You diagnose and treat the same way. To diagnose, perform each maneuver and determine which had the most resistance. To treat, do the maneuver for each area, but hold until you feel the release.

Mesenteric diagnoses/lifts do not involve the transverse colon b/c it does not have a mesentery.

• Small bowel- pull from umbilicus towards RUQ
• Cecum- cup the RLQ and pull up towards hepatic flexure (RUQ)
• Ascending colon- pull right side of abdomen towards umbilicus
• Descending colon- pull left side of abdomen towards umbilicus
• Sigmoid- cup the LLQ and pull towards umbilicus

Vs.   (4 main differences)

Colonic diagnoses/lifts do not involve the small bowel (1), you feel more medially (2), and you go in reverse order (3) AND YOU WON’T HAVE TO DIAGNOSE on the practical, just treat (4).

• Sigmoid
• Descending
• Transverse- pull epigastric area towards umbilicus
• Ascending colon

You will not need to do a valvular diagnoses or treatment for the practical either!

BLUE= useful stuff for boards you’ve prob not seen before

R torticollis= sidebent R (& rotated L)

Cervical extension w/ SB or R compromises the vertebral artery (branch of subclavian)

Rule of 3′s
T1-3   transverse process at level of spinous
T4-6   trans 1/2 segment above
T7-9   trans 1 whole seg above
T10      trans 1
T11      trans 1/2
T12      trans at

nipple at T4 level, scapula at T7, umbilicus at T10

diaphragm attaches to R 1st 3 lumbar vert, L 1st 2 lumbar

exhalation rib tenderpoint- tx at midaxillary line- 2min
inhalation rib tenderpoint- tx at angle- 2min

T2-4=  sinuses, dysfunction rotate towards the side with sinusitis
ie R sided sinusitis–>T3 N,R right,SB left

Rib Muscles utilized in tx:
rib1- ant scalene
rib2- post scalene
rib 3-5- pectoralis minor (med pectoral n.)
rib 6-9 serratus ant (long thoracic n.)
rib 10-12 lat dorsi

Rib motion
1-5= pump handle
6-10=bucket handle
11-12= caliper

True rib= 1-7
False rib= 8-10
Floating= 11-12

Spina bifida types:
1) occulta- failure of fusion of the post. elements of the spine, but intact thecal sac & normal spinal core
2) meningocele- failure of fusion, cystic outpouching of thecal sac, but no neural tube disruption
3) meningomyelocele- disruption of all areas of bony spine, open malformed neural tube

Back muscles:
Quad lumborum- extends & SB’s ipsi
Iliopsoas- hip flex & low extrem external rotator

Psoas syndrome–> key dysfunction= L1 or L2
-sometimes just treating L1/2 will fix
-patient is flexed and SB, can’t stand up straight
-other findings: contra pelvic shift, contra piriformis spasm, backward sacral torsion (in their language, that means they’ll have a L on R, or R on L)

Herniations:
almost always either L4-L5 (compressing L5 nerve root) or L5-S1 (comp S1)
those vulnerable b/c weak posterior longitudinal ligament
-pain is sharp, burning, electric and radiates down the leg
- pos straight leg test

Spondylolisthesis
-defect in pars interarticularis, one vert translating ant to rest, can feel the step down, see it on xray

vs Spondylolysis- same defect but no vert mov’t, see “collar on scotty dog” on xray

Sacral ligaments:
-sacrotuburous- ILA–>ischial tuberosity
-med border of greater sciatic foramen
-sacrospinous- ischial spine–>sacrum
-divides greater & lesser foramen
-iliolumbar- L4/5 trans processes–>PSIS
-generally 1st to become painful in lower back pain

Pelvic muscles:
-pelvic diaphragm- levator ani & coccygeus
-moves lymph back to heart
-piriformis- ant sacrum–>greater trochanter
-ext rotates femur
-11% of people have sciatic nerve running thru it= pain in butt that radiates down leg= “sciatica”

4 types of Sacral Motion:
1) postural ie bend forward–> sacrum moves POST on the MIDDLE TRANSVERSE axis
2) respiratory ie inhale–> POST on the SUP TRANS axis
3) inherent ie craniosacral flexion–> extends (or in their language, COUNTERNUTATES) on SUP TRANS axis
extension–> flexes (NUTATES)
4) dynamic (walking) ie bear weight on left foot–> engage the left axis

