Osteopathic Medicine Recall

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OSTEOPATHIC MEDICINE RECALL

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UOl103 S31U3S 11UJ3U

OSTEOPRTHIC

MEDICINE RECR Editors

Andrew D. Mosier University College of Osteopathic Medicine (OUCOM) Doctors Hospital at Stork County Beachwood, Ohio

Dai Kohara University College of Osteopathic Medicine (OUCOM) Cuyahoga Falls General Hospital Medina, Ohio

@. Wolters Kluwer I Lippincott Williams & Wilkins Health

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Andrew D. Osteop athic medicine recall/Andrew D. Mosier, Dai

Kohan,.

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Includes bibliographical re fe r en c es and index. ISBN-13: 978-0-7817-6621-0 ISBN-10: 0-7817-662 1-4 1.

Osteopat.hic Inedicine-Miscellanea.

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Koh ar.,

Dai.

II. Title.

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Ser ies. [DNLM: 1. Ma nipu lat ion. Osteopathic-Ex:lmination Qu es t io ns .

Osteo pathic Medicine-Examination Questions.

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A. T Stal, the father of osteopathic medicine

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Dedication

This book is dedicated to the entire dedicated faculty at Ohio University College of Osteopathic Medicine who encouraged us as students to master the fundamentals of osteopathic medicine. We would like to give special mention to Dr. Janet Bums, D.O., who spent countless hours encouraging us to follow our dreams to become knowledgeable physicians and help bring light to the field of osteopathic medicine. We would also like to devote this book to our families: Sue, Dennis, and Cindy Mosier, Aaron and Erin, Heidi, the "Chicago" Otts, Justin, Haruki, and Kazuyo Kohara for always believing in our far-reaching goals. \Vithout your love and support we could not have made it this far.

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Preface

Osteopathic lV1edicine Recall presents both students and teachers with an

up-to-date approach to learning and reviewing the basics of osteopathic med­ icine. The book uses a short question and answer format, addressing key prin­ ciples and high-yield information while maintaining the concept of the Recall Series that continues to be so widely utilized by medical students and physi­ cians throughout the world. The question and answer format gives the reader a chance to effectively review and read the most commonly tested fundamen­ tals, setting up a dialogue in the reader's mind that \vill assist in mastering the information. Osteopathic Medicine Recall is divided into 14 chapters to address topics in

a logically presented fashion that \vill make sense to the reader. The book has a strong emphasis on basic knowledge in osteopathic medicine, for it is our belief as fellow students that there is no concept too difficult to learn if the fundamentals are properly applied.

For this reason, the book begins lvith a

quick review of the most basic concepts in osteopathic medicine. Following the first chapter is a section devoted to both the axial and appendicular spine, the core of osteopathic medicine. Beginning with Chapter 4, select high-yield information is broken down into easy-to-read chapters that the reader should find both time effective and manageable. This book should be used by the reader as a gUide to understanding more difficult osteopathic texts, studying for board examinations, and recalling for­ gotten information quickly before hospital and office rotations where tech­ niques can be practically applied. The reader may choose to read through the book in short pieces between classes or while studying at night individually or with a group of colleagues. The book has also been designed so that the reader may read through the book in one weekend to brush up on the fundamentals of osteopathic medicine before a critical test. Osteopathic Medicine Recall was created to be a study guide with references listed for further reading. Many questions are concept questions \vith answers condensed from multiple para­ graphs and sometimes pages. The corresponding references have been listed to give you, the reader, the page(s) that best expound upon the answer pro­ vided for each question. The list of works cited appears in the back of the book. Please feel free to contact us if you have noted any acronyms that we may have overlooked or not used, if you have any corrections, or if you have any suggestions for possible future editions. You can reach us by e-mail in care of Lippincott Williams & Wilkins at LW\V.com/medstudent. We owe much gratitude to the contributing authors Ekokobe Fonkem, Chioma A. Ezeadichie, Jameelah Hanis, and Roxanna Rodriguez for their

ix

Copyrighted Material

x

Preface

Sands for their to

to undertake this text

Without their unconditional support and

endeavor could have never

h "

<,,,�,rl

Dai Kohara Andrew D. Mosier

Copyrighted Material

this

Contr'ibutors

Chioma A, Ezeadichie

Jameelah Harris

New York College of Osteopathic Medicine New York, New York

Doctor's Hospital Columbus, Ohio Chapters 7, 12

Chapters 2, 5 Roxanna Rodriguez Ekokobe Fonkem

Doctor's Hospital

St Joseph's Hospital

Columbus, Ohio

Warren, Ohio

Chapters 10, 11

Chapters 3, 6

xi

Copyrighted Material

Contents

Preface

ix

Contributors.

.xi

I.

T he Basics of Osteopathy

2.

T he Human Spine, Rib Cage. and Sacrum

3.

Upper and Lower Extremities

..38

4.

T he Autonomic Ner vous System

.57

5.

Lymph::ttics

.77

6.

Articulatory Techniques and Myofascial Release

.81

7.

Counterstrain

.85

8.

Facilitated Positional Release

.98

9.

Ligamentous Articular Strain.

10.

Muscle Energy

II.

The High Velocity. Low Amplitude Technique

12.

13

. ...101

.107

..124

Cranial Techniques and Osteopathy

139

in the Cranial Field 13.

Chapman Reflexes

14.

Travel! Trigger Points

...152

161

Works Cited

165

Figure Credits

167

Index

169

xiii

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Chapter

1

The Basics of Osteopathy

What are A ,T, Still's four

1. The body is a unit.

osteopathic principles?

2. The body possesses self­

1.10

regulatory mechanisms. 3. Structure and function are

reciprocally interrelated. 4. Rational therapy is based on

an understanding of the first three principles. What is the American

An impairment or altered

Osteopathic Association's

function among related

(AOA) definition of somatic

components of the body,

dysfunction?

including skeletal, arthroidal, and

1.567

myofa'icial structures, in addition to related vascular, lymphatic, and neural elements. A bodily state that deviates from

What is allostasis'?

U50

homeostasis, increasing activity of the neuroendoctine-immune network in response to any threat (i.e., disease, distress); the state of allostasis is supported by arousal of the sympathetic nervous system with increased levels of noradrenaline and cortisol. What does TART stand for

1. Tissue texture changes

when diagnosing osteopathic

2. Asymmetry

somatic dysfunction'?

3. Restriction

1.557, 1.562

4. Tendemess

'''hat are tissue texture

Edema, tendemess, hypertrophy,

changes?

atrophy, rigidity, bogginess,

1.562

stringiness What is restriction?

A joint \vith limited motion

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1.562

2

Osteopathic Medicine Recall

What is the only subjective component of the TART crite­ ria for somatic dysfunction?

component of the TART criteria

What is tenderness?

A discomforting or painful area

Tenderness is the only subjective

1.562, 1.634

for somatic dysfunction. 1.562

of tissue and the surrounding area of somatic dysfunction

What three types of barriers can an osteopathic physician encounter when searching for restriction using the TART criteria?

Anatomic (phYSiologic), restrictive

1.634

(pathologic), and elastic (which is the range between the physiologic and anatomic barrier of motion in which passive ligamentous stretch­ ing occurs before tissue disruption)

\\'hat is an anatomic barrier?

The point a physician or extemal forcl'

l' U1

1.634

passively move a given

joint to, but not beyond, without potential harm; this

C,Ul

be thought

of as the limit of passive motion.

What is a physiologic barrier?

The limit of active motion

1.634

What is a restrictive (pathologic) barrier?

A functional limit within the

1.634,

anatomic motion, which

12.8

abnormally decreases the normal physiologic range Normal R

( tJ> / __----'

>

,

(:. .j

/'

," - .... -

Ph barrier

\

\\

Ph 'Siologic Neutral

Right restriaion

t sor" r ";C dySf"nct;o nl

L (

' \!

barrier

left r t ..strictioo R ( ;g

, , , , \L! /:"

" ,-------.,\

.

(.,

/1 :­

('/ L

i

i oorner

Neutral

:

O

__

Phy ologic

ptl!'SIOIOgj(

barri(;;!r

,:

R

Restriction

PhYSiO,ogi barrier Restriction

Figure I-I.

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Nt.'Utral

Physiologic barrier

Chapter I I The Basics of Osteopathy A tissue texture abnormality

What is tissue bogginess?

3

12.8

characterized by a palpable sense of sponginess in tl1e surrounding tissues, resulting from congestion due to increased fluid content

A tissue texture abnormality

What is ropiness?

12.8

characterized by a cordlike or stringlike feeling

A tissue texture abnormality

What is stringiness?

12.8

characterized by palpable stringlike myofascial structures

Using the TART criteria: What type of tissue texture

Vasodilation, inflammation, warm

changes take place in acute

and moist skin, increased muscle

somatic dysfunction?

tone, edema, and bOgginess

What type of tissue texture

Cool and pale skin, decreased

changes take place in

muscle tone, doughy tissue texture,

chronic somatic dysfunction?

stlinginess, and fibrotic changes

What type of asymmetric

A visibly noticeable asymmetry

change takes place in acute

often "vith a history of recent

somatic dysfunction?

injury

What type of asymmetric

A long-standing asymmetry that

change takes place in

is less visibly noticeable because

chronic somatic dysfunction?

1562

1562

1562

1562. 1634

other body structures have compensated for the a<:ute asymmetry

1562

What type of reshiction

An acutely sluggish restriction,

takes place in acute somatic

often with a relatively normal

dysfunction?

range of motion

What type of restriction

Limited range of motion

1562

Severe, cutti n g and sharp

1562

takes place in chronic somatic dysfunction? "'hat types of tendemess

,

are felt in acute somatic dysfunction?

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4

Osteopathic Medicine Recall

What types of tenderness

Dull,

1562

are felt in chronic somatic dysfunc;tion? In acute somatic dysfunction.

The

increases.

12.8

what happens to temperature of the area rrount1Ul,e: the dysfWlctionai tissue? In acute somatic

the

128

what happens to of the surrounding dysfunctional tissue? In acute somatic dysfunction,

The tension is increased, and the

describe the tension of the

tissue feels rigid and boardlike to

dysfWlctionai tissue.

the examiner.

In acute somatic dysfunction,

Yes; edema o f the

is edema present?

tissu e

In acute somatic

The rednes lasts.

what

12.8

12.8

when an

erythema test (red is performed? In chronic somatic

12.8

dysfunction, what happens

is

to the temperature of the

sense of coolness is more

•

bv the exa miner

area surrounding the

.

dysfunctional tissue? It is absent and thl'

12.8

In chronic somatic

The tension

12.8

dysfunction, describe the

and the tissue

In chronic somatic dysfunction, what happens to the moisture of the tissue?

tension of the tissue.

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Chapter I / The Basics of Osteopathy In chronic somatic

No; although edema of the

dysfunction, is edema

dysfunctional tissue is present in

present?

acute somatic dysfunction, it is

5

12.8

usually not present in chronic somatic dysfunction.

In chronic somatic

The redness fades quickly or

dysfunction, what happens

blanching occurs.

12.8

when an erythema test (red reflex) is performed? What is a vertebral unit?

Two adjacent vertebra and their

1.569

associated arthroidal, ligamentous, muscular, vascular, neural, and lymphatic elements

What is a vertebral segment?

A single vertebra

1.569

True or False: AI] vertebral

True; this is a simple but easily

1.569

motions (flexion, extension,

and often confused basic concept.

sidebending (one word in style sheet) rotation, etc.) are described by how the anterior and superior surfaces of a vertebra move in relation to the vertebra below. How is somatic dysfunction

Somatic dysfunction is always

recorded by the physician:

recorded to the direction of ease,

to the direction of ease or to

the direction that the vertebra or

the direction of dysfunction?

1.569

dysfunctional joint can move most freely.

What is a direct treatment?

A technique where the

12.13

dysfunctional joint is positioned into restriction against its "

barrier"

What is the goal of a direct

To use force in such a way

treatment?

that motion will be created through and beyond the restrictive barrier

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12.13

6

Osteopathic Medicine Recall

12.13

What is an indirect is puslnulleu

treatment?

, in the direction where it most moves, away from the

barJier or restJiction of motion inherent

To allow the

of an

What is the

12.13

or intJinsic forces to

indirect treatment?

restriction of motion

Is a

at times it is direct, at

release

treatment technique direct

12.14-15

oth"r times it can be uscd

or indirect? at times it is direct, at

Is a ligamentous articular strain treatment te(�hlliQ

12.14-15

other times it can be used

direct or indirect? Is a counterstrain treatment

Indirect

12.14-15

Indirect

12.14-15

technique direct or indirect? Is a facilitated direct or indirect? Is a muscle energy treatment

Direct

techniaue direct or indirect?

in

it can be used

12.14-15

indirect manner)

Direct low

12.14, 12.15

or indirect? Is a cranial treatment

at times it is

technique direct or indirect?

at other times it can be used

When

Direct

is the treatment indirect?

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12.14-\5

12.14-15

Chapter 1 I The Basics of Osteopathy

When treating a Chapman

7

Direct

12.14-15

12.14-15

reflex, is the treatment direct or indirect? Is a myofascial release

Both; at times it is active, at other

treatment technique active

times it can be used in a passive

or passive?

manner.

Is a ligamentous articular

Both; at times it is active, at other

strain treatment technique

times it can be used in a passive

active or passive?

manner

Is a counterstrain treatment

Passive

12.14-15

Passive

12.14-15

Active

12.14-15

Passive

12.14-15

Passive

12.14-15

Passive

12.14-15

Passive

12.14-15

What osteopathic treatments

1. Chapman reflexes

12.14-15

are direct?

2. Lymphatic

12.14-15

technique active or passive? Is a facilitated positional release treatment technique active or passive? Is a muscle energy treatment technique active or passive? Is an HVLA treatment technique active or passive? Is a cranial treatment technique active or passive? When treating lymphatics, is the treatment active or passive? When treating a Chapman reflex, is the treatment active or passive?

3. HVLA 4. Muscle energy

What is the only osteopathic

Muscle energy

treatment that is always an active treatment?

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12.14-15

8

Osteopathic Medicine Recall

of the

Fryette laws

to the

1.569

thoracic and lumbar

What is another name for

Neutral mechanics

1.569

Side bending occurs first.

1571

Group

1 569--571

The spine

1571

type I motion i n first law? In type I motion, does side bending or rotation occur first? Are type I motion tions associated more with

vertebra? In type I motion, does the spine prefer flexion and extension or In type I motion do

They take

sidebending and rotation take

directions.

in opposite

1.571

place in the same direction or opposite directions? How would a

I motion

no

dysfunction be written if TIO was restricted in left

side bending? In type II motion, does

Rotation occurs first.

1571

sidebending or rotation occur first? A

Are type II motion

vertebra

157]

dysfunctions associated more with group dysfunctions or vertebra? In type II motion, does the

The

spine prefer flexion/extension

extension.

or neutrality?

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flexion/

1571

Chapter 1 / The Basics of Osteopathy

In t)'Pe II motion, do sidebending and rotation

9

They take place in the same direction.

1.571

no

ERRSR or no FRRSR, depending on whether the dysfunction was flexed or extended

1.571

Neutral mechanics Side bending before rotation in opposite directions 3. Restricted in the coronal plane 4. Croup dysfunctions

1.571

Nonneutral mechanics Rotation before sidebending in the same direction 3. No longer restricted in the sagittal plane 4. Single-vertebra dysfunction

1571

With a lateral CUlvature to the spine

125 . 6

The onset of pain is usually gradual.

12.56

Pain can be elicited on either the convex side (because of the sb·etched paraspmal musculature) or the concave side (because of the contracted paraspinal musculature).

1256

With either a flattening 01exaggeration of the anteroposterior (AP) spinal curve

12.56

take place in the same direction or opposite directions? How would a t)'Pe II motion dysfunction be written if TIO were restricted in left

sidebending? Summarize Fryette's first

1.

law of spinal mechanics.

2.

Summarize Fryette's second law of spinal mechanics.

1.

2.

How does the spine appear clinically to an examining physician when a t)'Pe I dysfunction is present? Is the onset of pain in a t)'Pe I dysfunction abrupt or gradual? Where is the site of pain usually elicited when palpating for a t)'Pe I dysfunction?

How does the spine appear clinically to an examining physician when a t)'Pe II dysfunction is present?

Copyrighted Material

10

Osteopathic Medicine Recall

in

12.56

abrupt or tn-'£u-IU!lrr» over the most nnd"'riAr

Where is the site of

12.56

facet

usually elicited when palpating for a we II dysfunction? What is

motion?

1.571

or relaxed voluntary

What is active motion?

1571

motion and end-feel

What type of information of a vertebral unit

1.571

of motion in each of the three

does passive motion ",n..ip·�

n..

cardinal

of motion

What I:)pe of information

An assessment of the vertebral

does active motion testing

unit's combined ease and

of a vertebral unit provide?

restriction of motion; this is

1.571

tbe transverse process as flexes or extends outside and free" neutral range. What does Frvette's third

Movement in one of the three

law of spinal motion

cardinal directions of motion

12.57

sidebending

describe?

and rotation)

a amount of flexion/extension and rotation would nOlmally be of and

Which directions are the facets oriented in the

medial

cervical spine?

Copyrighted Material

12.75-75

Chapter I I The Basics of Osteopathy Which directions are the

Backward, upward , and

facets oriented in the

lateral

11

12.76

thoracic spine? Backward and medial

12.76

The transverse axis

9.5-12

The anterior-posterior axis

9.5--12

The vertical axis

9.5-12

The sagittal plane

9.5--12

The coronal plane

9.5-12

The transverse plane

9.5--12

A sickel' patient should be

The sicker the patient, the less the

1.577

treated with a greater or

dose; caring and compasSionate

Which directions are the facets orient d in the lumbar spine? In what axis of motion does flexion and extension of the spine take place? In what axis of motion does sidebending of the spine take place? In what axis of motion does rotation of the spine take place? In what plane of motion does flexion and extension of the spine take place? In what plane of motion does sidebending of the spine take place? In what plane of motion does rotation of the spine take place?

lesser dosage (amount and

new D.O.'s often err on the side of

duration) of osteopathic

overdOSing/overtreating. Do not

manipulative therapy (OMT)?

forget to allow sufficient time for the patient to respond to the treatment.

Should pediatric patients

Pediatric patients can be treated

be treated more or less

more frequently; however, as with

frequently?

all fields of medicine, clinical judgment should be carefully applied.

Copyrighted Material

1.577

12

Osteopathic Medicine Recall

Should geriatric patients

Geriatlic patients need a longer

be treated more or less

interval to respond to treatment

frequently?

and should therefore be treated

1.577

less frequently; however, as with all fields of medicine, clinical judgment should be carefully applied. How should acute cases of

Acute cases should have a shorter

somatic dysfunction be

interval between treatments;

treated with regard to

the patient responds, the interval

frequency of treatment?

can be increased.

What part of the spine

The thoracic spine

1.577

What two body regions

Treat the upper thoracic spine

1.577

should be treated before

and ribs before treating the

treating the cervical spine?

cervical spine.

1.577

as

should be treated first in low back complaints where the psoas is presumed to be involved?

Should a physician treat the

Treatment of the thoracic spine is

ribs or the thoracic spine

recommended before treatment

first?

of specific rib dysfunctions.

True of False: For acute

False; for very acute somatic

somatic dysfunctions, focus

dysfunction, treat the secondary

your treatment immediately

and peripheral areas first to allow

on the dysfunctional area to

access to the acute area.

1.577

1.577

prevent further damage to the tissues. What type of osteopathic

Cranial techniques (discussed in

treatment may relax the

Chapter 12 with further detail)

1.577

patient and allow OMT to be more effective in other areas of the body? How should a physician

The physician should treat the axial

approach treatment of

skeletal components first and then

somatic dysfunction in the

reassess the exiremities for the

arms and legs?

best possible ensuing treatment.

Copyrighted Material

1.577

Chapter

2

The Human Spine, Rib Cage, and Sacrum

Cervical Spine

Which cervical vertebrae

Cl, because it has no spinous

are considered atypical?

process or vertebral body, and

9.1047

C2, because it has a dens

What cervical vertebrae are

C3-C6, because they all have

considered typical?

bifid spinous processes, facets,

9.1047

articular pillars, a vertebral body, and foramen transversariums

What is the clinical

They are used to evaluate

significance of the articular

cervical motion and are located

pillars?

between the superior and inferior

1.688

facets.

What is the function of the

They sidebend the neck

scalene muscles?

ipsilaterally with unilateral

9.10261027

contraction and flex the neck with bilateral contraction.

What are the attachments

The anterior and middle scalenes

for the scalene muscles?

attach to rib 1 and help to elevate

9.l0571058

this rib during forced inhalation. The posterior scalene attaches to lib 2 and helps to elevate this rib dUling forced inhalation.

What muscle divides the

The sternocleidomastoid muscle

neck into anterior and

9.1053-

lOSS

posterior triangles? Torticollis results from

The sternocleidomastoid muscle

shortening or restriction

9.10551056

of which muscle(s)?

