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OMM Study Guide

Frayettes principles
1. When SB from neutral position, rotation of vertebral bodies follows to opposite direction; SB precedes rotation.
2. When SB is attempted from non-neutral (F/E) position rotation precedes SB to same side
Applies to a single vertebrae
Rotation of vertebrae towards the concavity of the curve
Traumatic origin
3. Motion in one plane limits and modifies motion in another plane
Techniques (consider level of aggression for different diagnoses requiring gentle techniques)
o Myofascial release direct is engaging soft tissue restrictive barrier with constant force until release; indirect is finding point of balance
o Counterstrain monitor TP, find position of ease, hold for 90 seconds (120 for ribs), passively return to neutral, pain should be < 3/10.
o Still technique take joint into direction of ease (indirect) until tissues relax, add compression, guide through to barrier (direct)
o FPR add a compressive force (uses torsion in lumbar), guide joint into its direction of freedom, hold for 3-5 seconds, return to neutral.
o ME (indirect ME uses reciprocal inhibition, e.g. when tricep is contracted, bicep relaxes)
o Articulation (taking a joint through full ROM with focus on dysfunctional barrier)
o Springing (barrier engaged repeatedly with MVMA)
o Soft tissue (linear stretching and/or deep pressure to facilitate muscular and fascial relaxation)
o HVLA
o Inhibition
o Osteopathy in cranial field
o Lymphatic treatment (do not use pedal pump in cardiac / respiratory patient)
Chronic SD versus acute SD
Chronic
Acute
Somato-visceral effects
Minimal somato-visceral effects
Dull ache or pain
Acute pain, severe, cutting, sharp
Cool, pale, dry, scaly, itchy, blemished skin; folliculitis
Warm, moist, inflamed skin
Regional sympathetic vasoconstriction
Local vasodilation (sympathetics cause constriction, but
bradykinins overpower, causing dilation)
Decreased muscle tone; contracture; flaccid
Muscle spasm
Limited ROM due to contracture
ROM sluggish but normal
Doughy, stringy, fibrotic tissue
Boggy edematous soft tissue
Chapmans Reflex Tender Points
o Definition: predictable anterior and posterior fascial tissue texture abnormalities assumed to be reflections of visceral disease
Anterior used for diagnosis
Posterior used for treatment
o Small, smooth, firm, discrete, painful nodule, approximately 2-3mm in diameter
o Treatment: rub in a firm circular motion for ~ 10-30 sec
o Myocardial
Anterior: 2nd intercostal space close to the sternum
Posterior: Midway b/w the SP and the tips of the TP of T2 and T3
o Respiratory
Bronchial
Anterior: 2nd intercostal space close to the sternum
Posterior: Midway b/w SP and the tips of the TP at T2
Upper lung:
Anterior: 3rd intercostal space close to the sternum
Posterior: Midway b/w the SP and the tips of the TP of T3 and T4
Lower lung:
Anterior: 4th intercostal space close to the sternum

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Posterior: Midway b/w the SP and the tips of the TP of T4 and T5

Myocardium, bronchus, esophagus, and thyroid can all be found anteriorly between ribs 2 & 3
GI & GU
Liver: 5th and 6th ICS on the right
Gallbladder: 6th ICS on the right
Stomach acid: 5th ICS on the left
Stomach peristalsis: 6th ICS on the left
Pancreas:
Anterior: 7th ICS on the right
Posterior: B/w TP of T7 and T8 right
Spleen: 7th ICS on the left
Adrenal glands
Anterior: 1 inch lateral and 2 inches superior to the umbilicus ipsilaterally
Posterior: Midway b/w the SP and the tips of the TP of T11 and T12 (also Chapman reflex for hypertension)
Kidneys:
Anterior: 1 inch lateral and 1 inch superior to umbilicus ipsilaterally
Posterior: midway b/w SP and TP tips of T12 and L1
Bladder
Anterior: Umbilical area
Posterior: midway b/w SP and TP tips of L1 and L2
Appendix: Tip of 12th rib on the right
Colon- iliotibial band, as illustrated below
Urethra: myofascial tissues along the superior margin of the pubic ramus about 2cm lateral to the symphysis
Prostate: myofascial tissues along the posterior margin of the iliotibial band