They won’t ask this…oh yes they did!
Q: during craniosacral motion, the sacrum nutates
A: sup transverse axis
Q: during inhalation, the sacral base moves posterior
A: sup transverse axis
Q: as the patient bends backward, the sacral base moves forward
A: middle transverse axis
Q: as a patient walks, weight bearing on the R leg while stepping forward with the L engages this axis
A: right oblique axis

Innom dysfunction:
Anterior   ASIS inf, PSIS sup, long leg, AP compression restricted, pos standing flexion
vs post= opp

Superior   ASIS/PSIS/pubic rami sup, AP comp, pos SF
vs Inf=opp

Outflare   ASIS lat, PSIS med, leg ext rot, pos SF, lat to med compression restricted
vs
Inflare      ASIS med, PSIS lat, leg int rot, pos SF, med to lat comp
(opp but just though I’d spell it out)

Pubic dysfunction:
Sup shear   pubic tubercle sup, pos SF
vs
Inf shear      pub tubercle inf, pos SF, AP comp restricted (not sure why)

Sacral Torsion Rules (VERY IMPORTANT!!)
1) if L5 is SB right- sacrum moves on R oblique axis
2) if L5 is R right- sacrum R left
–> put it together ie L5 SBrRr, then sacrum is L on R
3) if seated flexion test is pos, then the sacrum moves on the opp axis
4) when the sacrum is rotating to the same side as its axis, it will improve in the sphinx position
and spring freely (which is a NEG springing test!)
–>put it together ie pos seated flex test on the R, sacral dys worsens in sphinx, pos springing= R on L
5) ant sacrums spring freely, post sacrums don’t, but either way they give a FALSE NEG seated flexion test

You think I’m kidding?! Actual questions from Qbank-
1) L5 rotated left, sacrum springs freely     
A: R on R
2) free springing, neg seated flexion          
A: sacral base anterior
3) L5 SB left, sacral sulci findings improve with extension in the prone position
A: L on L
4) Lumbosacral area resists AP springing and the seated flexion test is neg
A: sacral base posterior
5) L5 R right, sacral findings exaggerated in extension in prone position
A: L on R
6) L5 R left, sacral findings exaggerated upon extension in prone position
A: R on L

Types of Muscle Contractions with examples from Qbank:
1) concentric- contraction resulting in the approximation of the muscle’s origin & insertion
ie the patient flexed his arm and touched his shoulder
2) eccentric- lengthening of the muscle during contraction due too an external force like gravity
ie electromyographic gait analysis demonstrates firing of the ant tibialis during the
loading phase when the heel strikes the ground and the foot falls flat
3) isolytic- contraction against resistance while forcing the muscle to lengthen, physician’s force is     greater than patient’s force
ie a patient with chronic muscle shortening contracts against resistance while
the physicians greater forces causes lengthening
4) isometric- contraction that causes an increase in the tensio w/o an approx’n of origin & insertion
ie a patient was asked to contract a mucles against equal resistance in a direct ME tx
5) isotonic- contraction that results in the approximation of the muscle’s origin & insertion w/o change in its tension
ie patient with muscle weakness of the triceps performs an extension exercise
with a 5 lb dumbbell
6) myotatic- contraction caused by sudden passive stretching or tapping of the muscle’s tendon
7) paradoxical- contraction due to passive approximation of its extremities

Rotator Cuff (SITS)
S= suprapinatus (abduction)–> most commonly injured, you’ll see pos drop arm test
I= infraspinatus (external rotation)
T= teres minor (ex rot)
S= subscapularis (internal rotation)

Normally the arm can abduct 180 degrees
-120= glenohumeral motion
-60= scalupothoracic motion
so 2:1 ratio! if less than this–called frozen shoulder

Thoracic Outlet Syndrome- compression of subclavian art & vein & brachial plexus at one of 3 places:
1) ant & mid scalenes
2) clavicle & 1st rib
3) pectoralis minor & upper ribs
-you’ll have neck pain radiating to arm, paresthesia

Supraspinatus tendonitis
-impingement of the greater tuberosity against the acromion as the arm is flexed and internally rotated
-you’ll have tenderness, esp at tip of acromion, pos drop arm

Rotator Cuff tear
-tear at insertion of a rotator cuff tendon, esp supraspinatus
-you’ll have tenderness just below the tip of the acromion, usually trauma involved where there was a sharp pain and a steady ached following for days, pos drop arm test, atrophy

