OMSIII OMM Clinical Cases

Family Medicine

Bethany Powers, D.O.

VCOM Carolinas Campus
 Content and reading references included in this presentation
will tested during the next End of Rotation OMM quiz.

A separate video contains an Osteopathic patient encounter

addressing some or all of the topics of this presentation. This is
considered part of the presentation and contains testable
content as it relates to the Objectives.
 Objectives
Reading Assignment: Supplemental readings will be provided as needed.
• Acute Neck Pain
• Recognize the structure-function approach to differential diagnosis of acute neck pain and identify potential neck
pain generators.
• Identify approaches that integrate the entire postural mechanism within the biomechanical model considered for a
patient complaining of acute neck pain.
• Identify approaches that integrate the respiratory/circulatory model in the evaluation and treatment of acute neck
pain.
• Describe the manifestations of the neurological model in the evaluation and treatment of facilitation resulting from
acute neck pain.
• Recognize the metabolic and physiologic alterations that occur with acute neck pain using the metabolic energy
model.
• Identify approaches that integrate the psychological, behavioral, and social responses to acute neck pain and somatic
dysfunction using the behavioral model.
• Discuss the indications for referral to a spine or pain specialist for further evaluation and management of acute neck
pain.
• Recognize and identify an appropriate use of OMT in acute neck pain.
 
 Objectives Continued
• 2. Acute Low Back Pain
• Summarize the AOA recommended parameters for frequency of the application of OMM for patients with acute low back
pain.
• Define acute, subacute and chronic low back pain.
• Discuss the indications for obtaining radiological evaluation in patients with low back pain based on the American College
of Physicians and the American Pain Society.
• Differentiate between mechanical and non-mechanical etiologies of acute low back pain, and how their diagnostic
evaluation may differ.
• In patients presenting with low back pain symptoms, differentiate possible mechanical etiologies including psoas,
piriformis, and sacroiliac joint pain.
• Summarize the various considerations for treatment of acute low back pain, specifically related to biomechanical,
respiratory-circulation, metabolic-energy, neurologic, and behavioral models.
• Identify self-care recommendations that may be provided to a patient with low back pain.
• Discuss the function of the anterior and posterior muscles of the lumbar spine, including the different layers of the
posterior musculature (ie superficial, intermediate and deep layers).
• Recognize and identify an appropriate use of OMT in low back pain.
 Case

• 26 y/o male presents to your clinic.

• Chief complaint: neck pain.
 Start thinking differential…
• What is the most likely diagnosis?
• What will kill him?
• A couple other possibilities…
 What are some of those differentials?
• Horses:
– Muscle spasm, ligamentous strain, somatic dysfunction, spondylitis,
somatization, malingering, disc herniation, suboccipital neuralgia,
shingles, etc.

• Death Stallions:
– Meningitis, epidural hemorrhage, epidural abscess, embolus,
osteomyelitis, malignancy- primary or metastasis, etc.
 How to start narrowing it down
• History! History! History!

• What are some of the things you would like to know?

Remember your differential will help guide these questions.
 His History
• 26y/o male complains of neck pain starting two weeks ago.
Started after studying for a big exam. No known injuries. Located
in posterior neck. Prolonged sitting and leaning forward make it
worse, rest and heat make it better. Pain never completely
resolves. Describes it as a dull ache, no radiation. No prior history
of injuries. Full time student, occasional walks for exercise.
• No fevers, chills, numbness, tingling, weakness, or loss of
bowel/bladder control.
• Family, social, medical, and surgical hx unremarkable.
 So Far, Does He Need Imaging?
• Is he over 50? No
• Any history of cancer? No
• Any night sweats or unexplained weight loss? No
• Any complaints of weakness of numbness? No
• Any complaints of bowel or bladder incontinence? No
• Is there a lack of relief with bed rest? No
 Next up, Physical Exam
• We better know our anatomy
 Functional Anatomy- Skeleton

• Articulations between C2-C7 are considered typical.

• Facets form the palpable articular pillar (aka lateral
mass)
• Facets of the typical vertebrae are in a plane that
points to the eyes
• Rotation of typical vertebrae are in this plane
(vertebral rotation is toward the eye & not in a
horizontal plane)
Bony Anatomy
 Functional Anatomy - Ligaments
Cruciform Ligament
1. Superior and inferior limbs
2. Transverse ligament of the atlas
(articulates with odontoid)
Allows odontoid (dens) to function as a pivot with the atlas rotating
around the odontoid part of cruciform ligament

Actually has synovium like a joint

(one of the few ligaments that do!)