Counterstrain points
o Cervical
Posterior: C1 inion flex, C1-C7 extend and SARA, except C3 = flex and STRAW
Anterior: C1 rotate away, C2-C8 flex and SARA, except C7 = flex and STRAW

Thoracic
AT1: apex of sternal notch

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AT2: middle of the manubrium

AT3-AT6: on the sternum at the same numbered costal level
AT7: under the costalchondral margin, lateral, and inferior to the xiphoid process
AT8: approximately 3 cm below the xiphoid process
AT9: 1-2 cm above the umbilicus, 2-3 cm lateral to the midline
AT10: 1-2 cm below the umbilicus, 2-3 cm lateral to the midline
AT11: 5-6 cm below the umbilicus, 2-3 cm lateral to the midline
AT12: inner surface of the iliac crest at the midaxillary line
Posterior thoracic TP on spinous or transverse process of corresponding vertebra
Ribs
Anterior associated with depressed ribs
AR1: First rib where it articulates with the manubrium
AR2: Second rib in the midclavicular line
AR3-6: On corresponding rib, in the anterior axillary line
Posterior associated with elevated ribs
PR1-6: angle of corresponding rib

Inguinal
Tender point located on the lateral border of the pubic bone near the attachment of the inguinal ligament
Iliolumbar
Tender point located 1 inch superior and medial from the inferior margin of the PSIS in the iliolumbar ligament
Piriformis
Tender point located halfway from the PSISILA midpoint to the greater trochanter.

Cervical
o Dysfunction
Most clinically significant SD of newborns is condylar compression
Affects CN 9, 10, and 11; can cause poor feeding, swallowing, emesis, hiccups, torticollis, and perhaps pyloric stenosis
Cervical spondylosis
Ankylosis of adjacent vertebral bodies
Degeneration of intervertebral disc (dehydration and shrinkage)
Presents as chronic neck pain, radicular pain, and decreased ROM.
Affected contents of cervical canal (myelopathy and radiculopathy) present with distal motor, sensory, and proprioceptive loss.
Cervical disc herniation
Painful, stiff neck
BB and sidebending to side of herniation relieves pain by keeping nucleus pulposus from neural structures
Most adverse effects of OMT occur with excessive axial rotations in HVLA
o Special testing
Spurling extend and sidebend neck, add compression. Test for narrowing of foramina. Positive if pain radiates to ipsilateral arm.
Underburg extend and rotate neck in supine position. Test for vertebral insufficiency. Positive with dizziness, nausea, nystagmus.

Thoracic
o Rule of 3s
T1-3 SP in the same plane as the TVP
T4-6 SP between the TVP above and below
T7-9 SP at the plane of the TVP below
T10 follows 7-9
T11 follows 4-6

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T12 follows 1-3

Motion
Rotation> SB> Flexion> Extension
Scoliosis
Mild: 5-15 degrees, moderate: 20-45 degrees, severe > 50 degrees.
Idiopathic origin most common. Thoraco-lumbar double curve most common.
Curve is named for direction of convexity (left curve has apex on left)

Ribs
o Motion
Pump Handle ribs 1-5
Inhalation: anterior aspect of the rib moves cephalad
Increase in AP diameter of the thorax
Motion predominantly in sagittal plane
Best palpated at midclavicular line
Axis of motion is costovertebral-costotransverse line (see below)
Bucket Handle ribs 6-10
Ribs move laterally and increase transverse diameter with inhalation
Motion predominantly in coronal plane
Best palpated at midaxillary line
Axis of motion is costovertebral-costosternal line (see below)
Inhalation: lateral aspect of the rib moves cephalad
Caliper ribs 11-12
Ribs externally rotate with inhalation
Motion predominantly in transverse plane
Best palpated 3-5cm lateral to transverse process
Axis of motion in vertical line (see below)

