M1T1 OMM Study Guide

Intro to OMM
Educational Council on Osteopathic Principles (ECOP) started in the 70s
Osteopathic Manipulative Medicine is the specialty. Osteopathic Principles and Practice is the course.
The Four Basic Osteopathic Principles
1. The body is a unit Mind body and spirit are connected to make up the whole person.
2. The body is capable of self-regulation, self-healing and health maintenance.
3. Structure and functional are reciprocally interrelated.
4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the
interrelationship of structure and function. You need to look at the whole mind/body/spirit patient to develop a treatment that
is truly right for the whole patient.
OMM Techniques:
1. Myofascial soft tissue
2. Myofascial release
3. Myofascial unwinding
4. Counterstrain
5. Ligamentous articular release (LAS) v. Balanced ligamentous tension (BLT)
6. Lymphatics
7. Muscle energy
8. High-velocity/low- amplitude (HVLA)
9. Cranial
10. Facilitated Positional Release (FPR)
11. Still technique
12. Chapmans reflexes
13. Visceral
OPP: History of Medicine
D.O.s talk about internal and external forces blend of Asian, Indian, and Western medicine. Dr. Still may have been influenced by
other cultures
Internal stresses: somatico-visceral, visceral-visceral, and viscero-somatic stresses.
Osteopathic Palpation vs. Therapeutic Touch vs. Energy Palpation
8 Treatments in Indian medicine: - Many incorporated into Western Medicine
1. Surgery
2. Diseases above the clavicle
3. Internal medicine
4. Demonic Possession Psychiatry
5. Pediatrics
6. Toxicology
7. Immunity
8. Aphrodisiacs
Famous Individuals:
1. Benjamin Rush, M.D. advised Lewis and Clark Mercury trail Philadelphia = early medical mecca
2. Samuel Thomson Father of American Herbalism founded Botanical Medical College fought M.D.s
3. Samuel Hahnemann, M.D. Small Dilute Doses Vaccine Concepts Coined Homeopathy v.s. Allopathy preferred
using drugs with similar effect as illness v.s. Allopathic approach
4. Oliver Wendell Homes, M.D. attacked Homeopaths like rest of Allopaths
5. Dr. Eli Jones Herbalist for cancer treatment Naturalists
6. Sylvester Graham Hygienist Graham crackers Popular health movement
7. American Medical Association formed in 1847
8. Sir William Osler students until we die treat patient, not disease Golden Rule 4 Principles: Inspection, Palpation,
Auscultation, Contemplation
9. 1899 PCOM started by O.J. Snyder and Mason Pressly
10. 1910 Flexner Report closes 50% of Allopathic and Osteopathic Schools Medicine shifts scientifically
11. 1918 Flu Epidemic OMT helps where medications fail
12. 1918 Harrison Fryette, D.O. develops Coupling Motion of Vertebrae Fryettes Rules of Motion
1
Andrew Taylor Still (1828-1917) preceptorial medical education M.D. in Missouri
- Disillusioned with Allopaths when family died from meningitis
- Believed in concepts of musculoskeletal system, proper structure, and the bodys self-healing
- Osteopathic Ideas formed in 1874
- Opened American School of Osteopathic Medicine (1892) in Kirksville, Missouri
- Health = Harmony; normal flow of bodily fluids and nerve activity
- The rule of the artery is absolute, universal, and it must be unobstructed, or disease will result.
- Osteopathic Manipultive Treatment not in original OPP Dr. Still created 5 years later originally just diagnostic
patient demanded for treatment
Only four medications still in use from 1933: Quinine, Apririn, Digitalis, and Morphine
Fascia (Anatomical and Clinical)
Functions: Mechanical, Metabolic, Immunological
1. Compartmentalization Ex. Renal Capsule, Liver Capsule Epi-, Peri-, Endo- separations
2. Support ligaments, scaffolding (reticular fibers) Elasticity Fulcrum for power
3. Conduit for neurovascular bundles
4. Diffusion of nutrients via extracellular space
5. Energy Storage
6. Line of Defense Mast cells, Basophils, histiocytes, and lymphocytes found in fascia
7. Barrier prevents infections from going deeper. compartmentalizes infections
According to Kuchera: Packaging, Passageways, Power, Protection, Proprioception (25% by fascia)
Fibroblasts are the main manufacturer of collagen (primarily type 1), which is main component of fascia
Collagen is cross-linked for tensile strength and elasticity
Fascia is adaptable, moveable, and determined by its functional necessity. Viscous, Elastic, Plastic
Tensegrity = balance between tension and compression
Elasticity is dictated by the bodys H2O content DRINK MORE WATER!!
Wolffs Law If an item (bone, fascia) is pulled on with enough force for enough time, structure will change
Fascia determines structure. Superficial, Deep, Subserous
Fascia absorbs heat, energy, impact, and trauma
Some fascia named: Sibsons Fascia (Superior Thoracic Outlet), Scarpas Fascia (Abdomen)
OMT aims at removing fascial dysfunction and restoring homeostasis
Fascia allows palpation of tissue texture changes and traumatic forces
Models of Osteopathic Care
1. Postural-Biomechanical: Actue vs. Chronic Somatic Dysfunction
2. Respiratory-Circulatory: Dysfunctions go from Lymphatics Veins Arteries
3. Neurological-Autonomic
4. Biopsychosocial: Pain Depression more Pain Physiological changes in the body
5. Bioenergetic-Metabolic
Bind Vs. Ease (via strands connecting superficial and deep fascia)
Law of Connectedness Subdivisions of fascia are arbitrary
Hookes Law the more you pull on CT, the longer it gets
Hysteresis Retention of a deformity after force is removed
Stiffness vs. compliance Force Load : Deformity (ratio)
Creep: slow movement of tissues with force applied
Chronic stress bone spurs (Exostoses), calcified ligaments, bone remodeling
Piezoelectricity = fascias ability to store energy and to create energy when stresses are placed on it
Static Structure Exam
Dominant Eye
Symmetry vs. Asymmetry, Compensation, Gait Examination
Is visualized dysfunction related to chief complaint or physical dysfunction?
Caudal vs. Cephalad; Anterior vs. Posterior; Medial vs. Lateral; Proximal vs. Distal; Adduction vs. Abduction
Sprain vs. Strain
Diagnosis:
1. Static Structure Exam
2. Regional Range of Motion
3. Layer-by-Layer Palpation
4. Intersegmental Motion
Somatic Dysfunction: Impaired or Altered function of Somatic framework: musculoskeletal, fascia, ligaments....
2
1. Tenderness
2. Asymmetry
3. Restricted Range of Motion
4. Tissue Texture changes
Planes of the Body: Coronal, Sagittal, Transverse
Kyphosis vs. Lordosis; Primary vs. Secondary; Concavity vs. Convexity
Transitional Areas (occipitocervical, cervicothoracic, thoracolumbar, and lumbopelvic junctions)
highly susceptible to dysfunction
Hypertrophy (increased mass) vs. Hypertonicity (increased muscle tone)
Abnormalities:
Flat Feet = Pes Planis
High Arch = Pes Cavis
Everted vs. Inverted Foot
Bow-Legged = Genu Varum
Knock-knees = Genu Valgum
Caved Chest = Pectus Excavatum
Extreme Posterior Knees = Genu Recurvatum
Winged Scapula
Scoliosis
Exxagerated or Decreased Curvature
Lateral Mid-Gravitational Line: (Toe to Head)
Lateral Malleolus
Lateral Condyle of knee
Greater Trochanter of the femur
Anterior Third of the sacrum
Third Lumbar Vertebra
Lateral Head of the Humerus
External Auditory Canal
Body Segment
Body Segmentation is in relation to spinal nerve location
Neural Crest
Neural Folds
Neural Tube Formation
Somites
Notocord
Dermatome Subcutaneous Fascia
Myotome somatic muscle
Sclerotome Bone and Cartilage around neural tube
Anencephaly vs. Spina Bifida
Ventral Axon Sprouting and Neural Crest Migration Ventral and Dorsal Roots of Spinal Cord
When Somite splits into ventral and dorsal areas, arteries, veins and nerves also split
Epimere (Intrinsic Back Muscle) vs. Hypomere (all other musculature)
Upper Limb rotates laterally
Lower Limb rotates medially
Transverse Processes = rib remnants
Each Spinal Nerve has somatic sensory, somatic motor, visceral sensory, and visceral motor
Barrier Concepts
Types of Barriers:
1. Anatomical absolute limit of passive motion imposed by anatomical barriers Ex. Bone, muscle, etc..
2. Physiological absolute limit of active motion due to soft tissue tension can be moved
3. Restrictive functional limitation within anatomical range which decreases the physiological range
4. Pathological permanent limitation within the anatomical range
Passive vs. Active Motion in all three planes of the body
Physiological vs. Anatomical Range of Motion
Segmental Motion vs. Regional Motion vs. Postural Motion
3
End-Feel = perceived quality of end-motion as you approach the barrier
Springy, resilient, ease in all directions = normal physiology
Too Loose = orthopedic problem
Too Tight (Abrupt, hard, binding, resilient) in one direction = Somatic Dysfunction
Too Tight in all Directions = inflammatory, arthritic, capsular dysfunction pattern
Somatic Dysfunction is labeled based on the ease.
Ex: Inhalation Dysfunction = Inhalation Ease = Exhalation Restriction
Rotation is labeled based on movement on front Ex: Rotation Right = clockwise (from above)
Compensatory Pattern of Zink: - As you walk, you unwind and rewind the pattern for balance
Common Type 80% - asymptomatic
Hips right, Thoracic left, Upper Thoracic right, Cranial left
Uncommon Type 20% - asymptomatic
Hips left, Thoracic right, Upper thoracic left, Cranial right
Non-Compensatory Pattern traumatic symptomatic Pattern doesnt alternate Ex. RRLL
Ease = compliance, resilience
Bind = restriction, resistance
Spray and Stretch Technique Tight muscles are sending signals on unmyelinated nerves while cold receptors are on myelinated
nerves Game of Distraction to move restrictive barrier toward the physiological barrier
Indirect Myofascial Release Find the wobble point(balanced ligamentous tension) new neutral in restricted range. Hold at that
point and have the patient hold breath until starving and then release. tissue will move and decrease barrier
Direct Myofascial Release Go to the Restrictive Barrier, Have patient hold breath and release after starvation, Barrier will creep
toward normal physiological barrier
Myofascial Shortening Widens Physiological barrier by decreasing active range and increasing passive range. Ex. Latissimus Dorsi
Pinch
Tonus continuous contraction of skeletal muscle posture and blood return
Spasm = sudden, violent, involuntary contraction of skeletal muscle with pain and decreased function
Contraction:
Isotonic Muscle actually moves
o Concentric Normal movement
o Eccentric Patient contracts, but the muscle is stretched by an outside force (Doctor)
Isometric Muscle doesnt move patient is trying but is being held in position
o Post Isometric Relaxation Technique common in Muscle Energy alternating isometric status and muscle
relaxation muscle lengthening
Contracture: Fibers build-up to decrease length of muscle high resistance to passive stretch
Motion Testing (Quality and Quantity)
Quantifies OMT and patients available range of motion clinical tool
Function improves quicker than pain
A.T. Still: The body obeys the law of mind, matter, and motion.
Hypermobility (difficult to treat) vs. Hypomobility (OMT patients)
Mesomorph, Endomorph (heavy body-restricted), Ectomorph (long linear-mobile) Idea of Range of Motion
Normal Motion depends on person-to-person, body region-to-body region
Severe limitation in Active Motion Get an X-ray and wait on Passive Motion
Cervical:
Freest Movement (allowed by Oblique facets) = Forward-bending and backward bending (45 to 90)
Side-Bending 30 to 45
Rotation 70 to 90 - 50% comes from C1-C2
4
Elastic Region
Restrictive Barrier
Thoracic:
Motion is limited by ribs With ribs, freest motion = Side Bending, Without ribs = rotation
Coronal facets
Passive Motion Testing only
Side-Bending 5 to 25 (T1-T4), 10 to 30 (T5-T8), 20 to 40 (T9-T12)- translate with lower thoracic
Rotation T9-T12 70 to 90
Lumbar:
Freest Motion = Flexion/Extension (due to Sagittal Facets)
If someone cannot go forward because of leg pain/tingling --> herniated disk
If someone can extend back but not forward --> herniated disk
More free motion forward, but backwards almost non-existent --> spinal stenosis
Flexion 70 to 90; Extension 30 to 45
Side Bending 25 to 30 - Hip Drop test = Patient Passive Motion Hand down thigh = Active Motion
Ligaments tensed with forward bending: supraspinous, interspinous, flavum, capsular, posterior longitudinal, annulus fibrosis
Ligaments tensed with backward bending: anterior longitudinal ligament, Disc, articulate facet, spinous process, interspinous
ligaments
Regional Muscles:
Cervical: Trapezius, Splenius Capitus, Splenius Cervicis, Semispinalis Capitus, Sternocleidomastoid
Thoracic: Trapezius, Levator Scapula, Rhomboids, Erector Spinae, Semispinalis, Rotatores
Lumbar: Latissimus Dorsi, Erector Spinae, Quadratus Lumborum, Iliopsoas
Chief Complaint can be in a different area that somatic dysfunction. Motion Testing can define location.
Motion testing is possibly the most important measure of the somatic dysfunction components and the one objective measure which
can be documented with relative certainty
Layer-by-Layer Palpation
Touch - Important in human interaction Can rouse tender feelings conveys professionalism and empathy must always be
appropriate touch is personal
Palpation = Diagnostic Touch differentiate shape, size, consistency, position, and health of the tissues beneath
Cybernetic Loop When Physician touches patient, patient reacts, physician reacts to patients reaction.
Diagnostic Palpation can be therapeutic can also be restrictive (psychological aversion to touch)
Palpatory Diagnosis = Palpation to evaluate neuromusculoskeletal and visceral systems
Therapeutic Touch = Energy therapy manipulating energy field Highly Controversial
Somatic Dysfunction may be skeletal, arthroidal, myofascial, or vascular
Sensory Tissues:
Mechanoreceptors: Meissners Corpuscle, Pacinian Corpuscle, Hair Follicle Receptor, Merkel Disc
Proprioceptors: Free Nerve Endings, Muscle Spindle Receptors
Nociceptors
Thermoreceptors Volar Surface, Dorsal Hypothenar Surface
Use fingerpads not fingertips Relax the arms
Discuss what you are going to do. Asking permission invites the patient to say no.
Abnormalities: Hypertonicity, Ropes, Cords, Edema, Bogginess, etc.
Inherent Motion = Visceral Motion, Peristalsis, Fluid Motion
Layer by Layer Palpation:
1. Look and Observe
a. Spina Bifida Occulta Abnormal Lumbosacral Hair Pattern
2. Access Heat and Moisture Use Volar Surface
3. Skin Topography (no movement) access dry/moist, lesions
4. Subcutaneous Fascia
5. Muscle Layer Blanch Fingertips
6. Bone/Tendon/Ligament depends on area
7. Erythema Friction Rub
Thoracolumbar Motion Testing
Physiological Motions of the Spine
Harrison Fryette (1918) based his ideas on Robert Lovetts Spinal Curvatures and Round Shoulders
Punjabi and White coined term coupling to describe motion rules of Fryette
Vertebral Motion depends on:
1. Orientation of Facets
5
2. Vertebral Body Shape
3. Height and Width of Discs
Pressure shifted from being on facets with strong trabecular bone (quadrupeds) to the compressible vertebral bodies with cancellous
bone and discs (bipeds)
Flexion (not Purist) = forward bending = approximation of anterior, separation of posterior
Extension (not Purist) = backward bending = approximation of posterior, separation of anterior
Exaggerated Flexion = spondilolisthesis
Rotation around vertebral body axis (except lower lumbar, whose axis of rotation = spinous process)
Right = clockwise Right transverse process moves posteriorly, Left transverse moves anteriorly
Left = counterclockwise - Left transverse process moves posteriorly, Right transverse moves anteriorly
Sidebending = moving vertebrae toward side of concavity.
Ex. Sidebent right = facets on right approximate, facets on left separate
Translation = shifting of vertebral bodies
Coupling = Side-Bending and Rotation must happen together
Laws of Thoracolumbar Motion
1. Fryettes First Principle: In Neutral, sidebending and rotation happen in opposite direction - group
2. Fryettes Second Principle: In flexion or extension, sidebending and rotation are on in same direction usually a single
segment
3. Nelsons Third Principle: If there is a dysfunction, moving patient into flexion or extension may decrease the dysfunction
With 2 directions: non-neutral and another, you can guess the 3
rd
direction
Cervical Motion:
C2-C7 are Type 2-like with sidebending and rotation in same direction in extension, flexion and neutral
C1-C2 (Atlanto-Axial) is pure rotation
C0-C1 (Occipital-Atlanto) follows Type 1 with sidebending and rotation in opposite direction
Dysfunction: (only in segmental motion)
If there is asymmetry in one motion, evaluate if other motion is in same direction of opposite
Type 1 Dysfunction = sidebending and rotation in opposite directions label based on ease side
o Associated with groups of segments possibly caused by long restrictor muscles
Type 2 Dysfunction = sidebending and rotation in same direction find out if flexion or extension make it better label
based on ease of non-neutral.
o Associated with single segments possibly caused by short restrictor muscles or facet pressure
o Commonly found at beginning, apex, or base of primary curve
Thoracic Segmental Motion & Somatic Dysfunction
Acute Chronic
History: Recent Injury History: long standing
Pain: acute, severe, sharp, fire like Pain: dull, achy, itching, crawling, gnawing, burning
Increased Temperature (Vasodilation) Decreased Temperature (Vasoconstriction)
Skin: warm, moist, red/inflamed Skin: cool, pale due to chronic increase sympathetic vascular tone
Tissues: edema, acute (boggy) congestion Tissues: chronic congestion, stringy, ropy, fibrotic, contracture
Musculature: increase in local tone contraction,
spasm, poor quality of motion
Musculature: decrease tone, mushy, limited range of motion due to contracture
Viscera: minimal somatovisceral effects Viscera: somatovisceral effects common
Facilitation
Facilitation = a group of neurons in a partial or subthreshold status that requires less afferent stimulation to trigger nerve activation.
