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225 Cards in this Set

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What is the definition of Osteopathic Medicine
Complete system of medical care with a philosophy that combines the needs of the patient with the current practice of:
medicine
surgery
obestrics
that emphasizes the interrelationships between structure and that has an appreciation of the body's ability to heal itself
What are the 4 principles of Osteopathic Philosophy?
1. The BODY IS A UNIT: person is a unit of body, mind, spirit.

2. The body is capable of SELF REGULATION, SELF HEALING, AND HEALTH MAINTENANCE

3. Structure and function are reciprocally INTERDEPENDENT

4. Rational treatment is based upon an understanding of the basic principles of body unity, self regulation, and the interrelationships of structure and function.
What is this definition?

The impaired or altered function of related components of the somatic (body framework) system.
Definition of somatic dysfunciton
What is this definition?

- The maintenance of a pool of neurons in a state of partial or sub threshold excitation
- In this state less afferent stimulation is required to trigger the discharge of impulses
Spinal Facilitation
What are the different areas of spinal facilitation?
1. could be premotor neurons, motor neurons, or preganglionic sympathetic neurons in one or more segments in the spinal cord

2. Once est facilitation can be sustained by nl CNS activity

3. This theory helps explain the neurophsiological mechanisms underlying the neuronal activity associated with somatic dysfunction
What is Osteopathic Manipulative Treatment?
therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and or support homeostasis that has been altered by somatic dysfunction
What is the Criteria for diagnosing somatic dynsfunction?
TART

T - Tissue texture abnl
A - Asymmetry
R - Restriction
T - Tenderness
What Motion barrier is this?

The limit of Motion imposed by ANATOMIC STRUCTURE.....the limit of PASSIVE MOTION
Anatomic Motion Barrier
What Motion barrier is this?

The limit of ACTIVE MOTION
Physiologic Motion Barrier
What motion barrier is this?

Also called the restrictive barrier
A functional limit that abnl diminishes the nl physiologic range
Direct motion barrier

Use Techniques: ME, HVLA, Direct Myofacial Release
What barrier is from the ANATOMIC TO ANATOMIC barrier?
Passive Motion Barrier
Label this picture for Barriers
Anatomic: the limit of motion imposed by anatomic structure; the limit of passive motion

Physiologic : the limit of active motion

Direct: may also see it called the restrictive barrier; a functional limit that abnormally diminishes the normal physiologic range
Is this Direct or Indirect OMT?

- ______ techniques are ones in which the restricted tissue is initially taken in the direction of the restriction to motion
Direct OMT
Is this Direct or Indirect OMT?

- ______ techniques are those that initially position the tissue away from a barrier toward relative ease or freedom of motion
Indirect OMT

Techniques are located between neutral and new neutral barriers
What Freyette's Law is this?

When the spine is in neutral, sidebending and rotation are in OPPOSITE DIRECTIONS
Freyette's Law 1
Law I = when the spine is in neutral (easy normal), sidebending and rotation are in opposite directions. (Type I Mechanics)

- Occurs in neutral - (facets not engaged)
- Found in thoracic and lumbar spines
- Forms long curves, multiple segments
- Compensatory
What is Freyette's type 2?
Law II = when the spine is flexed or extended (non-neutral), sidebending and rotation are in the same directions. (Type II Mechanics)

- Occurs in flexion or extension- Facets engaged
- Found in thoracic and lumbar spines - Type II-like motion in cervical spine
- Usually single segments
- Found at apices and crossovers and/or sites of viscerosomatic reflexes
- Primary somatic dysfunction - Due to strain or viscerosomatic reflex
What is Fryette's Law Type III?
Law III - when motion introduced in one plane it modifies (reduces) motion in other two planes

When a segment is brought up to a restrictive motion barrier it will move in the position of greatest ease in the other two planes.
What are the symptoms of Type 1 SD?
- Posterior transverse process and paravertebral fullness visible when spine is in neutral.

- Asymmetry not significantly altered by flexion/extension.

- Sidebending and rotation opposite directions
What Cervical Spinal has Type 1 mechanics?
OA
What Fryettes is associated with:
short leg
rotational pelvis
type II SD
Fryette's Law Type 1
What Cervical spine is associated with Type II Mechanics?
Typical Cervical Spine C2-C7
&
A.A
What cervical spine has ONLY PURE ROTATION?
Type II
What Fryette's is associated with viscerosomatic reflexes?
Fryette's Type II
If the right facet was locked closed.
What findings would you find?
Type II mechanics - Extension SD

- In extension - NO ASYMMETRY
- Both facets can close easily in ext
- No apparent rotation or sidebending asymmetry ext
- most comfortable for the patient in ext
In a Type II extension SD if the right facet was locked closed what will your findings be?
Remember the left facet can move
SB and Rot to the right
In an EXTENSION SD what will your findings be in flexsion?

If the right facet was locked closed?
Remember SD is the position of ease so it gets better in extension and worse in flexsion!

In flexsion the left facet opens freely and can pivot around the right facet
- This leads to SB right and exaggeration of asymmetry
What will the restriction be if the SD is Extension Rot R, SB R?

