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OMM Study Guide •
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Frayette’s principles 1. When SB from neutral neutral position position,, rotation rotation of vertebral vertebral bodies bodies follows to opposit oppositee direction; direction; SB precedes precedes rotation. rotation. 2. When SB is attempte attemptedd from non-ne non-neutral utral (F!" (F!" position position rotati rotation on precedes precedes SB SB to same side side #pplies to a sin$le vertebrae %otation of vertebrae towards the concavit& of the curve 'raumatic ori$in . )otion )otion in one one plane plane limits limits and modifies modifies motion motion in another another plane Techniques Techniques (consider level of aggression for different diagnoses requiring gentle techniques) )&ofascial release * direct is en$a$in$ soft tissue restrictive barrier with constant force until release; indirect is findin$ point of balance o +ounterstrain * monitor ', ', find position of ease, hold for seconds (12 for ribs", passivel& return to neutral, pain should be / 1. Still techni0ue * tae oint into direction of ease (indirect" until tissues rela3, add compression, $uide throu$h to barrier (direct" o F% * add a compressive force (uses torsion in lumbar", $uide oint into its direction of freedom, hold for -4 seconds, return to neutral. o )! (indirect )! uses reciprocal inhibition, e.$. when tricep is contracted, bicep rela3es" o #rticulation (tain$ a oint throu$h full %5) with focus on d&sfunctional barrier" o Sprin$in$ (barrier en$a$ed repeatedl& with )6)#" o Soft tissue (linear stretchin$ andor deep pressure to facilitate muscular and fascial rela3ation" o 768# o 9nhibition o 5steopath& in cranial field o 8&mphatic treatment (do not use pedal pump in cardiac respirator& patient" o Chronic SD versus acute SD Chronic Acute Somato-visceral effects )inimal somato-visceral effects :ull ache or pain #cute pain, severe, cuttin$, sharp +ool +ool,, pal pale, e, dr& dr&, scal scal&&, itch itch&&, ble blemi mish shed ed sin; sin; folli follicu culit litis is Warm Warm,, moi moist st,, infl inflam amed ed si sinn %e$ional s&mpathetic vasoconstriction 8ocal vasodilation (s&mpathetics cause constriction, but brad&inins overpower, causin$ dilation" :ecreased mu muscle to tone; contracture; flflaccid )uscle spasm 8imited %5) due to contracture %5) slu$$ish but normal :ou$h&, strin$&, fibrotic tissue Bo$$& edematous soft tissue Chapman’s Refle Tender !oints :efinition predictable anterior and posterior fascial tissue te3ture abnormalities assumed to be reflections reflections of visceral disease o #nterior used for dia$nosis osterior used for treatment Small, smooth, firm, discrete, painful nodule, appro3imatel& 2-mm in diameter o 'reatment rub in a firm circular motion for < 1- 1- sec o )&ocardial o nd #nterior 2 intercostal space close to the sternum osterior )idwa& bw the S and the tips of the ' of '2 and ' %espirator& o Bronchial nd #nterior 2 intercostal space close to the sternum at '2 osterior )idwa& bw S and the tips of the ' at =pper lun$ rd #nterior intercostal space close to the sternum osterior )idwa& bw the S and the tips of the ' of ' and '> 8ower lun$ th #nterior > intercostal space close to the sternum o
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osterior )idwa& bw the S and the tips of the ' of '> and '4 )&ocardium, bronchus, esopha$us, and th&roid can all be found anteriorl& between ribs 2 ? @9 ? @= 8iver 4th and A th 9+S on the ri$ht @allbladder Ath 9+S on the ri$ht Stomach acid 4th 9+S on the left Stomach peristalsis Ath 9+S on the left ancreas th #nterior 9+S on the ri$ht osterior Bw ' of ' and 'C ri$ht Spleen th 9+S on the left #drenal $lands #nterior 1 inch lateral and 2 inches superior to the umbilicus ipsilaterall& osterior )idwa& bw the S and the tips of the ' of '11 and '12 (also +hapman refle3 for h&pertension" Didne&s #nterior 1 inch lateral and 1 inch superior to umbilicus ipsilaterall& osterior midwa& bw S and ' tips of '12 and 81 Bladder #nterior =mbilical area osterior midwa& bw S and ' tips of 81 and 82 #ppendi3 'ip of 12th rib on the ri$ht +olon- iliotibial band, as illustrated below =rethra m&ofascial tissues alon$ the superior mar$in of the pubic ramus about 2cm lateral to the s&mph&sis rostate m&ofascial tissues alon$ the posterior mar$in of the iliotibial band