Chronic Hypersypathetonia long standing sympathetic overstimulation
Coupling If no preference for flexion or extension, any dysfunction will be Type 1
6
Strain a muscle and tendon BUT sprain a ligament
Activating Forces to enhance techniques:
Compression-Distraction
Respiration
Release-enhancing maneuvers
Quick Impulses (High Velocity)
Techniques:
Indirect:
o Counterstrain
o Facilitated positional release technique (FPR)
Direct:
o Soft tissue
o Muscle energy technique (MET)
o High Velocity/Low amplitude Technique (HVLA)
Often Indirect or Direct
o Visceral technique
o Osteopathy in the cranial field (usually indirect in adults)
o Myofascial release technique
o Balanced ligamentous tension (BLT)
o Ligamentous articular strain (LAS)
Combined
o Still technique
Thoracic Rule of Threes
T1-3: spinous processes even with transverse processes
T4-6: spinous processes down vertebra
T7-9: spinous processes down 1 full vertebra
T10: spinous processes down 1 full vertebra
T11: spinous processes down vertebra
T12: no transverse process
If joint is extended rotational component is better
If joint is flexed rotational component is exacerbated
M1T2 OMM Study Guide
Principles of Myofascial Technique
Musculotendinous areas and Fascia are intimately connected and forces can be applied to this fascia to affect deeper
structures.
Myofascial technique may also affect ligaments and capsular areas
Myofascial Release (unwinding) puts pressure on a strained wound-up tissue to cause unwinding Indirect or Direct
Technique
Balanced Ligamentous Tension (BLS) & Ligamentous Articular Strain/Release (LAS/R) are the same technique with forces
being distributed at the musculotendinous junction Both are Indirect
Direct vs. Indirect techniques
Goals of Myofascial Techniques : Release of spastic musculature and stretching inelastic fascia to improve ROM (Primary);
Increase circulation and drainage (Secondary); stimulate the stretch reflex in hypotonic muscles and decrease reflexes to
setup patients for another technique (Tertiary)
Additional Benefits: Feels good, gain patient trust, primer to more treatment
Myofascial effects occur from: local action, stretch reflexes, and thermodynamic heat to cause fascial creep and gel sol
with the change in collagen properties
Traction: anchoring one side and pulling at the other Stretching
7
Unwinding: pulling both origin and insertion
Perpendicular Motion: pull or push the muscle perpendicular to the muscles long axis (Esp. for Thoracolumbar) Kneading
Relative Contraindications : (No absolute contraindications Alter hand positioning and style based on sutures, infections,
etc.) Acute strain/sprain, fracture, dislocation, neurological and vascular compromise, osteoporotic patients,
malignancy/infection since soft tissue may spread malignancy.
Soft Tissue Steps : Start slowly and rhythmically, be comfortable, NO friction, move with skin, no prodding
Myofascial Release Steps : Take Direct or Indirect, wait for creep, use release enhancing maneuvers, Re-assess
Myofascial Techniques used in direct/indirect and acute/chronic
Distal structures can be used to achieve a specific local goal
Principles of LAS Techniques
Soft Tissue Techniques: Myofascial Release, Ligamentous Articular Strain, Balanced Ligamentous Tension, Balanced
Membranous tension, Fascial Unwinding
Ease-indirect = balance point away from restrictive barrier toward the wobble point
Bind-ease = to feather edge of restrictive barrier
Time for Myofascial Release is dependent on how long it takes to get a tissue texture change
Use Passive Motion for discrimination of minor restrictions and assessment
Somatic dysfunction will feel abrupt, hard, resistant, binding
Various types of Barriers and patterns (Capsular = bound in both directions)
Anatomic Barrier: limit of motion imposed by an anatomic structure; absolute limit of passive motion
Elastic Barrier is a range from the end of physiological barrier to the anatomic barrier. All Passive
Engage all three planes simultaneously. Minor Motions: translation, gliding, spin, compression/traction
Dynamic (functional) Barriers: impediment to inherent tissue motion or function
BLT : INDIRECT - Take patient into ease to point where the stacked point will pull back to return to normal. The point will
have no pain, no fascial tension and a return to neutral
Acute : Physiological spasm, moist with heat, painful, tender, edema, responds to indirect techniques
Chronic : Skin trophic change, dry & cool, fibrosis, responds best to direct techniques
Direct vs. indirect: Feather-edge of barrier vs. Wobble Point (Balanced Tension Point)
In Indirect technique, follow creep until it begins to turn back towards neutral
In Direct Technique, follow the feather edge of the barrier as it moves. Dont go beyond Elastic Region
Viscoelastic Properties : : occurs when material containing a mobile fluid phase is stretched or compressed from resting
length to force a fluid out of an elastic matrix; dont elongate too fast or stop too soon; give it time
Some elongation is lost and some is retained after application of tensile forces
Goal : A plastic change without tissue damage
Indirect Techniques: Indirect Articular technique, Indirect Myofascial Release Technique, Myofascial Unwinding, Balanced
Ligamentous tension and Balanced Membranous Tension (related: counterstrain, FPR and Still Technique)
Indirect Enhancers: respiratory fascial pull, Holding breath to create Air Hunger, moving head-neck while holding onto
position, Fascial movements
Still: Indirect techniques; Sutherland: Osteopathy in the Cranial Field; Becker: LAS; Wales: BLT
8
LAS: what happens when you add a force to a joint
BLT: what should exist in a normal joint relationship
Integrated Neuromusculoskeletal Release (INR): treatment system in which combined procedures are designed to stretch and
reflexly release soft tissue and joint related restrictions.
Use left brain to learn the material and understand why it works. It is the right brain phenomenon, paying attention to the
direction that the tissue and joints move. You need to perform the treatment that the tissues indicate they need, not what you
memorize.
Exaggeration: Return the patient to their position and point of injury, which is usually the balance point
Sensory Receptors
Exteroceptive Sensory Information: Mechanoreception from deformed receptor; Proprioception; pressure receptors;
Thermoreception and Nociception use the same pathway; Electromagnetic (vision)
Enteroreceptive Sensation: Mechanoreception of Fill-Void Reflex; Chemoreception of Carotid Bodies; Nociception of
visceral pain; Gastrointestinal Reception
DRG: large collection of sensory nerve cell bodies that are pseudounipolar since dendrite = axon
Large Diameter faster impulse; More myelination faster impulse
Labeled Line = path of information travel
Collateralization can lead to summation but this depends on the # of collateral nerves in the Neuronal Pool of dendrites
within the CNS
Spatial Summation = # of neurons involved. Vs. Temporal Summation = # of action potentials in a time
Proprioceptive Neuromuscular Facilitation : Repetition of an action to create a labeled line: Practice
Because of collateralization, dermatome pain can be visceral pain
Weightlessness loss of proprioception vagus reaction (nausea & vomiting)
Receptor potential includes frequency modulation, local circuitry and stimulus strength
Adaptation: how fast or slow a neuron will reset itself to baseline with decreased impulse frequency
Pacinian Corpuscles are the fastest adaptors = rapidly adapting neurons
Muscle spindles and joint capsules can never adapt to 0 because we need constant signal from these receptors to be aware
of our bodies = non-adaptable neurons
Discrimination of two points of 1 mm at fingertip
Superficial mechnoreceptors: Meissners Corpuscles, Merkel cells and Free Nerve Endings
Deep mechanoreceptors: Pacinian Corpuscles, Ruffini endings, Deeper Free Nerve Endings
9
Proprioreceptors: Muscle Spindles, Golgi Tendons, Joint receptors, Vestibular System
In a spinal nerve: 80% sensory, 20% motor with 16% visceral and 4% somatic
Equilibrium Triad: Visual, Proprioceptive and Vestibular Systems
Thermoreceptors: Hot or Cold; Pain decreases after 46 C since there is damage to the receptors
Nociceptors: Non-Adapting continuously fire; Fast thick myelinated axons (A ) or slow, thin, lightly myelinated axons (C-
Fibers)
Nociception
Not Encapsulated Free Nerve Endings that responds to noxious stimulus Heterogenous Group
Two types: A responds to intense mechanical stimuli (fast, conducting, sharp, localized) or C-fibers that respond to a variety
of stimuli (burning, aching, poorly localized)
A particularly responsive to thermal stimuli and mechanical stimuli usually just skin
C-fibers are more common and non-adapting in presence of continuous stimulus
C-fibers are sensitized during inflammation and repair hyperalgesia (pain with normal stimulus)
DRG cell parts: Peripheral free nerve ending receptor, long transmitting axon, large cell body to provide necessary metabolic
needs of long axons, and peripheral secretions at the CNS
Analgesia is created from Endorphins from stimulus causing another action to mask the noxious stimuli
Allodynia: painful response to a non-noxious stimuli
Nociception information enters the dorsal root to enter spinal cord and is handled by the dorsal cord
Neurotransmitters from Nociceptors will collateralize with other neurons in the gray matter of the cord
Pain signal connects to an interneuron that connects to an alpha neuron and reciprocal inhibitor
Multiple Effect Potential Awareness of discomfort, reflex w/ local guarding, signals to other segments to spread the word
of what noxious stimulus is out there.
There is cross-talk between the somatic afferents and the visceral efferents and vice versa
Anterolateral System : (AKA Spino-Thalamic Pathway) A primary afferent will project to the DRG and dorsal horn where is
synapses with a neuron that crosses the spinal cord and travels up the cord to the thalamus where it synapses with another
neuron that will go the cerebral cortex (parietal lobes post-central gyrus)
The thalamus is the major sensory relay station of the brain
Visceral Pain uses C-fibers to send signals to the insular cortex
Painful Neurotransmitter: Substance P that explains referred pain since collateralization leads to pain being sensed in a
secondary location. Cyclooxygenase also plays a part
Secreted NTs act as cytokines in periphery to recruit mast cells, lymphocytes and neutrophils
10
Pain Mechanisms
Convergence: impulses from various sources coming in to the same area of the CNS: dorsal horn
Divergence: Multiple effect potential with collateralization multiple effects
Central target of nociception = specific laminae (layers) within the spine w/ different functions
o Ex: In the Interomediolateral Cell Column (T1-L2), an A will collaterize along with C-fibers and Interneurons in
this lamina and will hit a primary efferent that goes out and alerts the system as part of sympathetic division of
autonomic nervous system.
Referred Pain = convergence at dorsal horn and crossover between visceral afferent and ALS
Reflex Options:
o Somato-Somatic: Reflex Hammer Direct link btwn primary afferent & Alpha motor neuron. Lesion above the
reflex site hyperreflexia
o Somato-visceral larger stimulus than somatic alone. Autonomic response
o Viscero-Viscero sympathetic and parasympathetic. Ex: S2,3,4 defecation, Dyspepsia HR
o Viscero-Somatic Visceral pain will manifest as somatic issue. Ex. Abdominal Bleeding will manifest as rigid
abdominal wall muscles to prevent further injury. Ex. Menstrual Cramps
People who received OMT tend to get better faster, no matter the disease
During facilitation, the non-adapating C-fibers will move the resting potential closer to threshold
In Cardiac complaints: chief somatic dysfunction = T3 and T4
In Pulmonary complaints: chief somatic dysfunction = T3,T4,T5
In Gastric complaints: chief somatic dysfunction = T5, T6,T7
In Appendicitis, the chief somatic dysfunction = T5-T9, T9-T10
Many somatic dysfunction graphs have a small peak in the upper cervical area
An entire neuronal pool can become facilitated could be primary nociceptive neurons
If stimulus is still present, after some time, decompensation sets in with more pain and chronic inflammation postural
abnormalities
Chronic Pain release of Corticotropin-releaseing hormone from
Hypothalamus ACTH release from pituitary Cortisol release from
adrenal medulla
11
Organ Dermatome
Transverse Colon
Rectum
T8-L2
Uterus/Cervix T10-L2
Upper Extremity T5-T7
Lower Extremity T10-L2

Organ Dermatome
Diaphragm C3-4
Heart T1-4 (left)
Stomach T6-9 (left)
Gall bladder T7-8 (right)
Duodenum T9-10
Appendix T10 (right)
Gonads T10-11
Diaphragms of the Body
Hypersympathetonia = viscerosomatic reflex that increases sympathetic tone due to a facilitated joint which causes
Bronchodilation, vasoconstriction, thickened secretions, mucus plugs, and hyperesthesia of posterior pharynx
Sympathetic Nerves: T1-T6; Parasympathetic Nerves: Vagus
Vagus Nerve (CN X) causes thinning of secretions and viscerosomatic reflex
Phrenic Nerve provides motor innervation to diaphragm: C3,4,5
Respiration Impediments lack of homeostasis throughout body
Diaphragm allows for diffusion of fluids throughout
Aim for balance for parasympathetics and sympathetics
Sympathetic tone will lead to Bronchodilation and Vasoconstriction to ensure proper blood and air flow
Parasympathetics will thin secretions, Hypersympathetics will give you thick secretions
Nociception leads to hypersympathetonia
Visceral-somatic reflex is less in the lungs
Open the lymphatics in order for the thick secretions to be moved out of the lungs
Motor Efferents are occurring by phrenic nerve (C3-5)
Prolonged Hypersympathetonia will lead to structural change Mucus plugs
Increased Vagal tone will lead to posterior headache from visceral afferents
Parasympathetic efferents lead to profuse thin secretions
Pulmonary Disease in two categories:
o Asthma and COPD with Bronchoconstriction and Hyperinflation
12
Organ Dermatome
Lungs T2-T7
Esophagus T2-T8
Liver T6-9
Small Intestine T9-T11
Kidney T10-L1
Prostate L1-L2
Bladder T11-12

o Infectious Bronchitis with thick mucus
If there is pain with Type II SD, there may be a viscerosomatic reflex
Somatic clue to visceral disease: no nocioception and no viscerosomatic reflex
Correct thoracic spine dysfunctions to improve thoracic cage functions
Chapmans Reflexes: Diagnose Anteriorly and Treat Posteriorly
Vagus Dysfunction occurs are Occipitomastoid suture, OA, C2
Characteristic twists in the body decrease fluid flow
External respiration is the diaphragm and chest. Internal respiration = cellular
Improving the diaphragm will increase blood flow through the crura via aorta and inferior vena cava
Psoas Muscle is related to diaphragm and one may affect the other
Quadratus Lumborum is mainly a muscle of respiration
The 12
th
rib is kept down during inhalation to allow the diaphragm to work off of
An artery closer to blood supply will have more nutrients than a distant supply
Diffusion into the interstitial fluid helps provide nutrients to distal cells.
Musculature movement causes movement of the interstitial fluid
COPD Patient: long standing chest expansion (Barrel chested) with accessory muscle use associated with increase of
parasympathetic (vagus) tone many dysfunctions in SCM and not just scalenes and intercostals decreased rib cage motion
OMT for COPD: Treat chest wall: Rib mobility, thoracic spine SD
Association of Goblet cells and mucus production
Steroids Osteoporosis
Counterstrain
Place patient in position of comfort for 90 seconds (120 for costal extra 30 for positioning)
Founded by Dr. Jones originally called spontaneous release by positioning
Other indirect styles are similar to counterstrain: BLT, Facilitated Positional Release, LAS, Functional Technique (palpate for
ease of motion with gentle pressure and resp. assist), Mackenzie technique (used extension and flexion to decompress load on
herniated discs)
Aim to shut the tender points down no major palpatory skill
Tender points can be articular or myofascial
Intrafusal fibers in the muscle spindle register change in muscle length. Central region has non-contractile fibers that are
innervated by afferent sensory receptors that senses length & change
13
Afferents are sensitive to tension that sends a signal to the CNS. The gamma efferents return from the CNS to increase
tension in central region of intrafusal fibers. Afferent sensory receptors recognize this increased tension and send signal to
CNS that sends an motor neuron to cause contraction of Extrafusal Muscle fibers.
Golgi Tendon Organs indicates to the CNS the extent that a muscle can stretch before tear. Can be elicited by putting
pressure on musculo-tendonous junction soft-tissue inhibition techniques
The agonist is shortened and the antagonist is lengthened inappropriate reflex tender point
Fold & Hold with finger in same position to reset the gamma motor neurons
Anterior tender points need flexion; Posterior tender points need extension
Treat the most painful tender point can treat up to 6 points
Rate the patients original pain as a 10 try to reduce that pain down to 0, can settle with 3
Tender Points may occur at muscle bellies, point where nerve pierces fascia, areas of swelling, etc
Advantages: Easy, non-traumatic, increases confidence, effective
Disadvantages: Stoic patients, Arthritic patients, patients who cant communicate or quantify pain, time
Costochondritis, fibromyalgia do not respond to counterstrain (because tenderness is generic)
Can combine treatments with counterstrain:
o Use muscle energy to help get patient into position of comfort
o Use HVLA to treat the articular dysfunction after using counterstrain to loosen the tissue
C2-6 usually follow SARA because of Type II-like dysfunctions
Lumbar Counterstrain
Rapid lengthening of a muscle spindle rapid contraction tender point
There may be a neurochemical response from traumatic changes in myofascial tissue
Tenderpoint = BB of unexpected pain that may be different than what the patient is expecting.