Spinal cord is posterior to Transverse Ligament!

RA-->Synovitis-->subluxation of AA, can injure spinal cord! Also

Down’s Syndrome!
Functional Anatomy - Vascular

• Vertebral artery- multiple

90 degree turns
• Extension & rotation of
occiput produces
functional occlusion of the
opposite vertebral artery
Vertebral
Artery

Cervical manipulation
can put patients at risk
for vertebral artery
dissections

Obstructions can cause

vertebrobasilar CVAs
 Physical Exam
• Vital signs
• Standing: gait, posture, scoliosis, lordosis, standing flexion test,
ROM (active then passive)
• Seated: auscultate heart/lungs, inspection, sensation, reflexes,
strength, Spurling’s test
• Supine: Vertebral artery testing, Chapman’s points, abdominal
exam, soft tissue palpation, segmental motion testing
 Special Test: Spurling’s Test

1. Extend, sidebend and rotate

to same side.
2. Compressive force applied to
top of the head.
3. Positive test is pain radiating
into shoulder and/or arm on
ipsilateral side.
 Special Test:
Vertebral Artery Insufficiency Test

1. Patient prone. Extend, sidebend and rotate to

the same side.
2. Watch for nystagmus, ask about nausea,
dizziness, blurring of vison, or light
headedness. Hold for 30 seconds.
3. A positive test is any of the aforementioned.
The insufficiency is most likely from the
contralateral side as sidebending/rotation.
4. Test both sides.
 Evaluate for Tissue Texture Changes

• Think about acute vs chronic

tissue texture changes.
• Are the tissues warm, boggy,
moist?
• Are the tissues cool, ropey,
dry?
• Try to identify which
muscle(s) you find tissue
texture changes in.

https://athletestreatingathletes.com/self-muscle-massage-pt-12-the-neck/
 Typical Cervical
Segmental Motion Testing
• No Type I mechanics observed
• Can have single or stacked Type
II “like” dysfunction:
– All flexed
– All extended
– Mixture of flexion &
extension
– Sidebend & rotate the same
direction ALWAYS!!
 Your Patient’s PE Findings
• BP: 132/78 HR: 76 RR: 14 T: 98.4 O2sat: 98% room air
• Heart RRR, Lungs CTAB
• Normal gait, posture/walk, and ROM. No scoliosis.
• Loss of cervical lordosis.
• No rashes/skin lesions.
• Sensation intact throughout B/L UE and LE to light touch.
• Reflexes 2/4 in B/L UE and LE. Strength 5/5 throughout B/L UE and LE.
• Spurling’s test negative B/L.
• Vertebral artery insufficiency test negative.
• C2-4 FRlSl
• Bilateral upper cervical paraspinal muscle hypertonicity with ropey tissue texture
changes.
Now what is in your differential?
How Else Can Somatic Dysfunction Present?
• Neurological symptoms- Headaches, radicular pain
• Respiratory symptoms- asthma, cough, dyspnea
• (think C3, 4, 5 innervation)
• GI symptoms- constipation, diarrhea, abdominal pain
• (Think Vagus nerve, OA)
• Cardiac symptoms- tachycardia, irregular beats
• (Think Vagus nerve, OA)
 How would you like to treat him?
• Yes, yes, obviously OMT.
• NSAIDs (take with food, if no cardiac concerns)
• Acetaminophen
• Muscle relaxers (caution sleepiness/drug interactions)
• Heat/Ice
• Physical Therapy/Home Exercises
 Exercises

• Find some good resources you

like and trust for exercises
• Give your patients ‘homework’
when appropriate
– (tip: it usually is appropriate)