Again SD is position of ease
Position of laxity
Restriction:
Flexsion, Rot L, SB L
Flexsion SD Type II mechanics
If the right facet is Locked OPEN
What will your findings be in flexsion?
In flexsion.....NO ASYMMETRY***
Both facets can open easily
No apparent rotation or sidebending asymmetry
Most comfortable position for the patient
Flesion SD Type II
right facet is opened
In a Flexsion SD with the right facet open how will this present?
In Extension find asymmetry
Left facet closes nl
The right facet is Locked Open
SB and Rot to the left
Motion restriction = Res ESR right
SD = FRS left
If you find the person in:
Restriction ERS right

What is the SD?
FRS left
Memory Aid for Flexsion and Extension SD:
Chart to remember Type 1 and Type 2 SD
Type 1 mechanics
are facets engaged?
No
Type 1 mechanics
What type of segments are seen?
multiple segments
long curves
Type 1 mechanics
etiology?
compensatory
adaptive
Type 1 mechanics
In what direction is rotation in relation to convexity?
Rotation toward convexity
Out from under the load
Type 1 mechanics
What is seen?
Smooth curves
Should you treat Type 1 or 2 SD first?
Treat Type II (2) first
With a Type II SD know these things:
Type II

Facets are engaged
Single segments are affected
Causes: Traumatic / primary / viscerosomatic
Rotation toward the concavity into the load****
Treat these first
Where would you expect to find a Type II SD?
In apices and crossovers in curves

in relation to viscerosomatic reflexes**
When doing a posterior static postural exam what should the vertical line normally pass through?
The vertical line should normally pass: 1. halfway between the knees
2. along the gluteal fold;
3. through all spinous processes
4. along the midline of the head;
When observing the posterior static exam what should you look for horizontal levelness?
poplitleal creases
greater trochanters
iliac crests
inferior angles of the scapula
tops of shoulders
mastoid processes
What are some common anomalies found on posterior static postural exam?
foot external rotation
ped planus (fallen foot arch)
iliac crest asymmetry
pelvic side shift
thoracolumbar scoliosis
shoulder height asymmetry
head tilt
ON EXAM***
Lateral Static Postural Exam
What should the weight bearing line nl pass through?
hint (6 pts)
1. just anterior to lateral malleolus
2. middle of tibial plateau
3. great trichanter
4. body of L3 (center of body mass)
5. middle of humeral head
6. external auditory meatus
What are some common abnl seen on lateral static postural exam?
Anterior head carriage,
shoulders anterior or posterior,
thoracic hyperkyphosis,
lumbar hyperlordosis,
anterior pelvic weight bearing.
EXAM***
What does the Hip Drop Test screen for?
lumbar sidebending screening***
observe lumbar sidebending and amount of hip drop
How is the hip drop test performed?
Ask the standing patient to shift weight onto one leg, allowing the other knee to bend which induces lumbar sidebending toward the weight bearing leg;

Observe lumbar sidebending and amount of hip drop which is normally ≥ 25°;

Hip drop < 25° (positive test) indicates restricted lumbar sidebending toward the side of the weight bearing leg.****

Test is named for the bent leg side (+ right hip drop test indicates restricted left lumbar side bending)
What side is the hip drop test named for?
For the bent leg side

Ex. A (+) right hip drop test indicates restricted left lumbar bending
A women presents with restiction sidebending to the left. What leg is bent?

What side would he hip drop test be positive?
Right leg is bent

Positive right hip drop test
Hip Drop Tests - lumbar sidebending screening
What is defined as:
An abnormal lateral curvature of the spine in the coronal plane.
Scoliosis
What is main cause of scoliosis?
The most common cause for scoliosis is idiopathic, accounting for 70-90% of all scoliosis cases
How do we dx idiopathic scoliosis?
Idiopathic scoliosis is a diagnosis of exclusion, and a neural etiology of spinal deformity must be ruled out in every case
What is the Adam's test and what does it look for?
Scoliosis is characterized by both lateral curvature & vertebral rotation, giving it a characteristic “Rib Hump”.

Structural: does not reduce with side bending toward the rib hump

Functional: reduces with side bending toward the rib hump

This an application of Type 1 mechanics
What is the Key Difference between Functional and Structural SD?
Structural: DOES NOT reduce with side bending toward the rib hump

Functional: reduces with side bending toward the rib hump
Pt sidebendins into rib hump
Functional curve rib hump diminishes
What is the Epidemiology of Scoliosis?
10% of children have some spinal asymmetry
0.2% of children need treatment
Do women or men have scoliosis more commonly?
Female: Male ratio varies with the severity of the scoliosis
As the Cobb Angle INCREASES so does the female to male ratio

Meaning women have more scoliosis with more severe cobb angles
At what age is most scoliosis Dx?
Preteen to teen yrs
What are the presenting symptoms of scoliosis?
Children and adolescents present with back pain more often than adults, regardless of the severity.
What is the MOST COMMON CAUSE of Functional Scoliosis?
SHORT LEG SYNDROME***
What direction will the sacrum and pelvis tilt toward with short leg syndrome?
Sacrum and Pelvis tilt TOWARD the shorter leg****

SPINE CURVES BACK IN ATTEMPT TO KEEP THE EYES LEVEL
What are 2 other known causes to cause FUNCTIONAL SCOLIOSIS?
1. Muscle strain
- Tight muscle on one side of spine causes “bowstring effect” - Psoas syndrome
- Relaxing & stretching the muscle allows spine to straighten.