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Counterstrain points +ervical o osterior +1 inion fle3, +1-+ e3tend and S#%#, e3cept + E fle3 and S'%#W #nterior +1 rotate awa&, +2-+C fle3 and S#%#, e3cept + E fle3 and S'%#W
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'horacic #'1 ape3 of sternal notch 2
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%ibs
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#'2 middle of the manubrium #'-#'A on the sternum at the same numbered costal level #' under the costalchondral mar$in, lateral, and inferior to the 3iphoid process #'C appro3imatel& cm below the 3iphoid process #' 1-2 cm above the umbilicus, 2- cm lateral to the midline #'1 1-2 cm below the umbilicus, 2- cm lateral to the midline #'11 4-A cm below the umbilicus, 2- cm lateral to the midline #'12 inner surface of the iliac crest at the mida3illar& line osterior thoracic ' on spinous or transverse process of correspondin$ vertebra #nterior * associated with depressed ribs #%1 First rib where it articulates with the manubrium #%2 Second rib in the midclavicular line #%-A 5n correspondin$ rib, in the anterior a3illar& line osterior * associated with elevated ribs %1-A an$le of correspondin$ rib
9n$uinal 'ender point located on the lateral border of the pubic bone near the attachment of the in$uinal li$ament 9liolumbar 'ender point located 1 inch superior and medial from the inferior mar$in of the S9S in the iliolumbar li$ament iriformis 'ender point located halfwa& from the S9S*98# midpoint to the $reater trochanter.
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Cervical :&sfunction o )ost clinicall& si$nificant S: of newborns is cond&lar compression #ffects + , 1, and 11; can cause poor feedin$, swallowin$, emesis, hiccups, torticollis, and perhaps p&loric stenosis +ervical spond&losis #n&losis of adacent vertebral bodies :e$eneration of intervertebral disc (deh&dration and shrina$e" resents as chronic nec pain, radicular pain, and decreased %5). #ffected contents of cervical canal (m&elopath& and radiculopath&" present with distal motor, sensor&, and proprioceptive loss. +ervical disc herniation ainful, stiff nec BB and sidebendin$ to side of herniation relieves pain b& eepin$ nucleus pulposus from neural structures )ost adverse effects of 5)' occur with e3cessive a3ial rotations in 768# Special testin$ o Spurlin$ * e3tend and sidebend nec, add compression. 'est for narrowin$ of foramina. ositive if pain radiates to ipsilateral arm. =nderbur$ * e3tend and rotate nec in supine position. 'est for vertebral insufficienc&. ositive with diGGiness, nausea, n&sta$mus.
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Thoracic %ule of s o '1- → S in the same plane as the '6 '>-A → S H between the '6 above and below '- → S at the plane of the '6 below '1 → follows - '11 → follows >-A 3
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'12 → follows 1- )otion %otationI SBI Fle3ionI !3tension Scoliosis )ild "#$" de$rees, moderate %&#'" de$rees, severe "& de$rees. 9diopathic ori$in most common. 'horaco-lumbar double curve most common. +urve is named for direction of conve3it& (left curve has ape3 on left"
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)otion ump 7andle * ribs 1-4 9nhalation anterior aspect of the rib moves cephalad 9ncrease in # diameter of the thora3 )otion predominantl& in sa$ittal plane Best palpated at midclavicular line #3is of motion is costovertebral-costotransverse line (see below" Bucet 7andle * ribs A-1 %ibs move laterall& and increase transverse diameter with inhalation )otion predominantl& in coronal plane Best palpated at mida3illar& line #3is of motion is costovertebral-costosternal line (see below" 9nhalation lateral aspect of the rib moves cephalad +aliper * ribs 11-12 %ibs e3ternall& rotate with inhalation )otion predominantl& in transverse plane Best palpated -4cm lateral to transverse process #3is of motion in vertical line (see below"
Pump handle o
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Bucket handle