https://www.summitmedicalgroup.com/library/adult_health/sma_neck_strain_exercises/#&gi
d=1&pid=1
 Cervicalgia OMT Plans
• Quick:
• Suboccipital release
• Muscle energy directed at paraspinal muscles
• Medium:
• Soft tissue including longitudinal stretches
• Segmental Muscle Energy/HVLA
• Extended:
• Counterstrain
• Rib muscle energy/BLT
• OA treatment
• Thoracic muscle energy/HVLA
 Direct MFR for Suboccipital Muscles
1. Palpate for increased muscle tension on
either side of the occiput directly caudad to
the inion on the inferior nuchal line.
2. With firm pressure anteriorly, adjust the
position of your hands to increase the tissue
tension. Motion test the tissues in all
directions – cephalad/caudad, medial/lateral,
rotation cw/ccw.
3. It may be easier to adjust one hand first, and
then the other.
4. Maintain positioning that increases tissue
tension, adjusting as the tissues release.
 Soft Tissue-Longitudinal Stretching for
Hypertonic Cervical Paraspinal Muscles
• Objective: To relax the paravertebral
muscles (PVM).
• 1) physician sits at head of table;
patient is supine.
• 2) the palmar surfaces of fingers of
both hands lie under the neck near the
spinous processes
• 3) lift the PVM with fingers and draw it
toward you (cephalad = toward head)
• 4) release and carry tissue away from
you (caudally = toward tail)
Muscle Energy to Typical Cervical Vertebrae
Position the patient at the restricted barrier by
• Gently sidebending towards the barrier until motion is just felt at
the involved segment.
• Maintaining the sidebending component, rotate the patient’s head
towards the barrier until again motion is felt.
• Now engage the flexion/extension barrier by flexing the neck to the
involved segment, or if restricted in flexion, extending the segment
by pushing anteriorly on the inferior vertebrae.
Muscle Energy to Typical Cervical Vertebrae, cont.
• Holding the patient gently but firmly against the barrier, the patient is
then instructed to gently rotate their head in the opposite direction to
produce an isometric force. This position is maintained for 3 seconds.
• The patient completely relaxes their effort following muscle contraction
for another 3 seconds, while the physician maintains the joint position.
• The physician then repositions the restrictive barriers in all planes while
always palpably monitoring the joint. This is typically a small adjustment.
• Repeat one or two times.
• Always recheck the findings to make certain the dysfunction is corrected
 Muscle Energy- example C5 FRLSL

• Extension is induced at the • Rotate & sidebend to the • Pt. actively sidebends to the
right until motion is felt at left while the DO resists
segment with the fingers
the involved segment
ME Treatment for OA Dysfunction –
in this example for OA ESLRR
• Physician sidebends the head to the
restricted barrier at the OA
• Physician rotates the head to the
restricted barrier at the OA
• Patient looks away from the rotation
restriction, while gently trying to turn
their head the direction of their gaze
• Physician exerts counterforce for 3-5
seconds, then instructs patient to relax
for 3 seconds
• Repeat x 3-5. Reassess.
 HVLA for C2 and C3 Rotational Emphasis
Example for C2 or C3 F/E SlRl
1. The patient is supine on the table, physician
supporting patient’s head with their
forearms.
2. The patient’s head is flexed to the
dysfunctional segment.
3. The physician sidebends the patient’s neck
left to the segment, then rotates right to
engage the barrier.
4. A high velocity low amplitude thrust is
applied with both hands through the
restrictive barrier.
5. Recheck
 HVLA for C4 through C7 Sidebending Emphasis
Example for C4 through C7 SlRl
1. Patient supine on table with physician
supporting patient’s head on their
forearms. The physician contacts both
articular pillars of the involved segment
with the lateral edge of their index fingers.
2. The physician flexes the patient’s neck to
the involved segment by lifting the
patient’s head.
3. The patient’s neck is sidebent right to the
restrictive barrier, and then rotated left to
lock out the segment.
4. A high velocity low amplitude thrust is
applied through the right articular pillar.
5. Recheck
 Counterstrain Points (Anterior: AC2-AC6)

• In general, these points are treated in

flexion, with sidebending and rotation
away from the tenderpoint
– Listen with your fingers!
• Get tissues to position of ease
• Hold for 90 seconds or until you feel
tissues relax
• Return patient to neutral position
 Counterstrain Points (Posterior: PC3-PC7)

• In general, these points are treated in

extension, with sidebending and rotation
away from the tenderpoint
– Avoid too much extension
– Listen with your fingers!
• Get tissues to position of ease
• Hold for 90 seconds or until you feel
tissues relax
• Return patient to neutral position
Questions?
 Case

• 46 y/o female presents to your clinic.

• Chief complaint: low back pain.
 Start Thinking Differentials…
• What is the most likely diagnosis?
• What will kill her?
• A couple other possibilities…
 What Are Some of Those Differentials?
• Horses:
– Muscle spasm, ligamentous strain, somatic dysfunction, spondylitis,
somatization, malingering, inflammatory bowel disease,
pyelonephritis, kidney stones, gout, degenerative diseases, etc.