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I]

14

Osteopathic Medicine Recall

Which conditions can weaken

Rheumatoid arthritis and Down

the alar and transverse

syndrome

3.209

ligaments causing atlantoaxial

(AA) subluxation? What are the most common

Degeneration of the jOints of

causes of cervical nerve root

Luschka and hypertrophic

compression?

arthritis of facet joints

What are the signs and

1. Neck pain radiating to the

symptoms of intervertebral

3.212, 3.219

3.2193.220

upper extremity 2. Increased pain with neck

foraminal stenosis?

extension .3. A positive Spurling test

4. Paraspinal muscle spasm 5. Cervical tenderpoints How many cervical nerve

Eight nerve roots

13.330

roots are there?

CI-C7 exit above their corresponding vertebrae. C8 exits between C7 and Tl. Do Fryette's first and second

No; they apply only to the

laws apply to cervical

thoracic and lumbar vertebrae.

1571. 1.12421243

The occipitoatlantal (OA) joint

3188

vertebrae? Flexion and extension is the main motion for which Note: The

cervical segment?

OA joint is kno\\

as

the "yes joint" because it nods the head forward and back, as if shaking your head yes Rotation is the main motion

The AA joint along with C2-C4

3189

for which cervical segments? Note: AA is known as the "no

joint" because it rotates the head from side to side, as if shaking your head no. Sidebending is the main

The C5-C7 segments

motion of which cervical segments?

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3.189

Chapter 2 / The Human Spine, Rib Cage, and Pelvis

Do the OA and AA joints

T he OA and AA joints sidebend

sidebend and rotate in the

and rotate in opposite directions,

IS

3.1883.189

same direction or opposite directions? Do the C2-C7 cervical

The CZ-C7 cervical segments

segments sidebend and

sidebend and rotate to the same

rotate in the same direction

side,

3.188189

or opposite directions? Translation of C3 to the

Translation and sidebending are

right corresponds with

opposite of each other; therefore,

which direction of

light translation of C3 corresponds

sidebending?

with sidebending C3 to the left.

How is rotation at t.he

By flexing the neck to 45°,

joint tested?

because after the cervical spine

3.579580

3.582583

has been flexed to 45°, rotation at all other cervical joints from CZ-C7 is locked out. What initial treatments to

1. Indirect facial release

the cervical spine are best

Z. Counterstrain

indicated for acute injury?

3. Cranial techniques

1.688

Thoracic Spine

Which thoracic segments'

Levels Tl-T3, TlZ

1.715

Levels T4-T6, Tll

1.715

Levels T7-T9, TIO

1.715

spinous processes are located at about the same level as their corresponding h'ansverse processes? Which thoracic segments' spinous processes are located about one-half segment below their corresponding transverse processes? Which thoracic segments' spinous processes are located about one entire segment below their corresponding transverse pl'Ocesses?

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16

Osteopathic Medicine Recall

The level of the T2 vertebra

9.83

The T4 dermatome

9.51-53

The level of the T3 vertebra

9.83

The level of the T7 vertebra

9.83

The TI0 dermatome

95 . 1-

The level of the T4 vertebra

9.83, 13.141

What is the main motion of

The main motion of the thoracic

1.713

the thoracic soine-flexion!

spine is rotation,

The sternal notch corresponds to which thoracic vertebrae? What dennatome level is associated with the The spine of scapula corresponds to which thoracic vertebrae? The inferior angle of the scapula corresponds to which thoracic vertebrae? What dermatome level is associated with the umbilicus? The sternal angle of Louis corresponds to which thoracic vertebrae?

extension, sidebending, or rotation? to

1242-

thoracic

1243

Rib

\'\tbat are the primary

The diaphragm and intercostal

muscles of resnlrationi'

muscles

What are the

'''''.�nrul!.rv

muscles of re mirallOlrlt

1, Scalenes

9.93-998

2, Pectoralis minor 3, Serratus anterior and 4,

lumborum

5, Latissimus dorsi

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9.93-98

Chaprer 2 ! The Human Spine, Rib Cage, and Pelvis

'What are the attachments

17

13.234235

of the diaphragm? vPr·tpt)( 1 bodies 4. Intervertebral discs

V\'hat ribs are considered

Bibs

the typical ribs?

have a

through 9, because

ll142

and shaft

What ribs are considered

I. Rib 1, because it has no

13.142

and articulates only

the atypical ribs?

Tl 2. Rib 2, becausc of the

its shaft for the serratus anterior muscle .3. Ribs 11 and 12, because

have no tubercles with vertebrae it Bib 10

sometimes

considered because it articulates with TlO. For

know that

any rib with a 1 or 2 in number is considered

What ribs are referred to as

Ribs 1 through 7, because

the tme ribs?

attach to the sternum via the

l3.142

costal

"''hat ribs are I"eferred to as

Ribs 8

the false ribs?

do not

Copyrighted Material

11142

18

Osteopathic Medicine Recall

Jugular notch Manubrium Angle of

SternurT

Louis

True ribs

(1-7)

f.yl-A Costal

cartilageS

False ribs (8-12)

Figure 2-1.

13.142

What ribs are referred to as

Ribs 11 and 12, because they do

the floating ribs?

not attach to the sternum

Pump handle motion is the

Ribs 2 through 5

9.8 90, 1.720722

Bibs 6 through 10

9.89-90, 1.720722

Bibs 11 and 12

1.720-722

primary motion of which ribs? Which ribs move primarily with a bucket handle motion? Which ribs move primarily with a caliper-like motion?

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Chapter 2 I The Human Spine. Rib Cage. and Pelvis

19

Bucket handle motion

Pump handle motion

-

,1

... .. "

-----

.... ----..---

,./ "," "

- -sf-f

----

Caliper-like motion

Figure 2-2.

To varying degrees, do all

Yes; although ribs can be

ribs exhibit each of the

grouped by the primary type

three types of characteristic

of motion they demonstrate,

rib motion (pump handle,

including pump handle, bucket

bucket handle, and caliper­

handle, and caliper-like, all ribs

like)?

to varying degrees exhibit each of

1.720722

the three types of characteristic rib motion. \Vhat are the most common

Inhalation and exhalation rib

types of rib dysfunction?

dysfu net ions

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1.l245

20

Osteopathic Medicine Recall

What are the characteristics

The dysfunctional rib will move

of an inhalation dysfunction

cephalad during inhalation but

rib?

will not move caudad during

1724, 1.1245

exhalation; this indicates that the rib is stuck upward. What are the diagnostic

1. The rib is elevated anteriorly.

findings of an inhalation

2. The anterior rib moves

dysfunction pump handle

cephalad and is stuck on

rib?

inspiration.

4.123, 4.129

3. Anterior narrowing of intercostal space above the dysfunctional rib. 4. A prominent posterior rib angle

.

What are the diagnostic

1. The rib is elevated laterally.

findings of an inhalation

2. The shaft moves cephalad and

dysfunction bucket handle

4.123, 4.129

is stuck on inspiration. 3. Lateral narrowing of

rib?

intercostal space above the dysfunctional rib occurs. 4. There is

a

prominent lib shaft .

What are the characteristics

The dysfunctional rib will move

of an exhalation dysfunction

caudad during exhalation but

rib?

will not move cephalad during

1.724, 1.1245

inhalation; this indicates that the rib is stuck downward. What are the diagnostic

1. The lib is depressed anteriorly.

findings of an exhalation

2. The anterior rib moves caudad

dysfunction pump handle

4.126, 4.131

and is stuck on expiration. 3. Anterior narrowing of

rib?

intercostal space below the dysfunctional rib occurs. 4. There is a prominent posterior rib angle. What are the diagnostic

1. The rib is depressed laterally.

findings of an exhalation

2. The rib shaft moves caudad

dysfunction bucket handle rib?

and is stuck on expiration. 3. Lateral narrowing of intercostal space below the dysfunctional rib occurs.

Copyrighted Material

4.126, 4.131

Chapter 2 / The Human Spine. Rib Cage. and Pelvis

What is a key rib?

A lib that is "stuck" (little

21

1.722

mobility or immobile); this rib is usually considered the rib that causes the group dysfunction. The lowest rib of the dysfunction

1.723724

In an exhalation group

The uppermost rib of the

dysfunction, which rib is the

dysfunction

1.723724

In an inhalation group dysfunction, which rib is the key rib?

key lib? In a gl"OUp dysfunction ,

The key rib

1.723

The antelior and middle scalenes

3.565

The postelior scalene muscle

3.565

Pectoralis minor

3.565

Serratus anterior

3.565

Latissimus dorsi

3.565

Quadratus lumborum

3.565

treatment is directed at which rib? Which muscles are targeted for a muscle energy technique when treating a first rib dysfunction? When treating a dysfunction of rib 2 with muscle energy, what muscle is targeted? When treating a dysfunction of ribs 3 through 5 with muscle energy, what muscle is targeted? When treating a dysfunction of ribs 6 through 9 with muscle energy, what muscle is targeted? When treating a dysfunction of ribs 10 and 11 with muscle energy, what muscle is targeted? When treating a dysfunction of rib 12 with muscle enel'gy, what muscle is tal'geted?

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22

Osteopathic Medicine Recall

Lumbar True or False: At L4 and L5,

longitudinal

the

3.250

as it

ligament is half the width

that it is at Ll.

Where does the L3 nerve

It exits between L3 and L4.

9.518520

The L4 nerve root

9.518

root exit the spinal column? A herniation at L3-L4 Mil

521

compress what nerve root? What is the most common

Facet troohism

3.449

in the lumbar

In what lumbar

The lumbar

condition would the

kno\vn

condition

9.494

In what lumbar spinal

The lumbar spinal condition

9.494

condition does Sl fail to

known

transverse processes of L5 be

and abnormally

articulate Mih the sacrum?

as

fuse with the other sacral

What bony structure is

The lamina of L5 (aneVor Sl),

defective in

because it fails to

bifida

fuse

occulta? What

and

stnlcture is

defective in

One or

of spina bifida is

of

13.316, 9.494· 496

because

bifida

A

u()mvpl()t'Pip

a."''''''HT�''' with neurological deficits?

Copyrighted Material

13.316, 9.494496

(herniation

13.316, 9.494496

Chapter 2 I The Human Spine, Rib Cage, and Pelvis What is the main motion

The main motion of the lumbar

of the lumbar spine?

spine is flexion/extension.

How does motion at L5

l. Sidebending of L5 engages the

influence sacral motion?

23

1.737738 U80

ipsilateral sacral oblique axis.

2. Rotation of L5 causes rotation of sacrum to opposite side. What are some prominent signs and symptoms of back strain/sprain '?

l. Achy pain in the low back

9.478

buttock or posterior-lateral thigh

2. Increased pain with activity, prolonged standing, or sitting

3. Increased muscle tension What are some prominent

l. Numbness; tingling; and sharp,

signs and symptoms of a

burning, andJor shooting pain

herniated disc?

in the lower back, radiating

6.276

down the leg beyond the knee; worsens \vith flexion of the lumbar spine

2. Weakness 3. Decreased deep tendon reflexes (DTRs)

4. Sensory loss associated with the nerve root What test can be performed

A straight-leg raising test; the test

to check for disc herniation?

is positive if pain radiates beyond

1488

the knee. How is a herniated disc

Beu rcst and indirect osteopathic

typically managed?

manipulative therapy (OMT)

6.276

techniques, followed by gentle direct techniques; very few herniations require surgery. What are the more common causes of iliopsoas syndrome?

l. Prolonged positions that shorten the psoas llIuscle

2. Appendicitis 3. Ureteral calculi 4. Salpingitis 5. Prostatitis 6. SigmOid colon dysfunction 7. Ureter dysfunction

Copyrighted Material

1.748, 3.484

24

Osteopathic Medicine Recall

What are some prominent signs and symptoms of

1. Achy or spasmic low back pain that sometimes radiates to the

1.747748

groin

iliopsoas syndrome?

2. Increased pain when standing

or walking 3. Ll or L2 FRS (flexed, rotated, and sidebent) to same side 4. Positive pelvic shift test to the contralateral side

5. Contralateral piriform s spasm I

6. Sacral dysfunction on an

oblique axis What test can be performed

A Thomas test that is positive if

to check for iliopsoas

the patient's tight hip flexors \-vill

1.743

not allow the affected leg to

synd"ome?

completely straighten out when the opposite leg is flexed to the chest with the patient in a supine position How do you treat iliopsoas

1. Ice to decrease edema and pain

syndrome?

2. Counterstrain to the anterior

1.748, 3.488489

iliopsoas tenderpoint 3. Muscle energy or high velocity, low amplitude (HVLA) to Ll or L2 Degenerative changes in

Spinal stenosis, a condition

the lumbar spine, such as

that can lead to nerve root

hypertrophy of facet joints,

compression

9.489-490

loss of intervertebral disc height, and calcium deposits within ligaments, can lead to what spinal condition? What are some prominent

Achy, shooting pain,

signs and symptoms of

or paresthesias in the low back

spinal stenosis?

that radiates to the lower leg, along ",rjth pain that is worsened by lower extremity extension (standing, walking, or lying supine)

Copyrighted Material

3.575, 6.277

Chapter 2 / The Human Spine, Rib Cage, and Pelvis What radiographic findings

Osteophytes and a decreased

are commonly pl-esent in

intervertebral disc space

25

3575

spinal stenosis? How is spinal stenosis usually managed?

1. OMT to decrease any

6.277

restrictions and improve range of motion 2. Physical therapy 3. Nonsteroidal anti­

inflammatory drugs (NSAIDs) or low-dose steroids 4. If needed, epidural steroid

injections or a surgical decompressive laminectomy What is spondylolisthesis?

Anterior displacement of one

1.1250

vertebra in relation to the vertebrae below owing to fracture of par interarticularis; it often occurs at LA or L5. What are some prominent signs and symptoms of spondylolisthesis?

1. Achy pain in low back,

buttock, or posterior thigh 2. Increased pain with extension

3366367, 1.625, 1.627

3. Tight hamstrings bilaterally 4. Positive vertebral step-off sign Note. Half of all patients

with spondylolisthesis are asymptomatic. What radiographic findings

Anterior displacement of one

are commonly present in

vertebra on another seen with

spondylolisthesis?

lateral x-rays of the lumbar spine

What is spondylolysis?

Fracture of the pars interarticularis without anterior displacement of a vertebral body

What radiographic findings

Oblique x-rays of the lumbar

are commonly present in

spine will show what resembles

spondylolysis?

a "collar on the neck of a Scottie dog" sign.

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3.366367

13315, 13320, 1.490

6.278

26

Osreoparhic Medicine Recall

Degenerative changes withi. n .

What is spondylosis?

intervertebral disc and ankylOSiS of adjacent vertebral bodies What radiographic findings

1.1251, 13.315, 13.320

Lipping of the vertebral bodies

6.278

'\'hat causes cauda equina

A large central disc hemiation

syndrome?

that exerts pressure on the nerve

1.744, 6.276

are commonly present in spondylosis?

roots of the cauda equina What are some prominent

1. Saddle anesthesia

signs and symptoms of

2. Decreased DTRs

cauda equina syndrome?

3. Loss of bowel and

1744, 6.276

bladder control Is surgery required for

Yes; emergency surgery is

treatment of cauda equina

necessary and if delayed may

syndrome?

lead to irreversible paralysis.

1744

Scoliosis and Short Leg Syndrome

How is scoliosis named?

A curve that is sidebent left

6.226

causes scoliosis to the right, known as dextroscoliosis, and a curve that is sidebent right causes scoliosis to the left, known as levoscoliosis. What type of spinal curve

A functional curve: A Functional

is flexible and can be

spinal curve can be Fixed.

1.619, 6.227

corrected with sidebending or rotation? What type of spinal curve

A stmctural curve: You are STuck

will not correct with

with a STructural spinal curve.

sidebending or rotation? How do you measure

By evaluating the Cobb angle on

scoliotic curves?

an x-ray

Copyrighted Material

1.619, 6.226227

1620, 6.227

Chapter 2 I The Human Spine, Rib Cage, and Pelvis

27

Curvature

,----- Upper end vertebra of thoracic curve (highest vertebra with superior border Inclined toward thoracic concavity)

---':..,..30"..,---

Transitional vertebra (lowest vertebra with inferior border inclined toward thoracic concavity and highest vertebra with superior border inclined toward lumbar concavity)

toward lumbar concavity)

___ _

Figure 2-3.

What is the most common

Idiopathic; other causes include

cause of scoliosis?

congenital, neuromuscular, and acquired

Copyrighted Material

3.351, 1.619

28

Osteopathic Medicine Recall

How is scoliosis usually

1. For mild scoliosis: Physical therapy, Konstancin exercises, and osteopathic

IllcUllIIJW'<1UIV""

1.622, 3339, 3.354

(O IT). 2.

"Jfvlp,-nj'p

scoliosis: The

treatment for mild scoliosis in addition to

orthotic

bracing. scoliosis:

3. For

is

indicated. 1. The sacral base of short

lower on

the side of the short Anterior innominate rotation 3. Posterior innominate rotation 4. An increased 5.

lumbar

will

sidebend away and rotate toward the 5hOli leg side. What is the most common

The total hip

cause of an anatomic

most common cause of an

is the

anatomic leg 3.346

How is short usually managed?

Sacrum and Innominates What three bones make up

1. Illium

the innominate?

2. Ischium

1.762

3, Pubis V"'hat parts of the sacrum

The sacral base, sacral sulci,

are relevant for diagnosing

inferior lateral

sacral

of the SaCllln1,

Copyrighted Material

(IL"-) the psrs

1780781, 6.313

Chapter 2 / The Human Spine, Rib Cage, and Pelvis

Which ligaments help to

The sacroiliac ligaments

stabilize the sacroiliac (SI)

(anterior, posterior, and

joint?

interosseous)

Testing the tension of which

The sacrotuberous ligament,

ligament aids in diagnosing

which runs from the ILA to the

somatic dysfunction of the

ischial tuberosity

29

3406

3.407

sacrum? Which ligament divides the

The sacrospinous ligament,

greater and lesser sciatic

which runs from the sacrum to

foramen?

the ischial spine

In lumbosacral

The iliolumbar ligament

3407

Where does the iliolumbar

It originates from the L4 and L5

3.407

ligament attach?

transverse processes and attaches

3407

deL'Ompensation which ligament is often the first to become painful?

to the medial side of the iliac crest. What muscles make up the

The levator ani and the

pelvic diaphragm?

coccygeus muscles

In some people, the sciatic

The piriformis muscle

3.408

The piliformis muscle

3408

,,yhat motions occur around

Respiratory motion and

the superior transverse

craniosacral (inherent) motion

1.768, 3401

3408

nerve runs through what muscle? Hypertonicity of what muscle can cause buttock pain that radiates down the thigh without reaching the knee?

axis of the sacrum located at S2?

Copyrighted Material

30

Osteopathic Medicine Recall

Vertical axis

Superior transverse axis and craniosacral axis

Middle transverse axis

Inferior transverse axis'

Left oblique axis

Superior transverse axis

Craniosacral axis Middle transverse axis Anteroposterior axis

Inferior transverse axis

Figure 2-4.

Copyrighted Material

Chapter 2 / The Human Spine. Rib Cage, and Pelvis

31

Postural-type motion

1.768

What motion occurs around

Innominate rotation (during

1.768

the inferior axis of the

walking)

What motion occurs around the middle transverse axis of the sacrum?

sacnJm? While walking (dynamic

Weight bearing on the left leg

motion), what causes a left

while stepping forward with the

sacral oblique axis to be

right leg

1.768

engaged? An innominate dysfunction

6.305

Anterior innominate dysfunction

1.777. 4.219

If the standing flexion test is

Right anterior innominate

positive on the right, the

dysfunction

1.777. 4.219

A positive standing flexion test is used for the diagnosis of what type of dysfunction? What type of dysfunction occurs when a tight quadriceps muscle causes an innominate to rotate more anteriorly compared to the other?

right ASIS is more inferior, and the right PSIS is more superior, what is the diagnosis? Posterior innominate dysfunction

1.777, 4.214

If the standing flexion test is

Left poste11or innominate

positive on the left, the right

dysfunction

1.777, 4.214

What type of dysfunction occurs when a tight hamstring muscle causes an innominate to rotate more posteriorly compared to the other?

ASIS is more superior, and the right PSIS is more inferior, what is the diagnosis?

Copyrighted Material

32

Osteopathic Medicine Recall

If the standing flexion test is

Right innominate upslip, also

positive on the right , the

k':nown as a light superior

1.778, 4.223, 6.310-

right ASIS and PSIS are

innominate shear (Table 2-1)

3Jl

If the standing flexion test is

Right innominate downslip, also

positive on the right, the

known as a right infel10r

right ASIS and PSIS are

innominate shear

1.778, 6.310311

more superior, the right pubic rami is more superior, and the right leg appears shorter, what is the diagnosis?

more inferior, the right pubic rami is more inferior, and the right leg appears longer, what is the diagnosis? A tight rectus abdominus

A supel10r pubic shear

1.778, 4.185

An inferior pubic shear

1.778, 4.187

muscle causing an ipsilateral pubic bone to be displaced superiorly is known as what? Tight adductors that pull the ipsilateral pubic bone inferiorly can lead to what type of dysfunction? What types of dysfunctions

Sacral torsions

occur about the sacral

1.77S-

779

oblique axes? True or False: The seated

True; therefore if the seated

flexion test is positive on the

flexion test is positive on the

1.773,

1.779

opposite side of the engaged

right, the left sacral oblique axis

sacral oblique :u.is.

is engaged.