2. Weak musculature
- A weak muscle on one side of spine allows opposing muscles to cause “bowstring effect.”
- Strengthening the weak muscle allows spine to straighten.
How do we Name a Curve in Scoliosis?
What are the 4 patterns of Scoliosis?
You Side bend away from the short leg.
Short Leg and Convexity are on the SAME SIDE --> Scoliosis is name for the side of the side leg***

Double major - short leg is on the left
What is the most common type of scoliosis?
DOUBLE MAJOR***
Go through the 4 different studies to rule out scoliosis:

1. Static postural exam
2. Adam's test
3. Neurological exam
4. Radiographs
Static postural exam
Rule out short leg

Adam’s Test
Determines side & flexibility

Neurological Exam
Rule out underlying neurologic cause

Radiographs, if indicated
- Scoliosis
- Risser (ossification of iliac crest identified w/ x-ray) - Lower value = skeletal immaturity = curve more likely to progress.
- Brain MRI
What radiographic sign can tell you if the scoliotic curve might progress?
Risser***

This is ossification of iliac crest identified with X-ray

A lower value = skeletal immaturity = curve more likley to progress***
What are the 3 tests we have for determination of short leg?
1. posterior standing postural exam
2. iliac crest height
3. medial malleoli levelness
What are the 2 types of X-rays we order to see if scoliosis is present?
1. Scoliotic X-ray :
- erect AP from occiput to sacral base
- Measurement of Cobb angle

2. Postural radiographs:
- Anterior-posterior (AP) - Erect
- Lateral - Erect
- Obliques, when suspect spondylolisthesis (scottie dog deformity)
How do we measure the COBB ANGLE?
Draw lines from the top of the superior vertebra & the bottom of the inferior vertebra into the concavity of the curve.

Drop intersecting lines perpendicular to these lines & measure the acute angle.
What is the Ferguson's Angle?
Lateral View Standing***

Lumbosacral angle (Ferguson’s angle)
Normal = 40° + 2°****

Weight bearing line
Bisect L3, drop a vertical line. It should fall on anterior 1/3 of sacral base
Treatment of Scoliosis is based on the Cobb Angle***

What is Mild, Moderate, and Severe Tx for scoliosis?
Mild 5-15°
Conservative, including OMT, exercises & treatment of short leg

Moderate 20-45°
Above plus
Bracing (80% will not progress with bracing)
Electrical stimulation

Severe >50°
Surgical stabilization
What is pathology can present with Functional Impairment of thoracic curves?
Possible respiratory impairment >50 °

Possible cardiac impairment >75 °
Will the curve get worse over time?
What are prognostic factors?
Future growth potential:

1. Age at diagnosis:
- Risser sign (ossification of iliac crest identified w/ x-ray)
- Lower value = skeletal immaturity = curve more likely to progress.

2. Menarche in females:
- Growth spurt (critical time for curve increase) occurs 12-18 months prior to menarche.

3. Curve severity at diagnosis

4. Curve patterns:
- Thoracic curves have a higher risk for progression than lumbar

5. Gender:
Females are more likley to have curve progression
What are the principles of Indirect techniques?
(move into position of laxity)
Counterstrain
Indirect myofascial release
Indirect cranial
What are the principles of Direct OMT techniques?
(move into restriction)
Soft tissue
Direct myofascial release
Direct cranial
Muscle energy
HVLA
What are 2 examples of combined indirect and direct techniques?
Combined Techniques:
1. Articulatory
2. Visceral
What are the only 2 absolute contraindications to OMT?

EXAM***
1. The absence of somatic dysfunction.

2. The patient refuses to have OMT performed - to do so would be considered battery.
Please detail the system of Counterstrain:
1. Find and label tender point 10/10
2. Position to relieve tenderness (2/10 or less)
3. Fine-tune to 0/10 if possible
4. Hold position for 90 seconds (some schools teach 120 seconds for the ribs)
5. Slow passive return to neutral
6. Retest tender point
What is the lowest pt you need to get to for counterstrain?
2/10
What are some counterstrain principles you need to be aware of?

just read
1. Patient must be able to relax for the treatment to work
2. Treat the worse tender point first
3. The monitoring finger is only monitoring
So don’t be pushing with it during the treatment
4. Don’t move your monitoring finger until the treatment is finished
5. Some points may be “mavericks”
6. Positioned completely opposite of what you would expect based on the anatomy
7. Limit treatment to 5-6 tender point per visit
What is the MAX # of Tx for counterstrain you should try in 1 visit?
5-6 tender points
What is a maverick point?
“Maverick” which is used most commonly to describe a treatment position that is opposite of the common expected treatment position
If a person presents with say 5 tenderpoints which should you treat first?
Treat the WORST tender point first
Do you Tx babies with counterstrain?
NO!
What is the difference between the piriformis and Lower L5 pole counterstrain tenderpoints?
Piriformis

- Origin – anterior surface of S2-4 segments.
- Insertion – superior and posterior aspect of greater trochanter.
- Action – external rotation and abduction of hip.
Lower Pole L5 is located at the inferior surface of the PSIS
Notice the Tx for Piriformis and LPL5 are very different

Piriformis is external rotation and extension

LPL5 is more Flexsion and hip adduction
Just in case they ask you about the Lumbar tenderpoints for the Anterior and Posterior TPs. Let's review them
Woo extra slide
Now begin.....