• Death Stallions:
– Spinal cord tumors, epidural hemorrhage, epidural abscess, embolus,
cauda equina syndrome, AAA, osteomyelitis, malignancy- primary or
metastasis, etc.
 Age Specific Differentials
• 30-40’s: ankylosing spondylitis, reactive arthritis, spondylitis,
inflammatory bowel disease, benign tumors of the spine.
• 50’s: gout, diffuse idiopathic skeletal hyperostosis, Padget’s
disease, and osteomyelitis.
• 60+ : malignancy, chondrocalcinosis, degenerative diseases.
 Start Narrowing it Down
• History! History! History!

• What are some of the things you would like to know?

Remember your differential will help guide these questions.
 Her History

• 46y/o female complains of back pain starting one week ago. No

known inciting injury or event. Located in her low back.
Prolonged standing and activity make it worse, rest and heat
make it better. Pain never completely resolves. Describes it as a
dull ache, radiates to her left buttock. No prior history of back
injuries. Works at a desk job, occasional walks for exercise.
• No fevers, chills, numbness, tingling, weakness, or loss of
bowel/bladder control.
• Family, social, medical, and surgical hx unremarkable.
 So Far, Does She Need Imaging?
• Is she over 50? No
• Any history of cancer? No
• Any night sweats or unexplained weight loss? No
• Any complaints of weakness of numbness? No
• Any complaints of bowel or bladder incontinence? No
• Is there a lack of relief with bed rest? No
 Next up, Physical Exam
• On to our anatomy review…
Bony Anatomy
 Bony Asymmetry
• 30-40% of the population have
congenital osseous asymmetry
– Facet asymmetry
– Sacralization
– Lumbarization
– Spina bifida occulta
• The most common of these is facet
asymmetry
– One facet is in a different plane
 Disc vs. Deficit

X+1 Rule
• Herniation at disc X affects nerve
root X+1
• Nerve root X will have already exited
the foramina and will be unaffected
 Anatomy: Ligaments

• Iliolumbar Ligaments
– Attachment at L4 and L5
transverse process
– Increase stability at the
lumbosacral junction
– Commonly sprained in traumatic
injuries
 • Diaphragm
Lumbar Anatomy: Musculature – Left Crus attaches at L1-2
– Right Crus attaches at L1-3
Lumbar Anatomy: Musculature
 Physical Exam
• Vital signs
• Standing: gait, posture, heel/toe walk, scoliosis, lordosis, standing
flexion test, ROM (active then passive)
• Seated: auscultate heart/lungs, sensation, reflexes, strength,
straight leg raise, seated flexion test
• Prone: skin changes, Chapman’s points, tissue texture changes,
sacrum testing, segmental motion testing
• Supine: leg length, ASIS location, Chapman’s points, abdominal
exam, psoas testing
 Special Test: Thomas Test
Diagnosis of Tight / Short Iliopsoas
• Patient clasps fingers behind knee of
contralateral lower limb
• Have patient pull thigh toward chest
(physician assists patient flexion)
• Physician monitors gap under knee of
lower limb being tested
• Positive Iliopsoas Restriction: increased
distance between knee and table in the
leg on the table
 Straight Leg Raise (SLR) Test
• Designed to reproduce back
and leg pain in order to
determine its cause
• Pt supine, doctor raises testing
leg to ~70-90o
– support heel with one hand
– place the other hand above the
knee to prevent it from bending
• Positive is radicular pain https://www.aliem.com/wp-content/uploads/2011/08/SLR.jpg

– (not stretching from tight

hamstrings)
 Your Patient’s PE Findings
• 132/78 76 14 98.4
• Heart RRR, Lungs CTAB
• Abdomen +BS, soft, NTTP, no guarding or rebound tenderness
• Normal gait, posture/walk, and ROM. No scoliosis.
• Increased lordosis.
• No rashes/skin lesions.
• Sensation intact throughout B/L LE to light touch.
• Reflexes 2/4 in BLE. Strength 5/5 throughout BLE.
• SLR negative B/L.
• + Standing flexion on right.
• Sacrum left on left torsion.
• Left innominate posterior.
• L4-5 NSLRR
• Bilateral lumbar paraspinal muscle hypertonicity with ropey tissue texture changes.
• Tenderness over the left iliolumbar ligament.
Now what is in your differential?
 How Else Does Somatic Dysfunction Present?
• Genitourinary symptoms- i.e. dysuria with a negative urinalysis
• Gastrointestinal symptoms- constipation, diarrhea, abdominal
pain (check those Chapman’s points!)
• Leg symptoms- i.e. a painful knee coming from a tight IT band
from an innominate rotation trying to compensate for a
scoliosis.
• Upper back symptoms- i.e. compensating for a lower back
somatic dysfunction.
 How would you like to treat her?
• Yes, yes, obviously OMT.
• NSAIDs (take with food, if no cardiac concerns)
• Acetaminophen
• Muscle relaxers (caution sleepiness/drug interactions)
• Heat/Ice
• Physical Therapy/Home Exercises
 Exercises