As a clinician, diagnose problem as either fascial, muscular, articular, visceral, arthritic, or degenerative
Use pad of finger to do initial probing and then lighten up touch with same digit always on spot
Tender points can be associated with motor end points, where the nerve exits the fascia
Anterior Lumbar points are more common because people bend and lift and strain
Posterior Lumbar Points make more sense biochemically and are easier to treat
Transversospinalis muscle plays a large part in the posterior lumbar tender points
Multifidus follows a Type I pattern if only one side flexes - Bilateral extension unless ext. part
14
Interspinalis follows a Type II pattern
Intertransversarii muscles will follow Type II pattern - unilateral side bending
Rotatores follow Type I pattern
Posterior Lower Pole L5 requires flexion and not extension
Thoracic Counterstrain
Aim to remove tension, shut down nociception, and balance alpha and gamma neurons
AT1 and AT2 is usually associated with supraclavicular nerve as it pierces through the fascia
Anterior Thoracic Points may stem from Mid-back pain, epigastric pain, flank pain, GERD, Dyspepsia, Diarrhea,
constipation
Anterior Anatomic Correlation: Rectus Abdominis (T6-T12), External Oblique (T5-T12), Internal Oblique (T7-
L1), Transverse Abdominis (T7-L1)
Semispinalis follows Type II pattern (transverse process of one to spinous process of other)
The Sympathetic chain ganaglia are anterior to the costotransverse articulations: movement of the segments puts
tension on the ganglia
Correlations between visceral and somatic complaints
OMM Research
Manual Research done mostly by D.O.s; Three part of a physician: Education, Research and Service
Money for research comes from NIH (Center for Complementary Alternative Medicine), Osteopathic Heritage Foundation,
AOA
KCOM is researching SD; TCOM is reseaching MOA of OMM; UMDNJ is researching geriatrics and Primary Care;
OhioCOM is looing at basic sciences and teaching palpation; PCOM (neurodegenerative dieases and lymphatics)
Ongoing Topics in Osteopathic Research
o Carpal Tunnel
o Low Back Pain
o Pregnancy
o Headaches
o Parkinsons Disease
o Fibromyalgia Syndrome
EMG changes with SD; decreased nutrients atrophy; facilitated segments back in 50s; SD measured with doctors and
instrumentation
15
Kappa aims to determine interexaminer reliability (#1 Manual Medicine priority) and ability of a secondary examiner to find
the same dysfunction (FIMMS)
o Kappa = 0.5 50% chance probability and 50% total agreement
o Kappa = 1.0 rare and probably cheated = 100% agreement
o Kappa = 0.0 poor reliability, no agreement among examiners
o Clinically significant Kappa = 0.4
Kappa of pulmonary examination is 0.4-0.5; somatic dysfunction 0.4-0.88 (with tenderness highest)
Hysteresis measures displacement after treatment and documentation of segment locations: During loading and unloading of
connective tissue, the restoration of final length occurs at a rate less than during deformation; property of viscoelastic
behavior
Chapmans Reflexes: Viscerosomatic reflexes with tissue texture changes at specific spots
o Anterior points have 80% sensitivity
o Removal of these reflexes increases circulation in the visceral organ
o Posterior points have many DD but are better used for diagnosis and treatment
Dirty Half Dozen responsible for Low Back Pain:
o Non Physiologic SD: Sacral Shear, Innominate Shear, Pubic Shear
o Other SD: Ilio-Psoas Syndrome, Type II Lumbopelvic SD, Short-Leg Syndrome
Counterstrain used clinically decreases soreness/stiffness, reduces swelling (esp. in plantar fasciitis) and decreases cytokine
production, changes muscle spindle activity
Lymphatic Pump increases the amount of Leukocytes
In Parkinsons Patients, there has been improvement with length on stride, hip range of motion by treatment with Facilitated
Positional Release, Soft Tissue, & Muscle Energy (HVLA not as effective)
Tillinghast Independent Reviews have shown that D.O. are more cost effective in Workers Compensation Cases compared
to other healthcare professionals, which can be from OMT and conservative measures by D.O.s in using more palpatory
diagnosis
OMM and Immune System
Good and Bad stressors can decrease immune function
Decreased pain decreased facilitation decreased sympathetics calming of immune response
5 Osteopathic Models:
o Neurological-Autonomic Model = direct connection facilitated segment = key player that creates reflex arc with
the organ that has trauma or surgery
o Behavioral-Biopsychosocial Model: Psychoneuroimmunology and physiology of pain/stress
16
o Respiratory-Circulatory Model : Open pathway, turn on pumps to remove edema, local treatment for improvement of
local tissues. This model will not spread cancer as long as you dont push on the cancerous areas (controversy)
o Metabolic-Hormonal Model: Diet, vitamins and exercise in immune function. Ex. Breast cancer patients that
exercise decreased cancer and increased longevity
o Postural-Biochemical Model: Postural curve with cross-overs have linkages to organ function and immune
functioning
Systemic Disorders can be treated with OMT that targets sympathetics, parasympathetics and lymphatics
3:3:3 Rule: 3 techniques on 3 areas in 3 minutes
Ex. Of Paraspinal Inhibition = Rib raising
Non-compensatory Pattern of Fascia (Ex. Hospitalized patient) symptomatic w/ Dysfunction
Dr. Sutherland: Fluctuation of Fluids
Lymphatic Pumps and Splenic Pumps return drainage and fight infections
Inflammation changes in capillary permeability efflux of protein into interstitial tissue return of protein only
accomplished by lymphatics
Geriatrics have silent infections because of immune system decline
Fever spikes in pediatric patients post-lymphatic treatment from production pf pyrogens but then will improve. Warn the
patients that this will happen
Lymphatic System = 2
nd
Circulatory System
Current Influenza outbreaks must learn from old OMM to treat new pandemics
BLT and soft-tissue often feels better than HVLA and muscle energy
20-40 million died worldwide during 1918 Flu Pandemic (.5 million in US)
Osteopathic care of Influenza patients had a significant better improvement over allopathic care
C. Miller wrote about the lymphatic pump Miller Thoracic Pump Technique
Taking a deep breath will cause a negative pressure that will bring lympathics and venous return into the thoracic chest cage.
Breathing out pushes the lymph into the thoracic inlet into the neck. Breathing in again lymph to go from thoracic inlet
into the vasculature
Thoracic Pump Technique: Pull up on ribs to increase respiration, compress on ribs during exhalation. You can get a large
amount of fluid movement in the thoracic by having the patients breathe against resistance and then suddenly let go. Good for
pneumonia and atelectasis. Bad for Emphysema
Inhalation component with lymphatic pump: Pec Minor
Passive range of motion is involved with lymphatic pump.
Coughing uses expiration muscles rib dysfunction (exhalation dysfunction) inspiration restriction
Splenic Pump is contraindicated for splenomegaly and mononucleosis
17
Splenic pump releases B and T cells into circulation
Never work over a lymph node
Dr. Zink taught treatment of the 4 transition zones and fascial patterns
Lymphatic pumps improve vaccine response, increased basophilia, enhances survival, weight loss
Pedal Pump is contraindicated for surgery patients and thrombotic patients (DVT)
Costal Counterstrain
Motion testing: Pump Handle (Ribs 1-2), Bucket Handle (Ribs 3-10), Caliper (Ribs 11-12)
Inhalation (elevated rib) Dysfunction posterior tenderpoints
Exhalation (depressed rib) Dysfunction anterior tenderpoints
Muscles of inspiration: SCM, Scalenes (anterior, middle to rib 1; posterior to rib 2), Pec Minor (ribs 3-5)
Serratus Anterior attaches to outer surface of upper 8 or 9 ribs and to medial scapula border
For Posterior points, sidebend away to elevate the rib
Dont use the head as a fulcrum with ankylosis of the neck and degenerative of the neck
Hold ribs in position for 120 seconds
Cervical Counterstrain
Diagnose Somatic Dysfunction first
Cervical Spine is Type II like mechanics and can be extended, flexed, or neutral
Indirect techniques are great for acute injury: cervical counterstrain is good for acute whiplash and acute cervical strains
Anterior Cervical Tenderpoints:
o AC1: posterior surface of ascending ramus of the mandible, 2-3 cm from angle of mandible
o AC2-6: Anterolateral aspect of anterior tubercle of transverse process
o AC7: 2-3 cm lateral and superior to the medial end of the clavicle at the clavicular SCM attach.
o AC8: on the medial end of the clavivle at the sternal attachment of the SCM
Anterior cervical tenderpoints are F-SARA except AC7 which is F-STRA
TMJ benefits from cervical counterstrain
AC4 Anatomic correlation: Longus Capitis Muscle
AC6 Anatomic correlation: Longus Colli Muscle
18
Posterior Points are found during tension headaches
PC1 Inion: Flexion; Anatomic Correlation: Obliqus capitis inferior muscle
PC1-2 lateral: E SaRa; Anatomic Correlation: Suboccipital Triangle
PC2 midline is on the superior aspect of the spinous process
PC3-8 midline is on the inferior aspect of the spinous process
PC3: F Sara while PC 2 & PC 4-8: E. SaRa
Hold for 90 seconds
Back Test Notes:
Patient Distraction is not considered a patient-assisted-releasing-enhancement
Soft Tissue of shoulder girdle = 1
st
sign of lymphatic congestion of upper extremity
Visible motion to the pubic region with quiet supine inhalation = best sign of optimal thoracic diaphragm
Infectious Mononucleosis = contraindication for splenic pump
The liver should be evaluated in cases of R shoulder pain, depression, chronic Hepatitis, & Hormonal Imbalance
High Frequency Vibrations = Pacinian Corpuscles
Pain Receptors are Non-adapting and are free nerve endings
Reciprocal tension mechanism of Sutherland: states that tension distributed through the ligaments in any given joint is balanced
based on tensegrity where the entire structure changes from one changed part
BLT refers to indirect techniques for ligaments while MFR refers to direct/indirect techniques for muscle and fascia
M1T3 OMM Study Guide
Thoracic Mechanisms: Muscle Energy (ME) Techniques
Muscle Energy = a form of Direct OMT in which the patient uses his muscles in a specific direction against a counterforce
as directed by the physician after being taken to the feather edge of the barrier
History: Dr. Ruddys Rapid Resistive Duction to drain cerebral fluid and congestive muscle with alternating contraction and
relaxation, Neuromuscular Therapy and Reeducation, and Proprioceptive Neuromuscular Facilitation
Developed by Fred Mitchell Sr. D.O. in 1958 AAO paper
Muscle Energy mobilizes joints ( ROM), stretches tight muscles, improves local circulation, increases lymphatic drainage,
and balances neuromuscular relationships of sympathetics and parasympathetics
Isometric Contraction = No change in muscle length with balance of contraction and resistance
Isotonic Concentric Contraction = Origin and insertion get closer with contraction > resistance
Isotonic Eccentric Contraction = Origin and Insertion distance with contraction < resistance
Mechanisms of Muscle Energy technique
19
o Post-Isometric Relaxation (PIR) Main ME technique good for thoracic sub-acute/chronic conditions resets
fibers or Golgi tendon body stimulation with increased gel sol conditions
Patient contracts (3-5 seconds) away from the barrier via the agonist muscle against physicians
counterforce followed by a reestablishment of the barrier
o Reciprocal Inhibition (RI) Acute scenarios Goal = lengthen a cramped or acute spasm by using antagonist
Patient thinks about contracting the antagonist muscle toward the barrier (very gentle) while the physician
guides the movement with some counterforce
Crossed Extensor contraction of antagonist muscle to relax agonist very gentle motion used in single
muscle dysfunctions used when contact of the affected limb is not allowed 2 to burns, fractures, etc
o Joint Mobilization Using Muscle Energy Uses a maximal contraction to gap the joint in a HVLA-type
movement where the patients contraction is away from the barrier with maximal control of isometric contraction
o Respiratory Assistance used for Costal ME Ex: Pectoralis Minor for Depressed 3
rd
,4
th
,5
th
ribs based on
principles of continuity of fascia Physician applies fulcrum for movement
o Oculocephalogyric reflex Patient uses eye movements to illicit minute head movements Used in Acute
scenarios when there is pain and spasm of the neck
ME Indications: Relevant Somatic Dysfunction
ME Absolute Contraindications: Absent SD, Uncooperative patient, Poor communication
ME Relative Contraindications: Infection, Hematoma, Muscle tear, Fracture, Joint Dislocation, Rheumatologic conditions
causing instability of C-spine, positioning compromises vasculature
KNOW muscle origins, insertions, functional anatomy, and innervation
ME Sequence: Feathers Edge of Barrier in 3 planes, patient contracts against resistance for 3-5 seconds, Patient relaxes while
physician takes patient to new barrier and repeat 3-7 times, Dr. reevaluates
ME may be used alone, or in combination with other OMTs or as a precursor to HVLA
Principles of HVLA
One of the oldest forms of therapy practiced by Allopaths, Chiropaths, and osteopaths worldwide
Definition: Safe, quick and direct technique that aims to pierce the restrictive barrier by using High Acceleration/Low
Distance without pushing through the barrier that will cause injury
High Velocity actually means High Acceleration with minimal distance
Used to return an articular SDs restricted joint to normal ROM in spinal, pelvic and extremity joints
Inappropriate manipulations are caused by hyper-positioning techniques that arent caused by HVLA
Articular Somatic Dysfunction with a x/y/z axial diagnosis could be caused by hyper-positioning, vacuum effects, odd
placement and not because of a muscle restriction SD is named for the superior segment
Understand the positioning of the facets in order to determine the direction of the HVLA movement!
o Understand the tissue, joint structure, patients willingness
Short-Levered physician uses manual force with less motion and greater control directly at the SD site
Long-Levered Physician uses muscle attachments and positioning as a lever to assist with the HVLA
o Uses more motion for tall patients and for hyper-mobile patients
o Long levered gives you more force and increased power
European technique of exaggeration is indirect into the physiologic barrier that also has less restriction than the direct barrier
It is hard to determine the cause of the SD in terms of whether the cause is the open side or the closed side
o Some patients require a closure of the joint, while others require a opening of the joint on the opposite side that is
only discovered via experience
HVLA Success is determined by Joint gapping/closing, specific localization, quick acceleration, low amplitude/distance for
safety, balance and control with a compliant relaxed patient
HVLA: long learning curve, most studied, most supporting evidence, and fastest technique
HVLA Indications: restricted joint motion with decreased ROM in articular SD
HVLA Contraindications:
o Severe Vertebral Artery Stenosis where positioning can light-headedness
o Herniated Disk (depending on the type)
20
o Developmental Conditions that lack normal joints and other pathologic restricted joint causes
o Downs Syndrome with hyper-mobile joints
o Klippel-Feil Syndrome with fused vertebrae and other congenital anomalies
o Spinal Rheumatoid arthritis (especially at C1-C2 to avoid fracture of odontoid process
o Osteoporosis = classical contraindication that requires years of clinical experience
o Severe Ankylosing Spondylosis
o Fracture or dislocation of the SD joint in the near proximity
o Infection (Osteomyelitis)
HVLA caution with proper positioning for Osteoarthritis, mild instability, joint restriction from strain/sprain
HVLA associated formula: W = mAd = mass X acceleration X distance
o Maximize A for success while minimized d for safety
FPR (Facilitated Positional Release) affects joints by suction by sliding the joint open
Pop Theories: 1) Nitrogen, Oxygen and Carbon Dioxide release from capsule suspension
2) Vacuum Effect of stretched joint that is popped open (Dr. Alexs position)
Pop is not a ruptured bicep or torn tendon that also gives pop sound
Thoracic HVLA:
o Diagnose a SD Especially the rotational component
o Place physicians thenar eminence of same side as patients rotated segment to serve as fulcrum for movement. Ex:
Drs left thenar under left rotated segments transverse process
o Control the patients upper body for flexion/extension and side bending components
o Seated Technique for Thoracic and Lumbar SD:
Short levered for Type 1 or 2 with direct HVLA on prominent posterior transverse process
Long levered with body movement while physician locks and controls the lower segment
o Supine for High Thoracic Flexion: Dr places thigh under rotated side and extends patient
o Prone Technique = student favorite with parallel hands in opposite direction for rotational dysfunction with hand
pointing cephalad on rotational side transverse process.
Mechanisms of Muscle Spasm (actually hypertonicity)
Hypertonicity is not spasm. Hypertonicity has perpetuating and precipitating factors.
Spasm = upper motor neuron phenomenon
Muscle Tone Spectrum: Functional TensionContracted Dysfunctional PhysiologyContracture Pathology
o Contracture with fibrosis responds better to direct techniques (HVLA, ME)
o Acute nociceptive Hypertonicity responds better to indirect techniques (MR, BLT)
Muscle Hypertonicity occurs from misuse, overuse, and muscle imbalance in incorrect positions
o Long periods of time with shortened muscles hypertonicity and trigger points in these muscles
Causes
o Local Trauma (ex: Fall on Piriformis) (Poorly executed OMT) or Cold muscles become hypertonic
o Compensation to posture & Imbalance (#1 cause of Trigger Points)
Short Leg Syndrome is a common cause of muscle imbalance
Dudley J. Morton Foot = 2
nd
toe is longer Toe-off the 2
nd
toe during gait imbalance
Hypermobile segments can cause adjacent muscle hypertonicity
o Functional demand and overuse
Overuse of Anti-Gravity Muscles stress and strain (Ex: Scoliotic change in gravity center)
o Noxious Stimulus spinal cord reflexes Muscle Constriction connective tissue reorganizing with contracture
while sympathetics are activated visceral & immune effects
o Viscero-somatic Dysfunction with reflex mechanisms of the same innervation as viscera
Ex: GastroDuodenal Ulcer pain at T6,7 and right anterior/posterior costal margin
Most occurrences in muscle and less in joint. Facilitated segment E Type II toward side of visceral
input. HVLA is not effective
Ex: Appendicitis Peri-umbilical pain, 12
th
rib tip pain, ruptured rebound tenderness
21
Appendicitis, Ureteral Stones can irritation of psoas
Pain patterns: Visceral Reflex Pain (Vague), Viscerosomatic Reflex (Segmental Facilitation),
Peritoneo-Cutaneous Reflex (rebound tenderness & guarding)
Symptoms
o Pain and tenderness, changes in ROM, Neurovascular-lymphatic entrapment (Ex. Scalenes - thumbs)
Physiology (Gait Model of Pain)
o Trigger Point Nociception received by intrinsic muscle receptors pain-spasm-pain cycle to guard the muscle
via unmyelinated fibers while cold fibers use myelinated fibers that can be accessed to override the pain-spasm-pain
cycle via Spray-and-Stretch Method
Spray is the distraction over the entire longitudinal muscle, while the Stretch is the action
o To reestablish the relationship between muscle and nerve, other techniques must be used.
Diagnosis
o Muscle Dysfunction is a form of somatic dysfunction
o Hypertonic vs. Hypotonic; Resting tone vs. contraction; Agonist vs. Antagonist; Upper (from brainstem/cord) vs.
Lower Motor Neuron (from anterior horn reflex arc); Myotatic Unit; Flexors vs. Extensors; Anti-Gravity vs. Phasic
Muscles (antagonists to each other)
Upper motor neuron dysfunctions tend to have hyperreactive muscles that dont dampen
Myotatic Unit = shared function muscles that will become hypertonic by association
We are an articulatory lever system that resists gravity by maintaining postural and ligamentous tone.
Postural Muscles usually cross 2 or more joints.
With Hypertonic Postural Anti-gravity muscles, the phasic muscles have pseudo-paresis
Muscle Examples:
Postural (spastic): Quadratus Lumborum, Hamstrings, Gastrocnemius/Soleus, Piriformis, Upper
trapezius, Scalenes (Entrappers)
Phasic (weakness): Abdominal Muscles, Fibularis/Anterior Tibularis, Gluteus, Mid/Lower
Trapezius, Latissimus Dorsi
o Quadriceps are phasic (3 Vastus Muscles) and postural (Rectus Femoris)
o Psoas Syndrome Muscle imbalance to the lower extremities
Hip flexor, Lumbar spine extendor, external rotator, Amenorrhea
Key Lesion = L1/L2 Type II Flexion Use Counterstrain
Associated with decreased Lordosis and Piriformis contraction to prevent falling
(+) Thomas Test with shortened Psoas elevated leg when flexing other leg
o Piriformis Tenderpoint Syndrome located halfway between PSIS and greater trochanter
External Rotator and Abductor at hip joint
Contracture of the Piriformis Sciatic Nerve Compression pain down posterior leg but not past the
knee. Trigger point pain can also follow the attachments of the muscle.