If L5 is ERRSR, on what side

On the left side

1.780781

If L5 is NSRRv what is the

The sacrum would be rotated right

sacral diagnosis?

on a right oblique axis (R on R).

1.780781

is the seated flexion test positive?

Copyrighted Material

Table 2-1.

ILA

Deep

Shallow

L5

Seated

Lumbar

Sphim:

Posterior

Sulcus

Sulcus

Rotation

Flexion

Spring

Test

Diagnosis

Right

Right

Left

Right

Negative

Negative

Right unilateral shear

Left

Left

Right

Left

Negative

Negative

Left unilateral shear

Right

Left

Right

Rigllt

Left

!\cgative

\'egative

Right on rigllt (R on R) rotation

Right oblique

Right

Left

Right

Left

Left

Negative

Negative

Right on right (R on R) torsion

Right oblique

Left

Right

Left

Left

Right

Negative

Negative

Left on left (L on L) rotation

Left oblique

Left

Rigllt

Left

Right

Rigllt

Negative

Negative

Left on left (L on L) torsion

Left oblique

Right

Left

Right

Right

Right

Positive

Positive

Right on left (R on L) rotation

Left oblique

Right

Left

Right

Left

Right

Positive

Positive

Right on left (R on L) torsion

Left oblique

Left

Right

Left

Left

Left

Positive

Positive

Left on right (L on R) rotation

Right oblique

Left

Right

Left

Right

Left

Positive

Positive

Left on light (L on R) torsion

Right oblique

Even

Bilateral

Equivocal

Negative

Negative

Bilateral sacral flexion

Transverse

Equivocal

Equivocal

Bilateral sacral extension

Transverse

Bilateral

Even

... ...

Results

Tests

Static Findings

From DiGiovanna

2005:320 .

fL,

Schiowitz

S,

Dowling

OJ,

eds. An Osteopathic

Approach

to Diagnosis and Tr('atTnent . .3rd ed.

Copyrighted Material

Axis

---Philadelphia: Lippincott \Villi"ms & \\·ill.:ins,

]4

Osteopathic Medicine Recall

When is a lumbosacral

When the sacral base is posterior

1.781

Lon Land R on R

l.778, 4.203

spring test positive? What two dysfunctions are considered forward sacl"al tOI"sion?

Deep Sulcus Left axis

on

Left axis

on

Neutral

on

Righi axis

on

Figure 2-5"

Copyrighted Material

------'r- Deep Sulcus

Chapter 2 I The Human Spine, Rib Cage, and Pelvis True or False: Forward

35

True

1780

In a L on L torsion, what

The right sacral sulcus and the

landmarks are deep

right ILA

1780. 4.203

torsions occur when the lumbar spine is neutral.

(anterior)? On the right side

1.780, 4.203

Is the lumbosacral spring

The lumbosacral spring test is

4.203

test positive or negative with

negative.

What side is the seated flexion test positive on with a L on L sacral torsion?

a L on L sacral torsion dysfunction? In a R on R torsion, what

The left sacral sulcus and the left

landmarks are deep

lLA

1.780, 4.203

(anterior)? What side is the seated

On the left side

1.780, 4.203

Is the lumbosacral spring

The lumbosacral spring test

4.203

test positive or negative with

is negative.

flexion test positive on with a R on R sacral torsion?

a R on R sacral torsion dysfunction? What two dysfunctions are

L on Rand R on L

1779, 4.208

True or False: Backward

False; they occur when the spine

1.780

torsions occur when the

is demonstrating non neutral

spine is neutral.

mechanics.

In a L on R torsion, what

The right sacral sulcus and the

landmarks are deep

right lLA

considered backward sacral torsion?

(anterior)? What side is the seated

On the left side

flexion test positive on with a L on R sacral torsion?

Copyrighted Material

U81}781, 4.208

U80. 4.208

36

Osteopathic Medicine Recall

Is the lumbosacral spring bending

test

The lumbosacral

test

4.203

is positive

with a

positive or

L on R sacral torsion dysfunction? 1781, 4.203

What is the diagnosis of L5 if a L on R sacral torsion is present?

(NN

nonneutral wh ich could

elther flexion or In a R on L torsion, what

The left

landmarks are

ILl\.

sulcus and the left

(anterior)? On th e right

What side is the seated on

flexion test

usa, 4.203

ith

a R on L sacral torsion? [s the lumbosacral spring

The lumbosacral

test (backward bending test)

is positive

test

4.203

nel!ative with torsion

What is the L5 ruagnosis on

(F or E) NNHLSL

a R on L torsion? With a bilateral sacral

Both sacral sulci are deeD and

flexion dysfunction, how

both ILAs are shallow,

1781, 4.191

are sacral sulci and HAs

Is the lumbosacral spring

The lumbosacral

test (backward bending

is

positive or nel!ative

test

1781, 4.191

ith a

bilateral dysfunction? Which patients lend to have bilateral sacral f lexion dysfunctions?

Copyrighted Material

because

UBl

Chapter 2 / The Human Spine. Rib Cage. and Pelvis

With a bilateral sacral

Both sacral sulci are shallow and

extension dysfunction, how

both ILAs are deep.

37

1781. 4.195

are sacral sulci and ILAs positioned? Is the lumbosacral spring

The lumbosacral spIing test

test (back-ward bending test)

is positive.

1.781. 4.195

positive or negative with a bilateral sacral extension dysfunction? What happens to the lumbar

It decreases.

1.781. 4195

How are unilateral sacral

They are named for the side

flexion and extension

of the positive seated flexion test.

1.781. 4.211

curve with a bilateml sacral extension dysfunction?

dysfunctions named? With a right unilateml sacl'al

The light sacral sulcus and the

flexion, what landmarks are

left ILA

4.211

deep (anterior)? Is the lumbosacl'al spl·jng

The lumbosacral spIing test is

test (backward bending test)

negative.

4.211

positive or negative with a left unilateral sacral flexion dysfunction? The light sulcus and the left lLA

4.213

Is the lumbosacral spring

The lumbosacral spling test is

4.213

test (backward bending test)

positive.

With a left unilateral sacral extension, what landmarks are deep (anterior)?

positive or negative with a right unilateral sacral extension dysfunction? If a patient has both a sacral

L5, because most of the time

somatic dysfunction and an

a

L5 somatic dysfunction,

once L5 is successfully treated

sacral dysfunction will resolve

which dysfunction should the physician treat first?

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1782

Chapter -

3

Upper and Lower Extremities

What is the function of the

Rotator cuff muscles serve to

rotator cuff muscles?

protect the shoulder joint by

10.824829

holding the humerus in the glenoid fossa.

What four muscles make up

The four S.I.T.S. musc:les:

7.489

the rotator cuff? 1. Supraspinatus 2. Infraspinatus 3. Teres minor 4. Subscapularis

What is the maximum

The glenohumeral joint in active

degree of rotation in the

motion can rotate 120°.

6.410411

glenohumeral joint? What is the maximum

The scapulothoracic joint can

degree of motion of

rotate up to 60°.

6.410411

scapuJothoracic joint? What is the maximum

The arm in active motion can

degree of abduction of the

be abducted to 180°, \\ th the

ann?

6.410411

glellohumeral joint contJibuting 120° and the scapulothoracic

joint contributing 60°.

List the motions of the

The cla cIe can glide anterior

clavicle.

and posterior, superior and

6.416

inferior.

Which shouJder joint is not

Of the four shoulder

a true joint?

jOints-the scapu lothoracic, acromiocla cular, stemocla cular, and glenohumeral-the

scapulothoracic is the only pseudo joint.

38

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6.411

Chapter,

What is thoracic outlet

Thoracic outlet syndrome is

syndrome?

compression of the neurovascular

1445-447

bundle (subclavian vein, artery, and brachial plexus) as it exits the thoracic outlet Where within the thoracic

Compression of the neurovascular

outlet does compression of

bundle can occur between

the neurovascular bundle

the clavicle and the first rib;

occur'?

between the scalenes; and

1.446447

between the pectoralis minor and upper ribs. What is supraspinatus

Impingement of the greater

tendonitis'?

tuberosity against the acromion

7.489

as the arm is flexed and internally rotated How is supraspinatus

Ice, rest, and nonsteroidal

tendonitis treated?

anti-inflammatory drugs

6.467

(NSAIDs) are used for the treatment of acute cases, while steroids and osteopathic manipulative therapy (OMT) are used for the treatment of severe cases. \\'hat artery accompanies

The profunda brachial artery

the radial nerve in the radial

runs with the radial nerve in

groove'?

the radial groove.

What artery becomes

The subclavian artery

10.704

The subclavian artery

10.704

\Vhat structure passes

The subclavian vein passes

10.706

anteriorly to the anterior

anteriorly to the antetior

scalene'?

scalenes.

7.510

the axillary artery at the lateral border of the first rib? \\'hat artery runs between the anterior and middle scalenes'?

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40

Osteopathic Medicine Recall

At what point does the

The brachial artery divides into

brachial artery split into the

the radial and ulna alteries at the

radial and ulnar arteIies?

biCipital aponeurosis.

What treatment options can

Opening the thoracic inlet,

be utilized to relieve lymph

redoming the thoracoabdominal

congestion of the upper

diaphragm, and posterior axillary

extremity?

7.006

7 4 65 .

fold techniques can be utilized to relieve lymph congestion in the upper extremity.

Which plexus supplies all

The brachial plexus supplies

the nerves to the upper

all the nerves of the upper

extremity?

extremity.

What are the spinal cord exit

The brachial plexus exits the

levels of the brachial plexus?

spinal cords at the C5-Tllevels.

What is the most common

Erb-Duchenne palsy; this

brachial plexus injury?

results in paralysis of the deltoid,

7.J76

7.576

7.577

external rotators, biceps, brachioradialis, and supinator muscles. "Waiter's tip" palsy

7.577

In Klumpke palsy, what

Klumpke palsy results from

7.517

spinal cord levels are

injury of the C8-Tl nerve roots,

What is the nickname for Erb-Duchenne palsy?

injured?

and paralysis involves the intrinsic muscles of the hand. "Claw hand" palsy

7.577

What nerve injury results in

Injmy to the long thoracic nerve

7.577

winging of the scapula?

will cause winging of the scapula.

What is the nickname for Klumpke palsy?

What artery supplies the

The lateral thoracic artery

muscle paralyzed in a long

supplies the serratus anterior

thoracic nerve palsy?

muscle; this muscle is paralyzed in an injury to the long thoracic nerve.

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Chapter 3 / Upper and Lower Extremities

What muscle is innervated

The anterior serratus muscle is

by the

innervated by the

thoracic nerve?

41

7.577

thoracic

nerve. What nerve is

The axillary nerve is

during shoulder
during shoulder dislocation.

5.794

In what direction does

Most humeral dislocations occur

humeral dislocation usually

in an anterior and inferior

occur?

direction. The radial nelve

10.793

10.762

common nerve it is

upper injured \\-'hat muscles are affected

Injury to the radial nerve results

by injury to the radial

in paralysis of the extensor

nerve'?

muscles of the arm.

\\-'hat is the name

to

a palsy caused

to

the radial

10.762

A "wrist drop" or

night" palsy, from intoxicated on a

under the arm the crutch for a of time What nerve innervates most

The median nerve innervates all

of the primary flexors of the

of the primary flexor muscles of

hand?

the hand except the flexor

10.737

ulnaris, which is innervated the ulnar nerve. '''hat nerve innervates the

The primary

supinator muscles?

the forearm are

10.8008D]

musculocutaneous nerve, which

the

the radial nerve.

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42

Osteopathic Medicine Recall

What nel"Ve innel"Vates the

The primary pronators of the

pronator muscles?

forearm are the pronator

1O.S00SOl

quadratus and pronator teres, which are both innervated by the median nerve. What nerve innervates the

The median nerve innervates

muscles of the thenar

all the muscles of the thenar

10.770

eminPllec ('xcept the adductor

eminence?

pollicis brevis, which is innelvated by the ulnar nerve. What nerve innervates the

The muscles of the hypothenar

muscles of the hypothenar

eminence and the interossei are

eminence and the interossei?

innervated by the ulnar nerve.

What is the Significance of

A carrying angle greater than 1,5°

having a carrying angle

is called cubitus valgus and is

> 15°

at the elbow and the

significant for abduction of the

forearm?

ulna if somatic dysfunction is

10.770

6.421

pres('nt. What is the significance of

A carrying angle less than 3° is

having a carrying angle <3°

called cubitus varus and is

at the elbow and the

significant for adduction of the

forearm?

ulna if somatic dysfunction is

6.421

present. In what direction does the

The radial head will glide

radial head move when the

posteriorly when the forearm

forearm is pronated?

is pronated.

In what direction does the

The radial head will glide

radiaJ head move when the

anteriorly wben the fo rearm

forearm is supinated?

is supinated.

What injury causes a

Most posterior radial head

posterior radiaJ head?

injuries are caused by falling

6.424

6.424

6.424

forward on a pronated forearm. What injury causes an

Most anterior radial head

anterior radial head?

injuries are caused by falling backward onto a supinated forearm.

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6.424

Chapter 3 I Upper and Lower Extremities

What is carpal tunnel

Carpal tunnel syndrome is

syndrome?

entrapment of the median nerve

43

10.774

at the flexor retinaculum of the wrist. ,,yhat are the most common

Patients with carpal tunnel

symptoms manifested by

syndrome complain of

patients with carpal tunnel

paresthesias on the thumb and

syndrome?

the first two and one-half digits.

10.774

In addition, patients also have weakness and atrophy of the ulnar muscles. \Vhat physical tests are used

The Tinel, the Phalen, and the

to diagnose carpal tunnel

prayer tests are used to diagnose

syndrome?

carpal tunnel syndrome.

\Vhat are the gold standard

The gold standard tests for

tests for diagnosing carpal

diagnosing carpal tunnel

tunnel syndrome?

6.431

6.465

syndrome are nerve conduction studies and electromyography.

What are the osteopathic

Osteopathic treatment

treatment considerations for

considerations for carpal tunnel

carpal tunnel syndrome?

syndrome involve treating the

6.465

lib and upper thoracic somatic dysfunctions to decrease sympathetic tone in the upper extremity and treating cervical somatic dysfunctions and myofascial restrictions to enhance brachial plexus function. What is tennis elbow?

Tennis elbow is a strain of the

6.467

extensor muscles of the forearm of the lateral epicondyle. \Vhat is the cause of tennis

Tennis elbow is caused by

elbow?

overuse of the forearm extensors

6.467

and supinators, How is tennis elbow treated?

Tennis elbow is treated using NSAIDs, rest, ice, and OMT.

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6.467

44

Osteopathic Medicine Recall

Medial

is a strain

10.146

of the flexor muscles of the forearm near the medial

What is the pathogenesis of

Medial epicondylitis is caused

Olemal

overuse of the forearm flexor

10.746

pronator muscles. 'I,'Vhat is bicipital tPflo.wnoviti"P

is

, inflammation

10.771

the tendon and

its sheath of the long head of the brachii muscle. tenosynovitis is caused

What is the cause of bicipital

IO.771

muscle overuse in addition to

tenosynovitis?

wear and tear of the tendon on the bicipital groove. nllrno"..

scratch test is used to

of the

6A90

range of motion for the shoulder jOint. Using the how are

scratch test, and

external rotation tested?

To test for abduction and

6.490

external rotation, ask the to reach behind his head and touch the opposite shoulder.

How is internal rotation and

To test for adduction and internal

adduction evaluated using

rotation, ask the patient to reach

the Apley scratch test?

6.490

in front of her head and touch the opposite shoulder.

\Vhat is the purpose of a drop

The

arm test?

detect rotator cuff tears.

How is the

arm test is used to

arm test is

arm test

nprtr.rrr,o>'"

the patient to abduct

performed?

to 900 and then test results if the patient cannot lower the arm.

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6.416

6.41&417

Chapter 3 I Upper and Lower Extremities Wbat is Yerguson test?

Yerguson test is used to

45

6.416

determine the stability of the bicep tendon in the bicipital groove and is positive if pain is elicited in the tendon of the long head of the biceps when the patient internally rotates the shoulder of a flexed arm against resistance; a positive test indicates possible bicep tendon dislocation or tendonitis. For boards: You may also encounter the Speed test. which is also used to assess the bicep tendon in the biCipital groove. W'hat is the purpose of the

The Finkelstein test is used to

Finkelstein test'?

test the abductor pollicis longus

6.465

and extensor pollicis brevis tendons at the wrist and is positive if ulnar deviation of the wrist is not possible due to pain; a positive test indicates possible de Quervain tenosynovitis. W'hat is the purpose of the

Thl' Adson test is used to diagnose

Adson test?

thoracic outlet syndrome and is

1.701

positive if the radial pulse is diminished or lost; symptoms may be fUlther exacerbated by dt'ep inspiration if the diagnosis is difficult to make. What is the cause of

Pelfonning the Adson test causes

a positive Adson test?

the anterior scalene muscle to raise the first rib. which narrows the thoracic outlet. compressing the subclavian artery. which gives rise to the axillary artery. the brachial mtery. and then further divides into the ulnar and radial arteries.

Copyrighted Material

1.701

46

Osteopathic Medicine Recall

What is the Allen test

The Allen test is used to ass('ss

used for?

the adequacy of the blood supply

7.576

to the hand by the radial and ulnar mteries and is positive if capillary refill does not take place in under two seconds; a positive test indicates diminished pprfllsion and possible occlusion of the radial or ulnar arteries, depending on which artery was compressed. What is the purpose of the

The hip drop test is used to

hip drop test?

assess the sidebending ability

1.741

of the lumbar spine and the thoracolumbar junction. What does a positive hip

A positive hip drop test is

drop test indicate?

indicative of a somatic

1.741

dysfunction in thl' lumbar or thoracolumbar spine. What is the purpose of the

The straight-leg raiSing test is

straight-leg raising test?

used to evaluate for sciatic nerve

6482

compression and is positive if pain radiates past the knee; a positive test indicates possible lumbar disc herniation or sciatic nerve impingement. What is the use of the

The Trendelenberg test is used

Trendelenberg test?

to assess gluteus medius muscle

6480

stren)!;th and is positive if the patient's hip drops to the contralateral side of the leg the patient is standing on. What condition often results

Psoas syndrome often results

in pelvic shift from midline?

in a flexion contracture leading to a pelvic shift in the opposite direction of the dysfunctional psoas.

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6.539

Chapter 3 / Upper and Lower Extremities What is the purpose of the

The Ober test is used to assess for

Ober test?

a tight tensor fascia lata and

47

6.479

iliotibial band and is positive if the abducted leg does not freely return to midline; a positive test indicates possible IT Lliotibial

band contracture. What is the significance of

The Thomas test evaluates for

the Thomas test?

the possibility of a flexion

6.479

contracture of the hip, usually of iliopsoas origin, and the test is positive if the affected hip is unable to be fully extended.

When the hip glides

When the hip glides anteriorly,

anteriody, in what direction

the head of the femur glides

does the femoral head

anteliorly with external rotation

move?

of the hip.

When the hip glides

When the hip glides posteriorly,

posteriorly, in what direction

the head of the femur glides

6,479483

6,479483

does the femoral head

posteriorly with internal rotation

move?

of the hip.

What types of somatic

Piriformis and iliopsoas spasms

6479

Tibiofemoral joint

6.484

The ACL prevents excessive

6484485

dysfunctions are most likely to cause hip restriction with intemall"otation? Which joint is the largest joint in the body? What is the function of the anterior cruciate ligament

anterior translation of the tibia

(ACL)?

on the femur.

What is the function of the

The PCL prevents excessive

posterior cruciate ligament

posterior translation of the tibia

(PCL)?

on the femur.

What is the function of

The medial collateral ligament

medial collateral ligament?

helps to stabilize the knee.

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6.485

6.484

48

Osteopathic Medicine Recall

In what direction does the

The fibular bead

fibular head move when the

when the foot is

6,486

foot is In what direction does the

The fibular head glides

fibular head move when the

n()<tprif'lriv when the foot

6486

foot is supinated? What ankle motions occur

Dorsiflexion, eversion, and

when the foot is pronated?

abduction of the ankle occur

6498

when the foot is pronated, What ankle motions occur

Plantar flexion, inversion, ::md

when the foot is supinated?

adduction of the

6498

when the foot is Coxa

'Vhat is coxa vara?

occurs when the

6.488

between the neck and shaft the femur is less than 120°, occurs when the

\\!hat is coxa valga?

neck and the of the femur is greater than 135°, What nerve lies directly

The common

nndpMor to the

nerve

nr ..v'rn!>1

10.631

head? What is the cause of

Patellofernoral

pateHofemoral syndrome?

imbalance of the musculature of the

an


10.628

V[lstus

J ateralis and weak vastus

How is natellol·enro.o.ra

is

syndrome treated?

the

10.628

vastus True or Fruse: In

10.628

patellofemorru "vtuh·ot1np there is a decrease in the

Q

Copyrighted Material

Chapter 3 I Upper and Lower Extremities

What occurs to the ligament

In first degree ligamentous

in a first degree sprain?

spmins, there is no tear in the

49

1.543

ligament; the ligament retains relatively good tensile strength and has no laxity. What occurs to the ligament

Second degree ligamentous

in a second degree sprain?

sprains result in a partial tear of

1.543544

the ligament, with decreased tensile strength and mild to moderate laxity. What occurs to the ligament

Third degree ligamentous sprains

in a third degree sprain?

involve complete tear of the

1543544

ligament, resulting in no tensile strength and severe laxity. How many compartments is

The lower leg has four

the lower leg divided into?

compartments.

