OPP Course Review

John Garlitz, DO
Deborah Schmidt, DO
OPP 2
April 15, 2015
8:10 AM

1
 •Back

Class I "Some" = S = Sodium 

Mnemonic for Class I-IV agents Class II "Block" = B =BBs 

"some block potassium channels" Class III "Potassium" = K+CBs 

Class IV "Channels" = C =CCBs

Disopyramide (Norpace) PO
Class 1A
Double Quarter Pounder Quinidine (Quinalan) PO/IV
NA blocker, K blocker
Procainamide (Procanbid) PO/IV

2
• Front
•  Back
• Mnemonic for Class I-IV agents

"some block potassium channels"

• Class I "Some" = S = Sodium 

Class II "Block" = B =BBs 

Class III "Potassium" = K+CBs 

Class IV "Channels" = C =CCBs

• Class 1A
Double Quarter Pounder
NA blocker, K blocker
• Disopyramide (Norpace) PO

Quinidine (Quinalan) PO/IV

Procainamide (Procanbid) PO/IV

• Class 1B *not for Afib
Lettuce, tomato, Mayo
Cleanest agents only NA blocking
Only effective for ventricular arrhythmias
• Lidocaine IV in D5W

Tocainamide (Tonocard)PO

Mexiletine (Mexitil)PO
• Class 1C
More, Fries, Please
Cleanest for LOW ADR
Avoid in HF and IHD
• Moricizine

Flecainide (Tambocor)PO 3
 Objectives
At the end of this learning unit the student
should be able to successfully pass the OPP
portions of the level 1 COMLEX CE exam.

4
 Mnemonic for Class I-IV agents

"some block potassium channels"

Class I "Some" = S = Sodium 

Class II "Block" = B =BBs 

Class III "Potassium" = K+CBs 

Class IV "Channels" = C =CCBs

Class 1A
Double Quarter Pounder
NA blocker, K blocker
Disopyramide (Norpace) PO

Quinidine (Quinalan) PO/IV

Procainamide (Procanbid) PO/IV

Class 1B *not for Afib
Lettuc e, tomato, Mayo
Cleanest agents only NA blocking
Only effective for ventricular arrhythmias
Lidocaine IV in D5 W

Tocainamide (Tonocard)PO

Mexiletine (Mexitil)PO
Class 1C
More, Fries, Please
Cleanest for LOW ADR
Avoid in HF and IHD
Moricizine

Flecainide (Tambocor)PO

Propafenone (Rythmol)PO
To remember the Class III agents: 

"A Big Dog Is Scary"

Amiodarone, Bretylium, Dofetilide, Ibutilide, Sotalol
To remember calcium channel bloc kers: 

CCBs are "Very Nice Drugs"

verapamil, nifedipine, diltiazem

5
 How to use this material
• This is a review, nothing is new material
• If you are shaky on something I am reviewing,
go back to the original lecture and look over
the material
– And ask for help from the faculty or GTAs
• You may want to hold onto this handout even
after your level 1 exam
– Students often use it before level 2 and level 3

6
 Index of Review Material
• Foundational material
• Fryette’s Mechanics
• Posture, Scoliosis, and Postural X-rays
• Principles of OMT Techniques
• Fascial Diaphragms, the Common
Compensatory Pattern, and Lymphatic Pumps
• Viscerosomatic reflexes
• Somatic Dysfunctions by body region
• Clinical considerations in OPP
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Foundational Material

8
 Definition of Osteopathic Medicine
• Osteopathic medicine is a complete
system of medical care with a philosophy
that combines the needs of the patient with
the current practice of medicine, surgery,
and obstetrics, that emphasizes the
interrelationship between structure and
function, and that has an appreciation of
the body's ability to heal itself.

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 Principles of Osteopathic Philosophy
1. The body is a unit; the person is a unit of body,
mind, and spirit
2. The body is capable of self-regulation, self-
healing, and health maintenance
3. Structure and function are reciprocally
interdependent
4. Rational treatment is based upon an
understanding of the basic principles of body
unity, self-regulation, and the interrelationship
of structure and function

10
Definitions you should be familiar with:
• Somatic dysfunction: the impaired or altered
function of related components of the somatic (body
framework) system
• Spinal Facilitation: the maintenance of a pool of
neurons in a state of partial or sub threshold
excitation ; in this state, less afferent stimulation is
required to trigger the discharge of impulses
– These could be premotor neurons, motor neurons, or
preganglionic sympathetic neurons in one or more segments in the
spinal cord
– Once established, facilitation can be sustained by normal central
nervous system (CNS) activity
– This theory helps explain the neurophysiological mechanisms
underlying the neuronal activity associated with somatic
dysfunction
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Definitions you should be familiar with:

• Osteopathic manipulative treatment (OMT) : the therapeutic

application of manually guided forces by an osteopathic
physician to improve physiologic function and/or support
homeostasis that has been altered by somatic dysfunction
• Viscerosomatic reflex: localized visceral stimuli producing
patterns of reflex response in segmentally related somatic
structures
• Somatovisceral reflex: localized somatic stimulation
producing patterns of reflex response in segmentally related
visceral structures

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 Criteria for diagnosing somatic
dysfunctions can be remembered by the
mnemonic “TART”
• Tissue texture abnormalities
• Asymmetry
• Restriction of motion
• Tenderness

Testing thoracic rotation

in flexion
(from Pocket Manual of OMT, LWW 2011)
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 Acute vs Chronic Tissue Texture
Abnormalities
Acute Chronic
Warm/hot Cold/cool
Erythematous/
Pale/prolonged
prolonged red reflex blanching
Muscles may be spasmed Muscles feel fibrotic/ropy
Tissues feel boggy or
Dry/scaley
edematous
Moist/increased tissue
drag
Vasodilation Vasoconstriction
Please note that there was a typographical error in the 3rd Ed of Foundations.
It mistakenly listed ropy as an acute finding. (p.405) Ropiness is a chronic
finding.
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 Motion barriers
• Anatomic: the limit of motion imposed by anatomic structure; the limit of
passive motion
• Physiologic : the limit of active motion
• Direct: may also see it called the restrictive barrier; a functional limit that
abnormally diminishes the normal physiologic range

Neutral
Easy neutral or point of greatest
Direct Barrier relaxation

Physiologic Barrier Physiologic Barrier

Anatomical Anatomical
Barrier Barrier
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OMT may be classified as either
direct or indirect
• Direct techniques are ones in which the
restricted tissue is initially taken in the
direction of the restriction to motion
• Indirect techniques are those that initially
position the tissue away from a barrier
toward relative ease or freedom of motion
• There are techniques that are a
combination of both direct and indirect
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 Neutral
Easy neutral or point of greatest
relaxation
Direct Barrier

Physiologic Barrier Physiologic Barrier

Anatomical Anatomical
Barrier Barrier

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 A patient with asthma has a tissue texture change
bilaterally at the levels of T2-7 that is cool to the touch.
It blanches with pressure and the overlying skin is dry
and scalely. Which of the following phenomena most
likely accounts for this finding?
1. A locked facet
2. Somatic dysfunction
3. Spinal facilitation
4. Somatovisceral
reflex
5. Parasympathetic
innervation
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When a patient with no motion restrictions fully
flexes and extends his elbow, which barriers is
he engaging at the ends of motion?

1. Altered neutral
2. Anatomical
3. Pathologic
4. Physiologic
5. Restrictive

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FRYETTE’S MECHANICS
(physiologic motion of the
thoracic and lumbar spines)

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 Fryette’s Law I
Law I = when the spine is in neutral (easy
normal), sidebending and rotation are in
opposite directions. (Type I Mechanics)

• Occurs in neutral
– (facets not engaged)
• Found in thoracic and lumbar
spines
• Forms long curves, multiple
segments
• Compensatory

DiGiovanna, E. and Shiowitz, S. An

Osteopathic Approach to Diagnosis
21 and
Treatment. 1991: p. 52.
 Fryette’s Law II
Law II = when the spine is flexed or extended
(non-neutral), sidebending and rotation are in the
same directions. (Type II Mechanics)
• Occurs in flexion or extension
– Facets engaged
• Found in thoracic and lumbar spines
– Type II-like motion in typical cervical spine
• Usually single segments
• Found at apices and crossovers
and/or sites of viscerosomatic reflexes
• Primary somatic dysfunction
– Due to strain or viscerosomatic reflex DiGiovanna, E. and Shiowitz, S.
An Osteopathic Approach to
Diagnosis and Treatment. 1991:
p. 53.
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 Fryette’s Third Law
Law III = when motion introduced in one plane it
modifies (reduces) motion in other two planes

• When a segment is brought

up to a restrictive motion
barrier it will move in the
position of greatest ease in
the other two planes.

Essig-Beatty, D. Pocket Manual

23 of
OMT, LWW 2011
 Type I Somatic Dysfunctions
• Posterior transverse process and paravertebral
fullness visible when spine is in neutral.
• Asymmetry not significantly altered by
flexion/extension.
• Sidebending and rotation opposite directions.

