Internal Medicine II OMM Workshop

Cardiovascular Disease

Joseph Edison DO CAQSM

Adapted from Dr. David G Harden DO

VCOM OMSIII
 Learning Objectives
1. Outline the impact and effects of the autonomic nervous system on the function of the cardiovascular
system and describe the levels for the parasympathetic and sympathetic contributions.
2. Describe the important impact and effects of the lymphatic system on the function of the cardiovascular
system.
3. Relate somatic changes of the thoracic spine to effects in cardiovascular system.
4. Describe key OMM treatment approaches utilized in the care of patients with hypertension and specifically
how treatments might affect sympathetic and parasympathetic tone as well as lymphatic return.
5. Describe key OMM treatment approaches utilized in the care of patients with congestive heart failure and
specifically how treatments may affect sympathetic and parasympathetic tone as well as lymphatic return.
6. Identify OMM treatment approaches to the care of patients with atherosclerosis, cardiac arrhythmias and
myocardial infarction. Relate specifically how treatments might affect sympathetic and parasympathetic
tone as well as lymphatic return.
7. Identify wellness concepts such as diet, exercise, stress reduction and smoking cessation as components of
a comprehensive treatment program for cardiovascular disease.
8. Identify how the biomechanical, respiratory, neurological, metabolic and behavioral models describe
contributions to the development of symptomatic disease and address treatments for each component
• Identify methods to incorporate holistic care in the management of
the patient with cardiovascular disease xi. Demonstrate proficiency in
the evaluation and appropriate direct and/or indirect osteopathic
treatment for somatic dysfunctions found typically in the patient
cardiovascular disease xii. Osteopathic techniques reviewed in lab
may include any of the following techniques
• a. Direct Techniques 1) Inhibition suboccipital m. 2) ME OA-
oculocephalogyric reflex 3) ME cervicals 4) ME thoracics
• b. Indirect Techniques 1) FPR cervical 2) FPR thoracics 3) FPR first rib
• Content and reading references included in this workshop will tested during the
next End of Rotation OMM quiz.
• You will be responsible for this content whether you are present in today’s
workshop, or received an excused absence.

• You may review all or some of the included techniques as a group; however,
you will be expected to be knowledgeable of all the included techniques on the
quiz.
 Case
• Chief Complaint
• A 50-year-old male with a history of MI and congestive heart failure
(CHF) presents with complaints of mild chest pressure and nausea.
What is your differential based on current
information?
• What are the most likely diagnoses?
• What are the “don’t miss” diagnoses?
• A couple other possibilities…
 Differential diagnoses?
Diagnoses:
• Cardiac-STEMI , Non STEMI
• GI Related-esophagitis, GERD, gastritis
• Pulmonary-Asthma, COPD,PE
• Musculoskeletal related, somatic dysfunction ,chostochondritis, fractures
• Oncologic-primary or metastatic tumors
• Neurologic-C spine and Upper T spine HNP, Shingles,others
• Psychiatric-panic attacks
• Others
• Don’t Miss Diagnoses:
• Acute coronary syndrome
• Acute aortic dissection https://www.uptodate
• Pulmonary embolism .com/contents/evalua
• Tension pneumothorax tion-of-the-adult-with-
chest-pain-in-the-
• Pericardial tamponade
emergency-
• Mediastinitis (eg, esophageal rupture) department?
• Others source=history_widget
 How to start narrowing down your
differential
• History! History! History!

