neck GI esophagus stomach (parietal) stomach (peristalsis) small intestine appendix colon rectum SNS GANGLIA celiac ganglion superior mesenteric ganglion inferior mesenteric ganglion ORGANS heart, thyroid, bronchi upper lung lower lung liver gallbladder pancreas spleen adrenal ovary prostate URINARY kidneys bladder urethra

Diagnosis and Treatment

lateral superior humerus tip of the coracoid process medial inferior clavicle medial superior clavicle superior lateral edge of manubrium middle lateral edge of manubrium 2nd costosternal joint medial superior humerus superior aspect of 3rd intercostal space left 5th intercostal space left 6th intercostal space 8th, 9th, and 10th intercostal spaces tip of the 12th rib iliotibial band

T2-T3 between SP and TP T5 between SP and TP T6 between SP and TP T11 between SP and TP

flip the colon over; cecum near the greater trochanter and hepatic flexure near knee)

lesser trochanter of femur HINT: attachment site of psoas major

below xiphoid process between umbilicus and xiphoid process above umbilicus left 2nd intercostal space 3rd intercostal space 4th intercostal sapce right 5th and 6th intercostal spaces right 6th intercostal space right 7th intercostal space left 7th intercostal space 1in lateral, 2in superior to umbilicus lateral to pubic symphysis (superior edge) posterior ilotiband

T2-T3 between SP and TP T3 between SP and TP T4 between SP and TP right T5-T6 between SP and TP right T6 between SP and TP right T7 between SP and TP left T7 between SP and TP T11-T12 between SP and TP

1in lateral, 1in superior to umbilicus periumbilical superior pubic ramus, 2cm lateral to symphysis

T-12-L1 between SP and TP upper edge L2 TP L2 TP

Chapman’s)points)are)diagnosed) anteriorly)and)treated)posteriorly.)) ) Treatment)involves)pressure)applied) with)a)circular)rotation)until) release)is)felt)

It)is)unlikely)to)be)asked)a)question) about)actual)treatment)on) COMLEX.)More)likely,)question)will) directly)test)on)location)of)either) anterior)or)posterior)Chapman) point)

COMLEX

OMM

Chapman’s Reflex Points

Anterior Chapman’s Points:

Posterior Chapman’s Points: retina, conjunctiva

sinuses

cerebellum

retina, conjunctiva neck larynx pylorus small intestines

appendix (R)

middle ear nasal sinuses pharynx tonsils tongue esophagus, bronchus thyroid, myocardium upper long lower lung stomach (acidity) (L) left adrenal left kidney Bladder area

Umbilicus intestinal peristalsis

ovaries, urethra uterus

middle ear pharynx, tongue, larynx, sinuses, arms neck, esophagus, bronchus

cerebellum nasal sinuses cerebrum arms (and pectoralis minor)

thyroid upper lung, myocardium upper lung lower lung stomach (acidity) (L) liver (R)

neuroansthesia (and pectoralis minor)

stomach (peristalsis) (L) liver, gallbladder (R)

pyorus (R) ovaries intestines (peristalsis) appendix (R)

adrenals kidneys abdomen, bladder urethra uterus vagina, prostate, uterus, broad ligament rectum, groin glands

large intestines

sciatic nerve (posterior)

Fallopian tubes, seminal vesicles

hemorrhodial plexus

rectum clitoris, vagina

prostate or broad ligament

sciatic nerve (anterior)

colon

Most likely to be asked about on COMLEX (all are possible)

)

COMLEX

OMM

ANS Innvervation

Segmental Sympathetic Innervation STRUCTURE sinuses , eustachian tube, lacrimal glands thyroid trachea, bronchi lower 2/3 esophagus aortic arch heart lungs stomach dudodenum liver gallbladder, biliary tree spleen pancreas small intestine proximal colon distal colon appendix adrenal glands, kidney, upper ureter, ovary and testes lower ureter, bladder, trigone/sphincter, uterus, prostate genital cavernous tissue, penis, seminal vesicle mammary glands arms legs

