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CORE OMM Curriculum Board Review. Developed for OUCOM CORE By: Janet Burns, D.O. Edited by: James Preston, D.O., Clay Walsh, D.O., and the CORE Osteopathic Principles and Practices Committee Series A, B, & C - Session #5. Overview.

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CORE OMM Curriculum

Board Review

Developed for OUCOM CORE

By: Janet Burns, D.O.

Edited by: James Preston, D.O.,

Clay Walsh, D.O., and the

CORE Osteopathic Principles and Practices Committee

Series A, B, & C - Session #5


Overview

  • It is not the intention of this review to be comprehensive or exhaustive; that is best left to the several OMM board review books available.

  • The best use of your limited time is on high yield subject areas.

  • Current CORE residents provided the following recommendations for areas to focus on:


Suggested areas of study

1. Memorize Chapman’s Reflexes

2. Dx and Tx of Sacral Dysfunctions via Muscle Energy model

3. Know the difference between Direct and Indirect techniques

4. Know contraindications to certain techniques

SuggestedAreas of Study


Suggested areas of study continued

5. Memorize Viscerosomatic reflex levels

6. Memorize steps to Spencer Technique

7. Diagnosis and treatment of somatic dysfunction in: cervical, thoracic, lumbar spine, sacrum, pelvis, ribs, and extremities; utilizing Direct and Indirect approaches

Suggested Areas of Study - continued…


Board review web sites

OMM Board Review, John D. Capobianco, D.O., F.A.A.O.

http://www.md-do.org/NewOMMBoard%20Review02-REV.htm

- A free 32 page outline format review. Excellent for last minute studying; includes mnemonics for recall, clinical correlations, functionally relevant anatomy. Highly recommended.

60 multiple choice questions with key http://www.mommd.com/comlexsample.shtml

- Free, good questions, but are not labeled as to whether they are

Level I, II, or III

Board Review Web Sites


Board review resources

OMT Review 3rd edition - A Comprehensive Review in Osteopathic Medicine; Robert G. Savarese, D.O., 2003

- $36 Suitable for Levels I - III, has updated COMLEX-style questions, includes a lot more relevant anatomy than previousedition.

There are a few errors, if you own this book go to:

http://www.omtreview.com/errata.htm

Board Review Resources


Omm terminology

Major Resource for appropriate terminology:

OMM Terminology

Found in the back of Foundations for Osteopathic Medicine, 2nd Ed.



Barriers

Physiologic – limit of active motion

Anatomic – limit of passive motion

Elastic – range between physiologic and anatomic motion

Restrictive – limit within anatomic range which decreases Physiologic range

Pathologic – permanent restrictive barrier associated with pathologic change in tissue

Barriers



Somatic dysfunction

Definition – impaired of altered function of related components of the somatic system: skeletal, arthrodial and myofascial structures and related vascular, lymphatic and neural elements.

Somatic Dysfunction


Naming diagnosing somatic dysfunction

All somatic dysfunctions are named according to the POSITION of the dysfunctional structural element.

The POSITION of the structural element EQUALS the EASE OF MOTION of that structural element.

Therefore RESTRICTION OF MOTION of the structural element is OPPOSITE the POSTION diagnosis

Naming/Diagnosing Somatic Dysfunction


Somatic dysfunction physical findings

(T) A. R. T.

T – Tissue Texture changes

A – Asymmetry

R – Range of Motion (ROM)

(T) – Tenderness

CARDINAL INDICATOR – R.O.M.