• What are some of the things you would like to know? Remember,
your differential will help guide these questions.
 His History
Pressure started in his chest while shoveling snow 2 week ago. The pain
then spread to his left arm and was accompanied by nausea. Initially,
the symptoms responded well to SL-NTG .Pain has become more
frequent and has not gone away with NTG. The symptoms lessen with
rest but doesn’t completely go away. The patient waited 16 hours
before presenting to the emergency room.
 History
• Allergies: NKDA
• Meds: Losartan 100 mg PO daily and Simvastatin 20mg PO daily.
• Medical History: hypertension, hypercholesterolemia. MI 3 years ago , known
CHF, coronary artery disease, angina upon exertion,
• Family Medical History: Father deceased age 56, myocardial infarction;
Mother alive and well; 3 siblings, one with diabetes mellitus, hypertension; uncle
with tuberculosis
• Social History: Unemployed, Welder, Single, No religious affiliation, Tobacco:
1/2 packs of cigarettes daily for 5 years. Alcohol: occasional; denies drug use, no
exercise, sedentary, poor to fair diet/nutrition habits
 ROS
• Review of Systems:
• Gen-No night sweats, no weight loss,+ malaise
• HEENT-Negative
• Neck-Negative
• Cardiac-chest pressure/pain as per HPI, mild nocturnal dyspnea, chronic extremity
swelling
• Pulm-Mild dyspnea, nonproductive cough
• Abdominal, negative
• Skin-no rash
• Neuropsych- insomnia, anxiety
• Musculoskeletal-some back and anterior chest pain, no erythema or swelling of
joints
 Does he need studies?
• Does he need Imaging?
• Does he need lab?
• Any other studies acutely or chronically?
 His Diagnostics

• CBC with differential

• Chem-7 (basic metabolic panel)
• EKG
• Troponin
• Chest x-ray
CBC/Basic Metabolic Profile
 Troponin Level

• Troponin-1 – 5.1 (Normal Value: <0.4 ng/ml)

Normal EKG
 Our Patient

Braghadheeswar Thyagarajan et al..

American Journal of Cardiovascular Disease Research, 2016, Vol. 4, No. 2, 18-20. doi:10.12691/ajcdr-4-2-2
CXR of our patient
CXRs that might change your approach

Pleural Effusion

Lobar Consolidation

Non Small Cell Lung Ca

Rib Fracture
Tension Pneumothorax
 His Physical Exam
• Vital signs: Temperature, 99° F; Blood Pressure, 154/92: Respiratory Rate, 22;
Heart Rate,108; Height: 6’2”; Weight, 285 lbs
• General: Anxious; pale; slightly diaphoretic
• Skin: Warm, dry, no lesions or rashes; skin testing on the hand, forearm, and
• abdomen remains tented at 10 seconds
• Head: NCAT
• Eyes: PERRLA,EOMI BLT equal
• Nose: Nares without discharge; turbinates engorged; no epistaxis
• Throat: No adenopathy; thyroid non palpable and not enlarged; trachea midline
and moveable; no masses
 His Physical Exam : Cont’

• Cardiac: Increased rate and regular rhythm at108 bpm; S3 gallop noted
• Lungs: Scattered rales noted
• Abdomen: bowel sounds + x 4 Q; abdomen soft, protuberant; no masses, tenderness,
or rebound,no organomegaly
• Extremity: 2+ pitting edema noted
 His Structural Exam
• Patient examined in the seated and supine positions
• Head: OA FSLRR
• Neck: AA rotated left
• Chest: Left first rib elevated,T1 ERSL,T2–T4 NSRRL, with tissue texture
abnormalities in paraspinal soft tissues along T2–T4 left inclusive of rib
angles,T7−T10 NSLRR, Thoracolumbar Diaphragm motion restriction on the left,
with ribs 7−10 exhalation restriction (inhalation somatic dysfunction)
Now what is your assessment?
 Assessment
• MI
• CHF
• HTN
• Hyperlipidemia
• Obesity
• Tobacco abuse
• Somatic Dysfunction of
• Cranium
• Cervical
• Thoracic
• Rib
• Diaphragm
 Plan
Urgent or emergent medical management consistent with his diagnosis
prior to initiating OMT
Anatomy and Physiology Pertinent
to Structural Evaluation and
Treatment of the Cardiopulmonary
System
Configuration of the Thorax
Neurologic Model
 Neurologic Model
“The preferred homeostatic state
of the cardiovascular system is
under parasympathetic
dominance. In decompensated
Heart Failure and many chronic
cases of heart failure, there are
increased levels of catecholamines
and hypersympatheticotonia.”