SEGMENT T1-4 T1-4 T1-6 T5-6 T1-5 T1-6 T2-4 T5-9 left T5-9 T5 right T6 right T7 left T7 right T10-T11 T10-T12 T12-L2 T12 T10-11 T12-L1 T12-L2 L2 T1-6 T2-8 L11-L2

Parasympathetic Innervation

Vagal nuclei

STRUCTURE

SEGMENT

pupils (constriction aka miosis)

CN III (midbrain) ! ciliary ganglion

lacrimal and nasal glands

CN VII (pons) ! sphenopalatine ganglion

submandibular and sublingual glands

CN VII (pons) ! submandibular ganglion

parotid gland heart, bronchial tree, esophagus (lower 2/3), stomach, small intestine, liver, gallbladder, pancreas, kidney and upper ureter, ovaries and testes, ascending and transverse colon, ascending/transverse colon lower ureter and bladder, uterus, prostate, genitalia, descending colon, sigmoid, and rectum

CIX (medulla) ! otic ganglion

CN X (medulla) ! dorsal motor nucleus

pelvic splanchnic (S2-4)

Nucleus Solitarius !)visceral)Sensory) information)(e.g.)taste,)baroreceptors,) gut)distention).) ) CN)VII,)IX,)X) ) Nucleus aMbiguus)!)Motor)innervation)of) pharynx,)larynx,)and)upper)esophagus)) (e.g.,)swallowing,)palate,)elevation)) ) CN)IX,)X) ) Dorsal motor nucleus)!)sends)autonomic) (parasympathetic))fibers)to)heart,)lungs,) and)upper)GI) NOT)motor)fibers,)despite)the)name) ) CN)X) )

COMLEX

Treatment order

OMM

ANS Innvervation

1.))Treat'the'dysfunction'segment)responsible)for)initiating)the)facilitated)spinal)cord) segment) E.g.)cervical,)thoracic,)lumbar)somatic)dysfunction) ) 2.))Affect'SNS'activity') Chapman’s)reflex)points,)treating)the)sympathetic)chain)ganglia)(rib'raising),)and) then)treating)the)collateral)ganglia)(preaortic)and)cervical)ganglia))) rib'raising)–)initially)stimulates)sympathetics)!)reflexive)inhibition)of)SNS)mediated))))) by)medulla) ) 3.))Encourage'lymphatic'drainage)and)improved)venous)return) release)thoracic)inlets,)abdominal)diaphragm,)mesenteries,)pelvic)diaphragm) utilize)lymphatic)pump)techniques) release)the)craniocervical)junction) treat)fascial)restrictions)) open'diaphragms'! 'then)treat'pumps) ) 4.)))Affect'PNS'activity)) OA)(vagus)n),)sacral)splanchnic)nerves,)pelvic)splanchnic)nerves)) )

COMLEX

OMM

Upper Extremity

Upper extremity nerves NERVE

INNERVATES

Axillary (C5, C6)

deltoid and teres minor (arm abduction, external rotation)

Radial (C5-T1)

sensory shoulder arm and forearm (wrist) extensors supinator

NOTES injured by dislocated shoulder

common injury with fracture of midshaft humorous RES – radial, extensors, supinator

Median (C5-8, T1)

Ulnar (C8, T1)

Musculocutaneous (C5-7)

sensory posterior arm and forarm sensory part of thenar eminence on palmar hand, PIPs and proximal dorsum of hand from thumb to half of ring finger wrist flexors, pronator teres lumbricals 1 and 2, thenar muscles, cutaneous sensation sensory palmar hand ! thumb, first and second digit, half of third digit sensory dorsal hand ! PIP and distal thumb, index, middle, and half of ring finger flexor carpi ulnaris intrinsic hand muscles lumbricals 3 and 4, hypothenar muscles, interossei, adductor pollicis, flexor pollicis brevis sensory fifth and ½ fourth digit on both dorsal and palmar side anterior (flexor) compartment of the arm