Adhesive capsulitis/frozen shoulder
-pain and restriction of shoulder motion, usually b/c of prolonged immobility
-you’ll have pain in ant shoulder, restricted motion

weakness in ant serratus muscle= winging of scapula

Lateral epicondylitis=tennis elbow= strain in extensors
Medial=golfer’s=flexors

Pronation of ankle= dorsiflexion, eversion, abduction
Supination= opp

Post fib head= supinated foot

Pos ant drawer test= torn ACL
Pos valgus stress test= MCL
Pos varus stress test= LCL
Pos McMurrays= tear or displacement of medial meniscus
Pos Apleys compression= meniscus tears
Pos Apleys distraction= ligament tears

The most commonly injured ligament is the ant talofibular lig (Alwats Torn Lig)

Kaplan’s List of “Important” Chapman’s Points:
Appendix=tip of 12th rib
Adrenals=2 inches superior and 1 inch lateral to umbilicus and/or the spinous process of T11
Kidneys= 1 inch superior and 1 inch later to umbilicus and/or spinous process of L1
Bladder= at the umbilicus
Colon= along the femur
(I have seen all of these used in the middle of clinical scenarios, they really give away the diagnosis, ie person w/ severe hypertension, perfuse sweating, pallor & adrenal chapmans= pheochromocytoma= Great success!)

In craniosacral flexion, you’ll see:
-flexion of midline bones
-sacral counternutation
-dec’d AP diameter
-inc’d lat diameter
-all paired bones externally rotate

clinically depressed? dec’d cranial rhythm… tx: CV4 (also called bulb decompression)
(When in doubt, pick CV4, its been the answer to most of the cranial stuff)

Vault hold:
index finger on sphenoid
middle finger on zygomatic process of temporal bone
ring finger on mastoid process of temporal bone
little finger on occiput
thumbs crossed over sagittal suture

From OMM Review book

Fryette’s Principles
1) neutral will have SB & R opp (type I)
2) non-neutral will have SB & R same (type II)
3) moving a segment in any plane of motion will modify mov’t of the segment in other planes of motion

Myofascial definition= soft tissue technique directed at the muscle & fascia
Contraindications to myofascial= fracture, open wound, infection

Counterstrain definition= passive indirect, positioning at a point of ease, shortening the antagonist to relieve pain
How it works= resets the muscle spindle reflex
Same contra’s

Muscle energy definition= active direct, vol & precise mov’t against isometric resistance away from barrier
How it works= reflexive relaxation resets the Golgi tendon organ sensation of the induced tension
Contra’s= fracture or torn muscle, post surgical, ICU

Facilitated Positional Release def= passive indirect, derived from counterstrain, has 3 steps:
1) neutral positioning
2) facilitated motion by compression or torsion (activating force)
3) move toward freedom of motion in SB and R (indirect position)
How it works: same as counterstrain (and also same contra’s)

HVLAdef= passive direct, physician engages barrier and uses a precise, quick, small thrust thru the barrier
Wow there are alot of contra’s!
Absolute: osteoporosis, fracture, dislocation, skeletal neoplasm, RA, Down’s
Relative: blood problems in general, pneumonia, acute muscle injury, neuro probs, herniated discs, stroke, pregnancy, open wounds, recent surgery, hypermobile joints

Ligamentous Articular Strain (Balanced ligamentous tension) def= passive, balancing to point of ease
Contra’s= fracture, torn muscle

What type of reflex is a Chapman’s reflex? viscerosomatic
Same contra’s to treating them as counterstrain

What must you do before all lymph treatments? release the diaphragms

What is the common compensatory fascial pattern described by Zink?
OA rot L, CervicoThoracic rot R, ThoracoLumbar rot L, LumboSacral rot R

What is the uncommon? the opp
Why is this necessary? normal lymph flow

C1 has no spinous process or vertebral body
C2 has the dens
C7 does not have the vertebral artery thru its foramen transversarium

In cervical HVLA w/ rotational emphasis, which direction is the thrust?
C2-3= toward contra eye
C4-5= straight across
C6-7= toward contra axilla

Cervical tenderpoints-
all ant require flexion (except C4)
all post require extension (except C3)

What is the major determinant of the range in motion between vertebrae?
The size of the IV disc relative to the vertebral body (Remember- dec in ROM= dec in ratio)
Thoracic spine has smalled IV disc to vert ratio