Foundations of Osteopathic Medicine,3rd Ed, Chila , p.896

 Phrenic and Sympathetic Innervation
• Note
• Phrenic Nerve (C3-5) to Abdominal
diaphragm
• Cervical chain ganglia(sympathetic)
• Scalene muscles and attachments
to first and second rib
 Sympathetic Innervation/ Autonomic Reflexes

• T1-4 head and neck

• T1-6 heart and lungs
• T2-8 upper Extremities
• T5-9 stomach, duodenum, liver, gall bladder,
pancreas, spleen
• T10-11 small intestines, kidney, ureters, gonads, right
colon
• T12-L2 kidney, left colon and pelvic organs
 Sympathetic
• Head and Neck – T1-4
• Heart and Lungs T1-6
• Upper GI Tract-T5-9
• Sm Int / Rt Colon-T10-11
• Left Colon/Pelvis-T12-L2
• Kidney/Adrenal-T10-11
• Upper Ureter-T10-11
• Lower Ureter-T12-L1
• Bladder-T12-L2
• Appendix-T12
• Chapman’s Reflexes-ICS and 4 • Arms –T2-8
• Parasympathetic –CNX(OA,AA,C2)
• Sympathetic Viscerosomatic Parasympathetic
Viscerosmotor via cardiac reflex causes
Pupils-CNIII
muscle contraction and palpatory
findings in left upper ribs as well as Lacrimal and salivary glands-CNVII
demonstrated in T2-4 on the left Carotid Body and sinus-CNIX,X
Thyroid to Transverse colon-CNX
These can produce muscular changes creating vertebral (Including Lungs)-CNX
dysfunction. Left Colon and genitourinary-S2-4
Sympathetic Innervation/ Autonomic
Reflexes
• Sympathetic innervation origin cord segments T1-6
with synapses between pre and post ganglionic fibers
T1-6 and cervical chain
• Fibers are bilateral with some being very ipsilateral
• Right sided fibers tend to pass through the deep
cardiac plexus to innervate the R heart and SA node
• Hyper sympathetic of these fibers predisposes to
supraventricular tacchyarrythmias
• Left sided fibers tend to pass through the deep cardiac
plexus to innervate the L heart and AV node
• Hyper sympathetic of these fibers predisposes to ectopic foci
and ventricular Fib
• Selected stimulation of sympathetic fibers may cause
• Increase force of heart beat
• Shorten systole
• Increase ventricular output and rate of contraction/o
increasing BP
• May raise BP without increased vasomotor tone of the body

https://qph.fs.quoracdn.net/main-qimg-b0fc70386036e07cef74b9e2cf6233c7-c
 Autonomic Irritation/Activity
Sympathetic
• Increased catecholamines
• Increased inotropy
• Increased chronotropy
• Increased BP
• Increased O2 demand
• Decreased CBF
• Decreased time for diastole
• Cardiac remodeling
• Impaired lymph drainage
Parasympathetic
• Decreased inotropy
• Decreased chronotropy
• Decreased BP
• Increased CBF
• Improved lymph drainage
• Myocardial stabilizing
 Parasympathetic Nervous System
Ipsilateral CN X - Vagus
Heart
Bronchial Tree
Right Vagus innervates Esophagus (lower 2/3rds)
Small Intestine
heart through the SA node Liver
Gallbladder
Hyperactivity Pancrease
predisposes to Sinus Kidney & upper ureter
Ovaries & Testes
bradyarrythmias Ascending and transverse colon

Left Vagus innervates heart Structures

Heart
through AV node Occiput
OM suture
OA
Hyperactivity predisposes AA
C2
to AV blocks
 Interpretation of findings
 TART (Tissue texture changes, Asymmetry, Restriction, Tenderness)
 Somatic Dysfunction along involved segments
 Establish chronicity (is it acute, chronic or acute on chronic)
 Identify visceral disease in the presence of an acute reflex finding
(dysfunction suboccipital as well as Left T3-4 and rib areas)