Name the fmIT compartments

Anterior, lateral, deep posterior,

of the lower leg.

and superficial posteIior

\'\'hat compartment is

The anterior compartment

most often affected by

is most often affected by

compartment syndrome?

compartment syndrome; the

10579

10.579

10.580581

diagnosis should not be missed because immediate surgical release is required to prevent pennanent damage to the structures within the compartment. ''\'hat are the signs of

Pain (out of proportion to physical

compartment syndrome?

finding and with passive motion or stretch) Pallor Poikilothermia Paresthesias Pu lselessness and late paralysis

Copyrighted Material

1.813

SO

Osteopathic Medicine Recall

are affected

What

The anterior tibialis muscle

10.580

The ACL medial collateral

[0.626

and medial

in the terrible triad (O'Donahue's

meniscus

What are the main motions

The main motions

the tibiotaJar

6.486

flexion and

of the tibiotalar joint dorsiflexion.

(taJocrural joint)? Is the ankle more stable

The ankle is most ,table in

in dorsiflexion or

dorsiflexion.

6.495

plantarflexion? There are two

of arches are

longitudinal

of JJ1

6.499

the

foot: the medial and lateral

present in the foot?

arches. What stntctures make up

The medial

the medial longitudinal

made up of the

arch?

cuneiforms, and first to third

6. 99

metatarsals. What stnlCtures make up

6.49950a

the lateral longitudinal the fourth and fifth

arch?

metatarsals.

What structures make up

The transverse arch is made up

the transverse arch?

of the navicular, cuneiform. and

6.499500

cuboid bones. What arch is most prone t o

The transverse arch is very

somatic dysfunction? runners. What ligaments are known as the lateral stabilizers of the ankle?

Copyrighted Material

6.486

Chapter 3 I Upper and Lower Extremities The anterior talofibular

What livl}m.!'>nt

5I

6.486

L543544

a type 1 the ankle? Type 2

1.543-

in a

the anterior

544

of the ankle?

and the calcaneofibular

'''''hat lig2lmt�nts

1.543,,44

in a type 3 of the ankle?

What ligllnl.ent or.,,,pnt.'

Deltoid

1.544

excessive ankle? True

01'

False: Excessive

False; excessive

pronation of ankle will

ankle will rnore

result in a pure

a fracture of the

6.498502

injury, What is the function of the

The function

spring (CaIC!l:neon:aVlCI ligament?

6.499

is to support the arch.

What structures make up

6.499

the plantar

Which muscle is considered

The

muscle

6473

the primary flexor of the hip? What muscle is the

Gluteus maximus

6473

hip edensor? What muscles al'e considered

6.485

the major knee extensors?

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52

Osteopathic Medicine Recall

What muscles are considered

Tlle semimembranosus and semi-

the maior knee flexors?

tendinosus

hold

How many

the femoroacetabular joint

Name the

that

hold the femoroacefabular in

muscles

Four ligaments hold the

5A71

femoroacetabular loint in

1. 2.

""emUlel

3. 4.

femoris

Capitis femoris

6.471

Sacrospinous

6.473

What is the purpose of the

The anterior drawer test is

6.488

anterior drawer test?

used to assess ACL function

\Vhich

is attached

to the head of the femur? divides the

and is positive for

a

possible

tear of the ACL if excessive anterior motion is observed during the test. What is the purpose of the

The posterior drawer test is used to assess PCL function and

posterior drawer test?

is positive for a

kar

of the peL if excessive n()<rpdnr motion is observed the test. ouroose of the Lachman is if excessive anterior

of the

tibia is observed What is the

of the

The

McMurray meniscaJ during the test

Copyrighted Material

test is used to

Chapter 3 / Upper and Lower Extremities

What is the purpose of the

The patellar-gli nd test is used

patellar-grind test?

to assess the posterior articular

53

6.492

surfaces of the patella and is positive for possible chondromalacia patellae if crepitus of the joint is noted during the test. What does a valgus stress

Valgus stress tests for medial

placed on the knee test?

collateral ligament tears.

What does a varus stress

Varus stress tests for lateral

placed on the knee test?

collateral ligament tears.

What is the purpose of the

The anterior draw test of the

anterior draw test of the

ankle is used to assess the medial

ankle?

6.488

6.488

6.488

and lateral ligaments of the ankle and is positive for possible ligamentous damage or tears if excessive anterior glide at the ankle is observed during the test.

What ligaments are assessed

The talofibular ligament,

using the anterior draw test

superficial ligament, and deltoid

of the ankle?

ligament

What is the cause of hallux

Hallux valgus is a structural

valgus?

deformity of the big toe resulting

6.488

1.800

from contracture of various periarticular structures of the first metatarsophalangeal joint. What is the cause of

A bunion is caused by varus

a bunion?

deviation of the first metatarsal.

What are hammer toes often

Hammer toes are often

associated with?

associated with myofascial trigger

1.800

1.801

points in the dorsal interossei of the foot. What is sciatica?

Sciatica describes the condition in which patients have pain along the sensory distribution of the sciatic nerve down the back of the leg.

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7.711

54

Osteopathic Medicine Recall

Name the two nerves that

The common peroneal and tibial

branch from the sciatic

nerves

7.711

nerve.

A bow-legged appearance

1791

What ligament is damaged

Annular ligament; this condition

10.801

when a child is lifted by the

is known as "nursemaid's elbow."

A decreased

Q angle is

associated with which one of the following conditions: bow-legged or knock-knee appearance?

upper limb while the forearm is pronated? What is plantar fasciitis?

Plantar fasciitis is an inflammation

6.542

of the plantar fascia on the plantar aspect of the foot. At what location does the

The inHammation usually occurs

inflammation usually occur?

at the insertion of the plantar

6.542

fascia near the calcaneus. What OMT approach is

OMT is directed at freeing

used when treating plantar

motion of the bones of the foot

6.543

and stretching hypertonic

fasciitis?

muscles of the calf and fascia. What is a march fracture?

A stress fracture found at the

6.542

shaft of the second or third metatarsal bones What causes pes planus?

Pes planus (Hat feet) is a condition

6.543

in which there is dropping of the medial longitudinal arch. How is pes planus treated?

Pes planus is treated by prescribing

6.543

heel wedges or exercises to strengthen the muscles involved. What is Morton neuroma?

Morton neuroma is a fibrotendinous reaction occurring between the heads of the third and fourth metatarsals.

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6.542

Chapter 3 I Upper and Lower Extremities

True or False: In Morton

True; pain is neuritic in type and

neuroma, pain radiates to

radiates to the toes,

55

6542

the toes. What castles pes anserine

Pes anserine bursitis is caused

bursitis?

trauma to the knee

Contraction of what muscles makes the pain of a pes

6,541

6,541

sart0l1ns, and

anserine bursitis worse? Whet'e is OMT directed to

OMT is directed to the

treat pes anserine bursitis?

and

What is the most common

Acute

injury to the ankJe?

ankle

\"''hat is the most common

Inversion stress

6.541

is the most common

6541

6,541

cause of acute ankle sprain? What ligament is stretched

Lateral collateral

by inversion of the foot? What is the common cause

Calcaneal

stress

6,541

of chronic ankle sprains'? What is meralgia paresthetica?

Meralgia

is an

intlarnmation of the lateral cutaneous nerve of the also known

What physical

"gun-belt

are

found in patients """, ...."Imi"

paresthetica? a distribution, to

How is the te<;:nnlqule helpful in preventing adhesive capsulitis?

restore motion to the shoulder muscles involved,

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56

Osteopathic Medicine Recall Dupuytren contracture is

What is Dupuytren contracture?

6.465

contracture of the palmar fascia and nodule formation in the palm.

How does OMT help patients with Dupuytren contracture?

OMT is aimed toward keeping

6.465

the palmar fascia as free as possible, lessening the contracture.

What is the use of OMT in patients with de Quer\'ain syndrome?

OMT is directed at improving

6.465

motion of the joint, decreasing swelling, and treating tenderpoints.

Name two of the more common types of injuries to the shoulder girdle. What is the role of OMT in tendonitis of the shoulder joint?

Separation at the

6.465

acromioclavicular joint and tear of the rotator cuff muscles OMT of all the tendcrpoints

6.464

around the shoulclf'r girdle, especially those associated with the tendon, is helpful in diminishing pain.

What is the most common cause of fractures in the shoulder girdle?

Falls onto an outstretched arm

6.463

What shoulder girdle joints are most prone to somatic dysfunctions?

The sternoclavicular and

6.466

acromioclavicular joints

Copyrighted Material

Cha ter 4

The Autonomic

What are the two components

The somatic nervous

Nervous System L90

and the autonomic

of the peripheral nervous

nervous system

(PNS)? What is the main function

To facilitate the normal

of the ANS?

of

What is one distinctive

The ANS has a

L90

output

L90

feature of the ANS? neurons located

1.

Postganglionic neurons located What is faciUlation?

or

An area of

6.30

restriction that develops a threshold for irritation and when other structures are stimulated True or False: Facilitation occurs when more afferent stimulation is needed to

a facilitated state, less

6.30

afferent stimulation is needed for of

of

List the three of the

L An afferent limb

6.30

reflex. 2. A central limb

pathway) 3. An efferent limb

57

Copyrighted Material

58

Osteopathic Medicine Recall

Table 4-1.

Sympathetic Innervation Cord Level

Ganglion

Nerve

T5-T9

Celiac

Greater splanchnic

T5-T9

Celiac

Greater splanchnic

TIO-TIl

Superior mesenteric

Lesser splanchnic

Jejunum and ilium

TIO-TII

Superior mesenteric

Lesser splanchnic

Ascending colon

TIO-TIl

Superior mesenteric

Lesser splanchnic

Initial 2/3 of the

TIO-TIl

Superior mesenteric

Lesser splanchnic

TIO-TIl

Superior mesenteric

TI2-L2

Inferior mesenteIic

Least splanchnic

TI2-L2

InfeIior mesenteIic

Least splanchnic

TI2-L2

InfeIior mesenteIic

Least splanchnic

Lower ureters

TI2-U

Inferior mesenteric

Adrenal medulla

TIO

Testes and ovaries

TIO-TIl

Head and neck

TI-T4

Heart

TI-T5

Lungs and respiratory

T2-T7

system Esophagus

T2-T8

Upper extremities

T2-T8

Upper GI tract Gallbladder, liver, spleen, stomach Segments of the pancreas and duodenum Middle GI tract Segments of the pancreas and duodenum

transverse colon Kidneys and upper ureters Lower GI tract Final 1/3 of the transverse colon Descending and sigmoid colons Rectum

Uterus and cervix

TIO-L2

Cisterna chyli

TIl

Erectile tissue

TII-L2

(penis and clitoris)

Copyrighted Material

Chapter 4 I The Autonomic Nervous System

Table 4-1.

59

Sympathetic Innervation (Continued) Cord Level

Bladder

Tll-L2

Legs

Tll-L2

Appendix

Tl2

Prostate

Tl2-L2

Ganglion

Nerve

Parasympathetic innervation Vagus nerve

Everything above the diaphragm

Vagus nelve

Ascending and transverse colon

Vagus nerve

Kidneys and upper ureters Testes and ovaries

Vagus nerve

All other reproductive

Pelvic splanchnic

organs (not testes and ovaries) Descending and

Pelvic splanchnic

recto-sigmoid colons Pelvic splanchnic

Lower ureters and bladder

List the three areas that can

1. Higher centers (brain)

be facilitated.

2. Viscera, via sympathetic or

6.30

parasympathetic visceral afferents 3. Somatic afferents (muscle

spindles, golgi tendons, nociceptors, etc.) "That is a viscerosomatic

Localized visceral stim uli

reflex?

producing patterns of reflex

6.29-30

response, in segmentally related somatic structures Give an example of a

Acute cholecystitis often refers

viscerosomatic reflex.

pain to the midthoracic region at the tip of the right scapula

Copyrighted Material

1.105Ill, 6.29-30

60

Osteopathic Medicine Recall

TI-T5 somatic

Give other

and and

Ll05­ 111, 6.29-30

abnormalities, such as a myocardial infarction What is a somatovisceral

Somatic stimuli

reflex?

patterns of reflex response in

1.1048­ 1049

related visceral structures. Give an exam Die of a

that has been Imown to cause supravenhicular It causes constriction of the

VVhat effect does the nervous

l.99-100

pupils, also known as miosis.

on the pupils

It causes the lenses to contract

\'Vhat effect does the :raSVJm�,alne:nc nervous on the lenses

\\'hat effect does the

199-100

for near vision, also known as accommod.ation

It stimulates

to

199-100

secrete their

What effect does the

It stimulates the

198-99

of the hands to sweat.

"'hat effect does the

It decreases and conduction velOCity.

Copyrighted Material

LlOI­ [02

Chapter 4 / The Autonomic Nervous System

What effect does the

It causes contraction of the

pa.-asympathetic nervous

bronchiolar smooth muscle

system have on the

of the lungs.

61

1102103

bronchiolar smooth muscle of the lungs? What effect does the

It decreases the number of goblet

parasympathetic nervous

cells and

thins secretions.

1102103

system have on the respi.-atory epithelium of the lungs? What effect does the

It causes contraction of the

parasympathetic nervous

lumen of the GI tract.

1104111

system have on the smooth muscle lumen of the gastrointestinal (GI) t.-act? What effect does the

It causes relaxation of the

parasympathetic nervous

sphincters

within the GI tract.

1.104III

system have on the smooth muscle sphincters within the

GI h-act? What effect does the

It increases the amount of

parasympathetic nen'ous

secretion

system have on secretion

the GI tract.

and motility within

1104III

and motility within the GI tract?

parasympathetic nen'ous

The parasympathetic nervous system has no effect on tJ1e skin

system have on the skin and

and visceral vessels.

"''hat effect does the

1.97-98

visceral vessels? What effect does the

The parasympathetic nervous

parasympathetic nervous

system has no effect on skeletal

s)'stem have on skeletal

muscle.

1.97-98

muscle? What effect does the

It causes contraction of the

parasympathetic nervous

bladder wall.

system have on the bladder waH (detrusor muscle)?

Copyrighted Material

1113114

62

Osteopathic Medicine Recall

What effect does the

It causes relaxation of the

parasympathetic nervous

bladder sphincter.

1.113114

system have on the bladder sphincter (trigone)? What is the parasympathetic

It causes erection of the peniS.

1.116

nervous system function on Note: A good way to remember

the penis?

this is to think "point & shoot." Point is the erection pOltion controlled by the PNS; shoot is the ejaculation portion controUed by the SNS. What effect does the

The effect of the parasympathetic

parasympathetic nervous

lll'IVOUS system on the kidneys is

system have on the kidneys?

unknown.

What effect does the

It m aintains normal peristalsis.

1.112-113

What effect does the

It causes slight glycogen

1.111

parasympathetic nervous

synthesis.

1.111-112

parasympathetic nervous system have on the ureters?

system have on the liver? What effect does the

It causes relaxation of the body

parasympathetic nervous

(fundus) of the uterus.

1115-116

system have on the body (fundus) of the uterus? What effect does the

It causes constriction of the

parasympathetic nel"VOUS

cervix of the utell.ls.

1.115-116

system have on the cervix of the uterus? What effect does the

It causes dilation of the pupils,

sympathetic nel"VOus system

also known as mydriasis.

1.99-100

have on the pupils of the eyes? What effect does the sympa-

It causes lenses of the eyes to

thetic nervous system have

slightly relax to allow for better

on the lenses of the eyes?

far vision.

Copyrighted Material

1.99-100

Chapter 4 / The Autonomic Nervous System

What effect does the

It causes vasoconstriction of

sympathetic nervous

these glands for slight secretion

system have on the glands

of their products.

63

1.99-100

(nasal, lacrimal, parotid, submandibular, gastric, and pancl'eatic) of the body? What effect does the

It causes heavy sweating.

1.98-99

What effect does the

It increases contractility

sympathetic. nervous system

(inotropy) and conduction

1.101102

have on the heart?

velocity.

sympathetic nervous system have on the sweat glands?

What effect does the

It relaxes the bronchiolar smooth

sympathetic nervous system

muscle of the lungs.

1.102103

have on the bmnchiolal' smooth muscle of the lungs? What effect does the

It increases the number of goblet

sympathetic nervous system

cells to produce thick secretions.

1.102103

have on the I'espit'atory epithelium of the lungs? What effect does the

It causes relaxation of the smooth

sympathetic nervous system

muscle lumen within the GI

have on the smooth muscle

tract.

1.104III

lumen within the GI tmct? What effect does the

It causes contraction of the

sympathetic nervous system

smooth muscle sphincters within

have on the smooth muscle

the GI tract.

1.104III

sphincters within the GI tract? What effect does the

It decreases the secretions and

sympathetic nervous system

motility "'rithin the GI tract.

1.104III

have on the secretions and motility within the GI tract? What effect does the

It causes contraction of the skin

sympathetic nervous system

and visceral vessels.

have on the skin and visceral vessels?

Copyrighted Material

1.97-98

64

Osteopathic Medicine Recall

What effect does the

It causes rela,ation of skeletal

sympathetic nervous system

muscle,

1.97 -98

have on skeletal muscle? ""'hat effect does the

It causes relaxation of the

sympathetic nervous

bladder \,vall

1113114

have on the bladder wall (detrusor)? It causes contraction of the

What effect does the

bladder sphincter

paLIII�(JC nervous

U13114

have on the bladder spl:1linc,ter (trigone)? It causes

1116

What effeet does the

It causes vasoconshiction of

sympathetic nervous system have on the Irl.lnpv<

afferent arterioles, which

Llll112

What effect does the sympathetic nervous have on the penis?

decreases the filtration rate and results in decreased Uline volume,

What effeet doeslhe

It causes

What effect does the

It causes

1.112113

O'I"
which

Llll

increases into the bloodstream, It causes constriction of the

What effect does the

of the uterus,

sympathetic nervous system

1.115 116

have on the body (fundus) of the uterus? What effect does the sympa­ have

thetic nervous on the cervix

It causes relaxation of the uterine cervix,

Ll15116

the uterus?

From where does cranial

eN III emerges from the

nerve eN III emerge?

midbrain,

Copyrighted Material

5,654655

Chapter 4 I The Autonomic Nervous System

65

The ciliary ganglion

5.654655

From were does eN VII

eN VII emerges from the

emerge?

pontomedullary junction.

5.658660

Which ganglion within the parasympathetic nervous system causes constriction of the pupils?

Name the two ganglions

Pterygopalatine ganglion and

involved in parasympathetic

submandibular ganglion

5.660

nervous system activity that are located within eN VII.

The lacrimal glands

5.660

Within the parasympathetic

The submandibular and

5.660

nervous system, what glands

sublingual glands

Within the parasympathetic nervous system, what glands are associated with the pte,),gopalatine ganglion?

are associated with the submandibular ganglion? From where does eN IX

CN IX emerges from the

emerge?

medulla of the brain.

What ganglion involved in

The otic ganglion

5.662663

The parotid glands

5.663

From where does eN X

CN X emerges as a series of

emerge?

rootlets on the side of the

5.664666

parasympathetic nervous

5.662663

system activity is controlled by eN IX? What glands are parasympatheticaJly associated with the otic ganglion?

medulla. '\!hat effect does eN X have

It decreases contractility and

on the heart?

conduction velocity.

Copyrighted Material

1.101102

66

Osteopathic Medicine Recall

What effect does eN x have

It causes contraction of the

on the lungs?

bronchiolar smooth muscle

1.102103

and decreases the number of goblet cells to enhance thin secretions within the respiratOIY epithelium. eN x (the vagus nerve)

1.104111

eN x (the vagus nerve)

1.104III

eN x (the vagus nerve)

1.104III

eN x (the vagus nerve)

1.104III

eN x (the vagus nerve)

1.104111

eN x (the vagus nerve)

1.104111

The kidneys and upper ureters

I.ll1113

The testes and ovaries

1.114116

What two organs of the GI

The ascending colon and

system are parasympatheti-

transverse colon

1.104111

What eN innervates the lower two-thirds of the esophagus? What eN innervates the stomach? What eN innervates the small intestine? What eN innervates the liver? What eN innervates the gallbladder? 'What eN innervates the pancreas? What two organs of the urinary system are parasympathetically innervated by eN X? 'What two organs of the reproductive system are parasympathetically innervated by eN X?

cally innervated by eN X? What spinal cord levels

The S2-S4 spinal cord levels

make up the pelviC splanchnic nerve?

Copyrighted Material

1.113ll6

Chapter 4 I The Autonomic Nervous System

67

The lower ureters and bladder

Ll12114

The uterus

LlI4-116

The prostate

1.114116

The genitalia

Ll14116

What three organs of

The descending colon, sigmoid

the GI system are

colon, and rectum

1.104III

What two organs of the urinary system are parasympathetically innervated by the pelvic splanchnic nerve? What female organ of the reproductive system is parasympatheticaJly innervated by the pelvic splanchnic nerve? What male organ of the reproductive system is parasympathetically innervated by the pelvic splanchnic nerve? What organ of the reproductive system is parasympathetically innervated by the pelvic splanchnic nerve?

parasympathetically innervated by the pelvic splanchnic nerve? TlUe or False: Segmental

False; the innervation levels vary

sympathetic innervation

from individual to individual.