Sidebending right
Rotation left
DiGiovanna, E. and Shiowitz, S. An
Osteopathic Approach to Diagnosis and
Treatment. 1991: p. 52.
24
 The facets are engaged with type II
mechanics Neutral

• During flexion the facets

open
• During extension the
facets close

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 Type II Mechanics
Extension Somatic Dysfunction

• Let’s assume the right facet is

locked closed
• In extension - no asymmetry
– Both facets can close easily.
– No apparent rotation or
sidebending asymmetry.
– Most comfortable position for
the patient.

Netter Presenter: 2001.

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 Type II Mechanics Extension Somatic
Dysfunction

• In flexion
– Left facet can open freely
– Right facet locked closed - cannot open freely.
– Pivots around the right facet;
• Rotates and sidebends to the right.
• Exaggeration of the asymmetry
• Motion restriction =
– Restriction Flexed, Rotated left, Sidebent left
– Restriction FRS left
• Somatic dysfunction =
– Extended, Rotated right, Sidebent right
– ERS right
Netter Presenter: 2001.
• Position of ease
• Position of laxity
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 Type II Mechanics
Flexion Somatic Dysfunction
• Let’s assume the right
facet is locked open
• In flexion - no asymmetry
– Both facets can open easily.
– No apparent rotation or

sidebending asymmetry.
– Most comfortable position

for the patient. Netter Presenter: 2001.

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 Type II Mechanics
Flexion Somatic Dysfunction
• In extension
– The left facet closes
normally.
– The right facet locked open;
• Cannot close freely.
– Sidebending and rotation
to
the left.
• Motion restriction =
– Restriction ERS right
• Somatic dysfunction =
– FRS left
Netter Presenter: 2001.

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 Memory Aid
Type 1: Type 2

N F
Sidebending and Rotation
E
opposite directions Sidebending and Rotation
same directions
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Type I Somatic Dysfunc. Type II Somatic Dysfunc.
Neutral; sidebending and rotation Flexion or extension; sidebending
opposite sides and rotation to same side.
FR(R)S(R), ER(R)S(R),
NS(R)R(L) or NS(L)R(R)
FR(L)S(L), or ER(L)S(L)
Facets not engaged Facets engaged
Multiple segments, long curves Single segments

Compensatory, adaptive Primary/traumatic/ viscerosomatic

Rotation toward convexity, out from Rotation towards the concavity,

under the load into the load
Apices and crossovers,
Smooth curves viscerosomatic reflexes

Treat last after Type II, if necessary Treat first

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 A patient with upper back pain is found to have
the right posterior transverse process at T3. This
asymmetry increases with extension. Which of
the following accounts for this?
1. Left facet is locked
closed
2. Left facet is locked
open
3. Right facet is locked
closed
4. Right facet is locked
open
5. The facets are not
32
engaged
Posture, scoliosis and postural x-
rays

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 Posterior static postural exam
The vertical line should normally pass:
1. halfway between the knees;
2. along the gluteal fold;
3. through all spinous processes;
4. along the midline of the head;

Observe for horizontal levelness of:

popliteal creases; greater trochanters; iliac
crests; inferior angles of scapula, tops of
shoulders, and mastoid processes.

Observe for symmetry of: foot rotation; arm

length; arm distance from torso.
Common abnormalities: Foot external rotation, pes
planus (fallen foot arch), iliac crest asymmetry,
pelvic side shift, thoracolumbar scoliosis,
shoulder height asymmetry, head tilt.

Beatty The Pocket Manual of OMT, LWW342011

Lateral static postural exam
• The weight bearing line should
normally pass through:
• 1) just anterior to lateral malleolus

• 2) middle of tibial plateau

• 3) greater trochanter
• 4) body of L3 (center of body
mass)
• 5) middle of humeral head
• 6) external auditory meatus

Common abnormalities:
Anterior head carriage, shoulders
anterior or posterior, thoracic
hyperkyphosis, lumbar
hyperlordosis, anterior pelvic
weight bearing.

Beatty The Pocket Manual of OMT,

LWW 2011 35
Hip drop test (lumbar sidebending screening)

• Ask the standing patient to shift

weight onto one leg, allowing the
other knee to bend which induces
lumbar sidebending toward the
weight bearing leg;
• Observe lumbar sidebending and
amount of hip drop which is normally
≥ 25°;
• Hip drop < 25° (positive test)
indicates restricted lumbar
sidebending toward the side of the
weight bearing leg.
• Test is named for the bent leg side (+
right hip drop test indicates restricted
left lumbar side bending) Ward 2003 Fig 50.20

Beatty The Pocket Manual of OMT, LWW 2011

36
 Scoliosis defined
• Scoliosis is defined as: An abnormal lateral
curvature of the spine in the coronal plane.
 The most common cause for scoliosis is idiopathic,
accounting for 70-90% of all scoliosis cases
• “Idiopathic scoliosis is a diagnosis of exclusion,
and a neural etiology of spinal deformity must be
ruled out in every case.”
– 27% of children with scoliosis have abnormalities of
posterior cranial fossa, spinal cord or central nervous
system
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 Forward bending
(Adams) Test
• Scoliosis is characterized by both
lateral curvature & vertebral
rotation, giving it a characteristic
“Rib Hump”.
– Structural: does not reduce with
side bending toward the rib
hump
– Functional: reduces with side
bending toward the rib hump

This an application of Type 1

mechanics
Ward, Foundations in Osteopathic Medicine, LWW 1997
38
 Determination of Functional vs. structural
scoliosis

• Patient sidebends
into rib hump
• Functional curve: rib
hump diminished

Beatty The Pocket Manual of OMT LWW 2011

39
 Epidemiology of Scoliosis
 10% of children have some spinal asymmetry
 0.2% of children need treatment
• Female: Male ratio varies with the severity of the
scoliosis
– As the Cobb angle increases, so does the female: male ratio

• Most are diagnosed in the preteen to teen years.

• Children and adolescents present with back pain more

often than adults, regardless of the severity.
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 Functional scoliosis –
flexible, postural, compensatory

A common cause of
functional scoliosis is…

SHORT LEG SYNDROME

• Sacrum & pelvis tilt toward the
shorter leg.

• Spine curves back in attempt to

keep eyes level.

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 Functional scoliosis –
flexible, postural, compensatory

• Other known causes…

– Muscle strain
• Tight muscle on one side of spine causes “bowstring
effect”
– Psoas syndrome
• Relaxing & stretching the muscle allows spine to
straighten.
– Weak musculature
• A weak muscle on one side of spine allows opposing
muscles to cause “bowstring effect.”
• Strengthening the weak muscle allows spine to straighten.
42
Naming a Curve: the Convexity
• A scoliotic curve is always named for the
direction of the CONVEXITY.

Convex Concave

• Be sure to identify the location within the spine

of the scoliosis!
– Ex: thoracic, lumbar, thoracolumbar 43
 Patterns of Scoliosis
Double Major Right Thoracic Left Lumbar Right Thoracolumbar

Most common type

Ward, Foundations in Osteopathic Medicine, LWW 1997

44
 Evaluation of scoliosis
• Static postural exam
– Rule out short leg
• Adam’s Test
– Determines side & flexibility
• Neurological Exam
– Rule out underlying neurologic cause
• Radiographs, if indicated
– Scoliosis
– Risser (ossification of iliac crest identified w/ x-ray)
• Lower value = skeletal immaturity = curve more likely to progress.
– Brain MRI
45
 Determination of short leg

Iliac crest height Medial malleoli levelness

Posterior standing postural exam

Beatty The Pocket Manual of OMT, LWW 2011

46
 Scoliosis & Postural X-rays
• Scoliotic X-ray :
– erect AP from occiput to sacral base
– Measurement of Cobb angle
• Postural radiographs:
– Anterior-posterior (AP) - Erect
– Lateral - Erect
– Obliques, when suspect spondylolisthesis (scottie
dog deformity)

47
 Scoliosis X-rays
• Cobb Angle
– Draw lines from the top of
the superior vertebra & the
bottom of the inferior
vertebra into the concavity
of the curve.
– Drop intersecting lines
perpendicular to these
lines & measure the acute
angle.
Medline Plus (National Library of Medicine Consumer Health)
48
 Postural X-rays: lateral
• Lateral View Standing
– Lumbosacral angle
(Ferguson’s angle)
• Normal = 40° + 2°
– Weight bearing line
• Bisect L3, drop a vertical
line. It should fall on
anterior 1/3 of sacral
base

Ward, Robert
C. 1997, p. 49
1127.
 Treatment based on curve severity
• Mild 5-15°
– Conservative, including OMT, exercises & treatment of short leg
• Moderate 20-45°
– Above plus
• Bracing (80% will not progress with bracing)
• Electrical stimulation
• Severe >50°
– Surgical stabilization

 Functional impairment with thoracic curves

 Possible respiratory impairment >50 °
 Possible cardiac impairment >75 °

50
 Will the curve get worse over time?
PROGNOSTIC FACTORS:
• Future growth potential
– Age at diagnosis
– Risser sign (ossification of iliac crest identified w/ x-ray)
• Lower value = skeletal immaturity = curve more likely to progress.
– Menarche in females
• Growth spurt (critical time for curve increase) occurs 12-18
months prior to menarche.
• Curve severity at diagnosis
• Curve patterns
– Thoracic curves have higher risk for progression than lumbar
• Gender: Females more likely to have curve progression.