 Identify visceral disease in the presence of an chronic reflex finding

(dysfunction along T3-4 on the left in chronic cardiac disease)
 Interpretation of findings
ACUTE
• Increase in skin temp and
moisture
• Cutaneous hyperesthesia
• Red reflex
• Increased subq fluid (boggy)
• Increased mm contraction
• Motion testing may feel like a
hard rubber band – “firm
springiness”
CHRONIC
• Trophic changes in skin –
cool, dry
• Increased thickening of skin
and subq tissues (boggy
turns fibrotic)
• Localized mm contraction
involving 2 or more
segments
• Motion testing feels like
hard barrier
 Spinal Facilitation
• Self-sustaining loop beginning with sensory afferent
originating in periphery, spinal cord interneurons, and
ventral horn motorneurons/or to sympathetic chain ganglia
via white rami communicantes

• Incoming information can SPREAD above and below

incoming spinal segment – and two separate primary sites
can converge at common meeting ground

• Altered output from the ventral and lateral horn – effect on

paravertebrals and peripheral musculature
• Vasomotor effects, red reflex, tissue texture changes
• TART findings, acute vs chronic
Common viscero-somatic reflex patterns in the
paraspinal muscles
• Thyroid C7-8
• Bronchus T2-4
• Lung T2-5
• Pleura T1-11, same level
• Heart T2-5, left
• Stomach T5-9, left
• Duodenum T7-10, right
• Gallbladder T9, right
• Liver T5-9, right
 Somatic Findings
• Coronary arteries
• Viscerosensory from coronary arteries to upper ½ left chest and down inner arm to 4th and 5th digit on
left
• Classic MI
• Classic distribution over C8-T3 Dermatome usually when ventricle is involved
• Visceromotor via cardiac reflex causes muscle contraction and palpatory findings in left upper ribs as
well as demonstrated in T2-4 on the left

• Atria
• When atria involved usually in T4-5 dermatomal distribution

• Inferior and post wall MI show more consistent C2 dysfunction felt to be vagal mediated
 Somatic Findings
• Tacchyarrythmias:

• Thoracic crossovers and flattened

thoracic kyphosis have more
periods of tacchyarrythmias when
stressed-(Dr Kuchera’s clinical
opinion)

• Right pectoralis trigger point per

Travell associated with
tacchyarrthmias
Myofascial Trigger Points(mimics of MI)
 Scaleni
trigger point
referral

Travell and Simons’ Myofascial Pain and

Dysfunction, 2nd ed., 1999, Baltimore, MD. p. 506
 Serratus anterior
trigger point
referral

Travell and Simons’ Myofascial Pain and Dysfunction,

2nd ed., 1999, Baltimore, MD. p. 888.
Serratus posterior
superior trigger
point referral

Travell and Simons’ Myofascial Pain and Dysfunction,

2nd ed., 1999, Baltimore, MD. p. 901.
Perpetuating Factors for Trigger Points

• Postural
• Nutritional
• Systemic Diseases
• Psychological Disease
• Infections

From Travell
Respiratory-Circulatory Model
 Lymphatics
• Extrapleural lymphatics
drain to intercostal
vessels, to axillary
nodes and then to the
right or left lymphatic
duct
• Pleural sac and lung
tissues drain through
the pretracheal nodes
and then to the right
lymphatic duct.
 Evaluate for Chapman’s Reflexes:
Cardiac , Kidney , and Adrenal areas
Anterior Posterior
Heart Heart
2nd ICS near Cardiac T3 sup facet
sternum Adrenal
Adrenal Midway between
2-2.5” superior tip of transverse
and 1” lateral and spinous
to umbilicus processes at
intertransverse
Kidney space between
1” superior and T11-T12
1” lateral to Adrenal Kidney
umbilicus Kidney Midway between
tip of transverse
and spinous
processes at
intertransverse
space between
 Plan
Once medically managed and stable would consider OMT to address
patient from
Neurologic model
Respiratory-circulatory model
Structural /mechanical model
Energy efficiency model
 OMT Treatment Approaches
For MI-Initial Treatment- Assumes patient is medically managed and relatively
stable
Area Treatment Approach Anatomic/Physiologic Basis?Model
OA,AA Paraspinal inhibition ,BLT, FPR, Reduce pain(and associated anxiety), Reduces detrimental somatic
Upper Thoracics Suboccipital release, Rib raising influence to the facilitated segment and the heart (somatovisceral
(gentle) reflexes)
to reduce viscero-somatic chest pain.
Neurologic Model
OA,AA Paraspinal inhibition ,BLT, FPR, Reduces detrimental somatic influence to the facilitated segment
Cervical Suboccipital inhibition, Rib raising and the heart. (particular attention to these areas associated with
Upper thoracic (gentle) Arrythmia) Neurologic Model and Biomechanical Model
Rib
Upper thoracic somatic dysfunctions These areas are Paraspinal inhibition ,BLT, FPR, Reduces detrimental somatic influence to the facilitated segment that
usually located at T1–T2 and their corresponding Suboccipital inhibition, encourage inappropriate sympathetic outflow to the heart. (particular
ribs. attention to these areas associated with Tacchyarrythmias)
Neurologic Model