194-96

levels are the same in every individual.

Note. It is important to be familiar with innervation levels, but keep in mind that these levels Val), in each individual; as \vith all aspects of medicine, clinical judgment should be heavily relied upon by the experienced physician.

What spinal cord levels

The Tl-T4 spinal cord levels

sympathetically innervate the head and neck?

Copyrighted Material

199100

68

Osteopathic Medicine Recali

What spinal cord levels sympathetically innervate the heart?

The Tl-T5 spinal cord

"''hat spinal cord levels sympathetically innervate the respiratory system?

The T2-T7

cord levels

The T2-T8

levels

innervate

Which organs are considered part of the upper GI tract?

1. Gallbladder

LlOl102

U03

ll03104

LlOS

2. Liver 3. Stomach 4. Proximal duodenum 6. Portions of pancreas

From which portion of the embryological did the organs of the upper GI tract

The

!.lOS

Whlch organs are considered of the middle GI tract?

1. Distal duodenum

l.107

" 0.

Portions of pancreas

4.
5.

6. Proximal two-thirds of transverse colon

Which organs are considered part of the lower GI tract?

The

1107

1. Distal one-third of transverse

U07111

colon 2. 3. 4.

Copyrighted Material

Chapter 4 I The Autonomic Nervous System

From which portion of the em-

The

69

III

bryoIogical gut did the organs of the lower GI tract originate? The T5-T9 spinal cord levels

545

The T5-T9

cord levels

5.45

The T5-T9 spinal cord levels

5.45

The T5-T9

cord levels

5.45

The T5-T9

cord levels

U05III

sYlllpiatlilelticlllly irmen'ate

What spinal cord levels sympathetically innervate the liver? What spinal cord levels sympathetically innervate the gallbladder? What spinal cord levels sympathetically innervate the spleen? What spinal cord levels sympathetically innervate the

duodenum and

portions of the What corresponding nerve

The

nerve

545

The

nerve

5.45

The

splanchnic nerve

5.45

sympathetically innervates the stomach? VVhat corresponding nerve srmpatheticall}' innervates the liver? What corresponding nerve sympathetically innervates the gallbladder? 'What corresponding nerve

The

nerve

545

The

nerve

1.105III

sympathetically innervates the spleen? What conesponding nerve sympathetically innervates the proximal duodenum and portions of the

Copyrighted Material

70

Osteopathic Medicine Recall

What correspondine;

The celiac F(dll)t,llUIi

Ll05

What

The celiac

Ll06

The celiac

LlO6

The celiac

Ll06

The celiac [!an [!lion

1.106

ganglion innervates What ganglion innervates

What corresDondine:

The TIO-Tll

cord levels

I 107III

The TID-TIl

cord levels

L107III

The TIO-TII

cord levels

1107III

The TIO-TII

cord levels

U07III

The TID-TIl

cord levels

LlOlIII

innervate the jejunum? What spinal cord levels sympathetically innervate the ilium?

innen'ate colon?

innervate two-thirds of the transverse colon?

Copyrighted Material

71

Chapter 4 I The Autonomic Nervous System

What corresponding nerve

The lesser

nerve

L107III

The lesser

nerve

1107III

The lesser splanchnic nerve

1107III

sympathetically innervates the distal duodenum and portions of the pancreas?

What corresponding nerve sympathetically innervates the ilium? 'What corresponding nerve

The lesser

nerve

The lesser

nerve

sympathetically innervates the

III

colon?

What corresponding nerve sympathetically innervates

!.I07111

the proximal two-thirds of transverse colon? What corresponding

The

mesenteric

U07

The

mesenterie

1.107

ganglion sympathetically innervates the distal duodenum and portions of the pancreas? What corresponding ganglion sympathetically innervates the jejunum? What corresponding

The superior mesenteric ganglion

1107

gallglion sympathetically innervates the ilium? What corresponding ganglion

The

mesenteric crn,ocrilirv1

U07

sympathetically innervates

the ascending colon?

What corresponding

The

mesenteric

sympathetiCll1ly innervates

two-thirds of

the the transverse colon?

Copyrighted Material

LID?

72

Osteopathic Medicine Recall

What spinal cord levels

The Tl2-L2

cord levels

U07III

The Tl2-L2 spinal cord levels

1.107III

The Tl2-L2 spinal cord levels

!.l07111

The Tl2-L2 spinal cord levels

1.107111

sympathetically innervate the distal one-third of the transverse colon? What spinal cord levels sjnlpathetically innervate the descending colon? What spinal cord levels sympathetically innervate the sigmoid colon? What spinal cord levels sympathetically innervate the rectum? 'Vhat corresponding nerve

The least

nerve

The least

nerve

The least

nerve

sympathetically innervates

III

the distal one-third of the transverse colon? corresponding nerve

What corresponding

III

Il!

the sigmoid What corresponding nerve

The least snianehnic nerve

Ll07III

The inferior mesentelic

Ll07111

The inferior mesenteric

1107III

sympathetically innervates the rectum? What corresponding /i;""'/i;"''''

sympathetically

innervates the distal one­ third of the transverse colon? What corresponding ganglion sympathetically innervates the descending colon?

Copyrighted Material

Chapter 4 / The Autonomic Nervous System

What corresponding ganglion

73

The inferior mesenteric ganglion

U07III

The inferior mesenteric ganglion

l.lO7III

The TIO spinal cord level

5.161

The TIO-TlI spinal cord levels

1.111112

The superior mesenteric ganglion

1.111112

The TlO spinal cord level

1.111112

The TIO-TlI spinal cord levels

1.112113

The superior mesenteric ganglion

1.112113

The TI2-Ll spinal cord levels

U12113

The inferior mesenteric ganglion

1.112113

The TlI-L2 spinal cord levels

U13114

sympathetically innervates the sigmoid colon? What corresponding ganglion sympathetically innervates the rectum? What spinal cord level sympathetically innervates the appendix? What spinal cord levels sympathetically innel-vate the kidneys? What corresponding ganglion sympathetically innervates the kidneys? What spinal cord level sympathetically innervates the adrenals? What spinal cord levels sympathetically innervate the upper ureters? What corresponding ganglion sympathetically innervates the upper ureters? What spinal cord levels sympathetically innervate the lower ureters? What corresponding ganglion sympathetically innervates the lower ureters? What spinal cord levels sympathetically innervate the bladder?

Copyrighted Material

14

Osteopathic Medicine Recall

What spinal cord levels

The TlO-TIl spinal cord levels

sympathetically innervate

1.114115

the What spinal cord levels

The TlO-L2

cord levels

11 14-116

The TlO-L2

cord levels

U14liS

sympathetically innervate the uterus? What spinal cord levels sympathetically innervate the uterus'? levels

The TlI-L2 spinal

Lll6

. innervate the erectile tissue of the What spinal cord levels

The TlI-L2

cord

The Tl2-L2

cord levels

1116

sympathetically innervate the erectile tissue of the clitoris?

innervate

The T2-T8

cord levels

JJ5

1.97-98

innervate the upper exh-emities What spinal cord levels

The Tll-L2 spinal cord levels

197-98

C:-.J X (the vagus nerve)

5.153-

The

5.l6(}'" 164

sympathetically innervate the lower eYliremities (legs)? Name the three main systems below the diln�llrll
The entire small intestine is innervated by what nerve of the parasympathetic nervous system? What are the names of the four segments into which the colon is divided'?

Copyrighted Material

Chapter 4 / The Autonomic Nervous System

75

What two segments are

The ascendin g colon and the

5.160-

considered the proximal half

transverse colon

164

What two segments are

The descending colon and the

5.160-164

considered the distal half

rectosigmoid colon

of the large intestine?

of the large intestine? The proximal haIr of the large

CN X (the vagus nerve)

5.153160,

intestine is parasympatheti-

UII-

cally innet"Vated by

114

what CN?

The pelvic splanchnic nerve

The distal half of the large

5.153-

intestine is parasympathetically

160,

innervated by what nerve?

114

Ull-

What are the three major

The kidneys, ureters (upper and

organ systems of the CU

lower), and bladder

system?

5.ISOIS5, l.lll114

The kidneys and upper ureters

What two sections are considered the proximal

5.1S0IS5, 1111-

half of the CU system?

114

The lower ureters and bladder

\\That two sections are

5.1S0IS5,

considered the distal half

1.111-

of the CU system?

114

The proximal half of the CU

CN X (the vagus nerve)

system is parasympathetically

5.1S0-lS5, 1.111-114

innervated by what CN?

The pelViC spl anchnic nerve

The distal half of the CU

5.1S0-

system is parasympathetically

IS5,

innet"Vated by what net"Ve?

114

1111-

True or False: All

False; all reproductive structures

reproductive structures

except the ovaries and testes are

are parasympathetically

innervated by the p elvic

innet·vated by the pelvic

s plan chn ic nerve.

splanchnic nerve.

Note: The ovaries and testes are

innervated by the vagus nerve.

Copyrighted Material

l.lIHI6

76

Osteopathic Medicine Recall

What significance does the

It divides the duodenum and

ligament of Treitz hold as

jejunum.

5.153156

a landmark? What significance does the

It divides the transverse and

splenic flexure of the large

descending colon.

intestine hold

as

5.161164

a

landmark? What spinal cord levels

The T5-T9 spinal cord levels

1.106117

The nO-Tll spinal cord levels

1106-17

The T12-L2 spinal cord levels

1106117

sympathetically innel-vate the organs before the ligament of Treitz? What spinal cord levels sympathetically innervate the organs between the ligament of Treitz and splenic flexure? What spinal cord levels sympathetically innervate the visceral organs past the splenic flexure?

Copyrighted Material

5

Lymphatics

What are the main functions

1. Maintaining fluid balance

of the lymphatic system?

2. Purification and cleansing

1.1059

of tissues 3. Defense against toxins,

bacteria, and viruses 4. Nutrition

The light lymphatic duct

9.36-38

The left lymphatic (thoracic) duct

9.37-38

The light brachiocephalic vein

1.1058

Where does the left

The junction of the left internal

9.36

lymphatic duct drain into?

jugular and subclavian veins

Into which Iyrr.phatic duct do the right side of the head and neck, the right upper extremity, and the right half of the thoracic cavity drain? The remainder (most) of the body drains into which lymphatic duct? Where does the right lymphatic duct drain into?

Vhat effect does the

It constricts the lymphatic vessels.

1.1064

\\'hat are the results of

Initially, there is an increase in

1.1064

constricting the lymphatic

lymph peristalsis; however,

vessels?

sustained hypersympathetic tone

sympathetic nervous system have on lymphatics?

will decrease lymphatic movement. What effect does osteopathic

It increases lymphatic fluid

manipulative therapy (OMT)

circulation.

1.1060

and exercise have on lymphatic fluid movement?

77

Copyrighted Material

78

Osteopathic Medicine Recall

True or False: Decreased interstitial fluid pressure

any increase in interstitial

Ll060

fluid pressure will increase the

mil increase lymphatic fluid

of lymph into

movement. True or False: Contraction

muscle contraction will

of the diaphragm and other

increase movement

muscles of the body

fluid.

decreases

fluid

movement. True or False: Restricted

True; any restriction within the

thoracic cage motion or a

body has the potential to cause

6.587

tense pelvic diaphragm can lead to lymphatic congestion. What lymphatic treatment

The Dalrymple

pump

l.lO62

The Miller

(thoracic)

LlO6S

increases tota] body lymphatic movement and is useful for pediatric patients? Which

treatment

increases

cage motion in

pump

addition to increasing total body lymphatic movement? Which treatment techniques

Cranial techniaues

LlO65

can decrease dural strains and increase venous return from the head? What lymphatic treatment

Rib

technique VI n increase thoracic motion somatic dysfunction of the and sternomanubrial· complex? What treatment technique

Rib

will normalize I..- - .-the tic activity the ribs for improved respiration?

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LlO62, l.lO64

T,'ue or False: An anterior

Tnle; any release of restrictions

cervical fascia release wiU

throughout the body has the

encourage lymphatic

potential to encourage lymphatic

drainage,

drainage.

What treatment consists of

The treatment technique known

wave like motions of the

as

1.1072

1.1076

effleurage

arms and legs to help direct lymph movement out of an area of congestion?

The liver (splenic) pump

1.1070

The Galbraith technique

1.1071, U241

What treatment technique

Treatment of the thoracic inlet

shouJd be used first when

should be used first when

1.10621063

treating a dysfunction of

treating a dysfunction of

What treatment facilitates the movement of toxins and other antigens to liver macrophages (Kupffer cells) and encourages screening and removal of damaged cells by the spleen? What technique uses stroking of the skin overlying the mandible to force fluids through congested lymphatic vessels and has been shown to improve and shorten the expected course of patients with otitis media?

lymphatic drainage?

lymphatic drainage because it is the space where most of the lymphatic fluid eventually drains back into the venous circulation; if it is congested, all other lymphatic channels will be ad ersely affected.

What treatment is

Rib raising

recommended second, after treating the thoracic inlet?

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1.1062

80

Osteopathic Medicine Recall

What is the third step in the

the thoracoabdominal

1.1062

the thoracoabdominal

1.l062

pump ''''';W''ljue,

1.1062

treatment or lymphatic dysrunction? What treatment will optimize thoracoabdominal pressure gradients, thereby lymph return? At what point should pump

":;""'''''-1'''''3

be used after treatment of

used to treat lymphatic dysrunctions?

What are the relative

1. Carcinoma

contraindications ror

2, Bone fractures in the area of

lvrnnhanc: treatment?

treatment :], Abscess or localized infection It Bacterial infection vvilh >102QF

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Ll062, 6.591

Cha ter

6

Articulatory Techniques and Myofascial Release

Are articulatory considered direct

are

1.834

that are

01"

used to increase range of motion

indirect?

in a restricted What

of

most

to respond to

are

L835

articulatory te<:hlllqucs,

nature What al"C thc indications for .n:Ul""UIIV

techniques?

L The

must have limited

1836

or lost articular motion 2. To normalize

tone. and

of motion, What are the contraindica­

1835837

tions for articulatory

What are thc two most

and rib

1836--837

frcquently used articulatory techniqucs? "'hat is the purpose of the

The purpose of the Spencer

1836

,"n,f'n('p .. technique?

81

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82

Osteopathic Medicine Recall

How many stages are there

There are seven stae:es in the

1836

in the Spencer technique? What is stage I of the technique?

Stage I involves

the

tissues and Dumoine:

,,,,jth

1.836

the arm II involves

1.836

Ilexion/extension with the elbow flexed. What is stage III of the

Stage III involves

Spencer technique?

flexion/extension with the elbow

1.836

extended. 1.836 both

and

traction, with the ann extended. V involves adduction and

What is stage V of the

1.836

external rotation with the elbovv

technique?

flexed. VI involves abduction and

What is stage VI of the

1.836

internal rotation with the arm

technique?

behind the back. What is the seventh and

Stage VII involves stretching

final

tissues and

of the Spencer

technique?

the ann

What musculoskeletal

The

condition is a Spencer

in

technique useful for?

capsulitis.

What is the purpose of rib

The purpose of rib

is useful

6.444

is to

1.835

increase chest wall motion. lymphatic return, and normalize svnmathetlc tone.

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1.836

fluids'vith

Chapter 6 / Articulatory Techniques and Myofascial Release Patients with what

Patients with pneumonia are

respiratory iHness are most

most likely to benefit from this

likely to benefit from rib

technique because it increases

raising?

lymphatic flow.

True or False: Rib raising

True; rib raising is used to

reduces sympathetic activit)'.

decrease and thereby normalize

83

1.835

1.835

sympathetic activity. What is the myofascial

Myofascial release is a technique

release technique?

that combines several types of

1.1158

osteopathic manipulative therapy (OMT) in order to stretch and release muscle and fascial restrictions . "''hat are the goals of

To restore functional balance to

myofascial release

all tissues and improve lymphatic

treatment?

flow

What are the indications for

Myofascial release can be

myofascial release treatment?

performed on acutely ill patients

1.1158

1.1158

and elderly patients who cannot

tolerate aggressive therapy. What is the difference

The right lymphatic duct drains

between the right and left

the right upper extremity,

lymphatic drainage of the

including the left lower lobe

upper extremities?

8.324

of the lung and the heart; the left lymphatic drains the left upper extremity and the rest of the body.

True or False: The left

False; the right lymphatic duct is

lymphatic duct is the minor

referred to as the minor duct,

duct, and the right lymphatic

and the left lymphatiC duct is

duct is the major duct.

referred to as the major duct.

Is myofascial release passive

Myofascial release can be passive

or active, direct or indirect?

or active, direct or indirect.

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8.324

1836

84

Osteopathic Medicine Recall

in

1.

1 836

2.

or transverse forces. 4. Use enhancers s1.lch as

respiration, eye movement, and muscle contraction. 5. Feel for and await the release.

What are the

1.836

contraindications for m'vol:asci�ll release? nnrno '" of

To restrictions

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1836

Chapter

7

Counterstrain

Is counterstrain a direct

Counterstrain is an indirect

or indirect treabnent?

treatment technique.

What is the first step in

Finding a significant tenderpoint

1.10031004

What is the goal of

To normalize the gamma efferent

1.1003

counterstrain?

system to facil itate the removal of

using counterstrain as

1.1002

a treatment?

somatic dysfunction What is a tenderpoint?

A small, tense area the size of a

1.1004

fingertip that is extremely tender to palpation Where are tenderpoints

Tendinous attachments, the beHy

usually located?

of

a

1.1004

muscle, and other myofascial

tissues such as ligaments If there are multiple

The most severe (sensitive)

tenderpoints in a certain

tenderpoint

1.10041005

area, which tenderpoint do you treat first? After finding the tenderpoint,

To place the patient into

what is the ned treabnent

a

pOSition of ease

1.10041005

step? If several tenderpoints of

The middle tenderpoint is

equal tenderness occur in

treated first.

1.1007

a row, which one is treated first? When is the optimal position

The optimal position of

of comfort obtained?

comfOit is obtained when palpation

1.1007

of the tenderpoint no longer elicits discomfort. For boards, know that a physician needs to reduce the tenderness by 70%. 85

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86

Osteopathic Medicine Recall

How is the level of

On a 0 to 10 scale, with 10 being

discomfort associated with

the most severe

1.1005

a tenderpoint monitored? Do tenderpoints radiate

No; tenderpoints do not radiate

pain?

pain; however, trigger points do.

1.100:>1005, 1.10351038

How long should a position

A position of comfort should be

1.1006

of comfort be maintained

maintained for 90 seconds.

when treating a tenderpoint using counterstrain? True or False: As you

False; you want to reduce the

position the patient in ease,

tenderness at least 70% (3 out of

you want to reduce the

10 on a subjective pain scale with

tenderness of a tenderpoint

10 being the worst pain a person

by at least 30%.

has ever felt).

What are some common

1. The patient is moved back to

mistakes physicians make when using counterstrain that can cause the treatment

1.10061007

1.1006

neutral too quickly. 2. The patient or the physician

is not relaxed. 3. The patient is not optimally

to be ineffective?

positioned. 4. The most significant

tenderpoint is not treated. When is treatment with

'When no more than 30% of the

counterstrain considered

original tenderness remains

1.1007

successful? What is the last step in

Recheck the tenderpoint

11004

a counterstrain treatment? Note: For practical purposes,

always recheck your somatic findings after any osteopathic therapy. True or False: For maximum

True; any tension on the part of

results, the patient must be

the patient has the potential to

completely relaxed dudng

hamper the treatment results.

treatment.

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11007

Chapter 7 / Counterstrain Are there any complications

Yes; a generalized soreness or

or side effects associated

flu-like reaction is sometimes

with counterstrain?

observed.

Does this reaction occur in

No; it occurs in approximately

all patients?

30% of patients.

When does this reaction

Within the first 48 hours after

occur?

treatment

87

1.10061007

1.1007

1.1007

Is there anything that can

Analgesics for 1 to 2 days

be prescribed to help

following treatment \'lith

reduce this reaction?

counterstrain

What is a therapeutic pulse?

A pulsation felt by the physician when treating the tendelpoint

!.l003

When is the therapeutic

It only occurs when the patient

!.l003

pulse felt?

is moved close to the position

1.1007

of comfort.

How long is the pulse felt'?

It disappears after myofascial

!.l003

tissue relaxation.

How long does it take for

90 seconds

!.l003

LlO03

myofascial tissue relaxation to occur? Is the therapeutic pulse felt

No; it does not occur with every

with every tenderpoint?

tendelpoint.

What is the therapeutic

Improved treatment response

1.1003-

True or False: In general,

True; as a general rule, most

!.l007

the typical treatment

anterior tenderpoints are treated

position for anterior

in the flexion position.

pulse associated with?

tenderpoints is flexion. How can counterstrain

The goal of any counters train

treatments be easily

techniques is to "curl" the

remembered for practical

patient's surrounding muscle

application?

groups around the point of

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1004

88

Osteopathic Medicine Recall

treatment. For example, counterstrain of the biceps muscle would involve flexing and supinating the biceps muscle around the counterstrain point. In general, what is the

Positioning the patient in

typical treatment position

extension

11007

for posterior tenderpoints? What treatment positions

More rotation and sidebending

110061007

This is generally true.