Why are the bodies of T5-8 flattened on their L side? pressure from the descending aorta

Scoliosis= lateral curvature greater than 10 degrees
Most common scenario for idiopathic- 10yo girl, convex to the R
Functional= corrects on lying down (ie from short leg, muscle spasm, tumor)
Which vert should be targeted in tx? the one in the middle of the curve

What is the relation of the ribs to the sympathetic ganglia?
The ganglia lie ant to the head of each rib
So…Rib raising= normalizes sympathetics

Flail chest= TRAUMA- multiple rib fractures resulting in paradoxical mov’t of the thorax w/ resp, resulting in severe pain w/ poor ventilation (this was in Qbank too!)
Barrel chest=COPD (inc’d AP diam)
Pectus carinatum (pigeon chest)= inc’d AP diam w/ sternum anteriorly displaced
Pectus excavatum (funnel chest)= depression of the lower sternum which can compress the heart

Do thoracocentesis to treat pneumothorax or drain pleural fluid, should be placed at the fourth IC space just above the 5th rib (to avoid injury to the IC neurovasc bundle located below each rib)

Ant tenderpoints= depressed ribs
Post tenderpoints= elevated ribs
Hold these 120 sec (not 90 sec like everywhere else! this was in Qbank too!)

Perform lumbar puncture between L4 & L5 b/c the spinal cord ends between L1 & L2
The layers pierced through (out to in): skin, sup fascia, supraspinous lig, interspinous lig, ligamentum flavum, dura mater, subdural space, arachnoid, subarachnoid space

This was in bold–How is the tenderpoint of lower pole L5 treated with counterstrain?
Patient is prone and ipsi leg is dropped off the side of the table, the hip & knee are flexed and then used to induce internal rotation and adduction at the hip

Stork test- patient is standing, examiner has thumbs over PSIS’s, patient is asked to stand on one foot so they can flex the knee & hip to 90 degrees. The side with the least PSIS motion is the side of iliosacral locking.

Erichsen’s test (for sacroiliac disease)- patient is supine, examiner’s hands over lateral aspect of ilial alae bilaterally, examiner compresses medially. Pos test indicated by pain.

How many vert form to create the sacrum? 5
How many for the coccyx? 4 rudimentary
When do sacral vert fuse? After 20th year of life

Sacralization- L5 fusing with sacrum
Lumbarization- S1 separating from sacrum & fusing with L5

Most common vein used for venipuncture? median cubital in the antecubital fossa

What is nursemaid’s elbow? subluxation of the radial head

Which carpal bone most commonly fractured? scaphoid
Which most commonly dislocated? lunate

What is Dupuytren’s contracture? fibrosis and contracture of the palmar aponeurosis
You’ll see painless nodular thickening and raised ridges over the palmar surfaces, common in alcoholics

Cubitus valgus- carrying angle >15
Cubitus varus- carrying angle <5

Which artery is the main blood supply to the head of the femur? medial circumflex femoral
How does a person present with a femoral neck fracture? leg appears shortened and ext rot’d

What is SCFE? Slipped capital femoral epiphysis, in 10-17yo, weakened epiphyseal plate from acute trauma or obesity, most vulnerable in abduction & lat rotation, patient will have hip discomfort and dec’d ROM, referred knee pain, antalgic gait

What is Legg-Calve-Perthes disease? Osteochondritis deformans juvenilis or aseptic necrosis of ossification center of femoral head, you’ll have pain from groin, hip & thigh radiating to the knee, antalgic gait, inc’d ESR, psoas spasm

Unhappy triad of knee injuries? ACL, MCL, med meniscus
Mechanism? valgus stress w/ rotation on a planted foot

Genu varum= bow-legged
Genu valgum= knock-kneed

Bolded–What is the likely cause of unilateral lower extremity edema post-CABG?
dec’d venous return due to removal of great saphenous vein

Pes planus= flat foot
Pes equinus= plantarflexed so toe walk
Pes calcaneus= dorsiflexed so heel walk

Trendelenburg gait= injured sup gluteal n., weakness in glut medius & minimus
During stance phase of affected leg, the opp hip drops and patient SB’s toward affected leg to compensate

Vastus lateralis muscle can get the patella to track laterally in women with wider hips

Homan’s sign= DVT test= dorsiflex foot elicits pain in calf

Paired bones of head= parietal & temporal (though the frontal bone acts as a paired bone)
Unpaired= mandible & vomer

What dysfunction is typical in asthmatics? 3rd or 4th rib dysfunction

Others:
Indirect MFR= physiologic barrier
FPR= shifted neutral
Still= shifted neutral then restricted barrier
Regular Indirect= neutral position (BLT)

2) On the portal, all of this quarter’s videos should be up now, sorry for the lateness!