Trauma from falling on butt, Sacral Shear, Innominate Shear, sitting on wallets, etc
Treatment: Direct Adduction and Internal Rotation or Indirect Counterstrain with abduction, external
rotation and flexion while patient is prone and physicians is on side
o Myofascial Trigger Points changes in vasculature and tissue stiffness can occur in postural or phasic muscles. May
be easier to find the trigger point in the phasic muscle
Active Trigger Point: Pain pattern triggered at rest, muscle action, or palpation
Latent Trigger Points: Pain pattern triggered by muscle action and palpation, quiet at rest
o Visceral Problems referring to Muscles
Treatment: Prevention, Treat the muscle, treat the underlying mechanical cause, systemic osteopathic treatment to treat all of
the joints
o Techniques: Soft Tissue, MR, Counterstrain, Direct ME, Vapocoolant Spray & Stretch, Biofeedback, Percussion
Hammer, Exercise, PT, Injections (The Goal is the most important)
o Heat vs. Cold: Short-term heat helps MR w/ vasodilation, Long-tern heat vasodilation/edema, Short-term cold
pain, Long term cold muscle contraction. (15 min at a time)
22
Tight Hamstrings (postural muscle) can be treated with Spray and Stretch
o Tight Hamstrings will give a false (+) straight leg test (not a herniated disc)
o Perpetuated by: Gravity strain, prolonged sitting, inactivity, isthmic spondylolisthesis (L5 over sacrum)
Quadratus Lumborum continuity with diaphragm & 12
th
rib causes Lower Back Pain
o Superficial and Deep Trigger Points that can affect the rib dysfunction of 12
th
rib
Forearm Tenderpoints: For Carpal Tunnel Syndrome: Stretch region with extension and supination
o For Lateral Epicondylitis (Tennis Elbow): Stretch region with pronation and flexion to affect the SWEAT muscles:
Supinator, Wrist Extensors, Anconeus, and Triceps
Somatic Components of CVM Kyphosis and AP curvature
In a dire situation regarding OMT, treat the facilitated segment first!
The facilitated segment is common to both viscerosomatic & somatovisceral reflexes
Cardiac Viscerosomatic reflex clue of tissue change occurs at T1-6, OM suture, OA-C2 (via parasympathetic vagus nerve),
pectoralis major Trigger point and flattened kyphotic curve at T1-6
Test question: Match pain location with palpation with visceral relation to determine Somato-visceral or Viscerosomatic
relationship. Understand other symptoms associated with visceral/somatic disease
Cardiac Chapmans Point = Intercostal Space 2 on the left side
Autonomics of the Blood: Heart (T1-6), Upper extremity (T2-8), Kidneys/Adrenals (T10-11), Lower (T11-L2), Gastric (T5-9
between Angle of Louis and Xiphoid)
Posterior to Umbilicus = L2-3 interspace with T10 dermatome
3:3:3 Rule: 3 techniques at 3 regions in 3 minutes: Cardiac treatment: Thoracic Outlet for lymphatic drainage, Rib raising for
sympathetics and lymphatics, and C2 for parasympathetics
Right Vagus SA node, Left Vagus AV node, Right-sided SD = Atrial, Left-sided SD = Ventricular
Heart and Lungs drain into right thoracic duct.
Thoracic Inlet = circular space within manubrium, ribs 1-2 and T1-4
Thoracic Outlet = larger space between clavicles, scapulas, scalenes, and Rib 1-2
Thoracic Outlet Syndrome = entrapment of neurovascular via scalenes
o Test with Adsons Test with extended head rotated towards after deep inhalation (+) loss/decreased radial pulse
o Common Young females w/ long swan necks, poor posture: thoracic kyphosis, cervical lordosis
Scalenes entrap Subclavian Artery, and lower trunk of brachial plexus while clavicle entraps subclavian vein
Cerivical Rib Syndrome is tested with modified Adsons with head rotated away
Hyperabduction Manuever loss of radial pulses with exaggerated military posture from trapped subclavian artery and
vein between 1
st
rib and clavicle or behind pectoralis minor
Raynauds Phenomenon: (red white blue) Hypersympathetic in peripheral circulation in cold
Reflex Sympathetic Dystrophy = Pain from Injury in upper extremity cycle of pain and swelling from signal traveling to
CNS and then to the sympathetics inflammation and more pain
In Acute Coronary Intervention, follow ABCs along with calming of the facilitated segment
systolic/diastolic via CV 4 Cranial Technique or T1-4 paraspinal inhibition of the heart
Balance Sympathetics and parasympathetics for less peripheral resistance and better cardiac output
Opening of Lymphatic Pathways doesnt overwhelm CHF but helps remove pulmonary & systemic edema
Lymphatics and Thoracic Duct are under sympathetic control.
Costal Mechanics & Muscle Energy Techniques
Costal Dysfunctions are usually result from vertebral dysfunction(except 1
st
rib) that must be treated first
Exhalation dysfunctions require the use of accessory muscles to pull the ribs into inhalation
Know origins and insertions of bone and muscle attachments and the physiologic movement of the ribs
o Ribs 1-10 articulate posteriorly with transverse processes and vertebral body contacts
o Anteriorly, the ribs attach via cartilagenous attachments to sternum or confluence near rib 6
o Diaphragm attaches to lower 6 ribs anteriorly and to L1-2 posteriorly and is innervated by the Phrenic nerves (C3,4,5)
23
o Anterior Scalenes are attached to rib 1 (Hypertonicity Inhalation Dysfunction) (Muscle can also be used to treat
Exhalation Dysfunction to pull the rib up)
Muscles of inhalation: SCM, Anterior, Middle, Posterior Scalenes; External intercostals, Diaphragm
Muscles of exhalation: Internal Intercostals, Abdominal Muscles
Rib Motion : Ribs 1-2: Pump Handle, Ribs 3-6: Combined, Ribs 7-10: Bucket Handle, Ribs 11-12: Caliper
o There is some bucket handle motion in all ribs 1-10.
o Hand placement must reflect physiologic rib motion
Rib 12 moves posteriorly-inferiorly by the quadratus lumborum (Rib 11 as well in PCOM)
Rib angle is where the first twist of the rib after the costotransverse joint
Review: Rules of three for vertebral thoracic transverse processes and spinous processes. Rib 12 exception
Assess movement of the ribs by asking the patient to breath as you monitor the rib movement
The rib with the least excursion = the restricted rib.
Muscle energy techniques for the ribs = Post Isometric relaxation, Reciprocal Inhibition, Mobilization
Costal Dysfunctions are treated with 5-7 repetitions of contraction/reposition
In group costal dysfunction, the key rib is treated first, which resolves the remaining group ribs.
o Inhalation Dysfunction group: Key rib = lowest rib of the group
o Exhalation Dysfunction group: Key rib = highest rib of the group
Respiratory Assist Technique uses the patients breathing while the physician resists inhalation
Exhalation Dysfunction uses Mobilization Technique
o The rib angles are palpated posteriorly to allow for a fulcrum for rib via lateral/caudad traction
o Rib 1/2 can use pectoralis minor ME to pull the rib out of exhalation (with hand on head)
o Ribs 3-5 can use pectoralis minor (with hand over the head)
o Ribs 6-8 can use serratus anterior (with elbow pushing anteriorly at 90 angle)
o Ribs 9-10 can use Latissimus dorsi (with laterally outstretched arm trying to adduct)
o Ribs 11-12 can use quadratus lumborum (Prone patient is sidebent away with elevated side ASIS, while patient
attempts to lower ASIS to table)
Review anatomy of thorax anteriorly and posteriorly!
OMM Research
Similar responsibilities between researcher and physicians:
decision-making, protection of human subjects, addresses conflict
of interests, responsible authorship, data management and
misconduct
Pilot study: small # of patients to obtain preliminary data to
determine viability of extensive investigation via statisticians help
Recruitment of Study Patients must be diversified and is
influenced by physician/patient relationship, failure to adhere to
protocol, bad media, history of bad and harmful studies
Preoperative IV Morphine Sulfate with Postoperative Osteopathic Manipulative Treatment Reduces Patient Analgesic Use
after Total Abdominal Hysterectomy was a paper published by Dr. Goldstein and Dr. Nicholas in the JAOA in 2005 from
PCOMs City Avenue Hospital
o OMM Techniques: Rib Raising and Pelvic/Sacral Myofascial Release to decrease somatovisceral and
viscerosomatic reflexes prior to and post-surgery to decrease pain and increase lymphatics
o Placebo = Saline that was in addition to regular pain medication
o Sham Technique was utilized in all participants. No participants had OMT previously
Sham performers think about something else to avoid accidental OMT treatment
Hands are placed in the same position as a normal OMT treatment
o Three reasons for somatovisceral reflex:
Documented pathological history
24
Increased muscle tension in these areas
Surgical operation
o Viscerosomatic reflex is common in surgery because change in viscera from the surgery (removal, cutting, implants,
etc) afferent stimulus and subsequent somatic dysfunction
o 3 OMT or 3 Sham Treatment sessions: 4 hrs post-op, 8 am the day after surgery, 2 pm day after.
o Pain was determined by amount of morphine
o Result:
Group 4 (pre-Op Morphine and Post-Op OMT) used significantly less morphine in the first 48 hours after
surgery
Manipulative Treatment for Pt with Pulmonary Disease
Review anatomy of the lungs
Rib Raising effects on Sympathetic autonomics
OMT treatment is based on an assessment of Autonomics, breathing patterns, chapmans points, etc..
Sympathetic Stimulation vasoconstriction, Bronchodilation, and thickened secretions
o Hypoperfusion and more shallow breathing
o Sympathetic Chain Ganglia
Parasympathetic Stimulation Vasodilation, Bronchoconstriction, and watery secretions
o Vagus Nerve stimulation decreased diaphragm excursion rapid shallow breathing
Hering-Bruer Reflex is a signal that is triggered by excess lung inflation from air or water to prevent further damage can be
triggered by pulmonary congestion and/or edema
Chapmans Points are not required to be present 100% but may be beneficial for 2
ndary
confirmation
o Predictable Patterns based on body organ
o Upper Respiratory Diseases: Bilateral 3
rd
Intercostal space lateral to sternum
o Lower Respiratory Diseases: Bilateral 4
th
Intercostal space lateral to sternum
Pulmonary Viscerosomatic reflexes occur in T1-5 (2-6) area (Upper Thoracic) Left is greater Right
o Definitely check T3-4 on the left for increased tone and pain as a sign of pulmonary involvement
Musculoskeletal response: Immobility of ribs and spine, diaphragmatic stress viscerosomatic dysfunction, lung tissue
resistance Workload, lumbar lordosis, diaphragm flattening
Exhalation Dysfunctions limit rib expansion and cause pain with shallow breathing
Scalene Fatigue and Hypertrophy occur from overuse in COPD and Asthma
Treat the facilitated segment first.
Treatment:
o Occipital: Vagus nerve release via OA and occipital-mastoid suture
Headaches are often found in people with pneumonia due to thoracic-cervical relations
o Cervical: C3-5 for the phrenic nerve
COPD
o Findings: Hyperinflation, Pulmonary resistance, cardiac output, pulmonary HTN, cor pulmonale
o Evaluate: Flattened diaphragm, Upper Thoracics for autonomics, and cervicals for phrenic nerve
o Over 90% of COPD is caused by smoking and can be improved with OMT
o Treatments: Thoracic spine, Thoracic Inlet Release, Rib Raising, Redoming Diaphragm, Thoracic Pump, and
Pectoral Traction
Asthma
o Hyperinflation with expiratory wheeze, cardiac output, flattened diaphragm
o Treatment: Use thoracic pump for Acute Attack and Muscle Energy on T3-4 for non-acute attack
o Improve Lung/rib excursion via: Treat Facilitated Segment, Thoracic Inlet Release to release thoracic ducts, Rib raising
to rib motion and Sympathetics, C2 and Suboccipital for Vagus, and Thoracic Pump and Pectoral Traction for
lymphatics
Pneumonia
o In Early (Toxic) stage, no aggressive treatment and no sympathetic stimulation (vasoconstriction)
25
o Influenza Epidemic of 1918 with significant improvement with OMT
o Treatment cause: waste removal, vasoconstriction, improve antibiotics, improve respiration
o Treatments: Thoracic spine, Thoracic Inlet Release, Rib Raising, Thoracic Pump, Pectoral Traction, and Splenic
Pump (Contraindicated in Splenomegaly: Mono & caution in osteoporosis)
Respiratory OMT goals: congestion, Sympathetics, Mechanical Problems, improve respiration
Multiple Ways of Thoracic Inlet Release: indirect/direct myofascial release, muscle energy, BLT, sticking fingers straight up
in the subcostal space and pushing until feel resistance
Miller Thoracic Pump: Hands on chest with rhythmic pumping, female patient modification, side modification, atelectasis
modification (rapid release of progressive exhalation motion)
Pectoral Traction pulls on ribs 3-6 by pulling on the pec minor and some pec major
Doming of the Diaphragm by sticking thumbs subcostally and pushing cephalad to pop diaphragm up.
o Flattened Diaphragm occurs with fatigue and somatic dysfunction
Lymphatic Pumps with various research studies indicating its effects on immunity
Scoliosis 1, 2, 3 Classification, Etiology, and Treatment
Scoliosis Definition: Lateral Curve of the spine > 10 degrees that is named based on the convexity with the apex of the curve
= to most laterally deviated segment
Scoliosis can be associated with vertebral rotation (rotoscoliosis), kyphosis (kyphoscoliosis), lordosis (lordoscoliosis),
rotation of spine + ribs (rib hump), or other combination (kyphorotoscoliosis)
History : Hippocrates termed scoliosis = crooked; Galen termed lordosis and kyphosis
o Long history of bracing patients to reduce scoliosis and using traction
Prevalence and Rates depend on Cobb angle studied and age range from 2-3% to 4.5%
o More common in females than males (1.4 times with curves 11-20)(4x with curves > 20)
Theoretical Causes : Genetics, Musculature Imbalance, central/postural/mechanical brain systems
o Scoliosis is multifactorial with different etiologies depending on the form of scoliosis
o Genetics: Sex-linked from mother to kids or carrier father to daughter; multiple scoliosis kids;
Genes from both families with 1/3 chance of passing on genetics to your child
Genetic error can cause brainstem dysfunction balancing dysfunction scoliosis
Genetic mistakes may only be expressed 10-12 years later in adolescence or juvenile
o Progressive Scoliosis occurs in patients with curves > 45-60 or strong genetic cause
Categories of Scoliosis:
o Non-structural Sidebending to convex side straightening of the curve w/out rotation
Postural Type: slight lateral deviations that correct voluntarily with movement
Compensatory type: Shortened leg lumbar scoliosis with convexity on short leg side
o Structural decreased flexibility, Failure to voluntarily straighten with sidebending, shortened ligaments and
muscle on the concave side.
Idiopathic Type = most common structural (~80%); Genetic Cause = sex-linked (~90%)
Decreased vibratory sensation in all extremities
Infantile Subtype Boys (0-3 y/o) w/ Left thoracic convexity-resolves spontaneously
Juvenile Subtype Girls (3-10) w/ Right Thoracic convexity unrecognized until age 6
o Treatment: Observe curves <25, Brace curves 20-40, surgery inflexible>40
Adolescent Subtype Girls (85%) with Right Thoracic convexity (>90%)
o Atypical Left Thoracic Convexity = Tumor, syringomyelia, or tethered cord
Order MRI of brain, cervical, thoracic and lumbar w/out contrast
o Worse prognosis for early diagnosis, delayed skeletal maturity, delayed menses
o Treatment: Observe curves <30, Brace curves 25-40, surgery inflexible>40
Curve Patterns:
o Right Thoracic (Most common) From T4-6 to T11-L1 Rib involvement
Severe Cosmetic Defect and cardiopulmonary dysfunction
Major curve associated with minor curves above and below
26
o Right Thoracolumbar (common) From T4-6 to L2-4
Less cosmetic defect but has severe rib and flank distortions
o Double Major Curve: Right thoracic/Left Lumbar or other less common combo
o Lumbar Major Curve From T11/12 to L5 Convex Left (65%) Very rigid
Congenital Type = Defect in embryologic spine development; Girls > Boys (2.5:1)
Associated Embryologic Organ Dysfunctions: Genitourinary Defects, Cardiac Defects, Pulmonary
Function, Tethered cord, syringomyelia, Klippel-Feil Syndrome
o VACTERL mnemonic: Vertebral Anomalies, Anal Atresia, Cardiovascular Anomalies,
Tracheoesophageal Fistula, Esophageal Atresia, Renal/Radial Anomalies, Limb anomalies
o Associated dysfunctions warrant extensive pre-operative evaluations
Abnormal bone development: Failure of formation w/ unilateral or partial wedges, failure of
segmentation, congenital kyphosis or congenital lordosis
Neuromuscular Sclerosis Bad prognosis
Neuropathic
o Upper Motor Neuron Causes of Scoliosis: Cerebral Palsy, Friedreichs Ataxia, Syringomyelia
(cysts growth in cord), Spinal cord tumor or trauma
o Lower Motor Neuron Causes: Poliomyelitis, Dysautonomia
Myopathic : Duchennes Muscular Dystrophy (Male X-linked rapid muscle degeneration) or
congenital Hypotonia
Mesenchymal Origin : Marfan Syndrome, Ehlers-Danlos Syndrome, Homocystinuria
Neurofibromatosis with cutaneous caf au lait spots and subcutaneous neurofibromas
Scheuermanns Disease = Thoracic Kyphosis from wedge shaped deformity of 3-5 vertebrae
Other causes: Trauma, Tumors, Poor Nutrition, Klippel-Feil Syndrome, Sprengel deformity
Osteopathic Viewpoint: Compensation occurs with the bodys attempt at maintain eyes level
o Rotation occurs in opposite to sidebending rotation of the vertebral body toward the convexity
o Rib Hump occurs from scoliosis because the ribs on the concave side approximate anteriorly, while the ribs on
convex side approximate posteriorly
o Vertebral canal may narrow on concave side from narrowed disc space
o Wolfs Law: Shapes and structures reflect stresses places on them. Ex: Scoliotic Vertebrae
o Heuter-Volkmann Principle: Increased pressure on concave side of vertebral body slowed growth on that side, while
allowing growth on convex side wedge formation rigidity
o Denslow & Korr: Facilitation with lowered threshold muscle tension from lower stimuli
Clinical Presentation: Pain after activity, family history, Adams Forward Bending test
o Perform Osteopathic Structural Exam: Motion Testing and Layer-by-layer palpation
o Cobb Angle = Angle formed by two lines that are perpendicular to top and bottom of the curve
o Determine Bone Maturity via Risser Sign: ossification status of iliac apophysis from lateral to medial excursion
with Risser 5 = fused excursion w/ full end-height
Greatest risk of scoliosis progress with Risser 0-1 than 2-4 Earlier intervention
Treatment:
o Recent research with calmodulin ( in scoliosis) and antagonist melatonin ( in scoliosis)
o Modern Orthotic Bracing:
Milwaukee Brace: Cervico-Thoraco-Lumbo-Sacral Orthosis (CTLSO) by Dr. Blout & Schmidt
Prevents curve progression in immature patient Best with high spinal curves
Boston Brace: Thoracic-Lumbar-Sacral Orthosis (TLSO)(low-profile, under arms)
By Dr. Hall and Dr. Miller for Lumbar or Thoracolumbar curves
Charleston Bending Brace by Dr. Reed and Mr. Hooper for curves >25-35 below T8.