Somatic Dysfunction: Physical Findings


Somatic dysfunction acute

AcuteChronic

Temperature increased cool

Texture boggy, rough doughy, thin

Moisture increased decreased

Tension increased sl. increased

Tenderness Increased less tender

Edema yes no

Erythema yes, stays fades quick

Somatic Dysfunction: Acute


Contraction

Concentric – shortening of muscle during contraction

Eccentric – lengthening of muscle during contraction

Isolytic – contraction while forcing to lengthening; operator>patient

Isometric – inc. tension, length constant; operator= patient

Isotonic – approximation without change in tension: operator<patient

Contraction


Transverse: Shoulder to shoulder

Anterior-Posterior: Front to back

Longitudinal: (Vertical) Head to toe

Axes


Planes

Transverse: Separates top from bottom

Sagittal: Separates left from right

Coronal: Separates front from back

Planes


Flexion

Def. – ends of arc approximate

Sacral – base anterior

Craniosacral –sacrum counter nutates (base posterior); sphenobasilar ascends

Regional – cervical, thoracic, lumbar

Flexion


Sacral flexion
Sacral Flexion

Foundations for Osteopathic Medicine, 1st Ed., pp. 1130


Extension

Def. – ends of arc move apart

Sacral – base posterior

Craniosacral – sacrum nutates (base forward) sphenobasilar descends

Regional – cervical, thoracic, lumbar

Extension


Sacral extension
Sacral Extension

Foundations for Osteopathic Medicine, 1st Ed., pp. 1130


Fryette s principles

Rules apply to thoracic and lumbar spine only

Fryette’s I – with spine in neutral side – bending and rotation are opposite

Fryette’s II – with spine hyperflexed or hyperextended sidebending and rotation are to the same side.

Fryette’s III – motion in any plane of motion modifies motion in all other planes of motion.

Fryette’s Principles


Thoracic mechanics

Non-neutral Mechanics

Type II Rotation Before SB

Non-neutral Mechanics

Type II Rotation Before SB

Thoracic Mechanics

Kimberly Manual, millennium edition, pp. 11-12


Facilitation

Definition – area of impairment or restriction that develops a lower threshold for irritation and dysfunction when other areas are stimulated.

Reflex hyper-excitability

Hyper-irritable

Hyper-responsive

Facilitation


Spinal motion

OA – Type I only with flexion/extension

AA – Rotation only

C2 – C7 – Type II only

Thoracic – Type I and Type II

Lumbar – Type I and Type II

Spinal Motion


Gravitational line

External auditory meatus

Lateral head of humerus

Third lumbar vertebrae (center)

Greater trochanter

Lateral condyle of knee

Lateral malleolus

Gravitational Line


Gravitational line1
Gravitational Line

Foundations for Osteopathic Medicine, 1st Ed., pp. 1131


Iliosacral somatic dysfunctions

Movement of ilium on sacrum

Standing Flexion test

Landmarks: ASIS, PSIS

Anterior rotation – ASIS down, PSIS up

Posterior rotation – ASIS up, PSIS down

Inflare – ASIS in

Outflare – ASIS out

Inferior shear – ASIS down, PSIS down

Superior shear – ASIS up, PSIS up

Iliosacral Somatic Dysfunctions





Sacral somatic dysfunctions

Extension – unilateral and bilateral

Flexion – unilateral and bilateral

Forward Torsions – L on L, R on R (rotation on an axis)

Backward Torsions – L on R, R on L

Sacral Shear

Anterior Sacrum (translated)

Posterior Sacrum (translated)

Sacral Somatic Dysfunctions


Sacral torsions
Sacral Torsions

Seated Flexion Test

Axis (Oblique)

Superficial Sulcus Right

Superficial Sulcus Left

------------------------

------------------------

------------------------

------------------------

Positive Right

Left

Right on Left

Left on Left

(L5)

L5 Left Rotation

L5 Right Rotation

(Sacral bending)

Backward

Forward

------------------------

------------------------

------------------------

------------------------

Positive Left

Right

Right on Right

Left on Right

(L5)

L5 Left Rotation

L5 Right Rotation

(Sacral bending)

Forward

Backward


Pubic somatic dysfunction

Motion of pubic symphysis

Landmarks: pubic bone

Dysfunctions – superior, inferior

Pubic Somatic Dysfunction



Sacral somatic dysfunctions1

Seated flexion test

Sphinx test (lumbar extension)