For Pectoralis consider inhibition or For Pectotoralis major TP Reduces detrimental somatic influence to the
Right Pectoralis major trigger point counterstrain facilitated segment and the heart (somatovisceral reflexes)

Neurologic Model and Biomechanical model

OA/AA and cervical region somatic dysfunctions. Suboccipital inhibition, Reduces detrimental somatic influence to the facilitated segment
FPR,BLT,Indirect MFR and the heart (normalize the vagal response).Particular attention to
these areas associated with Bradyarrhythmias and heart block

Neurologic Model
 OMT Treatment Approaches
For MI-Long Term Treatment
Area Treatment Approach
Upper thoracic region ME, Still, FPR. Particular attention
to Type II dysfunctions
Perform this type of
treatment once the patient is
ambulatory.
Thoracic Inlet Soft tissue, Technique selection may
Abdominal Diaphragm involve direct or indirect methods;
myofascial release; thoraco-
abdominal diaphragm release using
indirect methods.
OA,AA Articular/ME,BLT,FPR,MFR(indirect
Cervicals or direct)
Chapman’s Chapman’s Reflex
2nd ICS near sternum ; and superior T3 facet
posteriorly
Anatomic/Physiologic Basis?Model
Sympathetic and Parasympathetic balance
Neurologic Model
Diaphragm mechanics; reduce pain
Lymphatic drainage; respiratory mechanics
Respiratory –Circulatory Model
SNS ganglia stimulation; respiratory mechanics(Treatment of mid
cervicals may help with diaphragm function via the phrenic nerve)
Neurologic Model
Respiratory –Circulatory Model
Biomechanical Model
Neurolymphatic reflex (diagnosis & treatment)
Neurologic Model
Respiratory –Circulatory Model
 OMT Treatment Approaches
For CHF
Area Treatment Approach Anatomic/Physiologic Basis?Model
Upper Thoracics BLT,FPR ,Inhibition SNS balance
Treat chronic motion restrictions of
the upper thoracic region, if Neurologic Model
present. Perform this type of
treatment once the patient is
ambulatory.

Thoracic Inlet and Thoracoabdominal diaphragm
Suboccipital and mid cervical
Soft tissue, Technique selection may
involve direct or indirect methods;
myofascial release; and thoraco-
abdominal diaphragm release using
indirect methods.
Articular/ME,BLT,FPR,MFR(indirect
or direct),
Cervical spine suboccipital
inhibition.
Diaphragm mechanics; reduce pain
Treat as necessary to maintain proper diaphragmatic function
Respiratory –Circulatory Model
SNS ganglia stimulation; respiratory mechanics
Neurologic Model
Respiratory –Circulatory Model
Biomechanical Model

This treatment may help with

diaphragm function via the phrenic
nerve.