Caliper
:&sfunctions !3halation d&sfunction lies to e3hale, difficult inspiration, found in pneumonia 'reat rib at bottom of space but top of $roup 9nhalation d&sfunction lies to inhale, difficult e3halation, found in +5: 'reat rib at top of space and bottom of $roup )uscles to use in rib )! %ib 1 #nterior ? )iddle Scalenes %ib 2 osterior Scalene %ibs -4 ectoralis )inor %ibs A-C Serratus anterior %ibs -11 8atissimus dorsi %ib 12 Juadratus lumborum
*pper etremity Shoulder mechanics o Scapulohumeral ratio * 21. For ever& 2 de$rees of humeral abduction, scapula rotates 1. rovocative testin$ o eer * rapid fle3ion of shoulder with arm e3tended. 'ests for subacromial impin$ement. 4
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7awins * rapid internal rotation of arm with shoulderelbow fle3ed at de$rees. 'ests for suprahumeral impin$ement. :rop arm test * drop arm at patientKs side. 'ests for subacromial impin$ement, rotator cuff problems (mainl& supraspinatus". #ppl&Ks scratch * internal rotation and adduction to touch opposite scapula. 'ests for adhesive capsulitis (mainl& anteriorl&" Ler$asonKs test * e3ternal rotation of arm with elbow fle3ed at de$rees. 'ests for instabilit& of biceps tendon in bicipital $roove. !rb-:uchenneKs als& 9nur& to the upper part of the cord, at the root level of +4 and +A, usuall& associated with birth trauma. aral&sis of deltoid, e3ternal rotators, biceps, brachioradialis and supinator %adial nerve inur& +aused b& mid-shaft fracture of humerus; MSaturda& ni$ht pals&N Dnocs out wrist e3tension !picond&litis @olferKs elbow - strain of the fle3or muscles near the medial epicond&le 'ennis elbow - strain of the e3tensor muscles near the lateral epicond&le (use counterstrain in old people" +oGenKs test (for lateral epicond&litis" - holdin$ pronated fist out and tr&in$ to e3tend and internall& rotate it. =lnar mechanics 9ncreased carr&in$ an$le with abducted ulna * cubitus val$us :ecreased carr&in$ an$le with adducted ulna * cubitus varus arallelo$ram effect 9ncreased carr&in$ an$le will cause adduction of wrist :ecreased carr&in$ an$le will cause abduction of wrist %adial mechanics )oves anterior with supination (from fall bacward" )oves posterior with pronation (from fall forward"
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'5S testin$ #dsonKs test nec e3tended, turned toward affected side arrows interscalene space +hecs patenc& of ipsilateral arter& passin$ between scalene trian$le ositive with decreasedabsent radial pulse 7alstead maneuver e3a$$erated militar& posture (scapula retracted and depressed" arrows costoclavicular space Wri$htKs maneuver shoulder e3ternal rotation, abduction be&ond de$rees +ompressed below pectoralis minor insertion Wrist testin$ +arpal tunnel tests + halenKs - Wrist fle3ion to ma3imum for A sec. 'est for +'S. ra&erKs - %everse of halenKs. 'est for +'S. 'inelKs - 'appin$ over transverse carpal li$ament. 'est for +'S. rovocation 'est - +ompress and hold over transverse carpal li$ament. 'est for +'S. erve conduction studies are the $old standard of dia$nosis 7&poth&roidism, pre$nanc&, and dial&sis-associated am&loidosis can mimic +'S. FinelsteinKs * ut thumb in palm and close fist, then ulnar-deviate wrist. 'ests for :eJuervainKs tenos&novitis. 5
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9nflammation of e3tensor pollicis brevis and abductor pollicis lon$us
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,umar )otion o Sa$ittal plane orientation of the facets #llows fle3ione3tensionISBIrotation Fer$usonKs #n$le * 4 de$rees (normal is ->" atholo$& o #nterior trian$le is an area of weaness and common site of compression fracture SacraliGation * 84 fuses to sacrum (batwin$ deformit&" 8umbariGation * S1 becomes A th lumbar vertebra. :isc hernation is common due to narrow posterior lon$itudinal li$ament 8>-84 and 84-S1 are most common levels. 7ernation at disc O will affect root OP1. 84sacral rule o 84 sidebends to the same side as the obli0ue a3is 84 rotates to the opposite side of sacrum eutral mechanics 858 or %5% forward torsions on-neutral mechanics %58 or 85% bacward torsions =nilateral fle3ion or e3tension produces no 84 chan$e