Spring test

2 Landmarks – Sacral Sulcus – ILA (inferior lateral angle)

Sacral Somatic Dysfunctions



Sacral motion

7 axes of motion

Vertical – rotation

A/P – sidebending

2 Obliques (diagonals) R and L – torsions

3 Transverse axes – flexion and extension

Superior transverse - respiratory axis

Middle transverse - postural axis

Inferior Transverse – Innominate rotation axis

Sacral Motion


Sacral axes
Sacral Axes

1 Longitudinal axis

1 Anterior-posterior axis

2 Oblique axes

  • Right and Left

    3 Transverse axes

  • Superior, Middle, and Inferior

DiGiovanna, 3rd Ed, p. 287


Sacral axes1
Sacral Axes

  • 3 Transverse Axes

    • Superior: Respiratory axis

      • Motion relative to the pull of the dura occurs around this axis

    • Middle: Postural axis

      • Bilateral Flexion & Extension occur around this axis (motion during flexion/extension of spine)

    • Inferior: Innominate rotation axis

DiGiovanna, 3rd Ed, p. 287


Me sacral diagnosis tips

Similar to algebra, you will be expected to solve the equation for the unknown, you need to know the “rules” and algorhythms:

(+) Spring or Sphinx (prone backward bending) tests reflect an extended sacral base (unilateral or bilateral extensions or backward torsions)

Sacral torsion “rules” of L5 on S1

Sacrum rotates opposite L5

When L5 is sidebent, it forms an oblique axis on that side

The (+) seated flexion test is found on the side opposite the oblique axis

Forward Torsions occur in Neutral (Type 1) mechanics

Backward torsions occur in Non-neutral (Type 2) mechanics

ME Sacral Diagnosis -Tips


Me sacral diagnosis tips1

Using these rules, if you are given L5 FrSr: equation for the unknown, you need to know the “rules” and algorhythms:

There will be a (+) flexion test on L, sacrum rotated L on R oblique axis

You then extrapolate that this is a backward torsion (because forward torsions are named same on same, i.e. L on L, Backward torsions are vice versa)

Therefore the Spring or Sphinx tests would be (+) reflecting the extended (posterior) sacral base on the L

Deep Sulcus (DS) is therefore on the R, Posterior /Inferior ILA is on the L

ME Sacral Diagnosis -Tips


Forward torsions review
Forward Torsions - Review equation for the unknown, you need to know the “rules” and algorhythms:

  • Findings for Left on Left:

    • (+) Standing flexion test on R

    • Deep sacral sulcus (DS) on R

    • Posterior/Inferior ILA on L

    • (-) Spring / Sphinx Test

    • Sacrotuberous Ligament taut on the L

Mitchell, The Muscle Energy Manual, Volume III, p. 62


Forward torsions causes

Forward Torsions equation for the unknown, you need to know the “rules” and algorhythms:

Occurs when lumbar spine is in neutral mechanics

Exaggerated ambulation mechanics

Sacrotuberous Ligament is taut on side of Posterior/Inferior ILA

Forward Torsions: Causes


Backward torsions review
Backward Torsions - Review equation for the unknown, you need to know the “rules” and algorhythms:

  • Findings for Right on Left:

    • (+) Standing flexion test on R

    • Deep sacral sulcus (DS) on L

    • Posterior/Inferior ILA on R

    • (+) Spring / Sphinx Test

    • Sacrotuberous Ligament taut on the R

Mitchell, The Muscle Energy Manual, Volume III, p. 62


Backward torsions causes

Backward Torsions equation for the unknown, you need to know the “rules” and algorhythms:

How do these occur?

Physiologically during Non-Neutral Lumbar Mechanics

Is backward torsional motion always dysfunctional?