3) Select videos have been burned onto DVD’s and put into the library:

• Putting it all together
• Sacral diagnosis in regional context
• Sacrum Review

+ test = the PSIS came up (cephalad) as the person flexed from the waist….dysfunction is on the side that came up

+ standing, – seated = innominate dysfunction
- standing, + seated = sacral dysfunction
+ standing, + seated = sacral dysfunction

Think of it this way…

A STANDING flexion test takes into account the ilia.
A SEATED flexion test CANCELS out the ilia…the patient is sitting on them therefore they are nullified…at least for the purpose of this physical exam technique.

An innominate dysf will give you a + standing flexion test
A sacral dysf will give you a + seated flexion test and often a + standing flex test

Lumbosacral Spring Test

So if you have poor motion or pain, there is some posterior element, like extension, posterior margin, or R on L.

Backward Bending

Positive= more asymmentrical= your posterior is posterior

Negative= symmetrical= your anterior is anterior

OMM Fellow Michelle has joined the KCOM’s Biggest Loser Challenge. Starting off at 153 lbs, she made a monster loss of 4 pounds in the 1st week and 3 pounds in the 2nd!

Its getting a bit harder in the 3rd week to lose the weight, so she needs our support. If you see her next to the elevator, tell her to take the stairs! If you see he eating unhealthily, tell her to drop and give you 20!

Help us make Michelle the Biggest Loser!

From there, you would check the ILA’s to narrow down your 3-4 choices, then confirm with motion testing.

Hope this helps! ~Michelle

So for this, pull out the packet and follow along with the drawings…

1) For S/R & T, picture you are standing behind them & name it for what the occiput is doing.

Sidebending/Rotation

Scenario: A traumatic force to the left side of the head (at the level of the SBS).
Findings: Right hand will feel fuller/wider, but more caudad
Visualization from behind: Occiput is tipped to the right and rotated right
Diagnosis: Right sidebending/rotation

SBS Torsion

Scenario: You notice your patient has a wide orbit/prominent eye on the right (due to externally rotating sphenoid).
Findings: Left hand will feel to rotate posteriorly. Left index finger moves superiorly. Left fifth digit moves inferiorly (occiput moving caudad)
Visualization from behind: Occiput is tipped to the left (while greater wing peaks out on the right)
Diagnosis: Left SBS torsion

2) For V & L, you name it for the sphenoid…

Vertical Strain

Scenario: Your patient was punched with an upper cut to the jaw
Findings: Sphenoid moves in flexion while occiput is in extension, Index fingers move inferiorly (sphenoid base moves superiorly), 5th digits move superiorly (occipital base moves inferiorly)
Visualization from the side: Sphenoid is superior to the occiput
Diagnosis: Superior Vertical Strain

(If inferior strain, the scenario would involve a force at the base of the skull upwards, or on the forehead downwards… something to push the sphenoid down or the occiput up)

Lateral strain-

(Easy to confuse with torsion in terms of scenario! With torsions, its in the center of the head, at the SBS junction. In lateral strain, its anterior or posterior to the SBS.)

Scenario: Traumatic force to the left temple.
Findings: Index fingers move laterally to the right, 5th digits move laterally to the left, Parallelogram head!
Visualization from above: Sphenoid is shifted right.
Diagnosis: Right lateral strain.

(For left lateral, there will either be a force on the right temple, or the left side of the occiput… something to shift the sphenoid left or the occiput right)

For example: Yergason’s

This other great page seems to cover about everything the last page didn’t!

For example: FABER test

Summary:
+ ant drawer test= torn ACL
+ valgus stress test= MCL
+ varus stress test= LCL
+ McMurrays= tear or displacement of medial meniscus
+ Apleys grind= ligament tears
+ Yergason’s & Speed’s= biceps tendon injury
+ Phalen’s & Tinel’s= median nerve entrapment
+ FABER/Patrick’s= sacroiliac pain
+ Apprehension= anterior glenohumeral instability
+ Hawkin’s= rotator cuff impingement
+ Empty can= supraspinatus injury