Pump handle

Bucket handle

Caliper

Dysfunctions
Exhalation dysfunction: likes to exhale, difficult inspiration, found in pneumonia
Treat: rib at bottom of space but top of group
Inhalation dysfunction: likes to inhale, difficult exhalation, found in COPD
Treat: rib at top of space and bottom of group
Muscles to use in rib ME
Rib 1:
Anterior & Middle Scalenes
Rib 2:
Posterior Scalene
Ribs 3-5:
Pectoralis Minor
Ribs 6-8:
Serratus anterior
Ribs 9-11:
Latissimus dorsi
Rib 12:
Quadratus lumborum

Upper extremity
o Shoulder mechanics
Scapulohumeral ratio 2:1. For every 2 degrees of humeral abduction, scapula rotates 1.
o Provocative testing
Neer rapid flexion of shoulder with arm extended. Tests for subacromial impingement.

Hawkins rapid internal rotation of arm with shoulder/elbow flexed at 90 degrees. Tests for suprahumeral impingement.
Drop arm test drop arm at patients side. Tests for subacromial impingement, rotator cuff problems (mainly supraspinatus).
Applys scratch internal rotation and adduction to touch opposite scapula. Tests for adhesive capsulitis (mainly anteriorly)
Yergasons test external rotation of arm with elbow flexed at 90 degrees. Tests for instability of biceps tendon in bicipital groove.
Erb-Duchennes Palsy
Injury to the upper part of the cord, at the root level of C5 and C6, usually associated with birth trauma.
Paralysis of deltoid, external rotators, biceps, brachioradialis and supinator
Radial nerve injury
Caused by mid-shaft fracture of humerus; Saturday night palsy
Knocks out wrist extension
Epicondylitis
Golfers elbow - strain of the flexor muscles near the medial epicondyle
Tennis elbow - strain of the extensor muscles near the lateral epicondyle (use counterstrain in old people)
Cozens test (for lateral epicondylitis) - holding pronated fist out and trying to extend and internally rotate it.
Ulnar mechanics
Increased carrying angle with abducted ulna cubitus valgus
Decreased carrying angle with adducted ulna cubitus varus
Parallelogram effect:
Increased carrying angle will cause adduction of wrist
Decreased carrying angle will cause abduction of wrist
Radial mechanics
Moves anterior with supination (from fall backward)
Moves posterior with pronation (from fall forward)

TOS testing
Adsons test: neck extended, turned toward affected side
Narrows interscalene space
Checks patency of ipsilateral artery passing between scalene triangle
Positive with decreased/absent radial pulse
Halstead maneuver: exaggerated military posture (scapula retracted and depressed)
Narrows costoclavicular space
Wrights maneuver: shoulder external rotation, abduction beyond 90 degrees
Compressed below pectoralis minor insertion
Wrist testing
Carpal tunnel tests:
Phalens - Wrist flexion to maximum for 60 sec. Test for CTS.
Prayers - Reverse of Phalens. Test for CTS.
Tinels - Tapping over transverse carpal ligament. Test for CTS.
Provocation Test - Compress and hold over transverse carpal ligament. Test for CTS.
Nerve conduction studies are the gold standard of diagnosis
Hypothyroidism, pregnancy, and dialysis-associated amyloidosis can mimic CTS.
Finkelsteins Put thumb in palm and close fist, then ulnar-deviate wrist. Tests for DeQuervains tenosynovitis.

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Inflammation of extensor pollicis brevis and abductor pollicis longus

Lumbar
o Motion
Sagittal plane orientation of the facets
Allows flexion/extension>SB>rotation
Fergusons Angle 35 degrees (normal is 30-40)
o Pathology
Anterior triangle is an area of weakness and common site of compression fracture
Sacralization L5 fuses to sacrum (batwing deformity)
Lumbarization S1 becomes 6th lumbar vertebra.
Disc hernation is common due to narrow posterior longitudinal ligament
L4-L5 and L5-S1 are most common levels.
Hernation at disc X will affect root X+1.
o L5/sacral rule
L5 sidebends to the same side as the oblique axis
L5 rotates to the opposite side of sacrum
Neutral mechanics: LOL or ROR forward torsions
Non-neutral mechanics: ROL or LOR backward torsions
Unilateral flexion or extension produces no L5 change