1.10061007

are typically used for tenderpoints more lateral to the midline? True or False: MidJine tenderpoints typically require pure flexion (if anterior) or pure extension (if posterior). While maintaining contact

Myofascial changes such

with the tenderpoint, the

in tissue tension and a reduction

physician should be

in tendeq)oint discomfort

as

ease

1.10061007

monitoring for what kinds of change? What is a Maverick point?

Tendelpoints that are treated by

11007

positioning the patient opposite of what is typically expected The cervical spine

11007

Within the cervical spine,

At the lateral aspect of the lateral

where are the anterior

masses or anterior to the lateral

1.10071008

tenderpoints typically

masses

Which region of the body has the most Maverick points?

located? Where are the posterior

1. On the oCciput

tenderpoints in the cervical

2. Tip of the spinous processes

spine typically located?

or just lateral to the spinous processes

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110071008

Chapter 7 I Counterstrain

89

Anterior border

�---"�--- of Sternocleidomastoid muscle (SCM)

Figure 7-1.

Figure 7-2.

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90

Osteopathic Medicine Recall

Where is the tenderpoint for

At the posterior edge of the

the anterior first cervical

ascending ramus of the mandible

located?

at the lobe of the ear

What is the counterstrain

Rotation of the head about 900

treatment position for the

away from the tenderpoint

Ll007

LlO07

anterior first cervical? Where are the tenderpoints

At the anterior surface on the

for anterior levels C2·C6

transverse processes of the

located?

corresponding vertebrae

What is the treatment

FSARA (Flex the head and neck

position for anterior C2·C6?

to 450; Sidebend Away and

1.10071008

1.1008

Rotate the head Away from the tenderpoint) Where are the tenderpoints

Anterior C7: 2 to 3 cm lateral to

for anterior levels C7 and

the medial end of the clavicle

1.1008

C8 located?

Anterior C8: the medial end of the clavicle at the sternal notch What are the treatment

C7: Flexion, sidebend toward

positions for anterior C7

and rotate away from tenderpoint

and C8?

1.10071008, 11.43-44

C8: Flexion, sidebend away and rotate away (FSARA) Where are the tenderpoints

At the tips of the spinous process

LlO08

Ll008, 11.39-42

for posterior cervical levels C2·C7 located? True or False: The treabnent

False; C2 and C4-C7 are

position for posterior cervical

extension, sidebending away, and

C2·C7 tenderpoints is

rotation away (ESARA). C3 is

extension, rotation away, and

flexion to 450, rotation and

side bending away from the

sidebending away (FSARA); C3 is

side of the tenderpoint.

the Maverick point of the cervical spine, meaning it does not follow the typical treatment pattern of the rest of the cervical spine. Approximately 5% of counterstrain points on the body are Maverick points.

Copyrighted Material

Chapter 7 / Counterstrain

( �f--+-- Costal

margins

Iliac crest

T,

/ T.

/

T5

J

T6 T7 T8

/

l

T9

)

TI1

T'2

'

\(

\

Figure 7-3.

Copyrighted Material

91

92

Osteopathic Medicine Recall

'Where are the anterior

Midline on the sternum at the

thoracic tenderpoints for

attachment of the

TI-T6 located?

ribs 1 inch

Where are the anterior

In the rectus

tenderpoints for T7-T12

lateral to the midline

Ll009

Ll009

located? What is the treatment

Flexion of the thorax with

position for anterior

internal rotation of the arms

L1009

tenderpoints TI-T6? False; T7-T9 is FS"RA (flex,

True or False: The treatment

With

rotate

sidebend

for

anterior T7-T12 is flexion of

TlO-Tl2, the

the thorax with sidebending

the

1.10091010

flexed with

and rotation away . '"'here are tbe posterior

Either side of

thoracic temlernol

process or transverse process

spinous

lJ0091010

located? T1-T9: Extension, rotation, and

What is the treatment

UOJO

away TlO-Tl2: Extension of the tnmk on the same side as the tpnrlprnnint

Deoressed ribs

llOll

Posterior rib tfmdemoints

1I0U

\'Vhere are the tenderooillt

Rib 1: on the first rib at the

1I011

locations for anterior Iibs?

manubrium

Are anterior rib tenderpoints associated with elevated or denn,,

<,d ribs?

\'Vhich tenderpoillts

correspond with elevated

Iibs?

Rib 2: on the second rib at the midclavicular line 6: on the

Rib 3

at the anterior line

Copyrighted Material

Chapter 7 I Counterstrain

9]

(

\

Figure 7-4. 'What are the treatment

Ribs 1 and 2: neck flexion,

positions for antedor ribs?

rotation, and sidebending toward

Ll011

the tenderpoint Ribs 3 tJm)ugh 6: flexion, elevation of the shoulder, sidebending and rotation toward the tenderpoint 'Where are postedor db

On the posterior aspect of ribs

tenderpoints located?

2 through 6 at the rib angles

What is the treatment

Flexion, elevation of the

position for postedor db

shoulder, sidebending, and

tenderpoints?

rotation away from the tenderpoint

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1.1012

11012

94

Osteopathic Medicine Recall

Countel'strain h'eatment of ribs is held fOl' what length of time? Whel'e are the anteriol' lumbar tenderpoints located?

120 seconds

1I01l. 1162 7

Ll: medial to the anterior

1.1012

superior iliac spine (AS1S)

L2: inferomedial to the AIlS L3: lateral to the AIlS L4: inferior to the AlIS L5: anterior surface of the pubic rami, 1 cm lateral to the symphysis 2 inches Abdominal '-2

r-,

Figure 7-5,

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Umbilicus

Chapter 7 I Counterstrain

Wbat is the counters train

Flexion of the hips with knees

treabnent position for

and feet pulled toward the side

anterior Ll?

of the tenderpoint

True or False: The position

False; the physician stands on

for treabnent of L2-LA

the opposite side of the

involves standing on the

tenderpoint with the knees and

same side as the tenderpoint

feet positioned away from the

and flexion of the hips with

tenderpoint.

95

1.1012

1.1012

the knees and feet positioned away from the tenderpoint. What is the counterstrain

Flexion of the hips with the knees

treatment position for

positioned toward the tenderpoint

anterior L5?

and feet away from the tenderpoint

Where are the posterior

On the inferolateral side of the

LI-L5 tenderpoints located?

corresponding vertebra's spinous processes

UPL

=

Upper Pole Ls

LPL

Figure 7-6.

Copyrighted Material

=

Lower Pole Ls

1.1012

1.1012

96

Osteopathic Medicine Recall

What is the counterstrain

Extension of the trunk on the

treatment position for the

ipsilateral side of the spinous

posterior LI-L5 tenderpoints?

process

Where is the tenderpoint for

Between the midline and ASIS,

the iliacus muscle located?

7 cm deep in the abdomen

!.l012

1.1013

What is the counterstrain

Flexion of the hips bilaterally with

treatment position for the

both hips laterally rotated and

iliacus muscle?

knees abducted (frog-leg position)

True or False: T he lower

True

1.1013

1.1013

1.1013

pole L5 tenderpoint is 2 cm below the posterior superior iliac spine (PSIS). How is the lower pole L5

Flexion of the ipsilateral hip to

tenderpoint treated with

90° with medial rotation and

counterstrain?

adduction of the hip

Where is the piriformis

In the piriformis muscle, between

muscle tenderpoint?

the greater trochanter and its attachment to the lateral side of the sacrum

JI!:J:- r /

Figure 7-7a.

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'<

{

;:� " Inguinal

ligament

1.1013

Chapter 7 I Counterstrain

97

Midpole sacral

.... <-----,I,--..:L '>.-Pi - riformis High flare-out sacroiliac

o Posterior sacral tenderpoints overlie the priformis muscle

Figure 7-7b.

Flexion of the ipsilateral hip with What is the piriformis

abduction and external rotation

muscle tenderpoint counterstrain treahnent position?

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11013

Chapter

B

Facilitated Positional Release

What is facilitated positional

It is an indirect positional

release (FPR)?

treatment method of either

1.1017

abnormal muscle tension or somatic dysfunction. It was developed by Dr. Stanley

Who developed FPR?

1.1018

Schio"' tz, D.O. In what position is the patient

T he patient is placed in a neutral

placed before the physician

position, which is a balanced

1.1017

position between flex.ion and

perfonns FPR?

extension. Why is the patient placed in

To unload the joints' articulating

a neutral position for FPR

sUlfaces, allo"' ng the dysfunctional

techniques?

area to respond morc eaSily and

1.1017

rapidly to the applied motion and force Once the patient is in the

An activating force is applied to

neutral position, what type

encourage immediate release of

of force is applied to

tissue tension, jOint motion

perfonn FPR?

restriction, or both.

What is the goal of FPR?

To decrease tissue hypertonicity

1.1017

1.1017

that maintains somatic dysfunction;

FPR

C
also be modified to

influence deep muscles involved in joint mobility. What supposedly initiates or

Increased gains in gamma

maintains the immobility of

motor neuron activity of the

a dysfunctional segment?

dysfunctional segment

1.1017

How is the patient

The anteroposterior (AP) spinal

positioned with FPR?

curve of the area that is going to be treated should be flattened

98

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.

1.10171018

Chapter B IFacilitated Positional Release \Vhy is it important to

To aJlow

flatten the

of the involved muscles

in FPR?

What is the initial

in

FPR?

1.10171018

A or

99

lJ017lOI8

is

maintained. involved myofascial

Describe the

The

!-'U>IUVII after

structu res are placed in a shortened and relaxed

LlOI71018

PV;>ll1'Jll.

Discuss the reasoning

110171018

behind the positioning of the patient. How long is the patient held

This pOSition is held for 3 to

in this position?

5 seconds and then

the

LlOI71018

is then re-evaJ uated. condition is

What is the final step in FPR?

LlOI71018

How would a C5

1. Flatten the cervical lordosis.

diagnosis be treated using

2. Place C5 into extension.

FPR?

3. Sidebend

UOl8

with

to C6.

4. Rotate right with

to

C6. force.

5. Apply the 6. Hold the seconds

for 3 to 5

release should be

pal.pa,me to the physician). 7. Re-evaluate the Does it take a long time to

in

nertonn FPR?

it

In theory, how does FPR

FPR allows the extrafusal muscle

immediately affect the

fibers to

muscle spindle-gamma loop?

relaxed state

to their normal to the

shortened and tense state they experience when somatic dysfunction

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1.1017

LlGH

100

Osteopathic Medicine Recall

What is the theoretical

When a muscle is shortened, it

reasoning behind shortening

causes a decrease in the muscle

a muscle in FPR?

11017

spindle output and lowers the afferent excitatory input to the spinal cord through the Ia nerve fibers.

What is the theoretical

With

result of shortening a

excitatory input to the spinal cord

muscle in FPR?

through the Ia nelve fibers, there

a

lowered afferent

11017

is a decrease in gamma motor gain (output) to the spindles and by reflex action, decreased tension of the extrafusal fibers as they lengthen to their more original and normal functioning state. Does all joint motion

No; only the motions that

asymmetry decrease with

were impaired by muscle

FPR treatment?

hypertonicity.

What are the two main goals

1. Normalization of palpable

of FPR?

tissue texture 2. Positively influencing the

deep muscles involved in joint mobility

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11017

11018

Chapter

9

Ligamentous Articular Strain

What was the principle

Exaggeration of the lesion to the

demonstrated by A.T. Still

degree of release that will allow

on how ligamentous

the ligaments to draw their

articular release (LAR)

articulations back into normal

strain works?

relationship

What are the three basic

1. Disengage, by compression

225

or decompression, until the

principles of treating a

injured part is able to move.

ligamentous strain with an

LAR technique?

2.13

2.

Exaggerate the ligaments back toward the original position of injury until a balance/stiU point is found.

3. Balance the tension until a release is felt. Remember DEB-Disengage, Exaggerate, and Balance. True or False: In a

False; the tighter ligament is

ligamentous injUl)', the

usually the healthy ligament

tighter ligament is usually

holding a joint in its place, while

the injured ligament.

2.23

the ligament that is more loose is usually the injured ligament.

Once the joint is returned

About 90 days (3 months), which

to its normal physiological

is the time it takes connective

223

position, how long does it

tissue to regenerate; if the joint is

take for the ligaments to

not restrained dUling this period,

heal?

no fUlther treatment is needed

Do weakened ligaments

In the direction of the lesion

2.24

Carrying the injured body part in

2.25

allow excess joint motion in the direction of the lesion, or opposite the direction of the lesion? What is indirect LAR?

the direction that caused the injury 101

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102

Osteopathic Medicine Recall

What is direct LAB?

Carrying the injured body palt

2.25

toward its normal position Which technique-direct

Indirect LAR techniques

2.26

This is known as crimping.

2.29

1. Fibrofatty infiltrates increase

2.29-30

or indirect-is usually less painful and non traumatic for the patient? What is the term for the orientation of ligaments that take on

an

undulating config­

uration, allowing the ligaments to work like a spring? What biochemical changes take place when a ligament is imm obilized?

in the joint capsule. 2. Loss of water ,ll1d glycosaminoglycans. 3. Optimal distance between fibers decreases. 4. Microadhesions form in a haphazard manner. 5. Joint stiffness increas(,s.

Describe direct myofascial

It is performed for pain at the

release of the plantar fascia.

bottom of the foot, heel spurs,

2.41

and plantar fasciitis by contacting the bottom of the foot at the tarsal-metatarsal junction with the thumbs crossed, applying direct pressure toward the sides of the foot and toes. Why is the calcaneus

Because the treatment motion

technique also described as

is similar to taking a boot off

the "bootjack" technique?

of one's foot

If a patient's talus is

The physician should compress

anterior, in which direction

the tibia posteriorly into the table

should the physician move

with the patient in the supine

the tibia when using a direct

position; this will move the tibia

LAB treatment technique?

posteriorly and the talus anteriorly, exaggerating the dysfunction so the involved ligaments once again reset themselves into balance.

Copyrighted Material

2.44

2.46

Chapter 9 !ligamentous Articular Strain How should a physician

With a supine direct myofascial

treat calf pain and cramping

technique, by pressing the four

of the foot?

103 2.49

fingers of each hand side by side into the tight gastrocnemius, compressing the tight muscles, and applying a slight inferior traction

Describe how to balance the

Place one hand under the knee,

fibular head in a patient

making contact at the fibular

with lateral knee pain or an

head with the thumb and the

unstable ankle,

other hand holding the foot; flex

2.50

the hip and knee to 90° with slight external rotation of the femur; press the fibular head inferiorly; invert the foot; and balance the tension between the two hands until a release is felt.

Contacting a posteriorly

Moving a posteriorly subllLxed

subhLxed meniscus in the

meniscus anteriorly into resistance

popliteaJ fascia and moving

describes a direct LAR technique.

2.55

it anteriorly back into its physiologic norma] position describes what type of LAR technique? Medial and posterior

2.58

Describe the lateral

Very close to its insertion on the

2.63

recumbent direct myofascial

femur, slightly posteriorly and

In which dr i ections a physician exaggerate a tight iliotibiaJ band in a supine direct myofasciaJ release?

release technique of the

inferiorly to the greater trochanter,

piriformis.

engage the pirifomlis muscle and maintain finn pressure with the pads of your thumb medially down into the table.

Treating the pelvic diaphragm

Urinary frequency, pain in the

that is stuck downward in

rectal area, prostatitis. hemOlThoids,

exhaJation, using a supine

dyspareunia, recurrent urinary tract

direct myofasciaJ release, is

infections

indicated with what types of complaints?

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2.71

104

Osteopathic Medicine Recall

DescJibe how to treat the

Have the patient lie in a supine

sacrum with a direct LAR

pOSition and reach both hands

technique.

around to the sacrum, aligning

2.75--76

the second- to fifth-digit finger pads along the sacral sulcus; rotate your fingers laterally and your thenar eminences medially.

VVhere is the iUopsoas

Slightly laterally to the femoral

muscle located in relation

altery

2.80

to the femoral artery? A spasm in the psoas muscle can

be treated by contacting

Carrying the iliopsoas muscle

2.80

laterally \vill help calm iliopsoas

the psoas muscle just laterally

spasms in a direct myofascial

to the femoral artery and

release.

carrying the muscle which way? Treating the median

The physician should rotate the

umbilical Ugament in patients

wrists and spread the fingers

with complaints of uJinary

apart in order to stretch the

frequency involves engaging

ligament until a release is felt.

2.85

the ligament halfway between the umbilicus and pubic bone and moving the wlists and hands in what manner? Treating the umbilicus by

Abdominal and pelvic pain,

rotating it with the pad of

gastrointestinal (Gl) complaints,

one thumb in the direction

and, interestingly, can aid in the

it prefers is used to treat

treatment of asthma

2.86

what complaints? supine

Postoperative patients

Place the patient in

often expeJience difficulty

position engage the abdominal

taking a deep breath. How

viscera underneath the costal

a

can a physician b·eat the

margin, and carry

thoracoabdominal diaphragm

the viscera against the diaphragm

to increase negative

until greater diaphragmatic

intrathoracic pressure and

motion and freedom is felt.

help the patient take a deeper breath?

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2.93

Chapter 9 / Ligamentous Articular Strain Anterior chest pain is often

Compressing the sternum and

treated by compressing the

carrying it into its ease is an

sternum and carrying it to

indirect LAR technique .

105 2.94

a position of ease. Is this an example of a direct or an indirect LAR technique? For lateral chest pain and

The ribs are carried medially

costochondritis, the patient

into the table, using a direct LAR

is placed in a lateral

technique used more often for

recumbent position and the

bucket handle-motion ribs.

2.96

ribs (4-8) are carried in what direction? Describe how to treat ribs

Disengage the rib anteriorly at

2 through 12 in the supine

the rib angles and then carry

position.

them superiorly and laterally; use

2.97

this technique for chest pain, especially associated with twisting and turning motions. What type of myofascial

A supine direct myofascial

treatment could be used to

release of the anterior ceJVical

decrease tension near the

fascia; apply a force directly

terminal pOl·tion of the

inferiorly into the anterior

thoracic duct to ensure

ceJVical fascia; when the release

optimum flow of lymphatic

is felt, draw the thumbs laterally.

2.113114

fluid? Pain at either end of the

Moving the clavicle slightly

clavicle is common in

posteriorly, superiorly, and

childhood injuries and can

laterally in a direct LAR

be treated by having the

technique

2.116

patient sit upward, grasping the clavicle at both ends, and moving it in what direction? Treating a shoulder that has

Either tl1e anterior

limited motion involves

posterior direction

having the patient laterally recumbent with the injured shoulder up, compressing the shoulder directly in the

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or

the

2.118

106

Osteopathic Medicine Recall

dkection of the onn{],sitl> glenohumeral joint and balancing the shoulder by moving the shoulder in what direction? Describe the foreann direct LAB treatment of tennis grasp the

elbow.

of tbe

olecrenon between your thumb and index fine:er; then, compress

tension; and

elbow into extension,

of force.

the other Hemorrhoids are comlnon

The

seen when which of the body is not properly? �What are the

functional

diaphragms of

body

1. Plantar fascia

163

2.

(all of which can be treated LAB or a

nn,,·,tl. ...in

release) that must working together in unison

.-., J.

to augment fluid movement

4.

throughout the body?

5. Thoracic outlet

cervical

subclavius

muscles, costocoracoid and costoclavicular 6. 7. 8.

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sellae

Chapter

10

What is muscle energy?

Muscle Energy

A fOlm of osteopatruc manipulative

1.881

therapy (OMT) in which patients actively llse their own muscles upon the physician's request from ,

a preCisely controlled pOsition, in a specific direction, against a distinctly exeCltted colmteiforce

by the physician Following a muscle energy

Recheck the patient's somatic find-

treatment, what must one

ings to confirm that the dysfunction

always remember to do?

12.1315

has been treated and has improved (if not completely resolved)

What is an active treatment?

A treatment during which the

patient will assist the doctor What is a direct treatment?

A treatment in which the patient

is moved toward the barrier What is an indirect

A treatment in which the patient

treatment?

is moved away from the barrier

Is muscle energy an active

It can be either an active direct

direct or an active indirect

or an ac tive indirect tech nique.

technique?

For boards, know that most

12.1315

12.1315

12.1315

1.881

forms of muscle energy are direct techniques. What types of patients

1. Comatose patients

would not benefit from

2. Uncooperative patients

muscle energy?

3. Patients who are too young

1.881

to cooperate 4. Unresponsive patients What are the main treatment goals when using muscle energy?