• Find some good resources you like

and trust for exercises
• Give your patients ‘homework’ when
appropriate
– (tip: it usually is appropriate)

https://www.summitmedicalgroup.com/library/adult_health/sma_neck_strain_exercises/#&gi
d=1&pid=1
 Lumbago Treatment Plans
• Quick:
• Psoas muscle energy
• Lumbar soft tissue/myofascial release
• Medium: (Quick plus the following)
• Innominate muscle energy
• Lumbar muscle energy or HVLA
• Extended: (Medium plus the following)
• Piriformis counterstrain
• Abdominal ganglion treatment
• Sacral treatment
• Respiratory diaphragm treatment
 Iliopsoas Muscle Energy

• Have Pt Move Toward Edge of Table On Side of

Positive Thomas Test
• Treated Limb is Lowered off Table
• Stabilize Contralateral ASIS
• Apply Gentle Posterior Traction to Treated Limb
• Have Pt Attempt Flexion Against Your Resistance 3
Second
• Rest 3 Seconds
• Gently Increase Traction
• Repeat 2 times
• Reassess

Kimberly, P. A. Outline of Osteopathic Manipulative Procedures. Millennium Edition. Marceline, Missouri: Walsworth Publishing Company; 2001: 274-81
 Lumbar Soft Tissue and MFR
Supine Lumbar Paraspinal Myofascial Release
• Pt supine, physician at side of dysfunction.
• Physician contacts paraspinal muscles, without crossing the spinous
processes, with their finger-pads.
• Identify any areas of restriction and direct forces into the restrictions.
• Gentle anterior and lateral pressure (towards physician) is held until a
release is felt.
• Fingers may be repositioned cephalad or caudally and technique
repeated as indicated.
Supine Lumbar Paraspinal Soft Tissue
• Pt supine, physician at side of dysfunction.
• Physician contacts paraspinal muscles, without crossing the spinous
processes, with their finger-pads.
• Gentle anterior and lateral kneading motion (towards physician) is
repeated until a release is felt.
• Fingers may be repositioned cephalad or caudally and technique
repeated as indicated.
Foundations 2ed. P 827 Nicholas 3ed. P 117
 Lumbar Soft Tissue and MFR
Prone Lumbar Direct Myofascial Release
• Pt is prone and physician is standing on side opposite of dysfunction.
• Physician’s cephalad hand is placed on opposite paraspinal muscles,
avoiding pressure on the spinous processes.
• Physician’s caudal hand is placed on the opposite ASIS.
• The caudal hand gentle lifts, while the cephalad applies anterior
pressure. This is held until a release is palpated.

Prone Lumbar Soft Tissue

• Pt is prone and phys. is standing on side opp. of dysfn.
• Physician’s cephalad hand is placed on opposite paraspinal muscles,
avoiding pressure on the spinous processes.
• Physician’s caudal hand is placed on the opposite ASIS.
• The caudal hand gentle lifts, while the cephalad applies anterior
pressure in a rhythmic motion until the tissue softens.
Foundations 2ed. P 826 Nicholas 3ed. P 115
 The following techniques may be
performed as Muscle Energy or HVLA.
If using Muscle Energy, rather than
thrusting through the restrictive barrier
have the patient push against you and
take up the slack for 3 cycles.
Lumbar HVLA Lateral Recumbent Neutral
Example: L5 NSLRR

1. The patient lies with the rotational

component down. Physician stands at their
front.
2. The physician’s cephalad hand palpates at L5-
S1 interspinous space. They flex the patient’s
knees up until L5 is in neutral relative to S1.
3. The physician drops the patient’s left leg off
the front of the table. It must not touch the
floor.