MFP – median, flexors, pronator

A OF A OF A first AOF thenar muscles Adductor pollicis, Opponens digit minimi, Flexor digiti minimi, Abductor digiti minimi

biceps brachii, brachialis, coroacobrachialis flexion and supination

sensory lateral arm

Rotator cuff muscles

Other shoulder muscles

) ) ) )

Meat-LOAF Median nerve, 2 Lateral Lumbricals, Oponens pollicus, Abductor pollicis brevis, Flexor pollicis brevis

Supraspinatus – initiation of abduction, suprascapular nerve (C5) Infraspinatus – external rotation, suprascapular nerve (C5-C6 Teres minor – external rotation, axillary nerve (C5) Subscapularis – internal rotation, upper and lower subscapular nerve (C5-C6) “SITS” muscles

)

Pectoralis major – one of two primary adductors, lateral and medial pectoral nerves (C5-T1) Deltoid (anterior) – primary flexor, axillary nerve (C5-C6) Deltoid (middle) – primary abductor, axillary nerve (C5-C6) Deltoid (posterior) – one of three primary extensors, axillary nerve (C5-C6) Teres major – one of three primary extensors, axillary nerve (C5-C6) Latissimus dorsi – primary extensor and adductor, thoracodorsal nerve (C6-C8)

COMLEX

OMM

Upper Extremity

) Upper extremity nerve injuries NERVE/MUSCLE

TYPICAL INJURY

MOTOR DEFICIT

Axillary (C5, C6)

Fractured surgical neck of humerus, dislocation of humeral head Fracture at midshaft of humerus; “Saturday night palsy” (extended compression of axilla by back of chair or by crutches) Fracture of suprachondylar humerus (proximal lesion)

Deltoid – arm abduction at shoulder “BEST extensors” – Brachioradialis, Extensors of wrist and fingers (C6-7), Supintor, Triceps

Over deltoid muscle

Atrophied deltoid

Posterior arm and dorsal hand and thumb

Wrist drop

Opposition of thumb Lateral finger flexion Wrist flexion (C7-8)

Dorsal and palmar aspects of lateral 3/12 fingers, thenar eminence

Fracture of medial epicondyle of humerus, “funny bone” Hook of hamate injury (bicycle riders) Upper trunk compression

Medial finger flexion Wrist flexion (C7-8)

Medial 1 ½ fingers, hypothenar eminence

“Ape hand”; “Popes blessing” (hand) Travels through the two heads of pronator teres Radial deviation of wrist upon wrist flexion

Biceps, brachialis, coracobrachialis Flexion of arm at elbow

Lateral forearm

Radial (C5-T1)

Median (C5-8, T1)

Ulnar (C8, T1)

Musculocutaneous (C5-7)

)

SENSORY DEFICIT

Tear of rotator cuff muscles ) acute, sharp pain in shoulder followed by ongoing dull achh and tenderness at acromion process

more commonly an injury of the tendons rather than the actual muscles

(+) drop arm test, weak abduction

supraspinatus tendon most frequently affected because it passes below the acromion

treat less severe cases with RICE, NSAIDS, and OMT

the site of injury usually occurs at the point of insertion at the greater tubercle of the

) )

Radial head somatic dysfunction )

Anterior radial head !)radial head does not glide posteriorly; Restricted Pronation, +/- pain with pronation most likely to occur with backswords fall on extended arm ) Posterior fibular head)!)radial head does not glide anteriorly; Restricted Supination; wrist and elbow pain FOOSH injury (fall on out-stretched hand) “Re stric te d A PPS ”