1. To decrease muscle

1.881

hypertonicity 2. To lengthen muscle fibers 3. To reduce the restraint of

movement 107

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108

Osteo pathic Medicine Recall 4. To produce joint mobilization 5. To improve respiratory and

circulatory function 6. To strengthen the weaker side

if there is asymmetlY What physiologic principles are used to accomplish these

1. Postisometric relaxation

(direct technique)

1882883

2. Reciprocal inhibition (direct

goals?

and indirect technique) 3. Joint mobilization using

muscle force 4. Oculocephalogyric reflex 5. Respiratory assistance 6. Crossed extensor reflex

How is postisometric

Golgi tendon organs in the muscle

"elaxation theoretically

tendon sense the change in muscle

1882, 6.44

tension and cause a reflex relaxation

accomplished?

of the agonistic muscle fibers; this relaxation allows the physician to passively move the patient toward the new restrictive barrier. What goals are accomplished

Lengthening of a muscle

when using "eciprocal

shortened by a cramp or acute

inhibition?

spasm

What is the physiologic basis

By contracting antagonistic

behind reciprocal inhibition?

muscles, Signals are transmitted

1883

1.883, 6.45

to the spinal cord using the reciprocal inhibition reflex arc that force the agonistic muscle to rela.x. True or False: Reciprocal

True; reciprocal inhibition can be

inhibition can be done

done either directly or indirectly.

1.883

di"ectly or indirectly. Note: Reciprocal inhibition is also

known What is joint mobilization?

as

reciprocal innervation.

Using muscle contractions to establish the joint's normal range of motion

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1.882

Chapter 10 I Muscle Energy of the cervical and

What is the

musculature to

reflex?

109 1.88283

extraocular muscle contractions as the

to follow

the lead

eye motion

What is a

assistance technique?

that uses the nQlc"""n

1.88

voluntary

motion to restore normal motion; may involve the direct use of

and extremities Will nonnal respiration

1.883

be useful if the physician is

to use a muscle energy technique with respiratory assistance?

clinical response.

How does a crossed extensor

the

1.883.

reflex theoretically work? muscle and contraction muscle on the An,"A,it"

side of the muscle

""'hat is an example of a

the

crossed extensor reflex?

will cause relaxation

645

the left

and contraction of the left muscle. When is a crossed extensor

In extremities in which the

reflex used in muscle

muscle

energy?

injured that it cannot be

Describe the muscle energy

1.

treatment

1.883

treated is so

the restrictive barrier treatment) in all

of motion.

2. Instruct the

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to move in

1.884

I 10

Osteopathic Medicine Recall

or 3, Maintain an

countelforce. 4. Hold for

to 5 seconds.

5, Instruct the patient to relax, 6, Take up the slack. 1 through 6 for

7. 3 to 5 times,

What must a physician

Recheck the range of motion

1.884

The muscle n "ivf'lv

1.884

Movement of the restricted

1.884

always do after completing any technique? What takes

when

the physician "takes up the slack"

the

postisometric relaxation phase of muscle What is accomplished by instructing the

a

to

contract appropriate

range of motion

muscle(s) during muscle

When does a saUSIaCU}T

About the third time the

response to muscle energy

is asked to maintain an

1.884

counterforce

typicall}' occur? What factors increase the

1.

success of a muscle energy

2,

at remo"ing

1884

3.

somatic dysfunction? Is the

of force or

localization more important?

Precise localization of the force

1884

in all olanes of motion is more than the intensity of force.

What critical factor does localization of the

The"

1.884

perception of movement (or

muscle energy force

resistance to

depend on?

about a

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at or

Chapter 10 I Muscle Energy

to make

\Yhy is it important to have

It enables the

good

subtle assessments about variations of

nh'l<:""'n"

treatment

of success

1.884

decreases because the not been

into an articulation that is one below the

U)e.;;:.C 'C'U

False; the

inh'oduces motion

<
1.884

and to create

of movement or resistance?

True or False: \Vhen the

II I

localized to the restrictive

dv"tmlMiron_ the probability

'Vhat effects can an

Excessive force recruits other

excessive physician force

muscles to

1.884

stabilize the body treated and may

have on a muscle enel'gy

the intent of

treatment?

where it was

\Vhat is the relative

could be

contraindication to muscle

adding

1884

energy treatments? Give some examples of

1.884

patients who cannot be treated with muscle energy. Describe how to treat an

1. Use the distal

of one

and monitor the OA

occipitoatlantal (OA) dysfunction with muscle enel'gy.

2.

to use

3.

small amount of force t o the head.

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1.888

112

Osteopathic Medicine Recall 4. Simultaneously exert an equal

amount of counterforce. 5. Maintain the forces for 3 to 5 seconds. 6. Repeat 3 to 5 times, each

time re-engaging the new restrictive barrier. Describe how to treat an

1. Cradle the patient's occiput in

1.888

your hands.

atJantoaxiaJ (AA) RII dysfunction with muscle

2. Flex the patient's cervical spine 45° to lock out all facets

energy.

below the AA joint. 3. Rotate the atlas to the left

until the point of initial resistance is felt. 4. Instruct the patient to gently

rotate his/her head to the right. 5. Apply an equal counterforce

through your fingers and hands. 6. Maintain the forces for 3 to 5 seconds.

7. Repeat 3 to 5 times, each time re-engaging the new restrictive barrier. Which joint is treated by

The AA joint

1.888

1. Use the distal pad of your

1.889

using only a rotational force? Describe how to treat a C3 ERIISII dysfunction with muscle energy.

finger on the articular pillar of the dysfunctional segment.

2. Reverse the dysfunction in all three planes of motion until the forc('s localize under your monitoring finger (rotation and sidebencling components are to the same side from C2-C7 in the cervical spine). 3. Instruct the patient to gently

straighten her head while you apply an equal counterforce.

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Chapter 10 / Muscle Energy

113

4. Maintain the forces for 3 to 5 seconds. 5.

Describe how to treat a T3

L

1.886

dysfunction with as a lever to induce motion at

muscle energy.

the

2.

rotate, and sidebend

.3.

until the forc'es are localized under your to use a

4.

small amount of force to his head while you

exert an

amount of

counterforce.

5. Maintain force for 3 to

5 seconds.

to relax.

6. Ask the 7.

barrier. 3 to 5 times, each

8.

the new

time

Describe how to treat a T7

1. Use your left hand to monitor

the

ERLSL dysfunction with

transverse

process of T7.

muscle energy.

2. Instruct the patient to

her left hand behind

across the

3.

chest with your

arm.

4. Sidebend and rotate T7 to

the

until the forces

are localized under your hand.

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1.886

I 14

Osteopathic Medicine Recall 5. Direct the

to use a

small amount of force to exert an counterforce. 3 to 5 times, each

6,

time re-enl!ae:inl! the new

What are the restricted

There is restriction of flexion.

1.886

T5-T9

1.886

motions of a T4 dysfunction? If a patient has restriction in left rotation and right sidebenciing at segments T5-T9, how would these

findings be recorded? What is a

1.723

rib?

What is a rib dysfunction

;)lUI1\.:UUH

in

Ll245

of

(rib lesion)? one or several ribs is

''''a 'h t is the key rib in an exhalation rib dysfunction?

11245 therefore the rib of the dvstUllCDO! should be

\\'hat is the key rib in an

The ribs are held upward;

inhalation rib dysfunction?

therefore the key rib is the bottom

11245

rib of the dvsfunctionall!TouD and shou.ld be

Which rib should he treated first if a group of ribs is found to be held in exhalation?

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1.890

Chapter 10 I Muscle Energy Why is this rib treated first?

I 15

1890

below it downward Describe the rib motion

The first rib elevates

of a first rib inhalation

inhalation but does not move

\vith

L891

with exhalatioll. Seated on the side of the table with the left arm muscle energy

L891

over

the physician's

to correct an elevated first rib dysfunction? Where should the nhv,,;l'iH

L891

the

stand when using muscle energy to correct an elevated

to the

first rib? 1.

l.891

enel'gy.

head and head away

4. As the patient

the

physician exelts a caudal and forward pressure on the surface

the rib, motion

the rib. 5.

instructs to

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1 16

Osteopathic Medicine Recall

When treating an elevated

To take tension off the scalene

right first rib with muscle

muscles

1.890

energy, the physician will guide the patient's head forward, sidebend and rotate it away from the dysfunction. What is the purpose of these motions? When does a physician know

When maximal motion of the

that an elevated right first

dysfunctional rib has been

rib has been improved with

obtained

1.890

muscle energy? The supine position

1.890

Describe how to treat an

1. Place one hand on the anterior

1.890

inhalation dysfunction of

aspect of the lower key rib.

In what position is the patient placed when performing muscle energy to correct an inhalation dysfunction of rib 4?

ribs 2 through 6 with muscle energy.

2. Flex the patient for pump

handle dysfunctions (sidebend the patient for bucket handle dysfunctions) down to the dysfunctional rib to remove the tension. 3. Instlllct the patient to inhale

and then exhale deeply. 4. Instruct the patient to hold

his breath at the end of the expiratory phase for 3 to 5 seconds. 5. During this time, adjust

flexionlsidebending to the

new restrictive barrier.

6. Follow tbe rib shaft into

exhalation with your hand dliling the expiratory phase. 7. On inhalation, the physician

resists the inhalation motion of the rib. 8. Repeat 3 to ,5 times.

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Chapter 10 I Muscle Energy When h'eating bucket

The patient is instructed to reach

handle dysfunctions, what is

for her knee on the affected side.

1 17 1.891

the patient instntcted to do befOl'e holding her b,'eath in expi,'ation for 3 to 5 seconds? Which muscles al"e used

The anterior and middle scalene

to treat an exhalation

muscles

3.565

dysfunction of rib I? Which muscle is used

The posterior scalene muscle

3.565

The pectoralis minor muscle

3.565

The serratus anterior muscle

3.565

The latissimus dorsi muscle

3.565

to treat an exhalation dysfunction of rib 2? Which muscle is used to treat an exhalation dysfunction of ribs 3-5? Which muscle is used to treat an exhalation dysfunction of ribs 6-9? Which muscle is used to treat an exhalation dysfunction of ribs 10 and ll?

Note.' Ribs 11 and 12 can be treated \-vith the quadratus lumborul11.

Which muscle is used

The quadratus lumborum muscle

3.565

1. The patient is instructed

18921.893

to treat an exhalation dysfunction of rib 12? Describe how to treat exhalation rib dysfunctions with muscle energy,

to place his forearm on the

dysfunctional side across

his forehead with his palm

faCing up.

2. Grasp the key rib posteriorly at the rib angle. 3. Instruct the patient to inhale deeply while applying an inferior traction on the lib angle.

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118

Osteopathic Medicine Recall 4. Instruct patient to hold his breath at full inhalation while performing one of the following isometric contrac­ tions for 3 to 5 seconds: Rib 1: Patient raises his head directly toward the ceiling Rib 2.: Patient turns his head 30· away from tlle dysfunc­ tional side and lifts his head toward the ceiling. Ribs 3 through 5: Patient pushes his elbow on the dysfunctional side toward the opposite anterior superior iliac spine (ASIS) Ribs 6 through 9: Patient pushes his arm anteriorly. Ribs 10 through 12.: Patient ad ducts his anTI. 5. Repeat 3 to 5 times, each time re-engaging the new restrictive barrier.

How is the patient positioned

The patient is placed in the

for muscle energy of the

seated position.

1.885

lumbar spine? Describe how to treat an

In the same manner as the lower

L3 ESRRR dysfunction with

thoracic spine

1.885

muscle energy. What information is

Two types of information are

required for diagnosing

needed:

sacral dysfunction?

The position of the two sacral sulci and the t\'IO inferior lateral angles (ILA), in addition to the results of (this test is a proce­ dure by which information is obtained) a motion test

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1.897

Chapter 10 / Muscle Energy

1 19

The results of a seated anclJor standing flexion test What tests can be used

l. Lumbar spring test

to screen for a unilateral

2, Sphinx test

sacroiliac dysfunction?

3, Seated flexion test

1.897

4, Seated assessment of ILA

asymmetry In what position is the

The patient is placed in the

patient placed when

prone position,

1.897

performing muscle energy to correct a right unilateral sacral extension?

l. Place your left hypothenar

Describe how to treat a unilateral sacral dysfunction

eminence on the patient's

[8991.900

right sacral sukus.

with muscle eneq�)'.

2, Ask the patient to exhale and

hold her breath while you push anteriorly and caudad on her superior sulcus, 3, Hold for 3 to 5 seconds, 4. Direct the patient to inhale

while you resist any anterior superior movement of the sacrum, 5, Repeat 3 to 5 times.

Is a L on L sacral dysfunction

1.898

Forward sacral torsion

considered a backward or forward torsion? To what position is the patient

Forward sacral torsion

rotated when perfonning

patient is rotated so that her/his

muscle energy to correct

chest faces

a Lon L sacral torsion?

the treatment table)

Describe how to treat

l. The patient lies on his left

---+

The

1.898

dOWll (forward onto

(axis side down) with his

a L on L sacral dysfunction

side

with muscle energy.

torso rotated so the patient's face is down. 2. Flex the patient's hips until

the motion localizes at the lumbosacral junction.

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1.898[899

120

Osteopathic Medicine Recall 3. Drop the patient's legs off table to induce left sidebending and engage a left sacral oblique axis. 4. Ask tile paticJlt to lift his legs toward cpiling against an ('(Iual countenorce for 3 to 5 sec:onds.

5. M on itor the right superior pole o[ the S,H:rum [or postelior movement with your other hand.

6. Repeat for 3 to 5 times. Backward s,lcral torsion

1.899

In what position is the

The patient is lying on her left

1.899

patient rotated when

side (axis side down) with torso

What type of torsion is a Ron L sacral dysfun ction?

performing muscle energy

rotated so that she is faCing

for a Ron L sacral torsion?

up ward with her back on the treatment table.

Note: When patients are being treated for

a

bac kw ard (noll­

neutral) torsion, they are placed on their backs.

1. Grasp the patient's left ;JfJn

Describe how to treat a Ron L sacral torsion with muscle energy.

and pull inferiorly to rotate his torso to the right.

2. Flex the patient's hips until motion is localized at the

IUlllbosacraljunction. 3. Drop the patient's legs off the

table to induce left si de ben din g and engage a left sacr al oblique axis. 4. Ask the patient to lift his legs toward the ceiling against an equal counterforce for 3 to

5 seconds. 5. Monitor the right superior pole for anterior movement with your other hand.

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1.899

Chapter 10 / Muscle Energy

121

6. Repeat for 3 to S times, each

time re-engaging the new restrictive barrier. 'What causes innominate

Irregularities in the biomechanics

dysfunction?

of the sacroiliac joint

\Vhat maintains innominate

Ligamentous tension

1.894

1.895

1.894

somatic dysfunction? \Vhat is the role of muscle

To restore normal articular

energy in innominate

relations across the sacroiliac

dysfunction?

joint

Describe how to treat a

1. Flex the patient's right hip and

right anterior innominate dysfunction with muscle energy.

1.895

knee until resistance is felt. 2. Instruct the patient to extend

hislher hip against a counterforce for 3 to 5 seconds. 3. Wait a few seconds for the tissues to relax. 4. Take up the slack to the new

restrictive barrier. S. Repeat until no restrictive

barrier is felt (3 to 5 times). If an innominate is rotated

Posterior innominate rotation

1.895

Right innominate anterior:

1.895

anterior, what is the

restriction?

How is a right innominate anterior treated differently

Patient flexes right hip and

than a right innominate

knee.

posterior?

Patient extends hip against a counterforce. Right 'innominate posterior:

Patient's right leg is dropped off the table and abducts. Patient flexes and adducts

knee against counterforce.

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122

Osteopathic Medicine Recall

When treating a right

The patient is placed in the

anterior innominate

supine position.

1.895

dysfunction, is the patient supine or prone? When treating a right

The patient is placed in the

posterior innominate

supine position.

1.895

dysfunction, is the patient supine or prone? What type of patient history

Recent childbirth or surgery per-

would lead a physician

formed in the lithotomy position

1.896

suspect an abducted pubic Note: The lithotomy position is the

bone?

position where a women is placed on her back with her knees bent and thighs apart; it is assumed for vaginal or rectal examination. and sometimes for childbeaIing. How do patients with

Because of fascia stn,sses placed

abducted pubic bones

on the urethra, some patients

1.895

e"'."perience urinary frequency and

usually present?

urgency suggestive of infectious cystitis. Note: LaboratOIY studies do not

support this diagnosis. In what position is the patient

The patient is placed supinely with

placed when perfonning

hips flexed to 45°, knees flexed to

muscle energy to correct

90°, and feet flat on the table.

1.897

bducted pubic bones? 1. The patien t's knees are

Describe how to treat abducted pubic bones with muscle energy.

separated about 18 inches. 2. The lateral aspect of the knee

closest to the physician is placed against the physician's abdomen (using a pillow to protect the physician). 3. Reach across the other knee

and grasp the latera.! aspect of that knee with both hands.

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1.897

Chapter J 0 I Muscle Energy

123

5. Hold for 3 to 5 seconds. 6. Ask the patient to relax and wait 2 seconds for the tissues to relax. 7. Pull the knees

closer

What are the differences

1.897

between treating a right superior h'eating a

shear and 2. The patient is instructed to

inferior

pubic shear with muscle

the

energy?

knee to

left ASIS.

2. The patient is instructed to

extend and adduct the knee. Describe how to treat a

1.897

1.

posterior radial head dysfunction with muscle energy.

patient's light forearm. 2. Supinate the forearm to

resistance while with

other thumb

radial Instruc t the an supplied by

nll1.f<1f'!QY'·<

hand. Hold for 3 to Relax. 6.

the

to a

resistance. 7

for 3 to .5 times.

How is motion of the lorearm

The patient's

affected when the patient has

rcstliction viitb

a right

radial head?

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1.900

Chanter 11



Is the high

The High Velocity, Low Amplitude Technique low

HVLA is a passive treatment

LS52

1.852

amplitude (HVLA) technique an active or a Dassive technique? IsHVLA a direct or an

HVLA is a direct treatment

indirect technique?

technique,

What are thrust

A collection of direct

1.852

treatments that

k

use HVLi\ activation "Vhat is another name for

Mobilization with impulse

1.852

To move a

1.852

HVLA (that may sound less

What is the

ofHVLA?

its restrictive barrier so joint resets itself when \\-11at is a joint resets itself after

Restoration

motion

1.852

treatment withHVLA? When is the thrust

1.852

administered illHVLA? restrictive barrier How is anHVLA thrust best

1.852

described? a click or pop is heard

is most ",ith

an

effective

at the time the force is

thrust technique?

124

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1.852

Chapter I I I The High Velocity. Low Amplitude Technique True or False: The pop or

False; although a noise is usually

click after an HVLA thrust

indicative of success, it is possible

indicates that the restricted

that an unrelated joint may have

125 [,855

made the noise and the restricted

joint is now "fixed."

joint remained unaltered. Note: Always retest motion after treatment. What is the normal

Muscles surrounding the joint

physiologic rE>action to a

protect it from excess motion by

1.854

splinting the jOint; a physical

painful hypermobile joint?

examination would reveal restriction of motion at the dysfunctional sp?;ment. T,"ue or False: HVLA can be

False; although HVLA may work

used eve,), time there is an

as evidenced by a decrease in

unstable hypermobile joint.

pain and improvement in motion,

[,854

the more it is used, the looser the joint becomes, possibly leading eventually to an unstable joint. 1. Modify the activity that

Describe the proper management of an unstable

1.854

contributes to the instability. 2. Mobilize less mobile adjacent

hypermobile joint.

joints. 3. Prescribe active rehabilitation exercises. What maintains the

Abnonmd muscle activity known

restricted joint motion at a

as hypertonicity

1.855

dysfunctional segment? What are the indications for

1. Restriction of joint motion

HVLA?

2. Conclusion by the physician

1.855

that treatment of the joint restliction \-vi II beneRt the patient When aloe thnJst techniques

vVhen a restricted segment is the

not indicated for treating

result of an abnormal anatomic

lost motion seen with

or patholOgiC change, such as a

somatic dysfunction?

trau matic contracture, advanced

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1.855

126

Osteopathic Medicine Recall

or

Note. Think of the riskibenefit

True

False: T hrust

01'

the barrier must feel

techniques are most

and discemible

effective and should be used

end

when the barrier feels and indistinct, '¥hen

a thrust

of

1.855

technique, what happens to the excess force not used in the dysfunctional past its restrictive barrier?

the minimal force necessary in past its restrictive barrier. True or False: Once the

True; do not back off before

barrier is engaged, the thrust should be applied without

L856

the corrective thrust and do

carrv the force

backing off of the restriction. True or False: Amplitude

refers to the

(in reference to oslte(.p�lthjc

1856

of the applied

treatment techniques) refers to the amount of applied force. How can a

to

mnrn",.. the eUectiveness corrective force What prOblems can occur

A

from performing HVLA on

overcome the

a tense patient?

force would be needed to thus increas­

the chance for slde effects an unsuccessful treatment.

Copyrighted Material

1.856

Chapter I I I The High Velocity. Low Amplitude Technique

What are signs that HVLA

Nonverbal cues, such as a facial

might be hurting the

glimace and the presence of

patient?

involuntaty muscle tightening,

127 1856

knov.'ll as guarding True or False: Oldel' and

False; older patients respond

younger patients usually

more slowly to HVLA, while

respond similarly to HVLA.

1856

response to HVLA in younger patients is relatively quicker.

During what phase of

Duling the exhalation phase of

respiration should the

respiration

1856

physician administel- the HVLA thrust? True or False: Daily use of

False; a physician needs to be

HVIA on a patient is good

compassionate and give the patient

osteopathic practice that will

time to respond to the treatment.

ensure the treated somatic

Sicker patients usually need more

dysfunction does not reoccur.

time between treatments.