Nicholas & Nicholas p.372/387

 Lumbar HVLA Lateral Recumbent Neutral
Example: L5 NSLRR
4. The physician’s caudal hand palpates at L5-S1
interspinous space. Their cephalad hand grasps
the patient's right forearm and pulls until
rotation is felt at the L5-S1 interspace.
5. The physician maintains palpation of L5. They
place their cephalad hand through patient’s left
arm, resting their forearm gently on the
patient’s anterior pectoral and shoulder region.
6. The physician places their caudal forearm
along a line between the patient’s left PSIS and
their greater trochanter.
 Lumbar HVLA Lateral Recumbent Neutral
Example: L5 NSLRR
7. The patient’s pelvis is rotated anteriorly to the edge
of the restrictive barrier, their shoulder and T-spine are
rotated posteriorly to the edge of the restrictive
barrier. The patient inhales and exhales, during
exhalation, further rotational slack is taken up.
8. When the patient is relaxed and not guarded, the
physician delivers and impulse thrust with the caudad
forearm directed at right angles to the patient’s spine
while simultaneously moving the patient's shoulder
slightly cephalad and the pelvis and sacrum caudad.
This induces both side bending and rotational motion.
9. Reassess.
Lumbar HVLA Lateral Recumbent Non-Neutral
Example: L5 ESRRR
1. The patient lies with the rotational
component down. Physician stands at their
front.
2. The physician’s cephalad hand palpates at L4-
L5 interspinous space. They flex the patient’s
knees up until L4 is in neutral relative to L5.
3. The physician drops the patient’s leg off the
front of the table. It must not touch the floor.

Nicholas & Nicholas p.373/388

Lumbar HVLA Lateral Recumbent Non-Neutral
Example: L5 ESRRR
4. The physician’s caudal hand stabilizes L5.
5. The physician pulls the patient’s lower arm forward until
rotation is palpated at the restricted segment.
6. The physician’s cephalad hand goes in the pt’s antecubital fossa
while resting their forearm on the patient’s shoulder.
7. The patient’s shoulders and pelvis are axially rotated in opposite
directions. The patient inhales and exhales with further slack
taken up.
8. When the patient is relaxed, the physician delivers and impulse
with the forearms. They are simultaneously moving the shoulder
slightly caudad and the pelvis/sacrum cephalad.
9. Reassess.
 Lumbar HVLA -OB Roll- Extended/Neutral
Example: L4 NSLRR
1. Pt supine with fingers interlaced behind their neck.
2. Physician at head of table. Physician’s right hand laced
through patient’s right arm, with palm up on mid-sternum.
3. Physician then walks around head of pt to the left side of
the table.
4. Physician uses their caudal hand to palpate posteriorly.
The physician side bends the pt right until motion is felt at
L4.
5. The physician then anchors the pt’s right ASIS and the
patient is rotated to the left.
6. With the pt relaxed and not guarding, the physician
directs an impulse that pulls the patient minimally into
further left rotation.
7. Recheck.
Nicholas & Nicholas p.375/390
 Lumbar HVLA -OB Roll- Extended/Neutral
Example: L4 NSLRR
1. Pt supine with fingers interlaced behind their neck.
2. Physician at head of table. Physician’s right hand
laced through patient’s right arm, with palm up on
mid-sternum.
3. Physician then walks around head of pt to the left
side of the table.
4. Physician uses their caudal hand to palpate
posteriorly. The physician side bends the pt right
until motion is felt at L4.
5. The physician then anchors the pt’s right ASIS and
the patient is rotated to the left.
6. With the pt relaxed and not guarding, the physician
directs an impulse that pulls the patient minimally
into further left rotation.
7. Recheck.
Visceral- Abdominal Ganglion Treatment
Questions?
 References
Unless otherwise noted on the slide, all pictures and information comes from the following sources:

• Chila, A.G. Foundations of Osteopathic Medicine. 3rd Edition. 2011.

Pages 660-668 and 786-808.
• DiGiovanna, Eileen; Schiowitz, Stanley; Dowling, Dennis An
Osteopathic Approach to Diagnosis and Treatment – 3rd Ed.
Lippincott, 2005
• Kimberly, Paul. Outline of Osteopathic Manipulative Procedures.
2008.
• Nicholas, Nicholas S., B.S., D.O., F.A.A.O. Atlas of Osteopathic
Techniques. Philadelphia: Philadelphia College of Osteopathic
Medicine, 1974.
• Savarese, R.G. OMT Review. 3rd Edition. 2003.