What is the POSTERIOR T10-L5
spinious process or 1/2-1'' lateral
What is the POSTERIOR L3?
gluteal muscle half way between posterior L4 and L5
What is Posterior L4
iliac crest in posterior axillary line
What is Posterior L5
aka Upper Pole L5
aka Upper Pole L5
superior surface of PSIS at insertion of iliolumbar ligament
What is Lower pole L5?
Inferior surface of the PSIS
Image of the Posterior Lumbar Counterstarin Tenderpoints

book pg 114
• T10-L5: spinous processes or 0.5-1” lateral
• L3: gluteal musculature halfway between posterior L4 and L5 (refer to as lateral L3)
• L4: iliac crest in posterior axillary line (refer to as lateral L4)
• L5 (upper pole): superior surface of PSIS at insertion of iliolumbar ligament
• L5 (lower pole): inferior surface of PSIS
Now describe the anterior Lumbar counterstrain tenderpoints
• T9: 0.5-1” superior to umbilicus
• T10: 1” below umbilicus
• T11: 2” below umbilicus
• T12: inner aspect of iliac crest in mid-axillary line
• L1: 0.5” medial to ASIS
• L2: medial surface of AIIS (push tender point laterally)
• L3: lateral surface of AIIS (push tender point medially)
• L4: inferior surface of AIIS (push tender point caudally)
• L5: pubic ramus 0.5” lateral to pubic symphysis
What is the Tx position for the T10-L5 Posterior counterstrain tenderpoints?
• T10-L5 Posterior Counterstrain (Figure 1)
o Patient is on prone
o Lift thigh on the side of tender point to extend the hip
o Fine tune with slightly more hip extension, abduction or adduction
What is the position for posterior Lower Pole L5 counterstrain TP?
• Lower Pole L5 Counterstrain (Figure 2)
o Patient is on prone
o Flex hip and knee 90°
o Fine tune with slight hip adduction
What is the position for T9-L5 Anterior counterstrain TP?
• T9-L5 Anterior Counterstrain (Figure 3)
o Patient is supine
o Passive flex both knees and hips 90°
o Fine tune with increased hip flexion and slight rotation and sidebending of knees
The location of counterstrain tender points can be suggested by the clinical history and presenting complaints......
More on Counterstrain:

- Patient tends to bend around tender points – If the patient presents forward bent, tender points tend to be anterior
- The location can also be suggested by the position the patient was in when the original injury occurred
If a pt presents bent forward....would his tenderpt be anterior or posterior?
anterior
You need to be able to differentiate between:
1. Counterstrain TP
2. Chapman's Points
3. Trigger Points

review Counterstrain TP
Counterstrain tender point
Usually tender
may be palpable tissue texture changes
non-radiating****
Chapman's Points are.....
Chapman's Pts
usually tender
that present as anterior and posterior fascial tissue texture abnormalities assumed to be visceral dysfunction or pathology (Glossary of Osteopathic Terminology)
Viscerosomatic reflex
Helps to know the locations!
Trigger points are......
Trigger points
Usually tender
a small hypersensitive site that, when stimulated, gives rise to referred pain and/or other manifestations in a consistent reference zone
Where might the Trapezius have trigger points?
Retro-orbital pain
Pain behind the ear
Where might the Sternocleidomastoid have trigger points?
 ipsilateral hearing loss (clavicular branch)
 tongue pain (sternal branch)
 visual disturbances
 chronic cough
 TMJ pain (sternal)
Where would Supraspinatus Trigger Point be found?
Where are trigger points for Iliopsoas?
Please review Myofacial release treatment
1. Diagnose restricted motion
2. Slowly move into position of laxity and follow release until completed (indirect)
3. Slowly move into restriction and stretch until tissue give completed (direct)
4. Retest motion
When referring to barriers which comes first the physiological or anatomical?
Physiological barrier is before the anatomical
When performing Myofacial release where should you position a person?
At the Point of balanced tension
What Law is:

When a muscle receives an nerve impulse to contract, its antagonists receive, simultaneously, an impulse to relax.
Sherrington's Law
What law is:

Fascia will deform as a result of the lines of force to which it has been subjected
Wolff's Law
What is Tensegrity?
Myofascial release (myofascial unwinding)
“Local” treatment produces changes in other parts of the body.
Fascia moves as a unit in a tensegrity matrix down to the cellular level.
Mechanical forces into fascia transmitted throughout the entire organism.
What is Fascial Continuity?
Fascial restrictions in one area will strain areas away from the restriction causing abnormal movement patterns.
Fascial continuity and tensegrity come into play during ______?
myofascial release (MFR) treatments***