51
 A patient has a left rib hump in the upper thoracics
that does not improve with left sidebending. How
would you describe this scoliotic curve.?

1. Functional left thoracic

2. Functional right
thoracic
3. Structural left thoracic
4. Structural right thoracic
5. Thoracic spinal
asymmetry

52
Take 10 minutes

53
Principles of OMT Techniques

54
 Principles of OMT
• Indirect techniques • Direct techniques
(move into position of (move into restriction)
laxity) – Soft tissue
– Counterstrain – Direct myofascial
– Indirect myofascial release
release – Direct cranial
– Indirect cranial – Muscle energy
– HVLA
• Combined Techniques
• Articulatory
• Visceral
55
 There are only 2 absolute
contraindications to OMT
1. The absence of somatic dysfunction
2. The patient refuses to have OMT performed
- to do so would be considered battery

56
Counterstrain - A system of treatment by positioning

1) Find and label tender

point 10/10
2) Position to relieve
tenderness (2/10 or less)
3) Fine-tune to 0/10 if
possible
4) Hold position for 90
seconds (some schools
teach 120 seconds for the
ribs only)
5) Slow passive return to
neutral
6) Retest tender point

57
(photos from Pocket Manual of OMT, LWW 2006)
 Counterstrain Principles
• Patient must be able to relax for the treatment to work
• Treat the worse tender point first
• The monitoring finger is only monitoring
– So don’t be pushing with it during the treatment
• Don’t move your monitoring finger until the treatment is
finished
• Some points may be “mavericks”
– Positioned completely opposite of what you would expect based
on the anatomy
• Limit treatment to 5-6 tender points
per visit
58
The location of counterstrain tender points can be
suggested by the clinical history and presenting
complaints
• Patient tends to bend around tender points – If the
patient presents forward bent, tender points tend to
be anterior
– The body is trying to be in the most comfortable position
• The location can also be suggested by the position
the patient was in when the original injury occurred

59
 Not everything that is tender is a
“counterstrain” tender point
• Counterstrain tender point
– Usually tender
– may be palpable tissue texture changes
– non-radiating
• Chapman’s points
– Usually tender if positive
– that present as anterior and posterior fascial tissue texture abnormalities assumed to
be visceral dysfunction or pathology (Glossary of Osteopathic Terminology)
– Viscerosomatic reflex
– Helps to know the locations!
• Trigger points
– Usually tender
– a small hypersensitive site that, when stimulated, gives rise to referred pain
(radiating pain) and/or other manifestations in a consistent reference zone

60
 Review the counterstrain treatment
positions in your lab book
• Cervical spine
• Thoracic spine
• Lumbar spine
• Upper extremity
• Lower extremity

61
Myofascial Release
1) Diagnose restricted motion
2) Slowly move into position
of laxity and follow release
until completed (indirect)
3) Slowly move into
restriction and stretch until
tissue give completed
(direct)
4) Retest motion

(photos from Pocket Manual of OMT, LWW 2006) 62

 Is there an indirect barrier?
Indirect Direct
methods methods

Point of Neutral
balanced
tension

Direct or restrictive barrier

Physiological barrier Rotation right
Rotation left
restricted Physiological barrier
normal
Anatomical
barrier
Anatomical barrier

63
 Considerations in Myofascial Diagnosis and
treatment
• Sherrington’s Law:
– When a muscle receives an nerve impulse to contract, its antagonists
receive, simultaneously, an impulse to relax.
• Wolff’s Law:
– Fascia will deform as a result of the lines of force to which it has been
subjected.
• Tensegrity
– Myofascial release (myofascial unwinding)
• “Local” treatment produces changes in other parts of the body.
– Fascia moves as a unit in a tensegrity matrix down to the cellular
level.
– Mechanical forces into fascia transmitted throughout the entire
organism.

64
 Fascial Continuity
“Fascial Sweater” Concept

• Fascial restrictions in one area

will strain areas away from the
restriction causing abnormal
movement patterns.

Cantu, R., Grodin, A. Myofascial

Manipulation: Theory and Clinical
Application. 1992, p. 19.
65
Fascial continuity and tensegrity come into play
during myofascial release (MFR) treatments

• Injury to fascia at one location is carried

through the whole fascial tissue.
• OMT to fascia at one level is carried through the
whole of fascial tissue.
• MFR engages tensegrity structure of the body.

66
 Cranial Manipulation
• Osteopathy in the cranial field
– Frontal and parietal lifts
– SBS compression-decompression
– Temporal decompression
– Compression of the 4th ventricle
– Balanced membranous tension
(Ligamentous articular strain)
– Sutural disengagement
– TMJ compression/decompression
– Occipital decompression
• Lymphatic and facial techniques
– Venous sinus drainage
– Facial effleurage
– Trigeminal stimulation
– Sphenopalatine ganglion stimulation
– Mandibular drainage

67
(photos from Pocket Manual of OMT, LWW 2006)
 Muscle Energy Technique
1) Diagnose restriction
2) Move into restrictive
barrier
3) Isometric contraction
away from the restrictive
barrier 3-5 seconds
4) Stretch until give stops
5) Repeat 3-5 times
6) Retest motion

68
(photos from Pocket Manual of OMT, LWW 2006)
 There are several types of muscle
contractions
• Concentric contraction – contraction of muscle resulting in
approximation of its attachments (counterforce is less than the
patient force)
– Isokinetic: a concentric contraction against resistance in which the angular
change of joint motion is at the same rate
– Isotonic: a from of concentric contraction in which a constant force is applied
• Eccentric contraction – lengthening of muscle during contraction due
to an external force (counterforce is greater than the patient force)
– Isolytic: a form of eccentric contraction designed to break adhesions using an
operator-induced force to lengthen the muscle
• Isometric contraction – change in the tension of the muscle without
approximation of its attachments (counterforce is equal to the patient
force)

69
 How does muscle energy work?
• Tissue creep
– constant load causes tissue give
• Conditioning
– less tissue resistance with repeated stretch
• Post-isometric relaxation
• Reciprocal inhibition
– reflex relaxation of antagonist

70
 Articulatory Technique
1) Diagnose restricted joint
motion
2) Slow movement of joint
to its position of laxity for
all planes
3) Slow movement of joint
into its restriction for all
planes
4) 3-5 repetitions as one
smooth movement
5) Retest motion

71
(photos from Pocket Manual of OMT, LWW 2006)
HVLA Technique

1) Diagnose restriction
2) Move into
restrictive barrier
for all planes
3) Short quick
movement through
barrier
4) Retest motion
(photos from Pocket Manual of OMT, LWW 2006)

72
Soft Tissue Technique
•Traction – longitudinal muscle
stretch
•Kneading – lateral muscle
pressure
•Inhibition – sustained muscle
pressure
•Effleurage – stroking pressure
to move fluid
•Pétrissage – squeezing
pressure to move fluid

Thoracolumbar kneading/traction
(from Pocket Manual of OMT, LWW
2006)

73
Visceral Treatment
• Autonomic normalization
– Sympathetic techniques
– Parasympathetic techniques
• Lymphatic treatment
– Diaphragm release
– Lymphatic pumps
– Effleurage/pétrissage
• Visceral treatment
– Ventral techniques
– Visceral manipulation

(photos from Pocket Manual of OMT, LWW 2006)74

 Manipulative Prescription
Acute/Severe Chronic
Problem Problem
METHOD Indirect Any technique
techniques including direct
DOSE Fewer regions, More regions,
lower dose higher dose
FREQEUNCY 1-2 treatments Every 2-6
per week weeks
DURATION 2-4 treatments As long as
helpful
75
 A patient presents with left elbow pain. Examination
shows restriction in abduction of the ulnohumeral joint.
How would you position the patient for a direct
myofascial release?
1. Glide the ulnohumeral joint
into abduction, hold steady
pressure until a release is
felt
2. Glide the ulnohumeral joint
into adduction, hold steady
pressure until a release is
felt
3. Move the ulnohumeral
joint into a position of
laxity in all planes and then
add compression or
traction 76
 Fascial Diaphragms
The Common Compensatory
Pattern
and
Lymphatic Pumps

77
 Common Compensatory Pattern
• Developed by J. Gordon Zink, D.O.
• Utilizes the respiratory-circulatory model.
• Identifies four patterns of body structure.
– Ideal
– Common compensatory
– Uncommon compensatory
– Uncompensated
• Treatment approach
– Emphasis on crossover points of spinal curves.
• Transverse fascial diaphragms

78
 Common Compensatory Pattern
Transverse Fascial Diaphragms

• Pelvic diaphragm (L5-S1)

• Thoracic diaphragm (T12-L1)
• Thoracic inlet (T1, 1st rib)
• Suboccipital region (OA, AA)

79
 Transverse Fascial Diaphragms

Pelvic Diaphragm Thoracic Diaphragm

Beatty The Pocket Manual of OMT. LWW. 201180

 Transverse Fascial Diaphragms

Thoracic Inlet Suboccipital

Beatty The Pocket Manual of OMT. LWW. 2011

81
 Common Compensatory Pattern

Common Uncommon Uncompensated

Compensatory Compensatory
Kuchera, W. Osteopathic Principles In Practice. 1991: p. 47.
82
 Common Compensatory Pattern

Always start off on your right foot.