Chapman’s 2nd ICS near sternum,periumbilical Chapman’s Reflex Neurolymphatic reflex (diagnosis & treatment)
Adrenal and Kidney reflexes; and superior T3 facet Neurologic Model
,interspace ½ way between TP and SP of ribs 11- Respiratory –Circulatory Model
12,T12-L1 -posteriorly
 Cautions and Contraindications with OMT
and cardiac patients
1. Do not treat the patient in the supine position or treatment positions that restrict respiratory
efforts.
2. Do not treat with forceful direct method treatments.
3. Do not over treat .
4. Note that liver pump, liver flip, and classic thoracic pumps are all too vigorous. Avoid undue
sudden compression or decompression changes in abdomen or undue abdominal pressure as
the liver and spleen may be friable,
5. Continue to treat the patient to provide optimal lymphatic flow to reduce the amount of
scarring from the healing process.
6.Care and monitor not to overload a decompensated heart with overt pump techniques
Foundations, pp. 1015–1024.
 Todays lab
1. OMT portion of the Lab is to
2. Practice diagnosis from seated position and comparing to supine
diagnosis
3. Practice FPR for the cervicals from a seated and supine position
4. Practice ME for the cervicals from the seated or supine position
5. If time allows the student can practice treating with FPR and with no
change in hand position switching the treatment to ME
For example
Treating C2 ERSR.
Flatten the spine
Place C2 in ERSR position
Compress gently to C2
After 3-5 seconds return C2 to neutral
If a restriction is still present take C2 into FRSL position and carryout ME with isometric contraction
 Todays lab
• Screen
• OA,AA,(vagal influence by and on Cardia)
• Cervical (C3-5 can affect diaphragm)
• Thoracic (upper T spine with sympathetic influence on and from
Cardia))(T1-2 particularly with lymphatic concerns and thoracic
outlet)
• Ribs(upper 4 ribs with sympathetic influence on and from Cardia)
(Upper 4 ribsparticularly with lymphatic concerns and thoracic outlet)
• Lower Ribs and T spine due to Kidney and adrenal areas of posterior
Chapman’s as well as Thoracoabdominal diaphragm)
 Todays lab
• Diagnose
• OA, AA, Cervicals from a seated position

• From a supine position recheck your diagnosis of OA,AA and cervicals

• How does it change? Or does it?
• Can you make a diagnosis of these areas with the patient supine from
the side?
Segmental Evaluation
One hand on Cranium near vertex

Palpating hand on cervical vertebrae

With fingers grasping the posterolateral portion of
the OA or articular pillars

To check for ability to sidebend to the left

The vertex hand (with head) moves to the left
While simultaneously inducing vertebral translation
to the right

Start with OA and proceed vertebrae by vertebrae

to C7

Assess and compare motion of each vertebral

motion
 Direct inhibition 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,apply pressure
to match the tissue tension.
3. As tissue relaxes continue to match pressure.
4. This approach may be used at any para
cervical or para thoracic region with evidence
of tissue tension due to a viscerosomatic
reflex
 Facilitated Positional Release (FPR)

2 basic types of FPR

1. Superficial
Normalization of palpable
(superficial) abnormal tissue texture

2. Deep
Deep muscle involved in joint mobility

62
 FPR
Generally
• Straighten out any A-P curves
• Take the dysfunctional segment to position of ease
• Facilitating force applied either before or after segmental motion*
• Wait 3-5 seconds & return patient to the neutral position passively
• Take affected area past neutral into the “Feathered edge “ of the
direct barrier

63
 Superficial FPR
Primary Myofascial Dysfunction

1. Palpate (tissue texture abnormality)

2. Flatten the anteroposterior spinal curve to reduce
myofascial tension(if area is near axial skeleton)
3. Place the dysfunctional myofascial structure into its
ease (shortened, relaxed) position
4. Add a compression or torsional facilitating force
5. Hold for 3 to 5 seconds, then slowly release
pressure while returning to neutral. *
6. May take area past neutral and into edge of
restrictive barrier to encourage increased ROM.
7. Reassesses the dysfunctional components (tissue
texture abnormality, asymmetry of position, Foundations of Osteopathic Medicine 3 rd Ed. 2011: 813-820
restriction of motion, tenderness [TART]) Atlas of Osteopathic Techniques, 1st Edition 64
 Deep
Primary Articular (x-, y-, z-axis) Type I and II Dysfunctions
1. Make diagnosis (e.g., type I or II)
2. Flatten (flex or extend) the anteroposterior
curve in the spinal region of treatment
3. Add the facilitating force FIRST (compression
or torsion)
4. Move the dysfunctional segment toward its
flexion or extension ease
5. Move the dysfunctional segment toward its
side bending and rotational ease
6. Hold for 3 to 5 seconds, then slowly release
pressure while returning to neutral
7. May take area past neutral and into edge of
restrictive barrier to encourage increased Foundations of Osteopathic Medicine 3 rd Ed. 2011: 813-820
Atlas of Osteopathic Techniques, 1st Edition
65
 Deep FPR
• Diagnosis of triplanar vertebral dysfunction is necessary
• Flexion/Extension
• Sidebending
• Rotation