- Injury to fascia at one location is carried through the whole fascial tissue.
- OMT to fascia at one level is carried through the whole of fascial tissue.
- MFR engages tensegrity structure of the body.
Review Cranial manipulation:
Frontal and parietal lifts
SBS compression-decompression
Temporal decompression
Compression of the 4th ventricle
Balanced membranous tension (Ligamentous articular strain)
Sutural disengagement
TMJ compression/decompression
Occipital decompression
Oh Boy here we go
Frontal and parietal lifts
1. Frontal Lift:
gently contact frontal bone posterior to orbital ridge on both sides.
Gently lift the frontal bone until slight give is equal on both side
Used for: restricted frontal mobility, headaches, depression, sinus congestion, etc

2. Parietal lift
located superior to the squamous sutures. Gently press medially into the parietal bones until give is equal on both sides.
Used for: Headaches, resp congestion, other problems
SBS compression - decompression
Used for: diminished CRI amplitude, mood disorders, cranial nerve entrapment, upper resp infec,

Using the temp or frontoccipital hold gently compress SBS then decompress
What Techniques are used for:
Falx Cerebri membranous strain?
Falx cerebri - treat with frontal/parietal lift, SBS compression/decompression, or balanced membranous tension
What techniques are used for:
Tentorium Cerebelli strain?
Tentorium cerebelli - treat with temporal decompression or balanced membranous tension
What is the purpose of CV4 technique?

compression of 4th ventricle
Compression of the 4th ventricle (CV4) is used to normalize CSF fluctuation (one of the most comprehensive and effective procedures in the whole cranial concept)
• Treats low amplitude
• In this treatment you encourage cranial extension and resist cranial flexion until still point is achieved. Once achieved, compression is then gently and slowly released **remember to keep off the occiptomastoid suture**
Describe Balanced membranous tension
o Balanced Membranous Tension:
 Find neutral point of strain pattern by Exaggeration of the Abnormal Motion
 Position toward ease of motion
 Hold until a “still point” is reached
 Inherent Motion returns --> recheck for symmetry/amplitude/rate
TMJ compression / decompression
Temporomandibular Joint dysfunction can be detected if there is jaw pain with eating (can also cause facial pain or headache)  jaw deviates to the side of TMJ restriction
 Progresses to more restricted mobility, cartilage degeneration, and/or subluxation
• Treat with anti-inflammatory medications, orthodontic evaluation, OMT for cervical and cranial somatic dysfunction
• Suboccipital inhibition, C1 treatment (anterior counterstrain), temporal balancing, and TMJ compression-decompression
Occipital Decompression
Used for restricted occipital mobility ass with infant feeding disorders, congenital muscular toricollis

gently contact the cranial base with index fingers on mastoid processes
middle finger on occipital condyles
ring fingers on supraocciput
Discuss Lymphatic and facial techniques
Venous sinus drainage
Facial effleurage
Trigeminal stimulation
Sphenopalatine ganglion stimulation
Mandibular drainage
wooo weeee
Facial effleurage
Facial effleurage: start at the neck (one side at a time) then depending on where the congestion is either work on the frontal portion, maxillary portion, and/or mandibular portion
Trigeminal Stimulation
Trigeminal stimulation: pressure on trigeminal nerve foramina stimulates vasoconstriction of mucous membranes to help open sinus orifices
Sphenopalatine ganglion stimulation
Sphenopalatine ganglion stimulation: pressure on pterygopalatine ganglion stimulates watery mucous that more easily drains from sinuses
How is Muscle energy Performed?
1. Diagnose restriction
2. Move into restrictive barrier
3. Isometric contraction away from the restrictive barrier 3-5 seconds
4. Stretch until give stops
5. Repeat 3-5 times
6. Retest motion
How does muscle energy work?
(hint 4 reasons)
1. Tissue creep - constant load causes tissue give
2. Conditioning - less tissue resistance with repeated stretch
3. Post-isometric relaxation*****
4. Reciprocal inhibition - reflex relaxation of antagonist
What is the most unique aspect about muscle energy that does NOT occur with any other treatment?
Post-Isometric Relaxation*** --> needs an activating force
What is:

Isometric contraction?
muscle contraction that results in increased tension without approximating the 2 ends of the muscle
i.e. stays the same length
ex. press palm to palm with hands
What is:

Isotonic contraction?
muscle contraction that results in NO increased tension;
but! does result in the 2 ends of a muscle approximating
i.e have increased tone
ex: lifting a dumbell
What is Isolytic contraction?
forcing a muscle to lengthen during contraction***
It is neither isometric or isotonic
i.e. outside force breaks contraction
Ex: loser in an arm wrestling match
Describe Articulatory technique
1. Diagnose restricted joint motion
2. Slow movement of joint to its position of laxity for all planes
3. Slow movement of joint into its restriction for all planes
4. 3-5 repetitions as one smooth movement
5. Retest motion
Describe HVLA technique
1. Diagnose restriction
2. Move into restrictive barrier for all planes
3. Short quick movement through barrier
4. Retest motion
Describe Soft Tissue Technique:

1. Traction
2. Kneading
3. Inhibition
4. Effleurage
5. Petrissage
1. Traction – longitudinal muscle stretch

2. Kneading – lateral muscle pressure

3. Inhibition – sustained muscle pressure

4. Effleurage – stroking pressure to move fluid

5. Pétrissage – squeezing pressure to move fluid
For an ACUTE SEVERE problem describe the following:

Method
Dose
Frequency
Duration
Method - Indirect Techniques

Dose - Fewer regions lower dose

Frequency - 1-2 treatments per week

Duration - 2-4 treatments
For an CHRONIC problem describe the following:

Method
Dose
Frequency
Duration
Method - Any technique including direct

Dose - More regions, higher dose

Frequency - Every 2-6 weeks

Duration - As long as helpful
Who invented the common compensatory pattern?