/A A

L1
2-
OA

L5-
T1
C7-T

1S
1

Ward, R. FOM. 1997: p. 505

83
 Common Compensatory Pattern
Order of Treatment

• Treat uncompensated findings first.

– Treat the worst first.
• Treat the compensatory findings with goal of approaching
ideal structure.

84
Deep Lymphatic Circulation Drainage

85
 Junction with Venous System
Right Lymphatic Duct Thoracic Duct
• Drains RIGHT upper • Drains LEFT upper
body body and all LOWER
body
• Crosses Thoracic
Inlet Once • Crosses Thoracic
Inlet Twice
• Drains into
jugulosubclavian • Drains into
junction subclavian and left
brachiocephalic vein
junction
86
 Lymphatic Pumps
• Intrinsic
– Lymphangions
– Vessels contract 6-8 times per minute
• Affected by autonomics
• Extrinsic: direct external pressure on vessels
– Diaphragms
– Respiration
– Peristalsis
– Arteries adjacent to lymphatics
– Body movement
• Vigorous exercise increases flow 15-20x
– External compression
• Bandages, water emersion, manual therapies
including OMT 87
Osteopathic Goals for the Lymphatic System

• Approach tailored to patient needs

• Remove restrictions (proximal to distal)
– Treat transverse fascial diaphragms
– Treat fascial restrictions
– Normalize autonomic activity
• Rib raising
• Suboccipital Inhibition
• Sacral rocking

88
Osteopathic Goals for the Lymphatic System

• Promote and adjust flow

– Pressure techniques
• Compression stockings
• Pétrissage (kneading/squeezing)
• Effleurage (Stroking)
• Soft tissue Mesenteric
Lift
• Abdominal lifts
– Pump techniques (distal to proximal)
• Pectoral traction
• Thoracic pump
• Abdominal pump
• Pedal pump (also called the Dalrymple treatment)
• Liver/Spleen pump
89
Viscerosomatic Reflexes

90
 Viscerosomatic Reflexes
EXAM Acute Findings Chronic Findings

Temperature Hot Cool

Tissue texture Moisture, fullness, Thickness, dryness,

edema, tension ropiness, pimples

Red reflex Increased or Prolonged blanching

prolonged
redness

91
 Autonomic Innervation
Organ Sympathetic Parasympathetic
Head and neck T1-4 Vagus
Cardiovascular T1-5 Vagus
Respiratory T2-7 Vagus
Stomach, liver, gall T5-9 Vagus
bladder
Small intestine T9-11 Vagus
Pancreas T5-T11 Vagus
Ovary, testicle T9-10 Vagus,S2-4
Kidney, ureter, bladder T10-L1 Kidneys (vagus)
ureter bladder S2-4
Large intestine T8-L2 Vagus, S2-4
Uterus T10-L1 S2-4
Prostate L1-2 S2-4

92
 A couple of omissions you could possibly see on
boards
(you won’t be asked this on the final)
Organ Sympathetic Parasympathetic
Arm T2-7 None
Leg T10-L2 None

93
 Treatment of sympathetic component of thoracic
visceral disease with rib raising

• Sympathetic chain
ganglia just anterior
to rib heads
• Constant or
repetitive lift of rib
angles stimulates
chain ganglia
RIB RAISING
(from Pocket Manual of OMT, LWW 2006)
94
 Treatment of sympathetic component of bowel
dysfunction with abdominal plexus inhibition

• Push posteriorly into celiac,

superior mesenteric, or
inferior mesenteric
ganglion
• Hold until tissue release,
about 10-20 seconds
• Ganglion inhibition is
contraindicated in patients
with peritonitis, bowel
obstruction Abdominal Plexus Inhibition
(from Pocket Manual of OMT, LWW 2006) 95
 Treatment of parasympathetic component of
visceral disease
• Upper cervical soft tissue (suboccipital inhibition)
• Sacral rocking

(from Pocket Manual of OMT, LWW 2006)

96
Chapman Reflexes

• Treat posterior points

– Anterior points may also be
treated but often to sensitive
and uncomfortable for patient
• Light rotatory massage with your
fingertip
• Treat about 10-30 seconds
• Treat 2 or 3 times each day for best
results

(from Pocket Manual of OMT,

LWW 2006)

97
Chapman Reflexes Colon

98
Ward, R. Foundations for Osteopathic Medicine . 2003: p. 1053.
Somatic Dysfunctions by Body Region

99
Somatic Dysfunctions of the
Lower Extremity

100
The ankle has both an upper and lower joint
that act together as a functional unit

• Upper joint is tibiotalar (talocrural)

• Lower joint is the subtalar (talocalcaneal)
• The upper joint involves the talus moving in
the ankle mortise
• The major motions of the of the tibiotalar
joint is described as dorsiflexion and plantar
flexion

101
 Ankle (talotibial) Mechanics

• Talus glides anteriorly

with plantar flexion
• Talus glides posteriorly
with dorsiflexion

Courtesy of Drs. James Wells & John Sharp

102
 Ankle Swing Test
• Tests for talus anterior glide
somatic dysfunction:
– Hold feet horizontally and
push them posteriorly.
– Tests ankle dorsiflexion and
posterior talus glide
– Positive swing test=
restricted posterior talus
glide= anterior talus =
plantar flexed ankle =
restricted ankle dorsiflexion
Pocket Manual of OMT 2006, pp. 47 103
Review the major ankle counterstrain points
for location and treatment position
• Extension ankle- gastrocenimus counterstrain with pt
on stomach and push foot into your thigh
• Lateral ankle – tenderpoint on the lateral
malleoulous - inferior and superior- eversion of foot
by push calcaneuous to the floor while pt lying on
problem side
• Medial ankle- pt lying on opposite side of the
problem – tenderpoint inferior to the medial
malleoulous – tx with inversion of the foot

104
• The common somatic
dysfunctions in the foot
are inversion somatic
dysfunctions of the
navicular and cuboid
bones

From Chilia Foundations of Osteopathic

Medicine 3rd Ed. LWW 2011
105
106
The major motions of the knee (tibiofemoral)
are flexion and extension

• Minor motions
– Anterior and posterior glide
– Medial and lateral glide
– Internal and external rotation
• Flexion results in an anterior glide of the
tibial plateau
• Extension results in posterior glide of the
tibial plateau

107
A tibia anterior somatic dysfunction means that
there is restricted posterior glide in that knee

• This could cause

– Restriction in knee
extension
– Pain at the end of knee
extension

108
 A tibia posterior (or posterior tibia) somatic
dysfunction means that there is restricted
anterior glide in that knee
• This could cause
– Restriction in knee flexion
– Pain at the end of knee flexion

109
The proximal tibiofibular joint is a separate
synovial joint at the knee

From Chilia Foundations of

Osteopathic Medicine 3rd Ed. LWW
2011 110
Fibular head dysfunction is checked by gliding the
fibular head anterolateral and posteromedial

• Fibular head anterior

somatic dysfunction =
fibular head
posteromedial glide
restriction
• Fibular head posterior
somatic dysfunction =
fibular head anterolateral
glide restriction
From Beatty The Pocket Manual of
111
OMT 2nd Ed. LWW 2011 p. 55
 When the fibular head glides anteriorly,
reciprocal motion occurs at the distal fibula
(lateral malleolus) which glides posteriorly
• Posterior fibular head motion is
accompanied by anterior motion of
the distal fibula
• External rotation of the tibia
carries the distal fibula posteriorly
and glides the fibular head
anteriorly
• The opposite occurs with internal
rotation of the tibia
• Eversion of the foot glides the
distal fibula posteriorly and the
fibular head anteriorly
• Inversion of the foot glides the From Beatty The Pocket Manual
distal fibula anteriorly and the of OMT 1st Ed. LWW 2006
fibular head posteriorly 112
Because of this reciprocal motion, fibular head
dysfunction often occurs with ankle sprains
• Inversion ankle injuries
are most common
• Failure to evaluate and
treat the fibular head can
cause continued pain in
the lower leg that persists
after the sprain has healed
• Review the treatment of
fibular head somatic
dysfunctions
From www.americaspodiatrist
.com
113
Review the major knee counterstrain points
for location and treatment position
• Patellar tendon- hyperextend knee slightly
• Medial meniscus- locate TP and flex knee and hold ankle –
slight internal rotation tibia and adduction to fine tune
• Lateral meniscus- locate TP and flex knee with external
rotation and abduction to fine tune
• Anterior cruciate- locate TP on distal medial hamstring then
push down on the proximal tibia with pillow under the thigh
• Posterior cruciate-locate TP near the fibula and place pilow
under the tibia nad fibula while press down on upper knee
right below the thigh

114
 Somatic dysfunctions of the Hip (femoral
acetabular Joint)
Somatic Dysfunctions Motion Restriction
(position of laxity)

Hip abduction Hip adduction

Hip adduction Hip abduction

Hip extension Hip flexion

Hip flexion Hip extension

Hip external rotation Hip internal rotation (posterior glide)

Hip internal rotation Hip external rotation (anterior glide)

115
 Prime movers of the hip joint
Action Muscles Involved
Abduction Gluteus medius and minimus
Adduction Adductor longus and brevis, and magnus, gracilis
Flexion Iliopsoas
Extension Semimembranosus, semitendinosus, biceps femoris, gluteus
maximus
External rotation Piriformis, obturator externus and internus, superior and inferior
gemelli
Internal rotation Gracilis and anterior portions of gluteus medius and minimus

116
Review the major hip counterstrain Points
for location and treatment position
• lateral trochanter- check entire IT badn- abduct
the leg with slight external rotation –pg 30
• Piriformis-halfway between sacral base and
greater trochanter in middle butt cheek-flex hip
to 90 and abduct and externally rotate
• Iliopsoas- pg 71- about halfway between ASIS and
umbilicus anterior – cross pt legs and flex knees
like indian style until not tender
117
 A patient is noted to have her left hip restricted in
extension. Which muscle would the patient contract
during a muscle energy treatment?