No, only if it can’t return to neutral

Backward Torsions: Causes


  • Backward Torsion: equation for the unknown, you need to know the “rules” and algorhythms:

  • possible mechanism

  • Mitchell, The Muscle Energy Manual, Volume III, p. 64


L unilateral sacral flexion
L. Unilateral Sacral Flexion equation for the unknown, you need to know the “rules” and algorhythms:

  • L half of Sacrum has moved forward & down relative to R

  • (-) Sphinx test

  • (+) Seated flexion test on L

  • Sacrotuberous lig. taut on L

Mitchell, The Muscle Energy Manual, Volume III, p. 60


Compare
Compare equation for the unknown, you need to know the “rules” and algorhythms:

Mitchell, The Muscle Energy Manual, Volume III, p. 61


Unilateral sacral flexions extensions

Deep Sulcus and Posterior/ Inferior ILA on Same side (i.e. both on L, could be L Flex or R Ext)

What separates a L sacral Flexion from a R sacral Extension is:

the Sphinx test: (-) in flex (+) in ext

or the Seated flexion test (+) R on R Ext, (+) L on L Flex

Some find it easier to think of it as a shear or combination of Sidebending and Rotational strains:

Sidebending and Rotation occur to opposite sides

Caused by unbalanced sacral base loading during trunk sidebending- same mech. that can cause innominate upslip, but trunk is sidebent, not upright

Unilateral Sacral Flexions / Extensions


Bilateral flexion extension
Bilateral Flexion / Extension both on L, could be L Flex or R Ext)

  • Extension Dysfunction

  • PSIS’s level

  • ILA’s level

  • Bilateral shallow (posterior) sacral sulci

  • (+) Spring / Sphinx test (restricted motion)

  • Flexion Dysfunction

  • PSIS’s level

  • ILA’s level

  • Bilateral deep (anterior) sacral sulci

  • (-) Spring / Sphinx test (unrestricted motion)

DiGiovanna, 2nd Ed


Causes of bilateral sacral flexion extension
Causes of Bilateral Sacral both on L, could be L Flex or R Ext)Flexion / Extension

  • Bilateral Sacral Extension

  • Improper lifting techniques

  • Fall in a seated position

Bilateral Sacral Flexion

  • Extremely common postpartum

  • Arched while holding heavy load


Optional activities

Practice Diagnosing and Treating Sacral Dysfunctions according to ME model…

Some Sacral ME treatments commonly found on exams are included in the following slides…

Optional Activities


Me forward torsion left on left

1 of 3 according to ME model…

ME: Forward Torsion – Left on Left

  • Operator flexes the hips to at least 90 degrees, (Non-Neutral) guides the knees to the right side of the table and facilitates lumbo-pelvic rotation right.

  • Pt.: Prone

  • Operator stands on the right side

  • Pt. is instructed to allow knees to be flexed & raise right hip.

Kimberly Manual, p.203-204


Forward torsion left on left

2 of 3 according to ME model…

Forward Torsion – Left on Left

  • Sidebending is introduced by supporting the pt’s. knees on the operator’s thighs and lowering the feet off the table

  • Localized to L-S Junction

  • Pt is instructed to inhale, then reach to the floor with the right upper arm during exhalation while monitoring L5

  • Operator may assist this motion by pushing the shoulder toward the floor to achieve rotation of L5 left

Kimberly Manual, p.203-204


Forward torsion left on left1

3 of 3 according to ME model…

Forward Torsion – Left on Left

  • Operator may additionally contact the spinous process of L5 to encourage rotation of that vertebra to the left.

  • This is usually notnecessary. It is important to monitor the right sacral base simultaneously.

  • Pt. is instructed to lift the feet toward the ceiling against isometric resistance

  • Sufficient force is needed to feel the localization at of the muscle effort to the right sacral base.

  • Hold for 3-5 seconds

  • Relax about 2 seconds, breathe as a reminder!

  • Repeat

  • Retest

Kimberly Manual, p.203-204


Me right on left sacral torsion

1 of 4 according to ME model…

ME: Right on Left SacralTorsion

  • Patient in left lateral recumbent position

  • The right lower extremity is flexed until the vector of force is palpated at the right sacral base by the monitoring fingers

  • The right knee is supported between the operator’s two thighs

Courtesy of David C. Eland, DO,FAAO - OUCOM


Right on left sacral torsion continued

2 of 4 according to ME model…

Right on Left Sacral Torsion - continued

  • The left lower extremity is extended by the operator

    • This encourages sacral base anterior motion

Courtesy of David C. Eland, DO,FAAO - OUCOM


Right on left sacral torsion continued1

3 of 4 according to ME model…

Right on Left Sacral Torsion -continued

  • Trunk rotation to the right is accomplished via a pull through the left upper extremity. - This right rotation is carried down through L5, which, in turn, encourages the right sacral base to move anterior.