What does is look at?

What is the treatment approach?
- Developed by J. Gordon Zink, D.O.
- Utilizes the respiratory-circulatory model.
- Identifies four patterns of body structure:
1. Ideal
2. Common compensatory
3. Uncommon compensatory
4. Uncompensated
- Treatment approach: Emphasis on crossover points of spinal curves.
- Transverse fascial diaphragms
Give me the locations of the common compensatory pattern TRANSVERSE FACIAL DIAPHRAGMS
1. Pelvic diaphragm (L5-S1)
2. Thoracic diaphragm (T12-L1)
3. Thoracic inlet (T1, 1st rib)
4. Suboccipital region (OA, AA)
What are the 3 different Common Compensatory Patterns?
2 Main types:
1. Compensated
A) Common
B) Uncommon

2. Uncompensated

Think** Always start on the Right foot (for pelvic) and then alternate for the common compensatory
What is the Main difference with the compensated and uncompensated patterns?
Compensated: alternates diaphragms directions

Uncompensated: has 2 diaphragms in the same direction
What is the order of treatment for the common compensatory patterns?
1. Treat uncompensated findings first.
Treat the worst first.

2. Treat the compensatory findings with goal of approaching ideal structure.
How the Lymph drained from the left and right sides of the body?
Right - area drained by the right lymph duct
Right Lymph Duct: drains right upper body, crosses thoracic inlet once, drains into jugulosubclavian junction

Left - area drained by the thoracic duct:
Drains Left upper and ALL LOWER body
Crosses thoracic inlet twice
Drains into subclavian and left brachiocephalic vein junction
What are the Intrinsic Lymphatic Pumps?
Lymphagions***
Vessels contracted 6-8 times per minute
Affected by autonomics*
What are the Extrensic Lymphatic Pumps?
-Diaphragms
-Respiration
-Peristalsis
-Arteries adjacent to lymphatics
-Body movement
Vigorous exercise increases flow 15-20x
-External compression
Bandages, water emersion, manual therapies - including OMT
What is the Osteopathic Goal for the Lymphatic System?
-Approach tailored to patient needs
-Remove restrictions (proximal to distal)
Treat transverse fascial diaphragms
Treat fascial restrictions
Normalize autonomic activity
Rib raising
Suboccipital Inhibition
Sacral rocking
What are some pressure techniques to promote and adjust flow?
- Pressure techniques
Compression stockings
Pétrissage (kneading/squeezing)
Effleurage (Stroking)
Soft tissue
Abdominal lifts
What are some pump techniques to promote lymphatic flow?
- Pump techniques (distal to proximal)
Pectoral traction
Thoracic pump
Abdominal pump
Pedal pump
Liver/Spleen pump
EXAM
What are Viscerosomatic Reflexes for Acute findings?

1. Temperature
2. Tissue Texture
3. Red Reflex
1. Temperature - hot

2. Tissue Texture - Moist, full, edema, tension

3. Red Reflex - increased or prolonged redness
EXAM
What are Viscerosomatic Reflexes for Chronic findings?

1. Temperature
2. Tissue Texture
3. Red Reflex
1. Temperature - Cool

2. Tissue Texture - thickness, dryness, ropiness, pimples

3. Red Reflex - prolonged blanching
The moment you have been dreading.....
Autonomic Innervation SNS reflex levels****
Head and Neck
SNS
PNS
SNS - T1-4
PNS - Vagus
Cardiovascular
SNS
PNS
SNS - T-5
PNS - Vagus
Resp
SNS
PNS
SNS -T2-7
PNS - Vagus
Stomach, Liver, Gallbladder
SNS
PNS
SNS - 5-9
PNS - Vagus
Small Intestine
SNS
PNS
SNS 9-11
PNS vagus
Ovary, Testicle
SNS
PNS
SNS 9-10
PNS S2-4
Kidney, ureter, bladder
SNS
PNS
SNS 10-11
PNS S2-4
Large Intestine
SNS
PNS
SNS T8-L2
PNS Vagus, S2-4
Uterus
SNS
PNS
SNS 10-11
PNS S2-4
Prostate
SNS
PNS
SNS L1-2
PNS S2-4
Have this memorized!!!