1. Piriformis
2. Gluteus medius
3. Iliopsoas
4. Biceps femoris
5. Semimembranosus

118
Take another 10 minute break

119
Somatic Dysfunctions of the
Pelvis and Sacrum

120
 Key Anterior Pelvic Landmarks
• Iliac Crests
• Anterior Superior Iliac
Spine
• Anterior Inferior Iliac
Spine
• Pubic symphysis

www.anatomyatlases.org/atlasofanatomy/plate03

From Netter Presenter

121
Key Posterior Pelvic Landmarks

• Posterior Superior
Iliac Spine
• Ischial Tuberosities

122
 Somatic Dysfunction of the Pelvis
Lateralization- determines the side on
which to record one’s findings.
– determines the SI joint that is
dysfunctional.

The lateralizing tests, in order from least

specific to most specific, include:
– standing flexion test (hamstrings,
innominates, sacrum, spine)
– seated flexion test (innominates,
sacrum, spine)
– compression test (innominates, sacrum)

Pocket Manual of OMT 123

 Diagnosing the Pelvis
• Standing flexion test and ASIS
compression test both indicate side of
restriction
– Diagnosis named as assigned by positive
test.
• After you know which side is restricted,
you simply need to interpret the
landmarks.
124
 Physical Exam
• Standing Flexion Test
– Positive test last side that
moves with flexion side of
iliosacral restriction
• The side of last superior PSIS
movement is the side of
pelvis restriction;
• Could be caused by iliosacral
dysfunction, short leg,
contralateral hamstring
tightness.
Pocket Manual Of OMT
125
 ASIS COMPRESSION TEST
• With the patient supine, place
your palms on the anterior
superior iliac spines (ASIS);
• Push posteromedially on one
ASIS while monitoring the other
ASIS and repeat for the
opposite side;
• Resistance to posteromedial Pocket Manual of OMT
pressure indicates sacroiliac
joint restriction on that side.

126
Foundations for Osteopathic Medicine
 Superior Innominate Shears
• Side of the dysfunction is
determined by the standing
flexion test and/or ASIS
compression test
– Left side in the example pictured
• All of the static landmarks on
the side of the dysfunction are
shifted superiorly
– ASIS, pubic bone, PSIS, iliac crest
www.anatomyatlases.org/atlasofanatomy/plate03...

Left superior innominate shear

127
 Inferior Innominate Shear
All of the landmarks are
inferior compared to the
opposite side

www.anatomyatlases.org/atlasofanatomy/plate03...

128
 Anterior and Posterior Innominate
Rotations
• For example:
• Positive ASIS compression test on
the right.
Dysfunction is on the Right
• Right ASIS inferior
• Right PSIS superior Anterior
Right Anterior Innominate rotation
• Associated Clinical Findings:
• Ipsilateral tight hamstrings, tight www.anatomyatlases.org/atlasofanatomy/plate03...

iliolumbar ligament. May be

accompanied by symptoms of sciatica
(piriformis dysfunction)

129
 Right Ilium Inflare
ASIS Compression test
Positive on the Right
– Dysfunction is on the right
side
Right ASIS closer to midline
relative to left
– Right innominate inflare
www.anatomyatlases.org/atlasofanatomy/plate03...

130
 Left Lateral Innominate Outflare
Positive ASIS compression test
left
• Dysfunction is on the Left
Left ASIS further from midline
relative to right
• Left innominate outflare

www.anatomyatlases.org/atlasofanatomy/plate03...

131
 Pubic somatic dysfunctions are usually
tender
• described as
• superior pubic shear
• inferior pubic shear
• pubic compression

From The Pocket Manual

of OMT 2nd Ed. p. 84

132
 Anterior inferior superior - -
innominate
Posterior superior inferior - -
innominate
Superior superior superior - -
innominate
shear
Inferior inferior inferior - -
innominate
shear
Innominate Medial Lateral - -
Inflare
Innominate Lateral Medial - -
Outflare
Pubic - - tender symmetrical
compression
Superior Pubic tender Superior
Shear
Inferior pubic tender inferior
shear

133
 Review the treatment of pelvic somatic
dysfunctions in your lab book

• Think not only of treatment positions

• Think of anatomical considerations
– Which ways does the patient push
– Which muscle is the patient contracting

134
 Sacral Somatic Dysfunctions
• Sacroiliac joint provides
stability for weight transfer
from trunk to pelvis and
lower extremities.
• Sacroiliac joint also
provides slight mobility in
complex mechanism of
ambulation
• The shape of the sacrum is
mostly responsible for the
somatic dysfunctions

135
 Sacral motion
Sacral base moves
posteriorly:
1. Anatomical
extension
2. What occurs as
the SBS flexes
Sacral base moves
(craniosacral
anteriorly:
flexion)
1. Anatomical
3. Counternutation
flexion
2. What occurs as
the SBS
extends
(craniosacral
extension)
3. Nutation
136
 Physical Exam
• Seated Flexion Test
– Positive test last side that
moves with flexion side of
iliosacral restriction
• The side of last superior PSIS
movement is the side of
pelvis restriction;
• Could be caused by
sacroiliac dysfunction

Pocket Manual Of OMT

137
 Key Sacral Landmarks
• Sacral Base

• Inferior Lateral Angle

From Netter Presenter 138

 Axes of Sacral Motion
• Superior Transverse
Axis (S1)
• Middle Transverse Axis
(S2)-Postural motion
• Inferior Transverse axis
(S3)- movement of illa
on the sacrum
• Left Oblique Axis
• Right Oblique Axis
• Vertical Axis
From Netter Presenter
139
 Axes of Sacral Motion
• Superior Transverse Axis
(S2)
• Axis of movement during
respiration
– Inhale-spine elongates
sacral base posterior
– Exhale- spine recoils  sacral
base anterior
• Axis of movement of Cranial
Rhythmic Impulse
– Cranial FlexionSacral base
extends/
counternutates/posterior
– Cranial Extension sacral
base flexes/nutates/ anterior From Glossary of
Osteopathic
Terminology April 2009
140
 Axes of Sacral Motion
• Middle Transverse Axis
(S2)-Postural motion
• The motion the sacrum
undertakes during
flexion or extension of
the torso
• Forward bending
base anterior
• Backward bending
From Glossary of
base posterior Osteopathic
Terminology April 2009
141
 Axes of Sacral Motion
• Inferior Transverse (S3)
– movement of ilium on
the sacrum
– Occurs during
innominate rotations

From Glossary of
Osteopathic
Terminology April 2009
142
 Axes of Sacral Motion
• Vertical Axis
– Right margin posterior
– Left margin posterior

From Netter Presenter

143
 Axes of Sacral
L
Motion R

• Oblique Axes (Left and

Right)
• Forward Rotation
– Right rotation on right
oblique axis
– Left rotation on left oblique
axis
• Backward Rotation
– Right rotation on Left oblique
axis
– Left rotation on right oblique
axis
• Oblique axes are important
component of gait cycle
From Netter Presenter
144
 Axes of Sacral Motion
Gait Cycle
• Right Heel strike
– Left rotation on left axis
– Lumbar spine sidebends to the
left
• Left Heel Strike
– Right rotation on right axis
– Lumbar spine sidebends to the
right
• Maintenance of normal L-on-
L and R-on-R sacral
movement is an important
therapeutic objective.
Right Heel Strike

From Pocket Manual of OMT 145

 Diagnosis of Sacral Somatic Dysfunction

Diagnosis is based on systematic evaluation of three

components:
1. Asymmetry of paired sacral landmarks
2. Asymmetry of range of motion of sacroiliac joint as
evidenced by:
• Seated flexion test and/or ASIS compression test
• Backward bending test/Lumbosacral springing test
3. Tissue texture changes
• In deep fascia and ligaments over SI joints
• Within the sacrotuberous ligaments
• Gluteal and peroneal muscles

146
 Sacral Somatic Dysfunction
• Sacral torsions – oblique axis of rotation
– Forward torsions- R on R, L on L
– Backward torsions- R on L, L on R
• Sacral flexions
– Unilateral sacral flexion
– Bilateral flexion
• Sacral extensions
– Unilateral sacral extension
– Bilateral extension

147
A patient presents with low back pain.
Osteopathic examination shows a positive
seated flexion test on the right, an anterior
sacral base on the left, a posterior/inferior ILA
on the right with a positive backward spring
test. What is the somatic dysfunction?