Molded to patient in sidebent position towards convexity for over-correction
SpineCor Brace by Dr. Coillard and Dr. Rivard for immature patients (6-11 y/o) w/ <30
Targets: Neuromuscular Dysfunction, Growth Asymmetry, Postural Disorganization, and Spinal
Deformation by bracing corrective movement
27
Greatest flexibility with opportunity to play sports
o Surgery to correct or improve spinal deformity and reduce risk of progression and 2
ndary
effects
Dr. Russell Hibbs 1
st
Spinal fusion for scoliosis with reconstructive bone grafts
Dr. Harrington (1950s-1990s) Posterior spinal fusion via instrumentation premature arthritis and
Lower Back Pain
Dr. Cotrel and DeBousset (1980s) developed segmental instrumentation with 3D correction
Current Gold Standard for surgical treatment of scoliosis
o Exercise to maintain normal motion and to remain flexible
o OMT: Soft Tissue, MR, but not HVLA
o Try to prevent further progression of the scoliotic curve to avoid cosmetic deformity and severe cardiopulmonary
dysfunction via multi-disciplinary treatment protocol over many year span
Short Leg Syndrome
o Could be functional or anatomic (OMT is not possible in anatomic Short leg)
o Significant issue if > 5-8 mm or is symptomatic; Goal = Level the sacral base
o Diagnosis with Postural (Upright) full body X-ray in AP and Lateral views to rule out other pathology, congenital
anomalies, # of vertebrae, and to determine severity of syndrome
Measure differences in Iliac Crest Heights, Femoral Head Heights, Sacral Base Unleveling based on femoral
head lines
Evaluate any sclerotic changes, calcifications, roughening, exostoses
o Heilig Formular for Heel Lifts: L = [Sacral Base Unleveling]/ [(Duration of adaptation)-Compensation]
Duration of adaptation: (0-10 years =1, 10-30 years = 2, >30 years = 3)
Compensation (None=0, Type 1 compensation = 1, Wedging, altered facets, spurs = 2)
Heel lift is placed on side of low sacral base
Fragile Patients: slow (1/16) increases in height every 2 weeks
Average Patients: (1/8) increases in height every 2 weeks
Build the sole to prevent pelvic rotation and if more than 12 mm heel lift is needed
Aggressive increases in heel height dysfunction and pain
Maximum under the heel: 6mm inside shoe, 6 mm outside the heel
Heel lift done by orthotist or shoe store using various foot measurements
Integration of OPP in the care of Pts with CV, Renal, and Pulmonary Disease
Osteopathic Approach to Diagnosis and Treatment
o Biomechanical Principles are based on articular and myofascial body components
o Vascular Principles includes fluid compartments: lymphatic, venous and interstitial
o Pneumatic Principles assess functional pressure gradients that affect the other 3 principles.
o Neuroreflexive Principles involves Sympathetics/Parasympathetics, Facilitation, and
Viscerosomatic/Somatovisceral/SomatoSomatic reflexes
Surgery is organized trauma scar tissue
In a pulmonary patient, neuroreflexive principles for autonomics are T1-6 (sympathetics) and Vagus from OA
(parasympathetics)
Myofascial connection of Deep cervical aponeurosis, thoracic fascia, mediastinum, pericardium, diaphragm, and pleura of
the lungs:: Treatment of the cervical area affects on lungs
Thoracic Inlet (Superior Thoracic Aperture) Neurovascular Space
o Boundaries: T1 Body (Posteriorly), 1
st
ribs (Laterally), Superior Border of Manubrium (Anteriorly)
o Contents: Esophagus, Trachea, Nerves, Carotids, Brachiocephalic & Subclavian Arteries and Veins
Stellate Ganglia at C7 near rib 1 neck projects sympathetic fibers down to the heart and lungs
Treatment Sequence:
o Paraspinal muscle stretch soft tissue in supine thoracics
o Rib raising for initial sympathetic and then later in sympathetics
28
o Diaphragm Release, Thoracic Inlet Release, Occipital-Atlanto Release, Cervical Paraspinals, Articulatory release via
indirect BLT, Lymphatic Pump Techniques
Pulmonary Viscerosomatic Reflexes: T1-3 Bronchomotor, T2 left Asthma, T2-3 Bronchial Mucosa, T3-4 Lung Parenchyma, T1-
12 Parietal Pleura; Parasympathetic Vagus, occiput, C1-2
Circulatory Efficiency = Myofascial Tension, mechanical efficiency of Thoraco-Abdominal Pump, Facilitation and
sympathetic tone on vasculature, peripheral vasodilation, afterload stress
Cardiac Viscerosomatic Reflexes: T1-T5 mostly left, Arrythmias at T2 (right SA, left AV), T5 posterior MI
Cardiovascular Chapmans Points:
o Anterior 2
nd
Intercostal Space lateral to sterum, Posterior: between T2-3 transverse processes
COPD Somatic Dysfunctions = Barrel Chest, Accessory Muscle Hypertonicity, Reduced chest compliance, Rib Restriction,
Loss of kyphotic curve, Base of Skull-C2
o Compliance and FEV1 decreases with age and decreases greatly with smoking
UTI Chapman Points: Anterior Pubes
Lymphatic Drainage
o Right Thoracic Duct: Heart, lungs and upper right body
Impaired drainage reduced collateral circulation
o Left Thoracic Duct: All left side of body and lower part of right side
o Respiratory-Circulature Model depends on patterns of Zink and junctions
SD impairs external respiration and then internal respiration
o Treatment Sequence: Remove Obstruction (correct SD, open fascia), Maximize Thoraco-
Abdomino-Pelvic Pump (correct SD, redome diaphragms), Augment Pumps (Rib raising, add
pumps) and Stimulate local lymph drainage to move fluid towards heart
Assessment, Documentation and Implementation of OMT
SOAP Notes often centered around pain based on the patients presentation
Subjective History: History of the presenting illness, Past Medical History, Past Surgical History, Medications, Allergies,
Social History, Family History
o Analgesics, Antibiotics cause constipation (not to be confused with post-op ileus)
o Location of pain is not always the location of lesion/dysfunction
o Visceral disease has a worse prognosis than musculoskeletal dysfunctions, unless it is cancer
o R/O serious conditions: Fracture, Tumor/Metastasis, Infection, Osteomyelitis
o Pain history: OPQRST: Onset, Duration, Location, Radiation, Quality, Severity, Modifying Factors
Spinal stenosis is worsened with extension
Bulging disc is worsened with flexion
Objective Physical Exam: Vital Signs, Observation of Gait, Posture/Guarding, In/Out Chair, Stand/Sit
o Lower back Pain presents with guarding as a positive tripod sign with patients grabbing their chair to stabilize
themselves as they sit down
o Structural Exam: Evaluate patient in standing position (posterior, lateral, anterior), seated, prone, and supine
positions to evaluate symmetry, scoliosis, landmarks, and active or passive range of motion
o Always wear gloves when doing a posterior exam on a supine hospital patient
Assessment and Plan go together with a Differential Diagnosis
o Determine primary location of pain and the cause of the pain
Ex: Disc, facet, spondylosis, osteophytic neuroforaminal encroachment, etc
o Somatic Dysfunction Diagnosis based on T.A.R.T.
o Patient Education/Assurance is important in the plan to improve the condition of the patient
o Treatment options and management need to be explored with the patient to decrease confusion, along with
reassessment to determine effectiveness
o Symptom Control
OTC analgesics, NSAIDS, muscle relaxants, opioids
NSAIDS are more readily available but have a high morbidity and mortality
Opioids are addictive but are more controlled and the most efficacious
29
Osteopathic Manipulative Treatment May not be the best treatment
Physical Therapy modalities, procedures, and therapeutic exercise
Ice vs. Heat: Ice for acute to subacute and Heat for chronic and some subacute
Chest Pain Differential
o Pleuritic Pain Sharp or stabbing pain worsened by deep inspiration, coughing, or upper body movements
Pneumonia, PE, TB, Systemic Lupus, Tumors, Pneumothorax, Chest Wall Pain, Neuritic Pain (Ex:
Dermatomal Zoster) (important),
Chest Wall pain can be caused by Rib fractures, costochondritis, pectoral Myositis (myofascial pain), sickle
cell crisis
Neuritic Pain can be caused by Intercostal Neuritis with a band around the chest, Herpes Zoster, tumors of
the spine or osteomyelitis (can also give you band-like pain pattern)
Cerival Strain/Sprain
o Acute techniques: Cranio-sacral, MR, Counterstain, Muscle Energy (RI), Soft-Tissue
o Chronic Techniques: Soft-Tissue, Muscle Energy (PIR), HVLA, LAS/BLT, MR, Counterstrain
o Acute receives indirect techniques, while chronic gets indirect or direct techniques
Whiplash shows up the next day as anterior neck pain
o Acute cervical strains/sprains are easy to treat
There must be a matching between CC, HPI, Subjective statements, and objective physical exam
Fastest way to treat multiple locations: Myofascial release at Cervico-Thoracic, Thoraco-Lumbar, and Lumbo-Sacral
Junctions
M2T1 OMM Study Guide
LOW BACK PAIN
Facts
80% of the population will experience LBP
2
nd
most common PCP complaint
Most common cause of disability < 45yo
Initial Assessment
1. Age
a. Young (<20yo): spondylolysis
b. Old (>50yo): systemic disease
i. Spine-related
1. Mets, multiple myeloma, osteomyelitis, epidural abscess
ii. Not spine-related
1. AAA, prostate, kidneys, PID, uterine fibroids, ovarian cysts
2. HPI
a. Need to rule out RED FLAGS
i. Fracture: X-ray, MRI, bone scan
1. Old (>70yo), female, premature menopause, no hormone replacement, trauma, sedentary
2. Hx of hyperthyroidism, Cushings, Addisons, osteoporosis
ii. Cancer: MRI, bone scan
1. Old (>50yo), family hx, weight loss, pain at night at rest, bowel/bladder/sensory dysfn
iii. Infection: MRI, bone scan
1. Fever, chills, leukocytosis w/shift, + cultures, ESR, weight loss, malaise
2. Hx of IVDA/immunosuppression/steroids, UTI/associated infection
iv. Cauda equina syndrome: urgent MRI
1. Sciatica, B/L leg weakness/numbness, difficulty walking, urinary retention/overflow incontinence,
unexplained constipation
2. Surgical emergency
a. Saddle anesthesia
b. anal sphincter tone
c. Bowel/bladder symptoms
d. Rapid neurologic deficits
30
b. Different types of pain
i. Dermotomal: superficial
ii. Myotomal: burning in muscle
iii. Sclerotomal: fire down bone
3. PE
a. Pt standing
i. Pt leaning forward to one side with ipsilateral foot everted
1. Spasm in left psoas (L2 FSLRL)
2. Pelvic shift right
3. Right piriformis spasm
4. Right sciatic neuritis
5. ROL sacral torsion
ii. Pt stands very erect and dislikes FB
1. Disc pathology
a. Annular tear/fissure
b. Pulposus bulge/herniation
i. Pulposus is NOT innervated
c. SINGLE SEGMENT DISTRIBUTION
2. Acute strains or sprains
iii. Pt dislikes BB
1. Degenerative disc disease
a. MULTISEGMENT DISTRIBUTION Facet Syndrome
2. Spondylolysis
3. Hypertrophy of facets
b. Pt seated
i. Focused neurologic exam
L4 L5 S1
Tibialis anterior (deep peroneal nerve)
Difficulty walking on heels (L5 too)
Diminished patellar reflex
Sensory loss: medial lower extremity
EHL, ext. digitorum L&B, glut. med.
Weak ankle/big toe dorsiflexion
L5 muscle stretch reflex: deep hamstring
tendon
Sensory loss: lat leg, dorsum foot
Peroneus L&B, gastroc/soleus, glut. max.
Difficulty walking on toes
Diminished Achilles reflex
Sensory loss: lateral/plantar foot/ankle
ii. Seated flexion test
iii. Straight leg raising
1. With and without cervical/trunk FB puts tension on dura
31
c. Pt supine
i. ASIS compression
ii. Straight leg raising (active/passive)
d. Pt prone
i. Motion testing
1. Intersegmental
a. L1-5
b. Sacrum
i. Passive SI joint motion testing (wiggle leg)
ii. Axes of sacral motion
1. Inferior transverse axis (innominate)
a. At S3 ilia/inominate movement
2. Middle transverse axis (postural)
a. At S2 nutation/counternutation
3. Superior transverse axis (respiratory)
a. At S2 (post to dural attachment) respiration
i. Craniosacral mechanism
e. Pt lateral recumbent
i. Passive regional ROM
ii. Intersegmental T12-L5/sacrum
Drug Therapy
NSAIDs: GI, liver, kidney ADRs
Analgesics: OTC/opoids/non-opoids
Muscle relaxants
Patient education agency for health care policy and research (AHCPR) and national institute for occupational safety and health
(NIOSH)
Prevention
o Exercise (CORE!)
o Proper lifting/bending/sitting
o Weight loss
o Smoking cessation
o Proper footwear
o Avoidance
LUMBAR SPRAIN/STRAIN
Facts
60-90% of the population
Most common complaint in ambulatory medicine
Third most expensive disorder most common and expensive cause of work-related disability in US
Mechanical LBP
o Usually after lifting/injury
Never let your nose go in front of your toes
Never turn your nose away from your toes
o 90% have resolution within 6 weeks (TIME HEALS)
o NOT common in children need to r/o red flags
Causes
1. Musculoskeletal
a. SD, sprains/strains, fibromyalgia, DDD, DJD
b. Osteomyelitis, sacroiliitis, malignancy
2. Nerve root syndromes
a. Herniated disc, spinal stenosis, cauda equina syndrome
b. Unremitting, associated with urine/bowel dysfunction, weakness URGENT REFERRAL
SPRAIN: injury to ligaments/capsule
STRAIN: injury to muscle/tendon/fascia
**normally occur together**
Lifting forces
-Straightening from bent position: 500 lbs in LS region
Symptoms
Pain at rest that is aggravated by activity
32
Guarded gait
Restricted painful lumbar motion attempt to stabilize whole trunk
Non-radiating
ACUTE lumbosacral strain/sprain
-Secondary to TRAUMA (eccentric contractions greater muscle damage)
-Nociceptors: broken fibers leak potassium; blood extravasation liberates bradykinin PG, neuropeptides
(CGRP and substance P), vasodilation
-Ischemia (only if muscle is contracting during ischemic event)
-Unilateral/bilateral muscle spasm/hypertonicity/guarding/pain
-May have sciatic scoliosis with unilateral pelvis shifts so sacral base in unlevel
CHRONIC lumbosacral sprain/strain
-Disease of middle age: difficult to treat
-Decompensation, poor health habits, lack of regular exercise
-Symptoms + flat affect = fibromyalgia
Kinetic Chain combination of several successfully joints constituting a complex motor unit (TENSEGRITY)
1. Open kinetic chain
a. Terminal joint is free
2. Closed kinetic chain
a. Terminal joint meets some external resistance
Anatomy
Lumbosacral fascia
o Covers deep muscles of back base of neck
Why FB of head/neck can cause lower symptoms of strain/sprain
o Inferiorly attaches to iliac crest, distal sacrum, lumbar SPs
Rhomboid of Michaelis
o Area formed b/t PSIS, lines of gluteal muscles, groove at lower end of spine
Where everybody hurts
TL fascia, erector spinae, IL ligament, latissimus dorsi, quadratus lumborum, multifidus, glut.max
Muscles directly related to movement of low back
o Latissimus dorsi
Spinous processes T6-12/TLF/sacrum/lowest 4 ribs bicipital groove of humerus
Thoracodorsal nerve (C6-8)
o External oblique
8 lowest ribs iliac crest/pubes/inguinal (Pouparts) ligament
o Internal oblique
Iliac crest/inguinal ligament/TLF 6 lowest ribs/linea alba/pubes
o Sacrospinalis (erector spinae)
Dorsal sacrum/lumbar SPs/iliac crest iliocostalis/longissimus dorsi
o Serratus posterior inferior
T11-L3 SPs ribs 9-12
o Quadratus lumborum
Iliac crest/L3-5 TPs 12
th
rib/TPs of L3-5
Primary cause of LBP
Brings hip up (balance/posture)
Refers to SI joint, lateral hip, gluteal area
o Psoas major
T12-L5 lesser trochanter of femur
TREATMENT
Manipulation dont over-treat!!