******************EXAM******************
Pancrease
SNS
PNS
SNS T5-11
PNS Vagus
Arm
SNS
PNS
SNS T2-7
PNS - NONE
Leg
SNS
PNS
SNS T10-L2
PNS - NONE
What are some Treatment of sympathetic component of thoracic visceral disease?
Rib Raising:

- Sympathetic chain ganglia just anterior to rib heads
- Constant or repetitive lift of rib angles stimulates chain ganglia
Treatment of sympathetic component of bowel dysfunction with _______?
abdominal plexus inhibition

-Push posteriorly into celiac, superior mesenteric, or inferior mesenteric ganglion
- Hold until tissue release, about 10-20 seconds
- Ganglion inhibition is contraindicated in patients with peritonitis, bowel obstruction
Treatment of parasympathetic component of visceral disease?
(hint 2 of them)
1. Upper cervical soft tissue (suboccipital inhibition)
2. Sacral rocking
How do you treat Chapman Points?
-Treat posterior points
-Anterior points may also be treated but often to sensitive and uncomfortable for patient

-Light rotatory massage with your fingertip
-Treat about 10-30 seconds
-Treat 2 or 3 times each day for best results
Ok Now the chapman's pts lol
i just wanta go to sleep ugggggggg

ONLY HAVE TO KNOW THE ANTERIOR PTS.......IM NOT GOING TO WRITE ANTERIOR FOR EACH ONE SO JUST KNOW THEY ARE ANTERIOR****
Chapman's
Middle ear
Superior to medial clavicles
Chapman's
Sinuses
Inferior to medial clavicles
Chapman's
Pharynx
Inferior to sternoclavicular joints
Chapman's
tonsils
medial 1st intercostal spaces
Chapman's
tongue
medial 2nd ribs
Chapman's
esophagus, thyroid, and heart
medial 2nd intercostal
Chapman's
Upper Lung and Arm
Medial 3rd intercostal
Chapman's
Lower Lung
Medial 4th intercostal space
Chapman's
Liver
Right medial 5th and 6th intercostal spaces
Chapman's
stomach acidity
Left medial 5th intercostal space
Chapman's
Gall Bladder
Right medial 6th intercostal space
Chapman's
Pancrease
Right medial 7th intercostal space
Chapman's spleen
left 7th intercostal space
Chapman's small intestine
medial 8th-10th intercostal space
Chapman's pyloris
midline body of sternum
Chapman's adrenals
1'' lateral and 2'' superior to umbilicus
Chapman's kidneys
1'' lateral and 1'' superior to umbilicus
Chapman's
bladder
periumbilicus
Chapman's
Intestine / Peristalsis
1-2'' inferior and lateral to ASIS
Chapman's
Appendix
tip of rib 12
Chapman's Ovaries
Pubic Tubercles
Chapman's Urethra
Pubic Tubercles
Chapman's Uterus
Inferior pubic rami
Chapman's rectum
lesser trochanters
Chapman's Colon
Anterior iliotibial bands
Chapman's
Prostate, Broad Ligament
Lateral iliotibial bands
Champan's reflexes why is the colon upside down?
What is the right and left colon found?
Look at it as if it were laid out in front of you

Right Iliotibial Band:
1. iliocecal area
2. ascending colon
3. hepatic flexure
4. right 2/5th of transverse colon

left iliotibial bands
1. sigmoid area
2. descending colon
3. splenic flexure
4. left 3/5th of transverse colon
The ankle has both an upper and lower joint that act together as a functional unit

1. What is the upper joint?
2. What is the Lower joint?
1. Upper joint is tibiotalar (talocrural)
2. Lower joint is the subtalar (talocalcaneal)

-The upper joint involves the talus moving in the ankle mortise
-The major motions of the of the tibiotalar joint is described as dorsiflexion and plantar flexion
EXAM****

How does the Ankle (talotibial) Mechanics move with:

1. Plantar flexsion
2. Dorsiflexsion
1. Talus glides anteriorly with plantar flexion

2. Talus glides posteriorly with dorsiflexion
What does the ankle swing test, test for?
Tests for talus anterior glide somatic dysfunction:***

-Hold feet horizontally and push them posteriorly.
-Tests ankle dorsiflexion and posterior talus glide
-Positive swing test= restricted posterior talus glide= anterior talus = plantar flexed ankle = restricted ankle dorsiflexion*****
Review the major ankle counterstrain points for location and treatment position
-Extension ankle
-Lateral ankle
-Medial ankle
Extension: Tenderpoint in gastronemius muscle assocaited with ankle pain, leg pain, foot pain, gait abnl
TP is proximal gastronemicus nead its medial or lateral origin

Lateral Ankle: Pt lying on side of problem, hold distal tibia and TP
TP - Anterior and Inferior to the lateral malleolus. Hold the calcaneous and evert foot for tx

Medial Ankle: Pt lays on Opposite pf problem, TP is inferior to the medial malleolus. Invert the foot and retest.
What 3 things can be associated with anterior and posterior innominate rotations?
1. ipsilateral tight hamstrings
2. tight iliolumbar ligament
3. piriformis syndrome ass with sciatica pain
tricky***

What are the findings for pubic compression?
tender pubic symphysis

Pubic Tubercles are symmetrical***
With Cranial Flexsion which way does the sacrum move?
sacral base moves posterior
aka
sacral base extends
counternuates
With Cranial Extension how does the sacrum move?
sacral base flexes
moves anterior
nutates
time to review the anterior and posterior THORACIC counterstrain tenderpoints.....
Remember that the anterior thoracic tender points are midline only from T1-4
Posterior thoracic tender points