Sacral
o Axes
Superior: Above S2, the cranial primary respiratory mechanism creates motion around this axis
Middle: At S2, forward and backward bending
Inferior: Below S2, rotation of the innominates
o Motion with gait
Lumbar spine sidebends towards weight-bearing leg
Anterior rotation of weight-bearing ilium; posterior rotation of leg swinging forward
An oblique sacral axis is induced on side of weight-bearing leg, and rotation in same direction.
Example: as left leg bears weight and right swings forward, SLRR motion occurs in lumbar spine, left innominate moves anterior, and
sacrum rotates left on its left axis.
o Sacral tests
Seated flexion test:
Lateralizes sacrolumbar and sacroiliac dysfunctions and eliminates lower extremity
Tests motion between innominates and sacrum
Positive test is side which moves first and farthest
Standing flexion test:
Identifies side of iliosacral dysfunction with positive side moving farthest and longest
Iliosacral dysfunction landmarks:
ASIS - assess overall position of ilium
PSIS - assess overall position of ilium
Pubic tubercles higher in superior innominate and superior pubic shear
Medial Malleoli - higher in posterior rotation and superior innominate
Sacral sulcus going to be deep on side of posterior rotation; narrow in outflare.
Sacrotuberous ligament lax in innominate thats superior (ischium closer to sacrum)
Knee pain / tight sartorius posterior rotation
Posterior thigh pain / tight hamstrings anterior rotation
Sacral dysfunction landmarks:
Sacral Base assesses overall position of sacrum
Inferior Lateral Angle (ILA) assesses overall position of sacrum
Sacral Sulcus deep with anterior base

Sacrotuberous ligament tight with posterior ILA (away from ischium)

Spring test:
Check if sacral base has moved posterior
Positive if there is NO movement (like in a backward torsion)
Sphinx test:
Check if sacral base has moved posterior
Positive if thumbs on sacral base become more asymmetric when patient extends (posterior part resists moving anterior)
Positive in unilateral sacral extension and backward torsions (LOR and ROL)

Lower extremity
o Neuro testing
L4: foot inversion (tibialis anterior), patellar reflex, medial foot sensation
L5: great toe extension (extensor hallicus longus), dorsum foot sensation, facilitates walking on heels
S1: foot eversion (peroneus longus and brevis), Achilles reflex, lateral foot sensation, facilitates walking on toes
Babinksi: positive if toes (or big toe) extend - UMN lesion
o Motion testing
Obers Test - Assessment for contracture of iliotibial band or tensor fascia latae
With knee flexed, extend hip and gently allow thigh to adduct toward table
Considered positive if thigh cannot adduct past midline
Straight Leg Raise Test - Assessment for sciatic nerve compression
Normal straight leg raise is 90
Keeping knee extended, flex hip until pt reports pain
Considered abnormal if cannot flex past 70
Lasegues Test differentiates between hamstring and sciatic pain in straight leg raise
Once pain is reported, extend hip about 5 and dorsiflex foot
This removes hamstring pain while adding stress onto sciatic n.
Thomas Test - Assessment for flexion contracture of hip (usually due to contralateral restricted or shortened iliopsoas muscle)
Flex one thigh up to abdomen
Considered positive if opposite knee lifts off table
Trendelenburg Test - Assessment of gluteus medius muscle strength
Pt stands on one foot while flexing opposite knee
Gluteus medius on opposite side of flexed knee should keep pelvis level
Considered positive if pelvis tilts toward side of flexed knee
McMurray Test Assessment for meniscal tears
Hip and knee both flexed to 90
Medial meniscus test - external rotation of foot with valgus stress on knee, followed by extension.
Lateral meniscus test - internal rotation of foot with varus stress on knee, followed by extension.
Ligament testing
Valgus stress - Assess stability of MCL
Varus stress - Assess stability of LCL
Anterior Drawer Test - Integrity assessment of ACL

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Posterior Drawer Test - Integrity assessment of PCL