  • Continue to support the right knee throughout the procedure

    • This helps maintain the fulcrum for change.

Courtesy of David C. Eland, DO,FAAO - OUCOM


Right on left sacral torsion continued2

4 of 4 according to ME model…

Right on Left Sacral Torsion - continued

-Carry the right ankle toward the floor

-The patient is instructed to try to lift the ankle toward the ceiling – isometric contraction with operator resistance

  • This gaps the sacroiliac and allows the other forces acting upon the sacrum to carry the right base anterior.

    -Relax

    -Reposition ankle & knee according to response noted by monitoring hand

    -Repeat, Retest

Courtesy of David C. Eland, DO,FAAO - OUCOM


L unilateral sacral flexion sacrum sidebent l rotated r me lvma
L. Unilateral Sacral Flexion; according to ME model…(Sacrum Sidebent L Rotated R) ME, LVMA

  • - Patient prone, Doc on side of Dysfunction

  • - ABduct & Int Rot Hip to gap SI Joint, brace with docs body

  • - Apply anterior pressure to Inferior/Posterior ILA to move (DS) baseposteriorly; Cephalad to side bend it Right. Can spring it or use respiratory assist: Pt inhales deeply and holds-should feel Base move posterior

  • Kimberly Manual, p.214


L unilateral sacrum extended lvma
L. Unilateral Sacrum Extended; LVMA according to ME model…

  • Heel of Caudad hand on Inferior Ischial Tuberosity

  • Hypothenar eminence of cephalad hand on Sacral Base

  • Carry Ischial Tuberosity SUPERIORLY

    • This produces an anterior rotation of the innominate to help engage the barrier

  • Carry Sacral Base Anterior and Inferior to barrier

Kimberly Manual, p.214


Me bilateral sacral flexion

1 of 2 according to ME model…

ME: Bilateral Sacral Flexion

  • Pt. Sits with feet & knees apart

  • Operator:

  • Heel of sacral hand contacts below the middle transverse axis

  • Cephalad hand monitors & maintains trunk flexion via contact with the mid to lower thoracic area

  • Kimberly Manual, p.192


Bilateral sacral flexion

2 of 2 according to ME model…

Bilateral Sacral Flexion

  • - Pt. is instructed to ‘push the lumbosacral junction posterior’ while operator maintains isometric counterforce

  • -3-5 second contraction followed by about 2 second relaxation

  • -Repeat

  • -Recheck

Kimberly Manual, p.192


Me bilateral sacrum extended
ME: Bilateral Sacrum Extended according to ME model…

Pt. Positioning Refinement: Pt. Is instructed to arch the back by pushing the abdomen toward the knees

Operator maintains compressive force on sacral base

3-5 repetitions of pt. Attempted trunk flexion (isometric), relax between efforts

Innate Force:

Exhalation assists in

Carrying the sacral

base anterior

  • Pt. Seated on stool

    • Feet together, knees apart, arms crossed

  • Operator:

    • Hand on sacral base

    • Other hand across chest

Greenman, 3rd Ed., p. 383


Atypical – Ribs 1, 2, 10, 11, 12 according to ME model…

Typical – Ribs 3 – 9

Pump handle – upper ribs

Mixed – middle ribs

Bucket handle – lower ribs (to rib 10)

Caliper – Ribs 11 and 12

Ribs




Rib somatic dysfunction

Exhalation Rib according to ME model… – free motion in exhalation other: exhalation strain, depressed rib, anterior rib tenderpoint

Inhalation Rib – free motion in inhalation other: inhalation strain, elevated rib, posterior rib tenderpoint

Rib Somatic Dysfunction




Rule of three s thorax

Refers to the position of a spinous process relative to its vertebral segment level.