1. Left on left sacral torsion

2. Left on right sacral rotation
3. Right on left sacral torsion
4. Right on right sacral torsion
5. Left on left sacral rotation
148
 Somatic Dysfunctions of the
Lumbar Spine and Thoracic Spines

149
 Anatomy to Review
• Iliopsoas Muscle
• Erector spinae
– Iliocostalis
– Longissimus
– Spinalis
• Quadratus lumborum
• Multifidus
• Latissimus dorsi
• Rectus abdominis
• Facet orientation

150
Viscerosomatic Reflexes Associated with the
Lumbar Spine

• Sympathetic
– Location: L1 and L2
– Organs innervated: distal colon, pelvic organs,
and lower extremity
• Parasympathetic
– Not present in the lumbar spine

151
 Posterior Lumbar Counterstrain Tender
Points

• Occur in 2 sets
– Along the spinous and
transverse processes
– Second group associated
with the ilium
• All are treated in a similar
matter with the exception
of the lower pole L5
tender point

From Beatty The Pocket Manual of OMT

2nd Ed. Lippincott Williams and Wilkins
152
Philadelphia 2011 p. 114
 Anterior Lumbar Counterstrain Tender
Points
• Occur in 2 sets
– Midline (T9-T11)
– Along the ilium
(T12-L5)
• L2, L3, and L4 are all
clustered around the AIIS
and are differentiated by
the direction in which you
push
• Treated in similar manner

From Beatty The Pocket Manual of OMT

2nd Ed. Lippincott Williams and Wilkins
153
Philadelphia 2011 p. 114
 Rule of 3s
• The Rule of Threes: the relationship of the
spinous process tip to underlying bony
structures

1. T1-T3: same level as its vertebral body

2. T4-T6: 1/2 vertebral level down
3. T7-T9: 1 vertebral level down
4. T10-T12: same level as its vertebral body

154
Review the Anterior and Posterior Thoracic
Counterstrain Tender Points and Treatment
Positions
• Remember that the anterior
thoracic tender points are
midline only from T1-4

Beatty The Pocket Manual of OMT LWW

2011
155
 Don’t forget the sympathetic
innervation levels in the thoracic
spine

156
Somatic Dysfunctions of the Ribs

157
 Diagnose rib dysfunctions as:
• Rib 1 elevation or
depression
• Ribs 2-10
– Inhalation or exhalation
– Anterior or posterior
subluxation
• Ribs 11-12
– Inhalation or exhalation
Rib 1 moves superior with
inhalation, inferior with
exhalation
(The Pocket Manual of OMT 2nd Ed.
LWW 2011) 158
Review the Rib Counterstrain Tenderpoint
Locations and Treatment Positions

Beatty The Pocket Manual of

OMT, LWW 2011 159
 Typical ribs have 5 articulations:
• Costovertebral
– Two demifacets
except ribs 1 and 10-
12
• Costotransverse
• Costochondral
– Except ribs 11-12
• Chondrosternal (Drawing by William A. Kuchera, DO, FAAO from
The Pocket Manual of OMT 2nd Ed., LWW 2011)
– Except ribs 8-12

160
 Ribs sublux anteriorly or posteriorly

pothole

Anterior
subluxation

Posterior
subluxation

Speed bump

From Netter Presenter 161

Review Muscle Energy Treatment for the Ribs

• Include the muscles being

contracted by the patient
during the treatment
• Remember to treat the key
rib

Beatty The Pocket Manual of OMT LWW 2011

162
Rib 1 is anterior or middle scalene
Posterior scalene rib 2 exhalation
Ribs 3-5 pectorals minor

163
Serratus anterior ribs 6-10 exhalation
Quadratus lumborum ribs 11-12

164
 Reminders on Sequencing
Treatment of the Thoracic Spine
and Ribs
• First treat thoracic spine
– type II, then type 1
• For a group of respiratory ribs, treat the
key rib:
• top rib for exhalation somatic dysfunction
• bottom rib for inhalation somatic dysfunction

165
Take a break

166
Somatic Dysfunctions of the
Upper Extremity

167
 The shoulder complex is made up of more
than just the glenohumeral joint

• Scapulothoracic joint
• Acromioclavicular joint
• Sternoclavicular joint
• Sternocostal joint
• Costovertebral joint
• Glenohumeral joint

From Shoulder Pain 3rd Ed., Cailliet

168
 Review Muscular Anatomy of the Shoulder Complex

• Know your attachments and biomechanics of:

– Rotator cuff muscles: supraspinatus, infraspinatus,
teres minor, subscapularis= SITS
– Other stabilizing muscles: trapezius, serratus
anterior, and rhomboids
– Prime movers: pectoralis major/minor, latissimus
dorsi, teres major, triceps, biceps, and deltoid

169
170
Rotator cuff muscles= SITS

171
172
173
Prime movers of the glenohumeral joint
Action Muscles Involved
Abduction Supraspinatus, middle portion of the deltoid
Adduction Pectoralis major, latissimus dorsi, teres major, subscapularis
Flexion Coracobrachialis, anterior portion of deltoid
Extension Posterior deltoid, latissimus dorsi
External rotation Infraspinatus, teres minor, posterior portion of deltoid
Internal rotation Subscapularis, teres major, pectoralis major, anterior portion of
deltoid

174
175
Review the Spencer Technique:
including anatomy

176
Ratio 2:1 during abduction of the arm between the
glenohumeral joint and the scapulothoracic joint

• For every 3 of abduction - 2

o o

occurs in the glenohumeral

joint and 1 occurs at the
o

scapulothoracic articulation
• A restriction in scapular
rotation = shoulder girdle
problem
• A restriction in humeral
abduction = glenohumeral
problem
From Shoulder Pain 3rd Ed., Cailliet

177
 Movements of the scapula
Movement Muscles producing movement
Elevation Trapezius (superior part), levator scapula, rhomboids
Depression Gravity, pectoralis major (inferior sternocostal head,
latissimus dorsi, trapezius (inferior part)
Protraction Serratus anterior, pectoralis minor, pectoralis major
Retraction Trapezius (middle portion), rhomboids, latissimus dorsi
Upward rotation Trapezius (superior part), serratus anterior (inferior part),
trapezius (inferior part)
Downward rotation Latissimus dorsi, gravity, pectoralis major

178
 Ulnohumeral Somatic Dysfunctions
• The ulnohumeral joint
passively adducts with
flexion and passively
abducts with extension
• This cause the hand to
deviate to the mouth
during flexion
From Physical Examination of • It is also responsible for
the Spine the carrying angle
and Extremities Hoppenfeld

179
Ulnohumeral somatic dysfunctions

• Ulnar Abduction
– Restricted adduction (lateral glide)
– Patient may present with pain or restriction at
endpoint of flexion
– Increases the carrying angle
• Ulnar Adduction
– Restricted abduction (medial glide)
– Patient may present with pain or restriction at
endpoint of extension
– Decreases the carrying angle
180
 Testing for ulnohumeral dysfunctions

• Medial glide of the

ulnohumeral joint
causes abduction of the Medial
forearm Glide
• Lateral glide of the
ulnohumeral joint Abduction
causes adduction

From karenswhimsy.com
181
 Radial Head Motion
• Near the end of full pronation, the
radial head glides posteriorly
• With a posterior radial head somatic
dysfunction:
– Ease of motion is posterior glide
– Restricted motion is anterior glide with
supination
• With a posterior radial head somatic
dysfunction there is ease of
pronation at the wrist
• A posterior radial head somatic
dysfunction is often caused by a fall
forward onto an outstretched hand From Foundations for Osteopathic
Medicine 2nd Ed. Ward

182
 Anterior Radial Head Somatic Dysfunction
• Near the end of full supination,
the radial head glides anteriorly
• With an anterior radial head
somatic dysfunction:
– Ease of motion is anterior glide
– Restricted motion is posterior glide
with pronation
• With an anterior radial head
somatic dysfunction there is ease
of supination at the wrist
• Can be caused by a fall backward
on an extended arm
From Foundations for Osteopathic
Medicine 2nd Ed. Ward

183
Somatic Dysfunctions of the
Cervical Spine

184
Cervical Spine Functional Anatomy

Cervical Spine has three

distinct biomechanical
areas:
1. Occiptial-antlantal
segment (C0-C1)
2. Antlantal-Axial segment
(C1-C2)
3. Typical cervical vertebrae
(C2 through C7)

From Netter Presenter 185

 Cervical Spine Mechanics

Fryette’s mechanics do not

apply to the cervical
spine:
• Occiptial-antlantal
segment (C0-C1):
– Primary motion is flexion
and extension
– When sidebending is
introduced, rotation will
occur in opposite direction
(SLRR)

From Netter Presenter 186

Cervical Spine Mechanics
Antlantal-Axial segment
(C1-C2):
– Primary motion is
rotation
– 50 % of cervical rotation
occurs at AA

From Netter Presenter 187

 Cervical Spine Mechanics
Typical Cervicals (C2-C7):
• (Inferior facet of C2 on C3
through C7.)
• Facets oriented backward,
upward, and medial.
• Facets articulate at 45 degree
oblique plane
• Motion: Flexion/extension
and coupled
sidebending/rotation to the
same side.