Dysfunctions
Terrible triad
Compromise of ACL, MCL, and lateral meniscus.
Commonly induced by valgus force on the knee
Fibular Head dysfunctions
DEA: dorsiflexed, everted, externally rotated anterior fibular head (distal talofibular joint posterior)
PIP: plantarflexed inverted, internally rotated posterior fibular head (distal talofibular joint anterior)
Treat with opposite for direct
Ankle sprains
80% are inversion sprains; produce posterior fibular head
Type I anterior talofibular ligament
Type II - anterior talofibular ligament, calcaneofibular ligament
Type III - anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament
Foot dysfunctions
Pes planus - Longitudinal & transverse arches fall
Pes cavus - Arches rise
Psoas syndrome
pelvis shift to the opposite side
non-neutral dysfunction of L1 and/or L2 - flexed and rotated to same side as the spasm
oblique axis sacral dysfunction - axis is same side as the spasm
spasm of the opposite piriformis resulting in sciatic irritation
gluteal and posterior thigh pain

Sympathetic innervation
o T1-4 head and neck
o T1-6 heart and lungs, visceral pleura
o T1-11 parietal pleura
o T2-8 UE, esophagus
o T5-9 stomach, duodenum, liver, gall bladder, pancreas, spleen
o T10-11 small intestine, kidney, gonads, upper ureter, ascending and proximal 2/3 of transverse colon
o T11-L2 - LE
o T12-L2 lower ureter, left 1/3 of transverse, descending, and sigmoid colon, rectum, pelvic organs
Cranial bones
o Paired bones frontal, palatine, maxilla, mandible. Paired bones go into internal/external rotation.
o Unpaired bones sacrum, occiput, sphenoid, ethmoid, vomer. Unpaired bones flex and extend.
Primary respiratory mechanism (PRM): interdependent functions among five body components
o 1. Wave-like movement of CNS (supposedly due to oligodendroglia contraction)
o 2. Fluctuation of CSF, with gradient for release by choroid plexus and drainage into veins produced by PRM
o 3. Mobility of cranial and spinal dura responds to 1 and 2, and influences bones of cranium and sacrum.
o 4. Cranial sutures allow motions
Serrate (sawtooth) rocking motion
Squamous (scale-like) gliding motion
Harmonious (edge-to-edge) shearing motion
o 5. Involuntary rocking of sacrum between ilia, on superior transverse axis through articular pillar of S2.
Cranial rhythmic impulse (CRI): fluctuation synchronous with PRM
o Rate of 10-14/min (pt with depression would have < 10; treat with bulb decompression/CV4 technique)
o Palpable in cranium and sacrum
o Increased rate: fast metabolism, acute infection
o Decreased rate: slow metabolism, chronic infection, fatigue
o Increased amplitude: increased ICP
o Decreased amplitude: dural tension, SBS compression
o Still point: a pause in CRI
Cranial motion

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Sphenobasilar junction is the reference point around which diagnostic motion patterns are described
Midline bones follow flexion/extension
Paired bones follow internal/external rotation
Sacrum follows the occiput
Temporals follow the occiput
Facial bones follow the sphenoid
Physiologic motions that occur at SBS (PRM motion):
Flexion
Midline bones flex
Paired bones go through external rotation
Decreased AP diameter of cranium (for some reason)
Extension
Midline bones extend
Paired bones go through internal rotation
Increased AP diameter of cranium
Non-pathological strains:
Torsion
Sphenoid and occiput rotate in opposite directions around AP axis
Named for side on which sphenoid wing is higher
Sidebending rotation
Sphenoid and occiput rotate in opposite directions around individual vertical axes
Both sidebend in direction of SBS deviation on single AP axis
Named for direction of sidebending
Pathological strains:
Lateral strain
Sphenoid and occiput rotate in same direction around individual vertical axes
Named for direction of deviation of sphenoid base (away from occiput)
Vertical strain
Sphenoid and occiput rotate in same direction around individual transverse axes
Named for direction of sphenoid movement (flexion = superior vertical strain)
Sphenobasilar compression
Diminished CRI