SIGN/NOTES

COMLEX

OMM

Upper extremity

Shoulder dysfunctions DYSFUNCTION

DEFINITION

ETIOLOGY

NOTES

Erb-Duchenne palsy

injury to upper brachial plexus, usually lateral stretching injury to lower branchial plexus,

infant ! lateral traction on neck during delivery adult ! trauma most often trauma during childbirth

long thoracic n injury ! paralysis of serratus anterior muscle compression of brachial plexus, subclavian vein, and subclavian artery

trauma to the long thoracic n shoulder blow, repetitive movements, mastectomy) can occur between: ant and mid scalenes clavicle and 1st rib pectoralis minor and upper ribs

waitor’s tip posturing, C5-6 upper trunk arm extended and pronated paralysis of intrinsic hand muscles C8-T1 sensory loss +/- Horner’s syndrome while patient pushes anteriorly (e.g. against a wall) scapula protrudes posteriorly ache and/or paresthesia of neck or arm

Klumpke’s Palsy

winged scapula

thoracic outlet syndrome

)

COMLEX

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Upper Extremity

COMLEX

OMM

Upper Extremity

Upper Extremity Special Tests STRUCTURE

EVALUATES

TECHNIQUE

Apley’s scratch test

range of motion

Adson’s test

thoracic outlet syndrome

Roos’s test

thoracic outlet syndrome

drop arm test

rotator cuff tear

Speed’s test

biceps tendon

Yergason’s test

stability of biceps tendon in bicipital groove

patient reaches behind head to scratch back – evaluates abduction and external rotation; patient reaches across chest to scratch other should and/or reaches around the back at waist and scratches back – evaluates internal rotation and adduction patient extends elbow and arm, turns head towards ipsilateral side. positive if radial pulse markedly weakened or absent patient abducts both arms to 90˚, externally rotates, then flexes the elbows to 90˚; patient repetitively opens and closes firsts for 3min positive if exacerbations of symptoms patient abducts arm to 90 degrees and slowly drops arm to side positive if arm rapidly falls patient extends elbow; supinates forearm while flexing the arm at the shoulder against resistance positive if there is tenderness in the bicipital groove patient flexes elbow to 90 degrees while clinician holds the patient’s wrist with one hand and elbow with the other clinician resists the patient’s flexion/pronation force while passively externally rotating positive if there is pain in biceps tendon as it pops out of the bicipital groove

Wrist Special Tests STRUCTURE

EVALUATES

TECHNIQUE

Tinel’s test

carpal tunnel syndrome

clinician taps over volar aspect of patient’s traverse carpal ligament (Tinel Tap)

Phalen’s (and reverse Phalen’s) tests

carpel tunnel syndrome

⊕test = paresthsia of thumb, index, ring fingers patient's wrist passively but maximally flexed (extended in reverse) by the clinical, held for one minute

⊕test = paresthsia of thumb, index, ring fingers Allen’s test

radial and ulnar artery patency/blood flow

Finkelstein test

tenosynovitis of pollicis longus and extensor pollicis brevis (DeQuervain’s tenosynovitis)

patient opens and closes hand several times and makes a tight first clinician occludes one artery and has patient open hand test failed if hand remains pale patient makes a tight first with thumb tucked into first clinician induces adduction of the wrist

⊕test = pain over tendons of wrist

COMLEX

OMM

Lower Extremity

Lower extremity nerves NERVE

TYPICAL INJURY

MOTOR DEFICIT

Obturator (L2-L4)

Anterior hip dislocation

Thigh adduction

Medial thigh

Thigh flexion and leg extension Foot eversion and dorsiflexion; toe extension Foot inversion and plantarflexion; toe flexion Thigh abduction

Anterior thigh and medial leg Anterolateral leg and dorsal aspect of foot

Can’t jump, climb stairs, or rise from seating position; can’t push downwards

Lateral forearm

Femoral (L2-4) Common peroneal (L4-S2)

Pelvic fracture

Tibial (L4-S3)

Trauma or compression of lateral aspect of leg or fibula neck fracture Knee trauma

Superior gluteal (L4-S1)

Posterior hip dislocation or polio

Inferior gluteal (L5-S2)

Posterior hip dislocation

SENSORY DEFICIT

⊕Trendelenberg sign contralateral hip drops when standing on leg ipsilateral to lesion