-Acute: MFR, ME (resp assist, RI), counterstrain
-Chronic: can add others
Exercise, ice (acute), heat/ice (subacute/chronic), rest (if essential)
Best treated by MOBILIZATION and PHYSIOTHERAPY
CONGENITAL LUMBAR ANOMALIES
Def: defects in development of body form or function that are present at the time of birth
-Very common, but exceeded in frequency by CNS/cardiovascular anomalies
-One anomaly should always make you look for more look for anomalies if you see hypoplastic 12
th
rib
Spinal dysraphism: failure of FUSION of parts along dorsal midline (skin, vertebrae, skull, brain, meninges, spinal cord)
33
Spinal hypertrichosis: excess hair over spine frequent marker for spinal dysraphism
Types of Anomalies
1. Localized: single vertebrae
2. Generalized: seen in osteogenesis imperfecta (fragile bones and blue sclera)
3. Aplasia: failure of bone formation
4. Hypoplasia: failure to grow to normal size
5. Dysplasia: abnormal growth
6. Hypertrophy: overgrowth
7. Supernumerary parts
8. Arrested development (i.e. spina bifida)
Conditions that can be treated with OMM
SPINA BIFIDA
Most common congenital anomaly of spine
o Most frequently at L5-S1 (last part of vertebral column to close)
o Pain related to ligamentous asymmetry/mal-loading/sacral base
unleveling
Most significant problem related to defective development of spinal cord NOT
spine
o Myelodysplasia
Mild muscle imbalance sensory loss complete
paraplegia
Types
o Occulta: no herniation of meninges through defect; associated with
coarse hair/skin discoloration at site (not always, but signify more complicated lesion)
Mildest and most common (10%)
Rarely associated with neurological defecit
o Meningocele: herniation of meninges therough defect
o Meningomyelocele: herniation of meninges and nerve roots through defect
Treatment
o Most myofascially oriented: soft tissue, MFR, counterstrain, FPR
o Refer to neurologist
SPONDYLOLISTHESIS W/ OR W/O SPONDYLOLYSIS
Spondylolysis
o Stress fracture/anomalous development of pars interarticularis
Usually at L5
Most commonly at age 7-8 history of minor trauma
o Presents as ache in back, buttock, leg
o Need oblique X-ray to diagnose Scotty dog
Spondylolisthesis
o Classification
Dysplastic (congenital)
Congenital abnormality of posterior facets or elongation of pars
o Severe anterior displacement of L5 cauda equina/nerve root pressure
Presents in childhood; more common in females
Isthmic (A & B) most COMMON
Defect in pars interarticularis (spondylolytic spondylolisthesis): bilateral or unilateral
Most common in pts <50yo; more common in males (from repeated micro-fractures)
Degenerative
Secondary to degenerative changes in facets of intervertebral discs
o From long standing intersegmental instability chronic LBP
o Most commonly at L4
Most common in pts >40yo; more common in AA females
Traumatic
Fracture in vertebra other than pars (articular processes, pedicles)
o Slip occurs gradually
Pathologic
Generalized or localized bone disease
34
o Osteogenesis imperfecta, infection, tumor, Pagets
o Grading
Based on percent of upper vertebral body that is overlapping the lower body
Grade 1: up to 25% forward slippage
Grade 2: 25-50% forward slippage
Grade 3: 50-75% forward slippage
Grade 4: more than 75% forward slippage
o Clinical presentation
Intermittent pain following a stressful injury
Aggravated by activity and relieved by rest
Pt may flex hips/knees somewhat
Decreased straight leg raising tight hamstrings
B/L
Higher grade slippage: stiff-legged, short stride, waddling gait
(pelvis rotates)
Can palpate step-off (grade 2/3)
Secondary thoracic and lumbosacral kyphosis (lose waistline)
o Risks
Most common cause of LBP and sciatica in children and adolescents
Gymnasts, dancers, paratroopers
o Treatment
Conservative (education, controlled activities, medication prn, brace, OMM)
OMM: generally treat grade 1 or 2 do not put ant stress on unstable level!
o Myofascial oriented: soft tissue (supine hip
flexion/frog/lat rec), MFR
o Articular based: ME, gapping (if stable and
no neuro sx)
Surgery
Anterior fusion (interbody), lateral fusion
(intertransverse), instrumental
FACET TROPISM
Unequal size/angling of zygo-apophyseal joints (AKA facet asymmetry)
o Symptoms from myofascial imbalance
Hypermobility counterstrain, MFR, FPR (avoid HVLA)
Hypomobility ME, HVLA with gapping techniques
TRANSITIONAL SEGMENT
Types
o Sacralization : one or both L5 TPs articulate/fuse with sacrum
Can lead to early disc problems from altered function of LS area
o Lumbarization : failure of S1 to fuse with rest of sacrum (less common)
Treatment
o Must decide if movement is possible may have to tx above/below
HVLA is not best treatment choice
o Soft tissue, MFR, ME, FPR
Intended to assist body in compensating for the abnormality
VISCERAL ETIOLOGIES OF LOW BACK PAIN
History
Red Flags
Duration >6 wks, <18yo, >50yo, major trauma (minor trauma in elderly), cancer, fever, chills, night sweats, weight loss,
IVDA, immunocompromised, recent GI/GU procedure, night pain, unremitting pain, pain worse when abdominal pressure
increases, pain radiating below knee, incontinence, saddle anesthesia, severe/rapidly progressing neurologic deficit
Extra-Spinal Causes of Back Pain
Visceral etiology: keep in mind when muscle spasm/tenderness/impaired mobility are absent
35
Viscerosomatic reflex: results from afferent stimuli from a visceral disorder on the somatic tissues (via dorsal horn)
-Neurons maintained at a state of partial/subthreshold excitation less afferents needed to trigger impulse
-Neurons involved are related to segmental paraspinal tissues because of collateral ganglia
Clinical examples:
1. Peptic ulcer
a. Posterior perforation interscapular radiation from T5-10 with epigastric pain
b. Duodenal perforation into pancreas location of pain changes with radiation to back
2. Perforating/gangrenous cholecystitis
a. Tender mass in right subcostal area accompanied by anorexia, emesis, high fever
i. Severe RUQ pain with radiation to back and shoulder
b. Perforation peritoneal signs (tenderness, spasm, rebound), bowel sounds normally absent
3. Chronic cholecystitis
a. Nausea and vomiting, mild tenderness in RUQ (can be after a meal)
i. Normally lacks physical findings
4. Perinephric abscess
a. Pain normally unilateral and above the iliac crest (L4)
i. CVA tenderness with possible muscle spasm tilt TOWARD affected
side
ii. Fever, chills, positive Murphys sign, pt wants to flex hip on affected side when recumbent
5. Urethral obstruction
a. Acute, colicky, unilateral pain in flank (with radiation to RLQ and perineum/testicle/labia/medial upper thigh)
i. Nausea and vomiting, peritoneal irritation, hematuria
b. Renal infection pain in same location, but dull, aching, continuous
6. Acute pancreatitis
a. Pain is midepigastric with radiation to back and flanks gradual onset, becomes unremitting, deep pain
i. Pt sits/leans forward to relieve pain
ii. Vomiting, rebound absent, mass rarely felt, adynamic ileus, tachycardia, sweating
7. Pancreatic carcinoma
a. Look for signs of extrahepatic biliary obstruction in lesions of the head
i. VAGUE complaints: abdominal pain, weight loss, depression
1. Pain continuous, worse at night, worse lying down, relief sitting up
8. Prostatitis/vesiculitis
a. Pain in low lumbar/sacral area nagging/aching (does NOT affect mobility of trunk)
i. Radiation into perineum/penis (can be worsened by sexual activity)
ii. Urethral discharge, dysuria, slightly enlarged prostate
9. Abdominal aortic aneurysm
a. Severe abdominal pain excruciating back pain is cardinal symptom of impending rupture
i. Diagnostic triad of ruptured AAA: pulsating mass, shock, severe abdominal pain
10. Dissecting aneurysm
a. Pain at onset in chest, with radiation down back no rebound tenderness or abdominal spasm
i. Check arms and legs for differences in pressure/loss of pulse
11. Pelvic origin
a. Low back pain is normally diffuse
i. Check for causes of pain: pregnancy/obesity/mass increase lordosis
b. Retroverted uterus: pain increased premenstrually/menstrually/prolonged standing and relieved by lying down
c. Fibroids: sacral plexus pressure refers pain to posterior thigh
OMT
36
Primarity directed toward balancing autonomic activity and improving lymphatic flow
-Improve pts own ability to: improve visceral response to stress, relieve congestion, improve circulation, enhance waste
removal, improve cardiac output, improve oxygenation/nutrition, enhance resistance to infection, enhance more predictable
tissue levels and pt response to meds, enhance relaxation and comfort of pt
LUMBAR MUSCLE ENERGY AND HVLA
**Direct techniques**
Motion testing:
Flexion/extension monitor SP in lateral recumbent position or spring test (restricted/+ = F and ease/- = E)
Side bending monitor TP in lateral recumbent position
Muscle Energy
1. Seated
a. Anchor level below
b. Take pt to feather edge of restrictive barrier (OPPOSITE the diagnosis)
c. Pt straightens against resistance
d. Pt relaxes and is repositioned
e. Repeat 3-7x
Post-isometric relaxation (pt pushes back to ease)
2. Lateral recumbent
a. Rotational component of diagnosis (ease) against table
i. Allows you to rotate pt to restriction
HVLA
1. Seated
a. Short or long-levered
i. Short: impulse on TP of dysfunctional segment
ii. Long: stabilize segment below and use trunk as lever
2. Lateral recumbent
a. Rotational component of diagnosis (ease) against table
3. Supine
a. Walk around technique long-lever
Low distance (amplitude) increases safety!
Muscle Energy Both HVLA
Direct
Long-lever Short-lever
Myo-fascial Articular
Specific
Safe
EXERCISE AND LOW BACK PAIN
Types of Sports/Athletes
Recreational
-Activity for fitness, cosmesis, fun LARGEST CATEGORY of athlete
Least likely to have formal program; can lack conditioning/experience that prevent injuries
-Pitfalls: muscle imbalance (dont work on small stabilizers), improper technique/form, overuse
Rehabilitation
-Exercise used to overcome injury
Principles depend on body part/severity of injury: therapy needs to be directed and sustained
Rest, ice, NSAIDs, intra-articular injection, electrotherapeutic modalities
-First principle is to STOP OFFENDING ACTIVITY
-Stages of injury
1. Acute inflammatory phase (0-72hrs): erythrocytes/inflammatory cells
-Cannot begin an effective program during this period
2. Proliferation/repair phase (2d-6wk): fibroblasts/collagen scarring best time for OMT
3. Remodeling/maturation phase (4wk-12mo): collagen no longer as organized (less strength)
-Important components of program
Muscular conditioning important in conjunction with flexibility/endurance
Open chain: quicker, lighter weights, simpler movements, stabilizers recruited
Closed chain: slower, compound movements, increase hormones/endorphins
37
Flexibility important in injury prevention, but lack of can create a vicious cycle
Balance/proprioception cycle: injury damages proprioceptors, which lead to further injury
Functional exercises
Correction of biomechanics often attempt to build muscle, but forget to foster endurance/flexibility
Psychology ability to be able to perform without fear of injury/failure
Professional
-Sport/exercise as a carreer CANNOT COMPLETELY ELIMINATE offending activity
Extreme training regimens increase likelihood of injury, but good shape helps stabilize
Specific Disorders
1. Fibromyalgia: diagnosis of exclusion
a. Point tenderness on palpation, pain in lower and upper halves of body, pain in left and right halves of body
b. May be due to decreased threshold of Pacinian corpuscles or aberrant increase in substance P
c. Strongly associated with insomnia, chronic fatigue, depression
i. Regular sleep schedules and cardiovascular exercise
2. Low back pain
a. Often have atrophied multifidi and delayed activation of transversus abdominus
b. Can be due to thoracolumbar fascia, paraspinals, quadratus lumborum, abdominals
i. Must assess muscle strength in all planes
c. Core provides functional stability that extremities power off of
** General rule of thumb: spondylolysthesis avoid BB; herniation avoid FB**
VISCERAL: GASTROINTESTINAL SYSTEM
Sympathetics
Facilitation: vasoconstriction and increased haustration break cycle with MFR and RIB RAISING
Celiac ganglion: T5-9 (stomach, liver, duodenum, pancreas, GB)
o Upper GI vasoconstriction, altered gastric bicarb and mucosal barriers, increases sensitivity to H+, relaxes
gallbladder
Superior mesenteric ganglion: T10-11 (SI, right colon, kidneys, upper ureters, adrenals)
Inferior mesenteric ganglion: T12-L2 (left colon, lower ureters, bladder, pelvic organs)
o Lower GI (T10-L2) vadoconstriction, increase haustration (constipation), slow transit time, abdominal distention,
flatus
Parasympathetics
Vagus: OM suture, C1-2
o Upper GI increased gland and bowel motility, N/V, contraction of GB, hypermotility
Related symptoms: gastric headache, upper respiratory symptoms, hoarseness
Pelvis splanchnics (S2-4)
o Lower GI (Vagus and PS) increase glandular secretions, increase bowel motility (diarrhea), hypermotility
(dumping syndrome)
Related symptoms: gastric headache, N/V
Clinical examples: IBS: inability of SNS and PNS to regulate/find balance
diarrhea/constipation
Lymhatics
Left thoracic duct (Upper GI)
o Lymphatic drainage sensitive to liver pressures can release liver
o Increased incidence of pancreatitis in pts with compromised lymph drainage
Cysterna chili and left thoracic duct drain lymph from abdomen (Lower GI)
o Important in absorbing nutrients
o Clinical examples: bloating, post-inflammatory healing with scar
Chapmans Reflex
Def: viscerosomatic and viscerocutaneous reflex
**Use anterior points to diagnose and posterior points to treat**
Viscerosomatic Reflex
Def: amplified afferents to dorsal root of spinal cord feeds back and creates pathophysiologic
loop to segment
-Associated with SYMPATHETICS
38
-HVLA will normally bounce off these segments
Visceral referral often diffuse in children
Pain Patterns
Visceral Reflex Pain: earliest pattern from stretch/contraction/
activity, vague/deep/diffuse pain 3 collateral ganglia
Viscerosomatic Reflex Pain: cord facilitation T-L/rib SD,
Chapmans reflexes, muscle TrP, tissue texture changes
-Level often rotated to same side as irritation may create
type II SD, HVLA may bounce off
Peritoneocutaneous Reflex: direct irritation of parietal peritoneum
wall rigidity, rebound tenderness
OMT
1. V-Spread and OA
release: balance
parasympathetics
2. Rib raising: balance sympathetics
3. Zinks compensatory patterns: remove fascial restrictions and increase fluid flow
4. Direct inhibition of collateral ganglia: can cause somato-emotional release
VISCERAL: GENITOURINARY SYSTEM
Chapmans Reflex
Gonads: pubic bone T9-10
Adrenal: periumbilical T11
Kidney: periumbilical T12
Uterus: pubic ramus lateral thigh L5
Bladder: periumbilical L1
Prostate: lateral thigh sacral base
**posterior points on intertransverse space between SPs and TPs**
WILL EXHIBIT A NON-NEUTRAL TYPE MOTION preference for extension
Trigger Points
GU system
-rectus abdominis: dysmenorrhea
-pelvic floor: chronic pelvic pain
-psoas: renal/gyn pathology
Sympathetics
T10-11: kidney, ovary, testes, UPPER ureter, adrenals
T12-L2: LOWER ureters, uterus, vagina, clitoris, vas deferens, prostate, bladder, urethra, fallopian tubes
Hypogastric plexus: plexus that carries the sympathetics
Parasympathetics
Vagus: kidney and UPPER ureter, ovaries/testes
Pelvic splanchnics (S2-4): LOWER ureter, reproductive organs
-Carried along Pudendal nerve
Lymphatics
All drain into cistern chyli and then into left thoracic duct
-Can perform ischiorectal fossa release to increase lymphatic movement/drainage
Increased lumbar lordosis can flatten pelvic diaphragm and inhibit proper function
Functional diaphragms: plantar fascia, popliteal fossa, pelvic floor, respiratory diaphragm, thoracic outlet,
submandibular fossa, diaphragma sellae
TREATMENT GOALS autonomics/circulation, increase pain threshold, increase function
Clinical examples:
1. Pelvic floor symptoms: stress incontinence, dyspareunia, pelvic congestion, prostatodynia, coccygodynia, levator ani
syndrome
39
a. Start treatment by addressing skeletal dysfunction (SI joint)
b. Ischiorectal fossa release
2. Primary dysmenorrhea
a. Painful periods without organic pathology
b. Remove pelvic strain, release diaphragm, treat autonomics and decrease congestion
i. Autonomic innervation: uterus
1. T10-11 sympathetics vasoconstrict, contraction
2. Pelvic splanchnic parasympathetics relaxation, vascular dilation, congestion
3. Treatment : SI joint manipulation, sacral rock, pelvic floor release
a. Trigger point: rectus abdominis
3. Back pain of pelvic origin
a. Normally diffuse if pinpoint at SP, think metastatic lesion
4. KUB disorders
a. Review: above ureter = T10-11/Vagus and below ureter = T12-L2/S2-4
i. Sympathetics: bladder relaxes, sphincter (trigone) contracts, kidney afferent arterioles vasoconstrict, GFR
and urine output promotes urine retention
ii. Parasympathetics: increased urine production, peristalsis of ureters, bladder contraction, relaxation of
sphincter promotes urine production/evacuation
b. UTI
i. Dysuria, hematuria, frequency, urgency, abdominal pain (fever pyelonephritis)
1. Chronic prostatitis most common cause of recurrent UTI in males
ii. Treatment : pubes, TL junction, redome diaphragm, psoas counterstrain, pump
c. Nocturnal enuresis/Urinary frequency
i. OMT not as effective
d. Ureterolithiasis
i. Can get tissue texture changes in TL junction, SI joint, psoas
ii. Treatment : rib raise TL junction, sacral rock, psoas counterstrain
e. Urinary incontinence
i. Treatment : Kegels, postural exercises,
5. Prostatitis
a. Fever, chills, dysuria, scrotal pain, boggy/warm/tender prostate on DRE, nocturia, hematuria, LBP
b. Chronic non-bacterial prostatitis: negative cultures
i. Treatment : Sitz bath, prostatic massage, OMT (pelvic diaphragm)
6. Infertility
a. 10% of married couples
i. 40% male gonadal deficiency, 20% female hormone deficiency, 30% tubal disorders, 10% poor cervical
environment
ii. Can be due to decreased parasympathetic tone or increased sympathetics (T10-11 blood supply)
b. Treatment : goal to decrease facilitation to decrease stress hormones and maximize function
7. Psoas syndrome
a. Will often be accompanied by posterior sacral rotations, type 2 L1-2, sidebending to affected side, contralateral
piriformis contraction, pelvic shift to opposite side
b. Treatment : counterstrain, trigger point
VISCERAL TECHNIQUES
Random facts: you dont treat transverse colon b/c there is no mesentery associated with it
: ganglion impar connects right and left sympathetic chains
: effects of OMT are mobility/motility/circulation/immunity/psyche/hormonal/chemical balance spasm
Viscera
Has mobility and motility can use these principles to treat
o The best way to improve emptying of tube is to stretch along longitudinal axis
Hold with one hand and push away with other
Sphincters should always be stretched
GE junction, gastric cardia, pylorus, sphincter of Oddi, duodenojejunal flexure, IC valve, rectal
area
o Paralytic ileus improved with paraspinal inhibition
Can also use sacral OMT, suboccipital release, pelvic diaphragm release, TL OMT, colonic stim
o GERD/Peptic ulcer
Rib raise T5-9, TL/suboccipital, dome diaphragm, linea alba release, Chapmans points
o IBD
40
TL/suboccipital, rib raising
Chapmans Points
LI: along lateral thighs, IMG
Bladder: around umbilicus
Appendix: tip of right 12
th
rib
Adrenals: 2 superior and 1 lateral to umbilicus, T11
Kidneys: 1 superior and 1 lateral to umbilicus, L1
TECHNIQUES
1. Doming diaphragm
a. Key technique need good passage (IVC, esophagus, aorta, cysterna chyli)
b. Heel of hand under costal cartilage, other hand on L1-2 posteriorly
2. Marion Clark drainage
a. Release pelvic congestion
b. Knee-chest position; lift abdominal contents out of pelvic bowl rhythmic
3. Mesenteric release
a. Lift up from mesenteric roots and allow recoil
i. Can be done supine or lateral recumbent
4. Colonic stimulation
a. Start distal and move proximal (descending colon ascending colon)
i. Kneed in direction of flow
5. Sacral rock
a. Addresses PNS
b. Pt prone with your hands b/t PSISs follow cranial/sacral rhythm
6. Splenic stimulation
a. Do NOT do when pt has mono/splenomegaly
b. Can be done anteriorly or ant/post
7. Hepatic stimulation
a. Do NOT do when pt has hepatitis
b. Same as splenic stimulation, but extend/abduct arm to create fascial tension
8. Ischiorectal fossa release
a. Pt can be prone or supine
b. Increase flow of lymphatics from lower extremities
9. Rib raising/Paraspinal inhibition
a. Balances SNS
SACRAL DIAGNOSTICS
Sacral Anatomy
-Sacral sulci medial to PSIS
-ILA is the attachment of the sacrotuberous ligaments
-Iliolumbar ligaments: L4/5 TP, anterior iliac crest, anterior SI ligaments sling-like mechanism
-Posterior SI ligaments
Deep: short, from sacrum to ileum
Intermediate: from posterior arches of sacrum to medial side of ileum
Superficial: long, from sacral crest to ileum, inferiorly blend with sacrotuberour and sacrospinous ligs
-Base articulates with L5 vertebra and apex with coccyx; bilateral articulation with both ilia
-Psoas: crosses over anterior SI joints, from lumbar vertebrae to lesser trochanter of femur
-Prirformis: from the anterior surface of the sacrum, through the sciatic notch, to the greater trochanter of femur
-Gluteus max and lats, when contracted, provide stabilization during stance and joint mobilization during swing
Sacral Relationships
-SI joints are arthroidal: joint space synovial capsule and articular cartilage (sacral: hyaline and ilia: fibro)
Joints are L-shaped; upper arm is shorter with antero-posterior beveling interlock at S2
-Superior surface of sacrum articulates with L5 and acts as support structure to vertebral column
-As part of the PRM, there is inherent mobility of sacrum between inominates, linked with motion of occiput
Sacral Function
-Gait and stance
Multi-axial motion of sacrum between ilia requires participation of both SI joints
-Stance (and FB and BB)
Sacral motion of nutation (flexion) and counternutation (extension) occurs about transverse axis @S2
Middle transverse axis
41
Sacral superior to inferior translatory motion coupled with posterior and anterior nutation
-Gait
Torsion where sidebending and rotation couple to opposite sides about an oblique axis
LOL ROR LOL ROR etc.