T1 – T3 – same level

T4 – T6 – ½ segment below

T7 – T9 – 1 segment below

T10 – 1 segment below

T11 – ½ segment below

T12 – same level

Rule of Three’s (Thorax)


What are chapman s reflexes

A system of predictable anterior and posterior fascial tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

They indicate increased functional activity of the sympathetic nervous system

Thought to reflect visceral dysfunction or pathology

They follow Sympathetic afferent pathways

Do NOTreflect parasympathetic nervous system

Treating them may alter sympathetic influences on the corresponding viscera

What are Chapman’s Reflexes?


Chapman s vs viscerosomatic reflexes
Chapman’s vs. tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:Viscerosomatic Reflexes

  • Similarities

    • Somatic result of a visceral input

    • Will return if underlying problem is not corrected

    • Tx of Somatic Component can improve Visceral homeostasis

  • Differences

    • Chapman’s are neurolymphatic reflexes; viscerosomatic are neural reflexes

    • Chapman’s manifest in the same place all of the time; viscerosomatic manifest within a range of vertebral segments, and of varying intensity


Chapman s reflexes anterior points
Chapman’s Reflexes: tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:Anterior Points

  • Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus OH: Greyden Press: 1994: pp. 232-3.

  • or

  • Ward R. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia: Williams & Wilkins: 2002: pp. 1053-4.


Chapman s reflexes posterior points
Chapman’s Reflexes: tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:Posterior Points

Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus OH: Greyden Press: 1994: pp. 232-3.

or

Ward R. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia: Williams & Wilkins: 2002: pp. 1053-4.


Craniosacral

Discoverer – Sutherland tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

Midline Bones – Flex/Extend

Paired Bones – External/Internal Rotation

Inspiration – Cranial Flexion + Ext. Rotation

Expiration – Cranial Extension + Internal Rotation

CV4 – Gently hold cranial extension forces CSF distally

Still point - Sutherland

Craniosacral


Cranial concept 5 components

The intrinsic motility of the brain and spinal cord tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

The fluctuation of the cerebrospinal fluid

The mobility of the intracranial and intraspinous membrane as functional system known as the reciprocal tension membrane

The sutural mobility of the cranial bones

The involuntary movement of the sacrum between the ilia

Cranial Concept: 5 Components


Foundations for Osteopathic Medicine, 1st Ed. tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:


? tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

Foundations for Osteopathic Medicine, 1st Ed.


Flexion at sbs
Flexion at SBS tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

?

Foundations for Osteopathic Medicine, 1st Ed.


Cranial flexion
Cranial Flexion tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

Flexion Phase: Sphenobasilar symphysis rises pulling the sacral base superior/posterior

Magoun, Osteopathy in the Cranial Field, 3rd Edition, p. 39


Cranial flexion extension
Cranial Flexion/Extension tissue texture abnormalities described in the 1920’s by Frank Chapman, D.O.:

Upledger, Cranial Sacral Therapy


Strain patterns

There are essentially six strain patterns to concern yourself with. They are:

Flexion & Extension

Torsion

Sidebending, Rotation

Vertical Strain

Lateral Strain

Compression

Strain Patterns


Flexion and extension
Flexion and Extension yourself with. They are:

Pratt-Harrington, “Except for OMT”, p 37


Torsion
Torsion yourself with. They are:

Pratt-Harrington, “Except for OMT”, p 38


Sidebending rotation
Sidebending/Rotation yourself with. They are:

Pratt-Harrington, “Except for OMT”, p 39


Vertical strain
Vertical Strain yourself with. They are:

Pratt-Harrington, “Except for OMT”, p 40


Lateral strain
Lateral Strain yourself with. They are:

Pratt-Harrington, “Except for OMT”, p 41


Sbs compression
SBS Compression yourself with. They are:

Foundations for Osteopathic Medicine, 1st Ed.