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Sacral #3es o Superior #bove S2, the cranial primar& respirator& mechanism creates motion around this a3is )iddle #t S2, forward and bacward bendin$ 9nferior Below S2, rotation of the innominates )otion with $ait o 8umbar spine sidebends towards wei$ht-bearin$ le$ #nterior rotation of wei$ht-bearin$ ilium; posterior rotation of le$ swin$in$ forward #n obli0ue sacral a3is is induced on side of wei$ht-bearin$ le$, and rotation in same direction. !3ample as left le$ bears wei$ht and ri$ht swin$s forward, S,RR motion occurs in lumbar spine, left innominate moves anterior, and sacrum rotates left on its left ais. Sacral tests o Seated fle3ion test 8ateraliGes sacrolumbar and sacroiliac d&sfunctions and eli minates lower e3tremit& 'ests motion between innominates and sacrum ositive test is side which moves first and farthest Standin$ fle3ion test 9dentifies side of iliosacral d&sfunction with positive side movin$ farthest and lon$est 9liosacral d&sfunction landmars #S9S - assess overall position of ilium S9S - assess overall position of ilium ubic tubercles * hi$her in superior innominate and superior pubic shear )edial )alleoli - hi$her in posterior rotation and superior innominate Sacral sulcus * $oin$ to be deep on side of posterior rotation; narrow i n outflare. Sacrotuberous li$ament * la3 in innominate thatKs superior (ischium closer to sacrum" Dnee pain ti$ht sartorius * posterior rotation osterior thi$h pain ti$ht hamstrin$s * anterior rotation Sacral d&sfunction landmars Sacral Base * assesses overall position of sacrum 9nferior 8ateral #n$le (98#" * assesses overall position of sacrum Sacral Sulcus * deep with anterior base 6
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Sacrotuberous li$ament * ti$ht with posterior 98# (awa& from ischium" Sprin$ test +hec if sacral base has moved posterior ositive if there is 5 movement (lie in a bacward torsion" Sphin3 test +hec if sacral base has moved posterior ositive if thumbs on sacral base become more as&mmetric when patient e3tends (posterior part resists movin$ anterior" ositive in unilateral sacral e3tension and bacward torsions (85% and %58"
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,o-er etremity euro testin$ o 8> foot inversion (tibialis anterior", patellar refle3, medial foot sensation 84 $reat toe e3tension (e3tensor hallicus lon$us", dorsum foot sensation, facilitates walin$ on heels S1 foot eversion (peroneus lon$us and brevis", #chilles refle3, lateral foot sensation, facilitates walin$ on toes Babinsi positive if toes (or bi$ toe" e3tend - =) lesion )otion testin$ o 5berKs 'est - #ssessment for contracture of iliotibial band or tensor fascia latae With nee fle3ed, e3tend hip and $entl& allow thi$h to adduct toward table +onsidered positive if thi$h cannot adduct past midline Strai$ht 8e$ %aise 'est - #ssessment for sciatic nerve compression ormal strai$ht le$ raise is QR Deepin$ nee e3tended, fle3 hip until pt reports pain +onsidered abnormal if cannot fle3 past R 8ase$ueKs 'est * differentiates between hamstrin$ and sciatic pain in strai$ht le$ raise 5nce pain is reported, e3tend hip about 4R and dorsifle3 foot 'his removes hamstrin$ pain while addin$ stress onto sciatic n. 'homas 'est - #ssessment for fle3ion contracture of hip (usuall& due to contralateral restricted or shortened iliopsoas muscle" Fle3 one thi$h up to abdomen +onsidered positive if opposite nee lifts off table 'rendelenbur$ 'est - #ssessment of $luteus medius muscle stren$th t stands on one foot while fle3in$ opposite nee @luteus medius on opposite side of fle3ed nee should eep pelvis level +onsidered positive if pelvis tilts toward side of fle3ed nee )c)urra& 'est * #ssessment for meniscal tears 7ip and nee both fle3ed to R )edial meniscus test - e3ternal rotation of foot with val$us stress on nee, followed b& e3tension. 8ateral meniscus test - internal rotation of foot with varus stress on nee, followed b& e3tension. 8i$ament testin$ 6al$us stress - #ssess stabilit& of )+8 6arus stress - #ssess stabilit& of 8+8 #nterior :rawer 'est - 9nte$rit& assessment of #+8 7