Nutation is anterior in direction and L5 displays neutral mechanics
-CRI (cranial rhythmic impulse)
Motion occurs about the superior transverse axis
Sacral flexion (nutation) in biomechanical model is sacral extension in craniosacral model
Sacral extension (counternutation) in biomechanical model is sacral flexion in CS model
Sacral flexion and extension are termed opposite in biomechanical/CS models!!!
Sacral Axes
-Transverse (3)
Craniosacral (superior)
Biomechanical (middle)
Respiratory (inferior)
-Oblique (2) right and left
-Vertical
-Anteroposterior
Sequence
1. History
2. Structural exam
3. Regional ROM
4. Layer-by-layer
5. Intersegmental motion testing
a. Innominate segmental diagnostics
i. Dynamic testing establishes side of dysfunction
1. Standing flexion, seated flexion, ASIS compression, SI joint motion
ii. Static testing determines spatial ease of position
1. Anterior and posterior landmarks
b. Sacral segmental diagnostics
i. Dynamic testing evaluates relationships of SI and LS joints: determines AXIS
1. Standing flexion, seated flexion, LS spring, sphinx, L5 intersegmental motion
ii. Static testing evaluates depth symmetry of landmarks
1. Sacral sulci, ILA
DIAGNOSES
Anterior Torsion Posterior Torsion Unilateral Flex Unilateral Ext Bilateral Flex Bilateral Ext
+ standing flex
+ seated flex
- spring
+ sphinx
L5 N SxRy
+ standing flex
+ seated flex
+ spring
- sphinx
L5 F/E SxRx
+ standing flex
+ seated flex
- spring
+ sphinx
+ standing flex
+ seated flex
+ spring
- sphinx
- standing flex
- seated flex
- spring
- sphinx
- standing flex
- seated flex
+ spring
- sphinx
Sulci: deep on +
ILA: deep on +
Sulci: shallow on +
ILA: shallow on +
Sulci: deep on +
ILA: shallow on +
Sulci: shallow on +
ILA: deep on +
Sulci: both deep
ILA: both shallow
Sulci: both shallow
ILA: both deep
ROR or LOL ROL or LOR Unilateral Flex Unilateral Ext Bilateral Flex Bilateral Ext
SACRAL BIOMECHANICS
1. Seated flexion test
a. Oblique axis opposite positive side
2. L5 is ALWAYS sidebending to the side of the axis!
a. Anterior torsion (ROR/LOL) L5 rotates opposite
b. Posterior torsion (LOR/ROL) L5 rotates same
3. Spring test
a. Positive: doesnt like to spring sacral base posterior (stuck in extension)
b. Negative: sacrum likes to spring
4. Sphinx test
42
a. Positive: landmarks get more symmetrical one side of sacral base anterior (stuck in flexion)
b. Negative: landmarks get less symmetrical
Diagnoses
Bilateral flexion
o Seating flexion does NOT matter
o Sulcus deep and ILA shallow bilateral
Axis: transverse axis about S2
o Clinical example: post-partum
o Treatment : pressure on ILAs during inhalation and resist during exhalation
Bilateral extension
o Seating flexion does NOT matter
o Sulcus shallow and ILA deep bilateral
Axis: transverse axis about S2
o Spring test positive
o Treatment : pressure on sacral bases during exhalation and resist during inhalation
Unilateral flexion
o Seated flexion positive on side of dysfunction
o Sulcus deep and ILA shallow on + side
Axis: transverse axis about S2
o Sphinx test positive (more symmetric)
o Treatment : pressure on + ILA during inhalation and resist during exhalation
Unilateral extension
o Seated flexion positive on side of dysfunction
o Sulcus shallow and ILA deep on + side
Axis: transverse axis about S2
o Spring test positive on dysfunctional pole
o Treatment : pressure on + sacral base during exhalation and resist during inhalation
Anterior torsion
o Seated flexion positive on side of dysfunction
o Sulcus deep and ILA deep on + side
Axis: right or left oblique axis
o Sphinx test positive (more symmetric)
o Treatment : pt in modified Simms position with anterior against table (ant torsion ant table)
Both legs bent and taken off table and ankles lowered to barrier
Pt pushes ankles up against physician pressure
Top leg internal rotators and bottom leg external rotators contract
o Causes inhibition of dysfunctional piriformis
Posterior torsion
o Seated flexion positive on side of dysfunction
o Sulcus shallow and ILA shallow on + side
Axis: right or left oblique axis
o Spring test positive
o Treatment : pt in lateral recumbent position with posterior against table (post torsion post table)
Legs bent with top leg over and hanging off table to barrier
Pt pushes leg up against physician pressure
Top leg piriformis moves top ILA anterior
M2T2 OMM Study Guide
Cervical Biomechanics
SOAP Note
o Subjective History of Chief Complaint
Onset trauma w/ biomechanics of injury based on anatomy
Location localized/diffuse w/ radiation and paresthesia
Where is the source of the pain
Quality/Character Intermittent/constant
Severity Pain Scale (0-10) varies over time
43
What makes it better/worse
Neurological: Vertigo, Dizziness, Headache, Vision Changes, Memory, Speech, Appetite
o Objective Physical Exam
Vital Signs
Observation gait, posture, symmetry/asymmetry
Neurological Exam
Layer by Layer Palpation
Active/Passive Range of Motion and Intersegmental Motion Testing
Forward/Backward Bending: 45-90, Sidebending: 30-45, Rotation: 70-90
o Assessment
Determine Differential diagnosis based on clinical impression to determine cause
Musculoskeletal causes
Muscle/Tendon Strain (Whiplash) vs. Ligamentous Sprain
Disc Pathology: Annular Bulge, Protrusion, Herniation, Extrusion vs. Fragmentation
o Radicular symptoms come with pressure on nerve root not definite
Degenerative Spinal Conditions: Disc, Facet, Osteophytic Neuroforaminal Encroachment,
Spondylosis, Stenosis (Esp. Lumbar Stenosis)
o Spondylosis = Degenerative Osteoarthritis of the vertebrae
o Spondylolisthesis = Anterior/Posterior slippage of vertebrae
o Spondylysis = Fracture of Pars Interarticularis
Neurological Testing (Important for test)
o C5
Motor Innervation to Deltoid (Axillary Nerve) & Biceps (Musculocutaneous Nerve)
Deep Tendon Reflex of Biceps Muscle Stretch reflex
Sensation to Lateral Arm above the elbow
o C6
Motor Innervation to Wrist Extensor Group (Radial Nerve)
Deep Tendon Reflex of Brachioradialis Supinator Reflex
Sensation to Lateral Forearm & 1
st
and 2
nd
digit (Musculocutaneous Nerve)
o C7
Motor Innervation to Triceps (Radial Nerve) & Wrist Flexor Group (Median & Ulnar Nerves)
Deep Tendon Reflex of Triceps Muscle Stretch Reflex
Sensation to Middle Finger
o C8
Motor Innervation to Finger Flexors
No Deep Tendon Reflex
Sensation to Medial Forearm & 4
th
and 5
th
digits (Medial Antebrachial Cutaneous Nerve)
o T1
Motor Innervation to Finger Abductors & Adductors
Sensation to Medial Arm above the elbow (Medial Brachial Cutaneous Nerve)
Cervical Anatomy
o Occipito-Atlantal (C0-C1),
OA: Type-1 like
OA is mainly flexion/extension with variable sidebending (~5) & rotation (~5)
Occipital Condyles are convex as they articulate with concave superior articular facets of C1
OA release accesses parasympathetics (Vagus N.) because nuclei of brainstem at that spot
o Atlanto-Axial (C1-C2),
AA: Rotation w/ R & L zygapophysial joints, anterior odontoid articulation with posterior atlas arch, &
posterior odontoid articulation with transaxial ligament
Odontoid moves in synovial cavity can have degeneration
o C2-C7
C2 = 1
st
palpable transverse body off of occiput
C2-C7: Type 2-like with flexion, extension, or neutral
Dysfunction can be in groups work on groups from the middle?
Bifid Spinous Process
Facets: Oblique at 45 with BUM (Backward Upward medial) of Superior Facet
44
Fryettes Rules dont apply due to atypical oblique facets, vertebral body shape, ligamentous
attachments & muscular insertions
Joints of Luschka at Uncinate Processes of vertebral bodies articulation w/ disc
Found at Postero-lateral corners of disc protects posterolateral disc herniation
Helps in gliding movements during forward & backward bending
Prone to degenerative changes (lipping) encroachment at anterior aspect of the lateral
intervertebral canal
As travel down C-spine, vertebral mass increases & spinous process looks thoracic
o Vertebral Artery
Begins its relationship at C6-7 up towards OA joint
Runs through transverse foramen and exits at superior C1
Turns posteriorly over posterior arch & penetrates post. occipitoatlantal membrane
Enters Foramen Magnum
Normal vertebral arteries can narrow as much as 90% of their luminal size on the contralateral side to cervical
rotation exacerbated in extension
NEVER do cervical HVLA in extension (Flex a little bit) shear vertebral artery
o Clinical Pearls
If Flexion-extension limitation w/ less sidebending/rotation loss = OA
If only rotational limitation = AA
If mostly sidebending limitation with some rotation loss = C2-C7
Neck = doorway to the head of vascular & neurologic flow (similar to thoracic outlet)
Dysfunction can Headaches, Migraines, Seizures
Nerve
o Brachial Plexus
o Ulnar Nerves
o Median Nerve
o Radiculitis = Swelling around the nerve root (Acute or chronic)
o Radiculopathy = pathologic changes in the nerve root DTR, Strength, Sensation Changes
Intro to Osteopathy in the Cranial Field
Osteopathy in the Cranial Field is a Clinical Model to explain findings and anatomical understanding as described by Dr.
William Sutherland, student of Dr. Still
o Gave rise to Balanced Ligamentous Tension and other indirect technique
o Model Components: Bony Model, Membranous Dural Model, Cranial Nerves
o The model is versatile based on the individual patients are present
Dural Strain Patterns
o Sutherlands Fulcrum = area where Falx Cerebri and Tentorium Cerebelli meet
o Anterior Attachments affect CN2, CN3, CN4, CN5, CN6
CN6 sits at petrous portion of temporal bone (may cause strabismus)
o Everything above Tentorium is innervated by CN5 anterior headaches
Posterior Cranial Fossa and under the Tentorium Cerebelli is innervated by CN10
Anatomy
o Structure Function Interrelationship or cranial sutures to accommodate inherent motility
Embryologic Mismatch of growth between CNS & cranium
o Cranial Base is formed from cartilage; cranial vault is formed from membrane
o Cranial Nerves exit the skull as the cartilage base grows around the nerve
o Cranial sutures are all mobile: suture motion = cranial compliance
The greater the cranial compliance, the least brain damage during hydrocephaly
o Temporal Bone affects 9/12 Cranial Nerves: CN7, CN8, CN9, CN10, CN11
Temporal Bone in bilateral external rotation have a low pitched tinnitus
Temporal Bone in bilateral internal rotation have a high pitched tinnitus
Imbalance in external/internal rotation of the temporal bone vestibular imbalance
o Temporal Lobes are actually the most anterior portions of the brain since they are bent back to that location
o Occipitomastoid Suture affects the Jugular Foramen
Primary Respiratory Mechanism:
1. Articular mobility (capability of movement) of cranial bones
2. Motility of CNS (Inherent motion)
45
3. Fluctuation of CSF (Fluctuates with motion)
4. Mobility of intracranial / intraspinal membranes (reciprocal tension)
5. Involuntary respiratory motion of the sacrum between the ilia
o Reciprocal tension Membrane & Fluid magnifies motion as well as asymmetries of shape & motion
This motion is referenced to the sphenobasilar synchondrosis
Uses: OA techniques, sacral techniques, TMJ
o Whiplash Injury, SCM/Neck spasm
o Torticollis, Otitis Media, Vagus disorders and its innervations
o Birth Trauma from twisting, hyperextension, condylar compression on the infant
Sacral base forward, ILA backward Extension on the mother (low energy, depression)
Observations
o Flexion Head is round with low palate and wide dental Ex: Hardy, Ernie
o Extension Head is long with high arching palate and narrow dental Ex: Laurel, Bert
Often have respiratory problems: Hay fever, Asthma
Clinical Triad: Asthma, Nasal Polyp, Aspirin Allergy
Conditions predisposing to Extension Mechanics
Anterior Sacral Base, Craniosacral extension
Hyperlordosis, Spondylolisthesis
Pregnancy, Obesity, birth Process
o Asymmetry: Plagiocephaly (misshapen head) Ex: Lateral Strain Pattern
Ex: Parallelogram Pattern may visual changes, torticollis from straighten head attempt
Back to Sleep SIDS, but Plagiocephaly (may be connected w/ Autism & Asthma)
Birth Forces leading to Vertical Strain Pattern
Palpation = Cranial Rhythmic Impulse
o Amplitude: 0.38-1 mm, Rate = 6(8)-14/min
o Vault Hold: 2
nd
digit at Greater Wing of Sphenoid, 3
rd
digit in front of External Auditory Canal, 4
th
digit behind ear,
5
th
digit at tip of occiput
o Takes concentration and removal of external/internal forces
Normal Motion
o Flexion is accompanied with external rotation of the paired bones (temporal bones)
Vault fingers move apart & caudad in flexion & together/cephalad in extension
SBS rises and sphenoid moves down
o Extension is accompanied with internal rotation of the paired bones
o Axes: A
Dysfunctional Patterns
o Torsion Named for the High Great Wing of the Sphenoid
o Vertical Strain Named for the direction that the Sphenoid Base moves
o Sidebending-Rotation named for the convex side
o Lateral Strain Named for the direction that the Sphenoid Base moves
o Flexion
Sacrum
o Motion occurring during respiration & with CRI occur around the S1 axis
o Flexion occurs around the S2 axis
o Sacroiliac motion of innominates on the sacrum occurs around the S3 axis
o Counter-nutation with inhalation as spinal curves straighten
o Nutation with exhalation as spinal curves bend
o Sacral Flexion = base moves anteriorly
o Sacral Extension = base moves posteriorly
o Cranial-Sacral Extension anterior movement of sacral base
o Cranial-Sacral Flexion posterior movement of sacral base
Autonomics: Craniosacral will be parasympathetic
Primary Respiratory Mechanism & Mechanics of Physiologic Motion
Provides unifying concept of motion
o Articular (Biomechanical)
o Membranous (functional)
o Fluid (Biodynamic)
46
Vault is formed from membranous-type bone: frontal, parietal, occipital squama & temporal squama
o Provides mobility
Base is formed in cartilagenous-based bone: Sphenoid Body, Petrous & mastoid Temporal, Occipital basilar and condylar
parts
o Provides stability
Unpaired Midline bones: Occiput, Sphenoid, Ethmoid, Vomer
o Move in flexion & extension
Paired Bones: Parietal, Zygoma, Temporal, Palatine, Maxilla, Nasal, Frontal, Mandible
o Move in internal/external rotation
Suture Bevels provide stability and determine direction of motion (similar to facets)
Sphenobasilar Synchondrosis (SBS) = Primary mover of cranial motion
Ethmoid rotates opposite to the sphenoid and vomer is carried caudad in flexion
External Rotation occurs with flexion and transverse diameter increases while AP diameter decreases
Internal Rotation occurs with extension and transverse diameter decreases while AP diameter increases
Temporal Bones Axis is around the petrous ridge and can cause many dysfunctions
Dura connects foramen magnum to C2,C3 and S2 to synchronize sacral motion
o Craniosacral flexion sacral base posterior & sacral apex anterior = counternutation
o Craniosacral extension sacral base anterior & sacral apex posterior = nutation
o Reciprocal Tension Membrane made by the Dura Mater at Falx Cerebri, Falx & Tentorium Cerebelli
Exhibits tension and Tensegrity
Tentorium Cerebelli = diaphragm of the craniosacral mechanism
o Sutherland Fulcrum at Straight Sinus: Junction of falx cerebri and tentorium cerebelli
Shifts if there is pathology
Primary Respiratory Mechanism
o Influences physiologic centers that control and regulate pulmonary respiration, circulation, digestion, and elimination
located in the floor of the 4
th
ventricle
o Inherent Motility of Brain & Spinal Cord: Subtle, slow, pulse-like movement
Biphasic cycle: CNS shortens/thickens, then lengthens/thins
o Fluctuation of CSF: formed by Choroid Plexus bathes & nourishes CNS in wavelike motion
o Mobility of Intracranial & Intraspinal Membranes: Dura responds to CNS & CSF motion to move the cranial
bones and the sacrum
o Articular Mobility of Cranial Bones: dictated by suture bevels w/ unique motion axes
o Involuntary Motion of Sacrum between Ilia: responding to Reciprocal Tension Membrane
o Intimately related to rest of body through fascial connections from skull through body
Intersegmental Motion Evaluation of Cranial & Sacral Bones, Membrane, and Fluid
SBS strain patterns: Flexion/Extension, Torsion, Sidebending rotation, Lateral or Vertical strain, Compression
o Torsion: A-P axis, named for superior sphenoid wing, Sphenoid & Occiput rotate opposite
Base of Sacrum mirrors motion of occiput
o Sidebending Rotation: 1 A-P Axis & 2 parallel vertical axes, sphenoid & occiput rotate same AP, but opposite
vertical axes, named for inferior greater wing of sphenoid
Smaller orbit & receded eyeball on named side of strain pattern
o Lateral Strains: 2 parallel vertical axes w/ sphenoid & occiput rotating in same direction (shearing)
Named for direction of basisphenoid movement
Trauma around parietal with force anterior parallelogram head
o Vertical Strains: 2 parallel horizontal axes w/ sphenoid & occiput rotating in same direction
Named for direction of basisphenoid movement relative to occiput
Superior Strain eyes look down with high apex & low forehead
Inferior Strain eyes look up with high forehead & low apex
Trauma at superior parietals perpendicular to occiput(superior shear) or perpendicular to sphenoid (inferior
shear) Superior shear can also occur with trauma to chin
o Compression
Sphenoid-occiput compressed together flexion/extension impairment
Trauma to back of head or circumferential force during birth
Somatic Dysfunction of the Sphenobasilar Synchondrosis
Disease is the result of anatomical abnormalities followed by physiological discord.