From Netter Presenter 188

Translating=Sidebending

Translating from left to right

testing left sidebending

From Pocket Manual of OMT, LWW 2006

189
Make sure you review the counterstrain tender
point locations and treatment positions

• Know the different locations

of the C1 tender points
• Don’t forget about anterior
C7 and C8
• Posterior C2-C7 and anterior
C2-6 and C8
– SARA (sidebend away rotate Beatty The Pocket Manual of OMT, LWW
away) 2011

• Anterior C7
– STAR (sidebend toward away
rotate)

190
Review the treatment set up for rotation
and sidebending muscle energy
treatments in the cervical spine

Beatty The Pocket Manual of

OMT LWW 2011
191
Somatic Dysfunctions of the
Head

192
 Primary Respiratory Mechanism (PRM)
Five Components
1. Motility of the brain and spinal cord.
2. Fluctuation of cerebrospinal fluid.
3. Mobility of the intracranial and intraspinal
membranes (later called the reciprocal tension
membranes (RTM))
4. Mobility of cranial bones
5. Involuntary mobility of the sacrum between the ilium.

(Motility=inherent motion Mobility=passive secondary motion)

193
 Cranial Rhythmic Impulse (CRI)
measurements
• Classified by
– Rate = cycles/min (10-14)
– Amplitude = distance from flexion to
extension (0- 5)
– Symmetry
Rate Cycle

Flexion

Neutral
Amplitude

Extension

194
 Cranial Bone Mobility
• Unpaired bones move in flexion and extension.
• Paired bones move in external rotation and internal rotation.
• Flexion of unpaired bones - external rotation of paired bones.
• Extension of unpaired bones - internal rotation of paired bones.

Unpaired Bones Paired Bones

Ethmoid Frontal * Palatine
Mandible Inferior Concha Parietal
Occiput Lacrimal Temporal
Sphenoid Maxilla Zygoma
Vomer Nasal

195
 Normal SBS Motion
• In FLEXION when the SBS rises superiorly the
sphenoid and occiput rotate in opposite directions
about 2 parallel transverse axes
• What you feel on the surface of the head is:
– the occiput expands inferiorly and widens
– the greater wings of the sphenoid (just behind the
zygomatic arch) move inferiorly and widens.
• The result is that the head feels fatter and
wider in FLEXION.
196
 Flexion
Sphenoid and occiput rotate in opposite directions about 2
parallel transverse axes. SBS rises superiorly.

Adapted from Wales, A. ed. Teachings in the Science of Osteopathy. 1990.

197
 Normal SBS Motion
• In EXTENSION, the SBS moves inferiorly and the
sphenoid and occiput rotate in opposite directions
about 2 parallel transverse axes
• What you feel on the surface of the head is:
– the occiput moves superiorly and gets thinner.
– the greater wings of the sphenoid move superiorly
and get narrower
• The result is that the head feel thinner and
longer in EXTENSION
198
 Extension
Sphenoid and occiput rotate in opposite directions about 2
parallel transverse axes. SBS moves inferiorly.

Adapted from Wales, A. ed. Teachings in the Science of Osteopathy. 1990. 199
 Types of SBS Strains
• Physiological SBS strains
– Flexion / Extension (normal physiologic motion)
– Torsion
– Sidebending Rotation
• Non-Physiological
– SBS vertical strains
• Inferior vertical strain
• Superior vertical strain
– SBS lateral strains
• Right lateral strain
• Left lateral strain
– SBS compression strains

200
 Physiologic Strain Patterns
SBS Torsion (right or left)
– Sphenoid and occiput rotate in opposite directions
about an anterior-posterior (AP) axis
– Named for the greater wing of the sphenoid that
is superior (higher)
• i.e., if the right greater wing of the sphenoid is higher,
then it’s a right torsion
• Using the vault hold, the right index finger moves
anteriorly
• Feels like unscrewing a lid off a jar

201
 Right Torsion

Right

Axis of
rotation
Left

From Wales, A. Teachings in the Science of

Osteopathy. 1990 202
 Physiologic Strain Patterns
SBS Sidebending Rotation
One AP axis and 2 parallel vertical axes
• AP axis (same axis around which torsion occurs but here the
sphenoid and occiput rotate the same direction)
• Vertical axes—thru body of the sphenoid and foramen magnum
and is perpendicular to the AP axis
» Occiput and sphenoid sidebend in opposite directions
» This opposite sidebending leads to a bulging of the head
on one side
– Rotation is towards the convexity
– Named for side of convexity
– Feel a down and out sensation using the vault hold (cracking an egg)

203
Left Sidebending Rotation

Vertical axes of
rotation
Right

A/P axis
of
rotation
Left

From Wales, A. Teachings in the Science of

Osteopathy. 1990 204
 Non-physiologic Strain Patterns
• SBS Vertical Strain (Superior or Inferior)
– Caused by a shearing force at the SBS (i.e. Helmet to helmet hit to
the top of the head)
– Causes the sphenoid and occiput to rotate in the same direction
around parallel transverse axes
– Rotation causes sphenoid to shift either superior or inferior to the
occiput
– Will feel opposite motion on palpation because you are monitoring
the greater wings of the sphenoid
• i.e., Using the vault hold, both index fingers will rise on a inferior vertical strain
– Named for relative position of the sphenoid base to the occipital base
• Superior vertical strain: sphenoid base superior
• Inferior vertical strain: sphenoid base inferior

205
 Superior Vertical Strain
named for the basi-sphenoid in relation to the basi-occiput

Sphenoid

Occiput

From Wales, A. Teachings in the Science of

206
Osteopathy. 1990
 Non-physiologic Strain Patterns
• SBS Lateral Strains (Right or Left)
– Caused by a shearing force applied just anterior or posterior
to the SBS (i.e. a bat nailing you on the side of the head)
– This forces causes the rotation of the sphenoid and occiput
in the same direction (both clockwise or counterclockwise)
around two parallel vertical axes
– Again, you will feel opposite motion on palpation
• using the vault hold, both index fingers shift to the right
and the pinky fingers shift to the left with a left lateral
strain
– Named for position of basi-sphenoid in relation to the basi-
occiput.
• Right Lateral strain: sphenoid base is sheared right in
relation to the occiput
• Left Lateral strain: sphenoid base is sheared left in
relation to the occiput 207
 Right Lateral Strain
Named for sphenoid location in relation to occiput.
“Parallelogram Head”

Vertical
axes

From Wales, A. Teachings in the Science of 208

Osteopathy 1990.
 Non-physiologic Strain Patterns
• SBS Compression
– The sphenoid and occiput have been forced together.
– May be caused by severe blow or by fever or
metabolic problem.
– Little or no motion at the SBS.
– Classically described as a “bowling
ball” head or a “bag of worms”.
– May manifest as no established pattern (i.e., a
different strain pattern every time in flexion).

209
Conventions in naming cranial strain patterns

• Torsions are named for the superior greater

wing of the sphenoid.
• Sidebending rotations are named for the side
of head convexity.
• Sphenobasilar strains are named for the
direction of basisphenoid movement (which is
opposite to greater wing movement).

210
 Cranial nerve entrapment
• Cranial Nerves III, IV & VI
– EOM dysfunction
• Cranial Nerve V
– Trigeminal neuralgia
• Cranial Nerve VII
– Bell’s Palsy
• Cranial nerve IX, X & XII
– Feeding disorders
• Cranial nerve XI
– Torticollis

211
OCF indications & contraindications
• Indications
– Congestion of respiratory system (sinusitis, otitis media)
– Cranial nerve entrapment neuropathies
• Vertigo
• Tinnitus
• Colic, GERD
• Torticollis
– TMJ syndrome
– Headache, neck pain, mood disorders
– Pediatric development abnormalities

• Contraindications:
– Intracranial bleed
– Increased CSF pressure
– CNS malignancy or infection
– Craniofacial fracture

212
 Which of the following SBS strain patterns
occurs around 3 axes?
1. Right torsion
2. Flexion
3. Right sidebending
rotation
4. Right lateral strain
5. SBS compression

213
Clinical Considerations in OPP

214
 Beighton Hypermobility Screen
• Dorsiflexion of second finger to 90 degrees or more
• Apposition of thumb to volar forearm
• Hyperextension of elbow by more than 10 degrees
• Hyperextension of knee by more than 10 degrees
• Hand flat on floor with knees extended
• Considered to have generalized hypermobility if
4-5 are + on non-dominant side

215
From Pocket Manual of OMT, LWW 2006
Red flag of low back pain – possible fracture
• Major trauma
– Involvement in a motor vehicle accident
– Fall from a height
– Physical assault
• Minor trauma
– Osteoporosis
– Metabolic bone disease
– Malignancy and infection
• Pain is usually axial, non-radiating, and severe and disabling
• Pain usually begins immediately following the trauma
• Palpation is important to correlate any reports of pain to
the radiographic level of injury
216
Red flag of low back pain - possible infection
or tumor
• Cancer risk factors:
– Age less than 20 or older than 50
– History of cancer
– Unexplained weight loss
– Failure to improve after four to six weeks of conservative therapy
• If all four of the above risk factors for cancer are absent, studies
suggest that cancer can be ruled out with 100% sensitivity
• Risk factors for possible spinal infection:
– Intravenous (IV) drug use
– Immunosuppression
– Fever and/or chills
• Pain that worsens when supine; severe nighttime pain
217
 Red flag of low back pain – possible cauda
equina syndrome
• Results from any lesion that compresses the cauda
equina nerve roots
• Defined as a complex of symptoms that include:
1. Lower back pain
2. Unilateral or more typically bilateral sciatica
3. Variable lower extremity motor and sensory loss
4. Saddle sensory anesthesia- butt numb
5. Bladder and bowel dysfunction (and erectile
dysfunction in men)

218
Neurologic examination of the lower extremities
should be done even in the absence of significant
sciatica

1. Deep tendon reflexes

2. Motor strength testing
by nerve root
3. Sensation testing
by dermatome
4. Straight leg raising test

From www.orthoinfo.aaos.org

219
220
 No reflex
for L5

Hoppenfeld, S. Orthopaedic Neurology.