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osterior :rawer 'est - 9nte$rit& assessment of +8 :&sfunctions 'errible triad +ompromise of #+8, )+8, and lateral meniscus. +ommonl& induced b& val$us force on the nee Fibular 7ead d&sfunctions :!# dorsifle3ed, everted, e3ternall& rotated * anterior fibular head (distal talofibular oint posterior" 9 plantarfle3ed inverted, internall& rotated * posterior fibular head (distal talofibular oint anterior" 'reat with opposite for direct #nle sprains C are inversion sprains; produce posterior fibular head '&pe 9 * anterior talofibular li$ament '&pe 99 - anterior talofibular li$ament, calcaneofibular li$ament '&pe 999 - anterior talofibular li$ament, calcaneofibular li$ament, posterior talofibular li$ament Foot d&sfunctions es planus - 8on$itudinal ? transverse arches fall es cavus - #rches rise soas s&ndrome pelvis shift to the opposite side non-neutral d&sfunction of 81 andor 82 - fle3ed and rotated to same side as the spasm obli0ue a3is sacral d&sfunction - a3is is same side as the spasm spasm of the opposite piriformis resultin$ in sciatic irritation $luteal and posterior thi$h pain
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Sympathetic innervation '1-> * head and nec o '1-A * heart and lun$s, visceral pleura o '1-11 * parietal pleura o '2-C * =!, esopha$us o '4- * stomach, duodenum, liver, $all bladder, pancreas, spleen o '1-11 * small intestine, idne&, $onads, upper ureter, ascendin$ and pro3imal 2 of transverse colon o '11-82 - 8! o '12-82 * lower ureter, left 1 of transverse, descendin$, and si$moid colon, rectum, pelvic or$ans o Cranial ones aired bones * frontal, palatine, ma3illa, mandible. aired bones $o into internale3ternal rotation. o =npaired bones * sacrum, occiput, sphenoid, ethmoid, vomer. =npaired bones fle3 and e3tend. o !rimary respiratory mechanism (!R.) interdependent functions amon$ five bod& components 1. Wave-lie movement of +S (supposedl& due to oli$odendro$lia contraction" o 2. Fluctuation of +SF, with $radient for release b& choroid ple3us and draina$e into veins produced b& %) o . )obilit& of cranial and spinal dura responds to 1 and 2, and influences bones of cranium and sacrum. o >. +ranial sutures allow motions o Serrate (sawtooth" * rocin$ motion S0uamous (scale-lie" * $lidin$ motion 7armonious (ed$e-to-ed$e" * shearin$ motion 4. 9nvoluntar& rocin$ of sacrum between ilia, on superior transverse a3is throu$h articular pillar of S2. o Cranial rhythmic impulse (CR/) fluctuation s&nchronous with %) %ate of 1-1>min (pt with depression would have / 1; treat with bulb decompression+6> techni0ue" o alpable in cranium and sacrum o 9ncreased rate fast metabolism, acute infection o :ecreased rate slow metabolism, chronic infection, fati$ue o 9ncreased amplitude increased 9+ o :ecreased amplitude dural tension, SBS compression o Still point a pause in +%9 o Cranial motion 8
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Sphenobasilar unction is the reference point around which dia$nostic motion patterns are described )idline bones follow fle3ione3tension aired bones follow internale3ternal rotation Sacrum follows the occiput 'emporals follow the occiput Facial bones follow the sphenoid h&siolo$ic motions that occur at SBS (%) motion" Fle3ion )idline bones fle3 aired bones $o throu$h e3ternal rotation :ecreased # diameter of cranium (for some reason" !3tension )idline bones e3tend aired bones $o throu$h internal rotation 9ncreased # diameter of cranium on-patholo$ical strains 'orsion Sphenoid and occiput rotate in opposite directions around # a3is amed for side on which sphenoid win$ is hi$her Sidebendin$ rotation Sphenoid and occiput rotate in opposite directions around individual vertical a3es Both sidebend in direction of SBS deviation on sin$le # a3is amed for direction of sidebendin$ atholo$ical strains 8ateral strain Sphenoid and occiput rotate in same direction around individual vertical a3es amed for direction of deviation of sphenoid base (awa& from occiput" 6ertical strain Sphenoid and occiput rotate in same direction around individual transverse a3es amed for direction of sphenoid movement (fle3ion E superior vertical strain" Sphenobasilar compression :iminished +%9
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