Direct techniques

HVLA yourself with. They are:

LVLA

Muscle Energy - Mitchell

Direct Techniques


Indirect techniques

Counterstrain – Lawrence Jones yourself with. They are:

Facilitated Positional Release – Schiowitz

Functional Technique

Indirect Techniques


Direct indirect techniques

Myofascial yourself with. They are:

Cranial – Sutherland

Still Technique

Direct/Indirect Techniques


Facilitated positional release

Schiowitz yourself with. They are:

Patient relaxed

Flatten A/P curve

Place in position of ease

Facilitated force – compression, traction, torsion

Hold 3 – 4 seconds

Facilitated Positional Release


Counterstrain

Lawrence Jones, D.O. yourself with. They are:

Patient relaxed

Position of least discomfort (70 % better)

Hold 90 sec. (120 sec. – ribs)

Slowly release

Counterstrain


Contraindications

There is no single definitive reference for these: yourself with. They are:

The Savarese review book has lists that are compiled from major Osteopathic texts including: DiGiovanna, Greenman, Foundations, and Kuchera & Kuchera.

Know the absolute vs. relative contraindications for different techniques, when noted.

Not all techniques have nice, clear-cut lists of relative vs. absolute.

Board questions tend to ask about contraindications that are commonly agreed upon, not the controversial ones.

Contraindications


Contraindications hvla
Contraindications: HVLA yourself with. They are:

  • Absolute

  • Osteoporosis

  • Osteomyelitis, incl. Pott’s Dz

  • Bone Metastasis

  • Fractures in area of thrust

  • Tx of C-Spine in patients w/ severe RA or Down’s Syndrome

    • Weakened ligament of Dens

  • Relative

  • Acute Whiplash

  • Pregnancy

  • Post- surgical conditions

  • Herniated nucleus pulposus

  • Hemophiliacs, anticoagulated patients

  • Vertebral artery ischemia


Contraindications me
Contraindications: ME yourself with. They are:

  • Absolute

  • Fractures & severe neuromuscular injuries to potential Tx sites

  • Inability of patient to cooperate

  • Relative

  • Patients w/ low vitality, who could be further compromised by active muscular exertion:

    • Post surgical

    • ICU /CCU patients

    • These pts may tolerate gentler forms of ME such as reciprocal inhibition


Contraindications counterstrain
Contraindications: Counterstrain yourself with. They are:

  • Absolute

  • Inability to relax muscles

    • Disease

      • Physical

      • Emotional

    • Severe pain

    • Age

    • Drugs

  • Relative

  • Severely debilitated patient

    • Decrease DOSAGE (intensity of treatment)

      • Do less than six points

      • Position for less than maximal relief of TP

  • - Avoid positions of extreme thoracolumbar flexion in osteoporotic patients


Osteopathy in the cranial field indications contraindications

Indirect Action / Exaggeration yourself with. They are:

Commonly used in ages 5 thru adult

NOT used in:

Overriding sutures

In acute head trauma when exaggeration could cause or increase intracranial bleeds

In young children who do not yet have a developed sutural pattern

Osteopathy in the Cranial Field: Indications & Contraindications


Osteopathy in the cranial field indications contraindications1

Direct Action yourself with. They are:

Recommended in ages 5 and under

used in:

Overriding sutures

In acute head trauma when exaggeration could cause or increase intracranial bleeds

In young children who don’t have a developed sutural pattern yet

NOT used when it could cause or increase intracranial bleeds, or tissue trauma.

Osteopathy in the Cranial Field: Indications & Contraindications


Osteopathy in the cranial field contraindications
Osteopathy in the Cranial Field: Contraindications: yourself with. They are:

  • Absolute

  • Acuteintracranial bleed

  • Increased intracranial pressure

  • Skull fracture

  • Relative

  • Traumatic brain injury

  • In patients with Hx of seizures or dystonia, great care must be used in order to not exacerbate any neurological Sx


Contraindications articulatory techniques springing low velocity moderate amplitude lvma

Contraindications: yourself with. They are:

Acutely inflamed joints, especially if due to infection or fracture

Recent surgery to Tx area

Repeated hyper-rotation of an extended upper Cervical spine may damage the Vertebral Art.

Contraindications - Articulatory Techniques: Springing, Low Velocity/Moderate Amplitude (LVMA)


Contraindications facilitated positional release fpr

None listed in Savarese or the FPR chapter in Foundations 2 yourself with. They are:nd ed..