1997: p. 70.

221
Hoppenfeld, S. Orthopaedic
Neurology. 1997: p. 70.
222
 Iliolumbar Ligament Syndrome

• Pain in Multifidus triangle

– Pain in sacroiliac, posterior thigh
and/or inguinal region.
– Mimics inguinal hernia.

Iliolumbar ligament

Ward, R. Foundations for Osteopathic

Medicine. Baltimore, MD. Williams & Wilkins;
223
1997: p. 985.
Netter Presenter: 2001.
 Anatomy Review
Sciatic Nerve

• Arises from L4-S3 nerve

roots and joins to form a
common trunk (peroneal
and tibial portions).
• Exits pelvis via greater
sciatic foramen.
– Most commonly passes
below piriformis m.
– In 10% of population nerve www.aafp.org

passes through piriformis m. 224

 Piriformis Syndrome
Pathogenesis
• Typical nerve structure like a coaxial cable with the sensory
nerves toward the outer aspect.
– Epineurium
• Surrounds the whole nerve.
– Perineurium
• Surrounds the nerve fascicles.
– Endoneurium
• Surrounds individual neurons.
• Piriformis syndrome is usually attributed
www.ifess.org
to pressure on sciatic
nerve.
• Nerve compression usually causes impairment or loss of
conduction.
• There are usually no motor neurological deficits in piriformis
225
syndrome.
 Iliopsoas Syndrome
• Patient flexed at time of injury.
• Sciatic pain usually not past knee.
• Patient often c/o new scoliosis.
• Key Lesion = Type 2 at L1-2.- superior
attachement
• Pelvis shift to opposite side of iliopsoas
spasm.
• Piriformis spasm on opposite side of
iliopsoas spasm.
• R/O herniated disc.
solihullsportsinjuryclinic.co.uk

226
227
 Chest Wall Pain Syndromes
• Costochondritis
– Inflammation at costochondral junction
• Scapulocostal syndrome-pain with grinding motion
– Posterior shoulder pain with scapular muscle trigger
points
– May be accompanied by grinding noises involving the
scapula
• Rib tip syndrome
– Stabbing pain and clicking at costochondral junction of
rib 8, 9, or 10
228
 Be sure you can differentiate between:
• Cervical radiculopathy
– Cervical compression test- spurlings
– Neurological exam
• DTR
• Motor strength testing by nerve root
• Sensation testing by nerve root
• Carpal tunnel syndrome
– Tinnel’s
– Phalen’s
– Flicking symptom worse at night
• Thoracic outlet syndrome
– Costoclavicular compression test
– Scalene compression test (Adson's)
– Pectoralis compression test
• Double crush syndrome

229
 Double Crush Syndrome

• Compression of a nerve at one point

renders it more susceptible to damage at
another site.
• Altered function is greater than the sum
of the impairment caused by individual
lesions. (1+1=3)

From Netter, F. Atlas of Human Anatomy. 1989.

230
 Neurologic Exam of
the Upper Extremity
• Motor Exam
• C5-deltoid m.
• C6-wrist extensors
• C7-wrist flexors
• C8-finger flexors
• T1-interossei mm.
• Reflexes
• C5-biceps
• C6-brachioradialis
• C7-triceps

231
There are 3 places the brachial plexus can
be impinged leading to thoracic outlet
syndrome
• Between the clavicle and
1st rib
• Costoclavicular
Compression Test
• Review treatments for
elevated first ribs

From Travell, J. Myofascial Pain and

Dysfunction. 1999: p. 823.
232
 There are 3 places the brachial plexus can be
impinged leading to thoracic outlet syndrome

• Between anterior and

middle scalene muscles
• Scalene compression test
(Adson's maneuver)
– Positive test = diminished
pulse and/or reproduction
or exacerbation of
symptoms

From Travell, J. Myofascial Pain and

Dysfunction. 1999:p. 508.
233
 There are 3 places the brachial plexus can be
impinged leading to thoracic outlet syndrome

• Under the pectoralis

minor muscle or tendon
• Pectoralis compression
test

From Travell, J. Myofascial Pain and 234

Dysfunction. 1999: p. 846.
 Red flags concerning arm pain and paresthesia

• Need to rule out

– Cervical radiculopathies
– Pancoast tumor- tumor apex of lung
– Metabolic causes: hypothyroidism, type 2 diabetes
mellitus, vitamin B12 deficiency

235
An acceleration-deceleration injury is the most
common cause of cervical strain and sprain
Quebec Task Force on Whiplash-Associated Disorders (WAD), 1995

• Strain
– Muscular injury
• Sprain
– Ligamentous stretch injury
• “Whiplash” or an
acceleration-deceleration
injury is a mechanism of
injury
– not a type or extent of From Barral 1999, p 34
injury

236
“Whiplash” causes neck and head symptoms

• Neck pain
• Neck stiffness
• Loss of ROM
• Headache
• Shoulder pain

237
Mehta, 1997
 Whiplash may cause other symptoms
(whiplash associated disorders)
• Facial or sinus pain
• Headache
• Ear pain
• Sensory disturbances
– Tinnitus/hearing loss
– Dizziness
– Visual disturbances
– Tongue pain
• Back pain
• Extremity pain

Gruber 1998, p 59 238

Acceleration-deceleration injuries can cause
chronic pain
• Prognosis at time of • Worse prognosis (Dufton 2006)
injury (Cote 2001) – Older age
– 56% asymptomatic @ 3 – Female
months – Initial pain in neck
– 82% recovered @ 24 – Increasing lag time
between injury date and
months
presentation for
treatment
– Higher initial pain
intensity
– Lawyer involvement
– Injury during work

239
Persistent restricted motion predicts chronic
pain Dall’Alba 2001

• Reduced cervical ROM at 3

months is a good predictor
of pain and disability at 2
years

Active flexion is normally ≥ 50°

(The Pocket Manual of OMT, LWW 2011)
240
 Quadratus Lumborum
“Joker of Low Back Pain”
• Easily mistaken for lumbar
radicular pain (coughing or
sneezing may increase the pain)
or piriformis counterstrain tender
point or hip pain
• Can be treated with inhalation
muscle energy treatment to the
12 rib which stretches the
quadratus lumborum

From Travell Myofascial Pain and

Dysfunction Vol 2 p. 30

241
 Gluteus Minimus
“Pseudo-sciatica”
• Pain is often attributed to
“sciatica”
• The more anterior the trigger
point, the more lateral the
referral zone
• Direct MFR to the hip

From Travell Myofascial Pain and Dysfunction

242
Vol 2 p. 169
 Iliopsoas
“Hidden Prankster”
• It serves many important
functions but Travell
considered it as relatively
inaccessible
• Correction of somatic
dysfunctions of the thoracic,
lumbar, or sacral areas and
avoid prolonged sitting

From Travell Myofascial Pain and

Dysfunction Vol 2 p. 90
243
Scalene Muscles
• Common source of back,
shoulder, and arm pain
• Often confused with cervical
radiculopathy
• Symptoms include myofascial
pain or secondary sensory
and motor disturbance due to
neurovascular entrapment
• Direct MFR or ME to the
scalene muscles

From Travell Myofascial Pain and

Dysfunction Vol1 p. 506

244
Trapezius Muscle
• Muscle most often found to
have trigger points
• Frequently overlooked source
of temporal and cervicogenic
headache
• OMT would be very similar to
those for the scalenes

From Travell Myofascial Pain and

Dysfunction Vol.1 p. 279

245
 No matter what modality you use
to treat trigger points, an essential
component in the treatment is
home stretches

246
 A patient presents with numbness in the right forearm. The
upper extremity deep tendon reflexes are +2/4 bilaterally. The
cervical compression test is negative. The patient has a positive
Phalen's, Tinel's at the wrist and pectoralis minor compression
tests on the right. What is the most likely diagnosis?

1. Carpal tunnel
syndrome
2. Cervical radiculopathy
3. Double crush syndrome
4. Thoracic outlet
syndrome
5. Ulnar neuropathy

247
Any questions?

248