Lower extremity muscles MUSCLE

ACTION

INNVERVATION

Ilopsoas

hip flexion

L1, L2, L3

gluteus maximus

hip extension

inferior gluteal n (L5, S1, S2)

gluteus medius, minimus

thigh abduction

superior gluteal n (L5, S1)

hamstrings

knee flexion

L5, S1, (S2)

(hip extension)

tibial n tibial n tibial n common peroneal n

hip adduction

obturator n (L2, L3)

pirformis

abduction of flexed thigh

S1, S2

quadriceps

knee extension

femoral n (L2, L3, L4)

adductors adductor brevis, longus, magnus, and minimus gracilis

rectus femoris vastus lateralis, medialis, and intermedius (deep)

Foot drop, foot slap, steppage gait

Sole of foot

PED = Peroneal Everts and Dorsiflexes; if injured, foot droPED TIP = Tibial Inverts and Plantarflexes; if injured, can’t stand on TIPtoes Sciatic nerve (L4-S3) – posterior thigh, splits into common peroneal and tibial nerve

semitendinosus semimembranosus biceps femoris (long head) biceps femoris (shorthead)

SIGN

COMLEX

OMM

Lower Extremity

Lower extremity muscles (continued) MUSCLE

ACTION

INNVERVATION

anterior tibialis

dorsiflexion and inversion of foot

deep peroneal n (L4)

extensor halluces longus

foor dorsiflexion and great toe extension

deep peroneal n (L5)

gastrocnemius

foot plantarflexion

tibial n (S1, S2)

peroneus longus and brevis

foot eversion

superficial peroneal n (S1)

) ) ) ) ) ) ) ) ) ) ) ) )

Fibular head somatic dysfunction

) ) ) )

Anterior fibular head !)foot stuck in internal rotation and plantarflexion; treat with muscle energy by placing the foot in Inversion (loose pack fibula), External rotation of tibia, and Dorsiflexion Tx = AED plus inversion ) Posterior fibular head)!)foot)stuck)in)external)rotation)and)dorsiflexion;)treat)with)muscle) energy by placing the foot in Inversion (loose pack fibula), Internal rotation of the tibia, and Plantarflexion Tx = PIP plus inversion

COMLEX

Piriformis syndrome )

OMM

Lower Extremity

Neuromuscular disorder in which the sciatic nerve is compressed by the piriformis muscle. Characterized by tingling and numbness in buttocks descending into the lower thigh and leg

) ) ) ) ) ) ) ) ) )

Treatment includes muscle energy and counterstrain: ME: patient abducts against resistance CS: patient prone, knee and thigh flexed, thigh abducted and externally rotated (“peeing dog” position) “peeing dog with a problem” is for LPL5 point alternate treatment is extension on prone patient

Ankle sprains

Ankle strain ! muscular injury Ankle sprain ! ligament injury Grade 1 (first degree) microtears Grade 2 (second degree) partial tear Grade 3 (third degree) complete tear Lateral ankle sprain much more common than medial ankle sprain (deltoid ligament supporting medial ankle very strain) Classifications Type I = sprained ATFL ATFL “Always Tears First Ligament” Type II = sprained ATFL and CFL Type III = sprained ATFL, CFL, and PTFL

Important angles

) angulation ! the angulation between Femoral head the neck of the femur and the shaft of the femur >135 degrees = coxa valgum <120 degrees = coxa varum Q Angle ! angulation between a line drawn from ASIS through the middle of the patella and a line from the tibial tubercle through the middle of the patella >12 degrees = genu valgum <10 degrees = genu varum )

Osgood-Schlatter Disease )

Coxa varum = <120˚

Normal = 120˚

Coxa valgum = >135˚

A

left: femoral head angulation right: Q angle; shaded region is the angle

Pain and swelling over the tibial tuberosity Exacerbated by squatting, climbing stairs, extending knee against resistance C

X-Ray ! tibial tuberosity may appear separated with new bone growth beneath TX: modifying physical activity to decrease stress on tendon Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling

B