If it shows up on boards, apply fundamental principles to reason it out:

It uses compression (usually) or distraction as its activating force; after putting patient in position of ease

Think of things that can’t tolerate compression, i.e. injured discs, etc.

Therefore it would not be the Tx of choice in an acute whiplash injury

Contraindications: Facilitated Positional Release (FPR)


Contraindications myofascial release

No absolute vs. relative, no discussion found about yourself with. They are:

Direct vs. Indirect contraindications

In general:

Nearby surgical wound or infection

Fracture

Specific Contraindications to Celiac, Inf., & Sup. Mesenteric Ganglia releases:

Aortic Aneurysm

Nearby surgical wound

Contraindications: Myofascial Release


Contraindications lymphatic techniques

No clear distinction currently made between Relative and Absolute.

The term “Absolute” is therefore generally not used with regard to Lymphatic Treatment.

Be aware of the difference between Lymphatic “Pump” and other lymphatic techniques.

Contraindications: Lymphatic Techniques


Contraindications lymphatics

There are many different kinds of Lymphatic Techniques; rather than try to memorize a separate contraindication list for every one, it is simpler to think about what category a specific technique falls under.

i.e., rib raising is a direct Articulatory technique and therefore shares the same list of contraindications

redoming the diaphragm shares those of the other direct myofascial release techniques

Contraindications: Lymphatics


Relative contraindications lymphatic pump tx

Fractures rather than try to memorize a separate contraindication list for every one, it is simpler to think about what category a specific technique falls under.

Bacterial infections with a temp > 102o F

Abscesses or localized infection

Thromboses

Fragility of nearby organs

Certain stages of Carcinoma, or Malignancy of Lymphatic System

Controversial Area

No clinical evidence to support this as a contraindication

Relative Contraindications: Lymphatic Pump Tx


Relative contraindications lymphatic tx

Physiologically, there is a difference between: rather than try to memorize a separate contraindication list for every one, it is simpler to think about what category a specific technique falls under.

Merely restoring normal motion and function to the components of the lymphatic system i.e. diaphragm/ fascial release and

Actively pumping lymph around, augmenting its flow, i.e. pedal, abdominal, or thoracic pumps.

For sake of boards, on a lymphatic contraindication question, it’s safest to go with malignancy as a contraindication;

unlessthey make you choose between several types of lymphatic tech., in which case techniques in category # 2 would be “more contraindicated” than techniques in # 1.

Relative Contraindications: Lymphatic Tx


A t still

1828 – 1917 rather than try to memorize a separate contraindication list for every one, it is simpler to think about what category a specific technique falls under.

1874 – announced osteopathic tenets

1892 – established first school

A. T. Still


Seven stages of spencer

Purpose: improve glenohumeral joint restrictions rather than try to memorize a separate contraindication list for every one, it is simpler to think about what category a specific technique falls under.

Some schools include a warm-up sequence with the Spencer Technique. For the sake of boards, the warm-up exercises do not officially count toward the 7 stages.

Seven Stages of Spencer


Seven stages of spencer1

Spencer Technique has undergone modification; may be done passively or Muscle Energy Techniques may be used at each of the restrictive barriers.

Depending on reference, the stages may be labeled differently (i.e. I, II, III, IVa, IVb) however, the basic sequence is still the same.

Seven Stages of Spencer


Seven stages of spencer2

I: Shoulder Abduction with traction /compression passively or Muscle Energy Techniques may be used at each of the restrictive barriers.

II: Extension / Flexion (elbow bent)

III: Flexion / Extension (elbow straight)

IVa: Circumduction w/ Compression (elbow bent)

IVb: Circumduction w/ Traction (elbow straight)

V: Adduction & Ext Rotation (elbow bent)

VI: Abduction & Int. Rotation – Arm behind back

VII: Repeat Stage I

Seven Stages of Spencer

Ward R. Foundations for Osteopathic Medicine. 2nd ed. 2002: pp.850-52.


THE END passively or Muscle Energy Techniques may be used at each of the restrictive barriers.

Good luck!


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