66
Hand placement for Seated Cervical FPR

One hand on vertex to control compression, rotation and sidebending. 67

Using “pincer grip “ with thumb and 1or2 fingers to monitor .
Hand placement for Supine Cervical FPR

One hand on vertex to control compression and somewhat rotation and sidebending.
Using “pincer grip “ with thumb and 1or2 fingers to monitor
as well as to encourage spinal sidebending.
68
 C2-C4 Dysfunction Example C4FRRSR
1.The patient lies supine, and the physician sits at the head of the
table.
2.The physician gently supports the cervical region with the right hand
3.With the left hand on the patients head , the physician neutralizes
the cervical spine by gently flattening the anteroposterior
curve(slight flexion)
4.An activating force(arrow) in the form of gentle (1 lb or less)axial
compression is added with the left hand
5.While maintaining compression, the physician gently positions the
patient’s head towards flexion and right sidebending and
rotation(arrows) until maximum reduction of muscle and tissue
tension is achieved(figs 12.3 and 12.4)
6.The physician holds this position for 3-5 seconds and then slowly
releases the compression while taking the area towards its position
of ease and then towards the restrictive barrier, then to neutral
7.If tissue relaxation is not noted within a few seconds ,axial
compression should be released and procedure should be repeated
8.Reassess Nicholas AS ,Nicholas EA, Atlas of osteopathic Techniques,2 nd
Ed, Lippincott
69
Williams and Williams,2012,(p.335)
 Contraindications
• Contraindications
• Inability to relax
• Herniated disc where the positioning could exacerbate the
condition
• Moderate to severe intervertebral foraminal stenosis, especially in
the presence of radicular symptoms at the level to be treated if the
positioning could cause exacerbation of the symptoms by further
narrowing the foramen
• Severe sprains and strains where the positioning may exacerbate
the injury

7
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 F RSL

• Extension is induced at the • Rotate & sidebend to the • Pt. actively sidebends to the
segment with the fingers right until motion is felt at left while the DO resists
the involved segment
 If Time allows or just for fun

• OA treatment with oculocephalogyric reflex

• FPR for rib 1
• Thoracic FPR( may also go from Thoracic FPR to Thoracic ME as we
practiced in the cervical region)
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. Reassess. Repeat again if necessary.
 First Rib Somatic Dysfunction
 
• The phyician places his near hand over the patient's rib with the fingers on the
posterior aspect of the first rib (right hand on right rib).
 
• The physician bends the patient's elbow and places his far hand over the
patient's flexed elbow, and then brings the humerus up to 90 degrees of flexion.

• The physician compresses down on the patient's elbow with the force directed
toward his monitoring fingers

• Maintaining this compression, the physician adds internal rotation of the

shoulder joint.
This is accomplished by placing the patient's right forearm on the ventral
aspect of the physician's near forearm and turning the patient's forearm
outwards by a caudal motion of the physician's forearm. This should create tissue
release or articular motion.
• The position is held for 3 seconds.
• Maintaining the compressive torsional force, the physician adducts the patient's
arm toward the midline and then circumducts the arm down to the table top
until the arm is along the patient's side
Posterior T spine Dysfunctions or Muscle Hypertonicity
 

•The physician monitors the somatic dysfunction with the hand

farthest from the patient.
 
•The patient is asked to sit up straight and push his chest forward.
 
•The physician's flexed elbow of his near arm is placed anterior to
the patient's shoulder with the forearm on top of the shoulder.
With this arm he compresses the thoracic region downward and
side-bends the region to the side of the dysfunction. With his
elbow he adds a rotary force drawing the patient's shoulder
posteriorly localizing to the site of the somatic dysfunction.
•Basically the physician is using is right hand and forearm to create
an axial load from the upper body straight toward the
dysfunctional area
 
•This position is held for 3 to 5 seconds.