1. Posterior T1-9
2. Posterior T10-12
1. Posterior T1-9
- spinious process or 1/2'' lateral

2. Posterior T10-12
Anterior thoracic tender points

T1
T2
T3-4
T5
T6
T7
T8
T1 - sternal notch pushing inferiorly
T2 - middle of manibrium
T3-4 - sternum @ level of corresponding rib insertion
T5 - 1'' above the xyphosternal junction or at rib 5 cartilage bilateral
T6 - xiphisternal junction or rib 6 cartilage bilateral
T7 - tip of xiphoid process or rib 7 cartilage bilateral
T8 - 1.5'' below xiphoid process or at chondral mass
Rib Angle Tenderpoints
Posterior:

Rib1 - lateral shaft anterior to trapezius muscle

Rib 2-7 - rib angles with scapula rotated away by flexing and adducting arms

Ribs 8-10
rib angles which are more lateral with each lower rib
Anterior Ribs

rib 1 - inferior to medial clavicle, lateral to sternum

rib 2 - rib shaft in mid-clavicular line

rib 3-10: rib shaft in anterior axillary line or mid-axillary line
What are the treatments fpr Rib subluxation Muscle energy?

Posterior subluxation
Anterior subluxation
Posterior - push the rib angle anteromedially
ask the pt to push her elbow medially

Anterior - push the costotransverse articulation posterior medially.
Have pt push elbow laterally
If a person has a rib exhalation restriction use rib inhalation muscle energy
for ribs 2-5 push inferiorly on rib shaft in the anterior axillary line.

For Ribs 6-10 push inferiorly on rib shaft in the mid axillary line

Ask the pt to inhale deeply while you resist superior rib movement
During exhalation push the rib more inferiorly as you flex and sidebend the neck and thorax

**Sidebend toward and Rotate away**
For rib exhalation muscle energy:
Rib inhalation restriction - always tx the superior rib***
Rib 2 - flex the head which is rotated slightly away (this is the Oh my look)
Rotate the head away*

rib 3-5 - push the elbow of the abducted arm across the chest
pectoralis minor contraction

ribs 6-10 push the abducted arm down toward the side
serratus anterior contraction
What muscles of the glenohumeral joint function in:
Abduction
Adduction
Flexsion
Extension
External Rotation
Internal Rotation
Abduction - Supraspinatus, middle portion of the deltoid

Adduction - Pectoralis major, latissimus dorsi, teres major, subscapularis

Flexsion - Coracobrachialis, anterior portion of deltoid

Extension - Posterior deltoid, latissimus dorsi

External rotation - Infraspinatus, teres minor, posterior portion of deltoid

Internal rotation - Subscapularis, teres major, pectoralis major, anterior portion of deltoid
You need to know the muscles for movements of the scapula:
elevation
depression
protraction
retraction
upward rotation
downward rotation
Elevation - Trapezius (superior part), levator scapula, rhomboids

Depression - Gravity, pectoralis major (inferior sternocostal head, latissimus dorsi, trapezius (inferior part)

Protraction - Serratus anterior, pectoralis minor, pectoralis major

Retraction - Trapezius (middle portion), rhomboids, latissimus dorsi

Upward Rotation - Trapezius (superior part), serratus anterior (inferior part), trapezius (inferior part)

Downward rotation - Latissimus dorsi, gravity, pectoralis major
Know the different locations of the C1 tender points
Anterior C1
1. tip of C1 transverse process
2. posterior mandible angle
Don’t forget about anterior C7 and C8 Yx
Anterior C7 - lateral sternocleidomatoid muscle
just superior to clavicle

Anterior C8 - just superior to medial clavicle
Posterior C2-C7 and anterior C2-6 and C8 Tx
Posterior C2-C7: midline spinous processes and lateral at articular pillar at facet joint.

Tx: SARA (sidebend away rotate away)
Anterior C7 Tx
STAR (sidebend toward away rotate)
Review the treatment set up for rotation and sidebending muscle energy treatments in the cervical spine
Sidebending: Rotate the head away from sidebending restriction.
Asj pt to sidebend head away from restriction

Rotation: Sidebend head away from rotation restriction
Ask pt to rotate head away from the restriction
Review treatments for elevated first ribs
Rib 1 counterstrain:
TP is on shaft of 1st rib at the lower neck just anterior to the upper trapezius muscle. Place foot on table and sidebend the head toward the tenderpoint

Rib 1 Articulatory:
hold pts head with one hand and place the 1st MCP joint of your other hand on the posterior aspect of the elevated rib, push inferiorly and mediallywhile you articulate around the joint.
There are 3 different Muscle energys for rib 1, what are they?
Supine - push rib anteromedial and inferior as you sidebend the head around your MCP jt and rotate the head to the opposite side**

Prone - reach across the pt as she lay prone and use your thenar eminence on the post aspect of the elevated rib, push toward ASIS on SAME side. Sidebend head away

Seated: place 1st MCP jt on the rib and lean pt on your knee, push anteromedial and inferior, sidebend the head toward the elevated rib and apply short thrust toward the opposite axilla.