Little acceptance of Sutherland research & theories until 1940
47
Current Text: Osteopathy in the Cranial Field by Harold Magoun, D.O.
Basiocciput is anterior to the foramen magnum while the occipital squama is posterior to the foramen
Craniosacral Flexion: Inhalation, SBS moves superiorly w/ opposite rotation of sphenoid & occiput
o Occurs around transverse axes in the sphenoid and occiput
o Head widens laterally from external rotation of paired bones and shortens in the A-P plane
o Sacrum counternutates (synonymous to physiological sacral extension) base moves posteriorly
Craniosacral Extension: Exhalation, SBS moves inferiorly w/ opposite rotation of sphenoid & occiput
o Head narrows laterally from internal rotation of paired bones and lengthens in A-P plane
o Sacrum nutates (synonymous to physiological sacral flexion) base moves anteriorly
Dura attaches to anterior portion of S2
SBS Strain Patterns
o Physiological
Flexion
Extension
Torsion
About AP axis Twist at SBS sphenoid & occiput rotate opposite
Named for Superior Greater wing of sphenoid (R/L)
Sidebending Rotation
About 1 AP Axis and 2 vertical axis
Named for side of convexity with greater wing of sphenoid & occiput low on this side
o Non-physiological
Lateral Shear
Vertical Axis of rotation
Basisphenoid and basiocciput shear in opposite directions
Named for direction of the basisphenoid
Vertical Shear
Horizontal Axis of rotation
Named for relative position of the basisphenoid
Superior Shear high forehead and low apex
Compression of sphenoid and occiput decreased flexion & extension
Blow to back of head or circumferential head trauma
Cranial Rhythmic Impulse
o Increases w/ exercise, fever & OMM
o Decreases w/ stress, depression, chronic fatigue, chronic infection
Treatment Principles
o Establish free and uninhibited physiologic motion
o Normalize nerve function
o Counteract stress-producing forces
o Eliminate circulatory stasis
o Normalize cerebrospinal fluid function
o Release membranous tension by returning to neutral position based on all influential factors
o Correct cranial articular lesions
o Modify gross structural patterns
Contraindications: Intracranial Hemorrhage, Post-traumatic brain injury, Unstable intracranial pressures, dont use
exaggeration in acute traumas and before 5-6 y/o
TMJ Dysfunction
A painful condition affecting the temporomandibular joint which impairs function & sensation in face & jaw
Debilitating effects: pain syndromes, eating problems, depression, sleep disturbances, anxiety
Majority are women in their childbearing years
Signs & Symptoms
o Facial pain or preauricular pain with or without chewing or yawning
o Limited mouth opening/closing or deviation of jaw from midline
o TMJ sounds: popping, crepitus, or clicking with jaw movement
o Headache, tinnitus, ear pain, diminished hearing, dizziness, visual disturbances
Etiology unknown
48
o Possible causes: dental/medical procedures, oral habits, grinding teeth, oral appliances, psychosomatic
Anatomy: Mandibular Condyle, articular tubercle of the temporal bone, mandibular fossa, articular disc
o Lateral temporomandibular ligament (intrinsic), sphenomandibular & stylomandibular ligaments (extrinsic), fibrous
capsule
Center of the articular disc is not vascularized
o Ginglymoid Hinge movement (open/close) and Arthrodial Gliding movement (protrude/retrude)
The jaw must protrude a little bit when opening
o Muscular Depressors: Lateral Pterygoid, Digastric (post. & ant. bellies), Geniohyoid, Mylohyoid
o Muscular Elevators: Masseter, Temporalis, Medial Pterygoid (attaches to inside of jaw angle)
o TMJ Mechanics: Moves in synchronous motion with temporal bones
Moves forward with external rotation of temporalis (Craniosacral flexion)
Moves backward with internal rotation of temporalis (Craniosacral extension)
With jaw opening, the condyle moves forward out of the mandibular fossa onto the articular tubercle of the
temporal bone
o Sensory Innervation: Trigeminal nerve
Patholphysiology
o Intracapsular Disorders
Altered Disc Morphology DJD
Elongation of Discal ligaments
Disc displacement occurs with clicking of joint
Can lead to inflammation
Malposition of the TMJ malocclusion
o Altered movement of the Articular disc with the condyle when there is damage to the disc
o Locking has anterior displacement of the condyle anterior to the articular tubercle
Evaluation
o Mal-occlusal problems, jaw opening severity, deviation of jaw, teeth/gum infection, mid-incisal lines
o Observe for trouble talking, biting pattern, edema, erythema in supine position
Hear a click, feel crepitus, evaluate tenderness
o Three Knuckle Test: Indication of TMJ dysfunction. (If can place 3 knuckles in mouth, then pt is ok)
o Cranial mechanics must be assessed: Sphenobasilar Compression, Temporal Bone Restrictions, Sphenomandibular
Ligaments, and Stylomandibular Ligaments
Therapy
o Pharmacology: Analgesics, Anti-arthritics, NSAIDS, muscle relaxants, TCAs
o Physical Therapy: Coolant Therapy, E-stim, Jaw restriction, Passive Exercise, Ultrasound
o Principle aim of treatment
Establish free & uninhibited physiologic motion
Normalize nerve function
Counteract stress-producing forces
Eliminate circulatory stasis
Normalize cerebrospinal fluid function
Release membranous tension
Correct cranial articular lesions
Modify gross structural patterns
o Osteopathic Techniques
Direct to barrier: Muscle Energy, Soft-tissue, Myofascial Release, HVLA, Cranial (kids)
ME: have pt relax jaw, move jaw to the barrier, do PIR or RI, reassess
Indirect toward ease: BLT/LAS, FPR, Counterstrain, Myofascial Release, Cranial
Counterstrain: Palpate tenderpoint, monitor and hold for 90 seconds
o Masseter Tenderpoint inferior to Zygoma move jaw toward tenderpoint and is likely
on side of the jaw deviation
o Jaw Angle Tenderpoint (AKA Medial Pterygoid TP) press anteriorly from posterior
surface of mandibular jaw angle protrude jaw anteriorly and away from TP
o Pterygoid Tenderpoint (AKA Suprahyoid/Digastric) undersurface of the jaw angle
move jaw toward tenderpoint
Combined Technique for TMJ Dysfunction
o Gentle, continuous pressure is exerted up into the mandible resulting in impaction of the
TMJ, external rotation of the temporal and parietal bones, and compression of the sagittal
suture
49
o Caudad traction on the mandible body distraction of the TMJ
Release of Sphenomandibular Ligament
o BLT technique with one finger intra-oral & balance TMJ w/ sphenoid bone
o Sphenoid is stabilized while caudal traction is maintained on mandible
Release of Stylomandibular Ligament
o Temporal bone is stabilized while the gloved finger applies gentle caudal and anterior
traction on the mandible until balanced point release is felt
Zygomatic Maxilla Release
o Cephalad Hand grasps zygoma on the orbital border and inferior border
o Gloved Index finger is positioned intrabucally under zygomatic process
o Aim to externally rotate zygoma caudal and laterally during cranial flexion and vice versa
with cranial extension until balanced point release
Cervical Indirect Techniques
Indirect techniques
o Indications: Severe Arthritis, Severe Headaches, HA w/ nausea, Edema
o Risk-to-benefit ratio is great, but not the fastest techniques
o In MFR you listen to the muscle, fascia, soft tissue
o In BLT you listen to the ligaments
o Functional Techniques that monitor palpitory findings and readjust positioning
An indirect treatment method in which the physician guides the manipulative procedure while the
dysfunctional area is being palpated to obtain a continuous feedback of the physiologic response to induced
motion
Goal: Guide the dysfunctional part so as to create a decreasing sense of tissue resistance (increased
compliance)
Added strategies:
Load or unload tissues with compression/traction
Release-Enhancing Maneuvers: Eyes, Breathing, Air Hunger
General Process:
Distraction with compression or traction depending on mechanism of injury
o Disengagement with pulling on the osseous structures to separate sutures
Exaggeration that moves away from the barrier
o Position back to point/place of injury & exaggerate that positioning
o Compress or decompress the joint balanced point
Balancing at the loosest point
o After reaching the Balance Point, follow it to balance the pulling elements
o Balance Point = the point of balance of an articular surface from which all the motions
physiologic to that articulation may take place
Loosest point in all 3 planes
Change occurs at the balance point Maintain the balance until release
Release will feel like a pull-back toward neutral position
Return body to anatomic neutral
o Sutherland: Ligamentous Articular Strains are treated by using Balanced Ligamentous Tension.
Each structure has tensegrity with stresses creating different balance point
o 1949 AAO emphasized motion and function in somatic dysfunction
o 1964 Jones founded counterstrain based on positioning of balanced point
Positioning
o Gross Movement: parts of body placed in approximate position
o Repositioning: fine tune positioning to decrease sensitivity at the tender point very specific
o Find the wobble point that is balanced in all 3 planes of motion
Hand pressure
o Pressure is deep enough to engage the tissues but allows for physiologic motion
o Osteopath is the catalyst for the change but doesnt force the change
MOA
o Position to decrease pain away from barrier and remove pain-spasm-pain cycle
Position to decrease tension for edema to drain via lymphatics
o Tight muscles relax to shift balanced point
50
o Newer Models: Mechanotransduction: mechanisms focusing mechanical energy on cellular & molecular
transducers permits biomechanical interventions (manual medicine) to guide the cellular response
o Repetitive muscle strain to tissue with OMT decreased amount of interleukins formed
Balanced Ligamentous Tension (BLT)
o Refers to what should exist in a normal joint relationship coined by Wales for technique & goal
o Technique
Make Segmental diagnosis in all three planes based on direction of ease
Position segment in position of ease (same as the diagnosis name)
Fine-tune positioning with respiration
Inhalation causes spinal curves to flatten and extremities externally rotate
o Corresponds to craniosacral flexion
Exhalation accentuates relaxation and spinal curves internally rotates extremities
o Corresponds to craniosacral extension
Add Release-enhancing maneuvers
Inhalation-exhalation fascial pull, breath holding, air hunger
Movement of head-neck or extremities while holding tissues
Patient-evoked cranial nerve activities (eye, jaw, tongue movements)
Wait for release and ligaments will direct back to neutral
o Success requires permitting palpatory feedback to guide the treatment
o Balanced Membranous Tension (BMT)
o Mnemonics: Better listen to Tissues, Best Loosening of Tissues
Ligamentous Articular Strain (LAS)
o What happens with force applied to a joint coined by Becker for technique & problem
Facilitated Positional Release (FPR)
o Position to indirect barrier but quickly move to neutral position
o Technique
First Flatten Curve
Flatten Person (compress segment to disengage)
Free Float to the freedom ease of balanced point
Five Minute Hold
Fast back to neutral position
Still Technique
o Positioned to Ease and then follow quickly back through restricted barrier in HVLA movement
o Combined Indirect and Direct technique
o Technique
Stack the balanced point in all three planes
Seek disengagement with compression or distraction for a second
Swiftly move through the barrier
Slowly move back to neutral
Cervical Reminders
o OA: Flexion/Extension/Neutral all independent of SB & Rotation = Type 1-like
Rotation is set up last since only 3-5 degrees with flexion/extension/neutral set up first
o AA = C1 rotation only
o C2-C7: Flexion/Extension/Neutral all independent of SB & Rotation Type 2-like
Rotation scooping motion (anterosuperior) for plane of facet
Trigger Points (TrP)
Trigger Point refers pain with pattern of radiation of the pain when pressed
o Form of Somatic Dysfunction
o Active Trigger Point = pain pattern occurs at rest, with muscle action, or during palpation
o Latent Trigger Point = pain pattern is not reproducible in office and is triggered by cold, stress
o Criteria
Deep Achy regional/local pain with spot tenderness
Tender spot within taut band of skeletal muscle distant from referred site
2-4 kg/cm pressure reproduces pain within 10 seconds
Diminishes ROM of involved muscle due to pain
Local twitch with palpation or local needling
51
Characteristic referred pain pattern
Spontaneous EMG at nodule
Biomechanical Factors that cause trigger points
o Posture
Postural Muscles, crossing 2 joints, respond to trigger points by developing hypertonicity
Phasic Muscles, opponent to postural muscles, respond to trigger points by developing pseudo-paresis
(weak)
o Overuse
o Repetitive misuse
o Dudley J. Morton foot long second toe
o Muscle constriction
o Poorly conceived treatment
o Chilled muscle
o Radiculopathy disrupts axoplasmic flow to the muscles muscle atrophy predispose to TP
Treatment
o Spray & Stretch
Spray is the distraction, while stretch is the action over the length of the longitudinal muscle
Vapocoolant held 18 inches from skin at 30 angle for 4 per second just cool skin
Anchor one end of muscle to be able to stretch origin from insertion
Just go to barrier and dont overstretch
Clinically relevant Trigger points
o Gluteus Minimus Trigger point resembles L5 nerve radiculopathy & diagnosis can be misleading
Failed Laminectomy Trigger Point = Gluteus Minimus TP since do laminectomy w/out relief for falsely
suspected L5 radiculopathy
d incidence of TP in radicular pattern & must be ruled out before aggressive treatment
Pain pattern resembles a Pseudosciatica with Positive Trendelenburg Test
Usually doesnt go past the knee, while Sciatica will
Weakness in the Gluteus Minimus and Medius instability in the pelvis SI dysfunction
o SCM TP
Refers pain behind eye or vertical lines in vision, or HA in posterolateral occiput
Headaches: Treatment of Occipital-mastoid suture will improve CNXI, SCM TP & Trapezius TP
o Buckling Knee Syndrome = Quadriceps (Vasti)
Unbalanced Hamstrings & Vasti Patella doesnt glide properly Chondromalacia Patellae
Stretch Hamstrings before trying to stretch vasti exercise the vasti muscles
Pain pattern at the knee and anteromedial thigh
o Weak Ankles & Foot Drop Fibularis
Referred Lateral Ankle pain instability
o Joggers heel Soleus
Referred pain in the heel from a soleus trigger point
Differential: Heel Spur, Plantar Fasciitis
Pain can also radiate to the calf and sacro-iliac joint
Pain patterns cause plantar flexion of the ankle less stability recurrent sprains
o Foot Drop Tibialis Anterior
Weak dorsiflexors from trigger points or neurologic
Neurologic Causes: L4-L5, Peroneal Nerve Entrapment @Piriformis or at fibular head
o Frontal backache Iliopsoas
Referral pattern in mid low back and anterior proximal thigh
Key lesion = Type II L1 or L2 ipsilateral to the iliopsoas that is involved
Short muscle positive Thomas Test
o Frozen Shoulder Subscapularis
Subscapularis Referral Pattern into shoulder
Adhesive Capsulitis inability to abduct or externally rotate
Common occurrence after using a sling or crutches at wrong height
o Carpal Tunnel Group: wrist and forearm flexors & pronator teres
Treatment of the TP will have positive Phalen test to go away and EMG to be normal
o Lateral epicondylitis Forearm Extensor & Supinator
SWEAT muscles: Supinator, Wrist Extensor, Anconeus, Triceps
52
o Thoracic Outlet Syndrome
Myofascial Trigger Points in Anterior Scalenes will entrap the lower brachial plexus and have swelling of
the hand from poor vasculature
Pain pattern into the thumb, index finger, posterolateral arm & medial scapula
Pain can alternate between the little finger and the thumb
Do Addisons Test to use scalenes to elevate 1
st
rib
Other Differential: Thoracic Spine Dx/Tx, Costal Dx/Tx (esp R1), Cervical Spine Dx/Tx, Thoracic Inlet
MFR, Clavicular BLT, Pectoralis minor
o Lattissimus Dorsi TP
Lattissimus Dorsi Referral Pattern into medial hand
Chronic Mid-Thoracic Backpain
Trigger point will be found in the posterior axillary fold
o Pectoralis Major TP
Causes Supraventricular Tachyarrhythmia that converts to normal rhythm w/ TP removal
Pain pattern in chest area that radiates down the arm
o Quadratus Lumborum TP
Most overlooked cause of Low Back Pain and may affect respiration
May give appearance of scoliosis and shortened leg from hypertonicity
o Piriformis TP
Piriformis TP is located between PSIS & inferolateral angle and Greater Trochanter
Sciatic Nerve exits just 1 inch below the trigger point
o Pelvic Floor TP
Levator Ani TP = #1 cause of referred pain to perineal region
Treatment with Ischiorectal Fossa Release compresses ischiorectal fat against pelvic floor
o Lateral Pterygoid TP refers pain into sinuses and is treated with Sphenopalatine ganglia technique
o Medical Pterygoid TP refers pain to the inner ear & can be deactivated by putting tongue to roof of mouth
o Gallbreath Technique treats Otitis Media
53