1856

Note: Daily treatment is excessive

for any patien t. What major complications

1. Permanent neurolOgiC damage

may occur when using thrust

2. Vertebral basilar thrombosis

techniques?

3. Death (or quadliplegia)

1856

from ruptulinglweakening of the transverse ligament of the atlas What guidelines can be followed to ensure patient safety when using HVLA?

1. Be aware of possible

complications. 2. Make an accurate diagnosis. 3. Palpatory examination is a

prerequisite. 4. Listen with hands and fingers

(if it does not feel light. collect more data). .5. Emphasize specificity. 6. Ask for permission to treat. 7. If the patient is not responding

to treatment, re-evaluate. 8. Be aware of the total picture.

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1857

III

128

Osteopathic Medicine Recall

In what position should the

The patient is placed in the

patient be placed when

supine position.

1.857

treating an occipitoatlantal

(OA) FSRRL dysfunction? Where should the physician

At the head of the table

1.857

1.857

be located when treating an

OA FSRRL dysfunction? Describe how to treat an

1. Grasp the patient's head.

OA FSRRL dysfunction with

2. Flex the neck slightly.

lIVIA.

3. The physician's metacarpalphalangeal (M CP) joint of the thnJsting hand is placed at the base of the patient's occiput. 4. Slightly extend the occiput, limiting the extension to the OAjoint. 5. Sidebend the occiput to the left and rotate to the light.

Describe the direction of

Translate the OCCiput to the right

the HVLA thrust used when

and direct the HVLA thrust

1.857

treating an OA FSRRL

towards the patient's opposite

dysfunction.

(light) eye.

What must the physician

Re-evaluate the range of Illotion

1.857

AARn

1.857

In what position should

The patient is placed in the

1.857

the patient be placed

supine position.

always do after completing any osteopathic procedure?

If a patient's atlas is rotated to the right in relationship to the axis, how is this recorded by an osteopathic physician?

when treating an AA RR dysfunction? Where should the physician

At the head of the table

be when located treating an

AA RR dysfunction?

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1.857

Chapter II I The High Velocity, Low Amplitude Technique

1. The physician grasps the

Desct;be how to h'eat an AA

1.857

patient's chin with the

Rn d)'sfunction with

HVLA

129

physician's left palm.

.

2. The physician's right index

finger is placed by the AA joint. 3. The physician's thumb contacts the patient's zygomatic process. Describe the direction of

It is applied in a left rotational

the HVlA thrust used when

pattern, using the right index

treating an AA Rn dysftmction,

finger as a fulcrum.

In what phase of respiration

At the end of exhalation

1.857

Sidebending or rotational thrusts

L858

In what position is the

The patient is placed in the

1.858

patient placed when

supine position.

1.857

is the HVLA thrust applied'? Describe the type of HVLA thrusts used when treating the cervical spine (C2·C7).

petfonning HVLA to correct a C3 FSLRL dysfunction? "''here does the physician

To the right side of the patient,

stand when petfonning

at the head of the table

L858

t'otational HVLA to treat a C3 FSLRL dysfunction? Describe how to treat a

1. Grasp the patient's head.

C3 FSLRL dysfunction with

2. Slightly flex the neck.

HVLA M

3. Place the MCP joint of the

.

thrusting hand at the articular pillar ofC3. 4. Flex both the head and neck to C3. 5. Slightly extend the neck by applying an anterior translation at C3. 6. Rotate the head and neck to

the restrictive barrier. 7. Sidebend the head and neck

to the right.

Copyrighted Material

1858

130

Osteopathic Medicine Recall

Describe the direction or

1858

the HVLA thrust used when opposite eve.

a C3

in the

position is the

Describe how to treat a

1. The

1.858859

at the articlliur ,

with

C6

1858859

2. Flex the head and neck to the

HVLA.

C6-C7

J

3. Add a small amount of extension anterior 4. Sidebend the neck I('ft, ,)

,

,

6, Rotate [wek to the lock the above Describe the direction of

Translate C6

the HVLA thrust used when

sidebend the HVLA thmst

R to

1.851l-859

Direct the

a C6

toward the shoulder, True or False: T he thoracic

False; the thoracic

spine and ribs can effectively

segments and ribs

be treated with HVLA only

using HVLA with the

when the

is placed in

1.859

positioned in

the Where is the corrective

1860

thrust directed when an extended thoracic lesion?

How do

1.860

thoracic

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Chapter I I I The High Velocity, Low Amplitude Technique When using HVLA on a

131

Away from the physician

1.860

Away from the physician

1.860

1. Make a bilateral f ulcrum using

1.860

purely flexed thoracic spinal cord lesion, in what direction should the patient be sidebent? 'When using HVLA on a purely extended thoracic spinal lesion, in what direction should the patient be sidebent? When using HVLA , describe

the thenar eminence and

the placement of the physician's hand and the

flexing the fingers of your

setup of a purely flexed or

caudal hand.

extended thoracic spinal

2. Straddle the spinous processes.

cord lesion?

3. Contact the soft paraspinal

tissues over both transverse processes at the level of the dysfunctional segment. Describe the direction of

Towards the floor (posterior) at

the HVLA thrust used when

the level of the dysfunctional

treating a flexed thoracic

thoracic spinal segment

1.860861

lesion. In what position is the

The patient is placed in the

patient placed when

supine position.

1.860861

performing HVLA for an SnRR diagnosis? Where should the physjcian

On the left side of the patient

stand when using HVLA to

(the opposite side of the

treat a T7 FSRRR dysfunction?

posterior transverse process)

Describe the procedure fOl'

1. Cross the patient's arms over his

using HVLA to treat a T7

chest (superior arm should be

FSRRn dysfunction after the

opposite that of the physician;

patient has properly been set up for the technique,

"opposite over adjacent"). 2. The physician's thenar eminence

(fulcrum) is placed under the posterior transverse process of the dysfunctional segment.

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1.860861

1.860861

132

Osteopathic Medicine Recall

4.

barrier. through

Describe the HVLA thrust

eminence, toward the

used to treat a T7

1.860861

floor

dysfunction. diagnosis of T5

1.860

rotates to the

in

to T6;

be stated as T5 is restricted in both sidebenrli

this can

and rotation to the left in relationship to T6. In what ...""iti",...

1.860

plared HVLA to oon'ect a T7

Where should the physician

On the left side of the process)

to treat a T7

Describe how to treat a T7 HVLA.

1.860

the posterior transverse

stand when usin!! HVL-\

vt'ith

L Cross the

arms

opposite over adjacent. 2. The

thenar under transverse

process of the

other hand is

3, The

to

the

to the T7-T8 4. Side bend the

to engage the restrictive

barrier.

Copyrighted Material

1860

Chapter

I I I The

High Velocity, Low Amplitude Technique

Describe the direction of

Straight dovlTl (posterior) through

the HVLA thrust used when

the thenar eminence, towards the

treating a T7 NSLRR

floor, produced more by a

dysfunction.

momentary drop of one's body

133

1860861

weight than by compression of the patient What are the absolute

1. Osteoporosis

contraindications for using

2. Osteomyelitis

1852855

3. Fractures in the area of thrust

HVLA?

4. Bone metastasis 5. Severe rheumatoid arthlitis 6. Down syndrome Where should the physician

At the head of the table it placing

stand when using HVLA to

the patient in the supine position

1.864

treat a first rib inhalation dysfunction with the patjent in the supine position? Describe how to set up and

1. The physician's first MCP is

1.864

placed on the tubercle of the

properly position a patient for HVLA treatment of a

first rib. 2. Rotate the head and neck

first rib inhalation dysfunction with the patient

away from the side of the dysfunctional rib.

in the supine position.

3. Sidebend the head and neck to the side of the dysfunctional rib. 1. The thrust is through the

Describe the direction of the HVLA thrust used when

1.864

thenar eminence.

treating a first rib inhalation

2. The directions are medial,

d)'sfunction with the patient

inferior, and posterior.

supine. What does the diagnOSiS

The first rib is held cephalad

of a first rib inhalation

upon expiration instead of

dysfunction mean?

correctly moving caudad.

In what positions can a

The supine, seated, and prone

patient be placed to perform

positions may all be used.

HVLA on a fh'st rib dysfunction?

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1.864

1.865

134

Osteopathic Medicine Recall

In what position is the patient

The patient can be placed in

placed when perfonning HVLA to correct a right rib 5

either the supine or prone pOSitions; we will discuss the

inhalation dysfunction?

supine positioning below,

In what position is the patient

The patient can be placed in

placed when perfonning

either the supine or prone

HVLA to correct a right rib 5

pOSitions; we will discuss the

exhalation dysfunction?

supine positioning below,

Where should the physician

On the left side of the patient

stand when using HVLA to

(the opposite side from the

treat a right rib 5 inhalation

dysfunctional lib)

1.866867

1.866867

1.866867

or exhalation dysfunction? True or False: A right rib 5

True; both rib dysfunctions are

inhalation dysfunction is

treated in a similar manner,

1.866867

treated in a similar manner to a right rib 5 exhalation dysfunction. Describe how to treat a

1. Stand on the opposite side

right rib 5 inhalation or

from the dysfunctional rib.

exhalation dysfunction using HVLA with the patient in the supine position.

1.866867

Z, Cross the patient's arms opposite over adjacent. 3, The thenar eminence of the physician's cephalic hand is placed under the posterior rib angle of the key rib. 4. The physician's caudal hand is used to flex the patient's torso and sidebend the patieni away from the dysfunctional rib.

Describe the direction of

Straight down (posterior) through

the HVLA thrust used when

the thenar eminence, toward the

treating a right rib 5

floor

1.866867

inhalation dysfunction. What is the rib's

The dysfunctional rib is held

motion in an exhalation

downward; it moves freely down

rib dysfunction?

during expiration but fails to move upward (is restricted) during inhalation.

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1.866

Chapter

I I I The High Velocity, Low Amplitude Technique

L866

rib is held

What is the rib's

135

motion in an inhalation rib dysfunction?

A

What is a key rib?

L866

rib is the lib to which

treatment should be directed when a group

of the

ribs is rib of the With what technique are levels TIO-L5 traditionally treated when

1.869

It is a treatment commonly referred to as the "lumbar roIL"

using HVLA? True or False: When h,.,,,ti.H'

l1exion, extension,

1.869

extension, and

True;

neutral lesions of

levels

and neub'al lesions of

TIO-L5 can all be treated with

levels nO-L5 v\lith the

the patient

lumbar roll technique,

recumbent

placed

patients are in the same

When using the lumbar roll rp('hrnnnP

to treat flexion!

extension and neutral lesions

L868870

may treat the

The

patient with the posterior transverse process up or dOl'm.

of spinal levels nO-LS, should the physician

the

patient so that

posterior

transverse process is directed up or directed down'? to the direction

With

Type I

dysfunction:

the patient's inferior arm is

Transumie process up

pulJed, what is the only

the patient's infell0r

1869870

=

arm

up

diffel-ence between the two HVLA treatments the

with his/her

posterior transverse process up and

Transverse process down

pull the arm down

the

vvith his\her transverse process down)?

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inferior

=

136

Osteopathic Medicine Recall Type n (non-neutral) dysfunction: Transverse pmces,\ up

=

pull

the patient's inferior arm down

Transverse process dawn

=

pull the patient\ inferior arm up

In what position is the patient

The patient is placed in the left

placed when perlonning HVLA

lateral recumbent position,

1.870

on a Lon Lsacral dysfunction? Where should the physician

The physician stands facing the

stand when using HVLA to

patient,

1.871

treat a Lon L sacral dysfunction? In what position is tJle patient

The patient is placed in the

placed when pelfonning

lateral recumbent position,

1.871

HVLA on an anterior rotated innominate? Where should the physician

The physician stands facing the

stand when using HVLA to

patient.

1.872

treat an anterior rotated innominate? Describe how to treat an

1. Flex the patient's legs to 90°,

anterior rotated innominate

2, Drop the patient's upper leg

dysfunction witJI HVLA.

over the lower leg, making sure the patient's upper leg is also off the table.

3, Contact the ilium with the physi­ cian's caudal forearm between the posterior sup< 'rior iliac spine

(PSIS) and lC grt'atcl' trochanter. 4, The thenar eminence of the physician's cephalic hand is placed on the patient's anterior supelior iliac spine (ASIS),

5, Use the ccphalic hand to cany the patients shoulder backward until localization has occurred against the restrictive barrier,

Copyrighted Material

1.873

Chapter II IThe High Velocity, Low Amplitude Technique

Describe the direction of

A rotary thrust down the shaft of

the "VLA thrust used when

the

an anterior rotated

1873

because the thrust is

below the axis

rotation, the

innominate rotates

innominate. In what

137

in the

is the

L874

patient placed when performing HVLA on an upslipped innominate (superior iliac Where should the

1874

"[lVM''''''

stand when using "VLA to treat an upslipped innominate? Describe how to treat an

1.874

L

upslipped innominate dysfunction with HVLA. 2, Flex the patient's 3,

traction and internally rotate the

Describe the direction of

to relax the

L

treating an upslipped

L874

and

the HVLA thrust used when

2, Use tractional force to the leg,

innominate. 'Where should the

is on the

" .. '1'3.'".....

l.B74

side of the

HVLA to

treat a omiterior radial head? 1874

Describe how to treat a posterior radial head dysfunction with IIVLA. wrist with your other

(thumb is

over the dorsum of the distal 3,

wrist

the extend

patient's elbow

at the same time.

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138

Osteopathic Medicine Recall

Describe the direction of

Apply force on the radial head

the HVLA thrust used when

through the physician's thumb, in

treating a posterior radial

a ventral direction.

1.874

head. How does a patient with a

1. There is tendemess over the

1.874

radial head.

posterior radial head dysfunction usually present?

2. The radial head moves freely with pronation. 3. The radial head is posterior. 4. The radial head is restricted in

anterior glide. What is the goal of treating

To increase the posterior glide of

an anterior fibular head?

the restricted fibular head

Describe how to treat an

1. Place a pillow below the

1.876

1.876

patient's dysfunctional knee to

anterior fibular head dysfunction with HVLA.

avoid locking it in extension. 2. Grasp the patient's leg

immediately proximally to the ankle with the physician's caudal hand. 3. The thenar eminence of the

physician's cephalic hand is placed on the anterior aspect of the patient's fibular head. 4. Intemally rotate the patient's

ankle to draw the distal fibula anterior. Describe the direction of the HVLA thrust used when treating an anterior fibular head.

1. Using the cephalic hanG,

apply a posterolateral force to the fibular head. 2. Simultaneously apply a s light internal rotational

counterforce to the ankle

using the caudal hand.

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1.876

Cha ter

12

Cranial Techniques and Osteopathy in the Cranial Field 1. Inherent mobility

What are the five mechanism

brain

cord

components of the primary

2. Fluctuation of the fluid (CSF)

(PRM)?

1.986989, 10.177178

3. Movement of the and intracranial membranes 4. Articular mobility cranial bones of the

5.

sacrum between the ilia

How is the inherent motion

A subtle, slow

of the brain and spinal cord

movement

1.986987

described? 1.986987

lengthen and thin.

What happens to the brain and spinal cord during the exhalation What are the three

1. The dura mater

intracranial and

2. The arachnoid

1.987

3, The pia mater

Where are the firm

Around the foramen magnum,

attachments of the dura

C2,

1.987-

and S2

mater located as it descends down the spinal cord? The rocking motion of the sacrum in

t o the

transverse axis, also known as the

axis

1987990

movement membrane occurs about which axis? 139

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140

Osteopathic Medicine Recall which phase of

The inhalation

1.986987

Flexion and extension

1.987990

respiration do the brain and spinal cord shorten and thicken? In what way do the midline bones move in response to the pull of the dural membrane? Which bones move through

bones of the cranium

1.987990

The SBS is the mticulation of the

L98/990

The

an external/internal rotation phase in response to the pull of the dural membrane? What is the significance of the sphenobasilar

with the response to the pull

synchondrosis

in dural

membrane, Which bones are known as

The spnen()lO

the unoaired midline bones?

and vomer

what

When the SBS

990

The midline bones

cardinal movement of the

the

midline and

external rotation,

bones

flex as

bones move into

1.990991

occurs? The AP diameter of the head

What happens to the

decreases with flexion of the diameter of the heads when

midline

the midline bones are

diameter of the head increases

\.990991

the transverse

flexed? Wben the SBS

does

With flexion of the SBS, the

the sacral base move

sacral base moves

posterior or anterior?

the dura is pulled cephalad,

When the midline bones

The paired bones will move into

what motion takes place with the oaired bones?

as

internal rotation, and the head \vill increase in AP diameter and decrease in transverse diameter,

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L990991

1.990991

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field

When the SBS extends, does

With extension of the SBS, the

the sacra] base move

sacral base moves anterior as the

posterior or antel;or?

dura drops in a caudal direction.

Describe what happens

l. Flexion at the SBS as well as

functionally (to the midline

the midline bones

141 1.990991

1.987991

2. Postelior movement of the

bones, the sacral base, the AP diameter of the head,

sacraJ base, also known as

motion of the paired bones,

counternutation 3. Decreased AP diameter of the

brain and spinal cord

head

dimensions, and the slope

4. External rotation of the paired

of the foreheau) during

bones

craniosacral flexion.

5. Shortening and thickening of

the brain and spinal cord 6. Increase in the slope of the

forehead l. Extension at the SBS as well

Describe what happens functionally (to the midline

sacral base, also known as

AP diameter of thc head,

motion of the pail'cd bones, dimcnsions, and the slope of the forehead) during craniosacral extension.

1.987991

2. Anterior movement of the

bones, the sacral base, the

bmin and spinal cord

as the midline bones

nutation 3. Increased AP diameter of the

head 4. Internal rotation of the paired

bones 5. Lengthening and thickening

of the brain and spinal cord 6. Decrease in the slope of the

forehead, creating the appearance of frontal bossing

'�r;t :v

-

Sphenoid OcCiput

SClcrum

Relationship of

EHects on reciprocal

Direction of force

sph enoid to occiput

tension membrane system

in flexion

Figure 12-1.

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142

Osteopathic Medicine Recall

=�

SplH llold OccipuL .....-

Sacrum

Relationship of

Etfects on reciprocal

Direction of force

nenoid to occiput

tension membrane system

in extension

Figure 12-2.

What is the cranial rhythmic

It is the palpatory sensation

impulse (CRI)?

of the skull widening and

10.177

narrowing; this sensation is the result of the five components of the PRM. What is the rate of the CRI?

Although this is a widely debated question, for

1.991, 10.177

boards know that the rate of the cm is 8 to 14 times per minute.

What factors may increase

1. Vigorous physical exercise

the rate and quality of the

2. Systemic effects

CRI?

3. Effective osteopathic

1991, 10.177

manipulative therapy (OMT) of the craniosacral mechanism What factors are associated with a decrease in the rate and quality of the CRI?

1. Stress (mental, physical.

emotional)

1.991, 10.177

2. Chronic fatigue 3. Chronic infection 4. Depression 5. Other debilitating or

psychiatric conditions compromise

Why can strains of the SBS

Strains of the SBS

be very significant?

the efficiency of the PRM, leading

can

to dysfunction and disease.

Copyrighted Material

1.992

143

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field

What types of strains occur

Six types.

at the SBS?

1. Torsions 2. Sidebending and rotation

l.992993, 10.177

3. Flexion and extension 4. Vertical 5. Lateral 6. Compression

Which type of strain occurs

A torsion strain

l.992993

How is a torsion strain

It is named for the greater \\ ng of

named?

the sphenoid that is more supetior.

l.992993

around an AP axis, with the sphenoid and structures of the anterior cranium rotated in one direction, while the occiput and posterior cranium are '·otated in the opposite direction?

A sidebending and rotation

Rotation occurs about the AP a'
strain occurs about what

and sidebending occurs about

types of axes'?

two parallel vertical axes

l.992993

.

During a sidebending and

The sphenoid and occiput rotate

rotation strain, do the

in the same direction.

l.992993

sphenoid and occiput rotate in the same direction or in opposite directions? Superior view

Left A

Right A'

Superior view Righl

Left

A'

A

o

o

Right torsion

Left torsion

Figure 12-3,

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144

Osteopathic Medicine Recall

How is a sidebending and

This strain pattern is named

rotation strain named?

for the side of convexity; the

1.992-993

direction in which the sphenoid and occiput rotate when viewed from behind. Clockwise rotation would therefore be a right sidebending and rotation strain; conversely, countere:lochvise rotation would be

a

left

sidebending and rotation strain. Which strain patterns are

Torsion strains, in addition to

considered physiologic?

sidebending and rotation strains,

1.992993, 10176177

are considered physiologic because they do not interfere \'lith the flexion or extension components of the PRM.

Superior

SUlJt 'nor view

view

C3

Le"

",h'

m

c

C

Lell

c:

(i!.

Righi

a3

fa

c

o

Lell lilleral view

B

Ao'

f)(l

DPG c

'm

Superior strain Figure 1 2-4.

Copyrighted Material

Left l,ltef,11 view


. \? nG

Ao'",m

Inferior strain

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field

When does a flexion and

It occurs when the motion at the

extension strain pattern

SBS does not completely move

occur?

through the flexion and extension

145 1.992993

phases equally and fully. When is a vertical strain

When the sphenoid moves

present?

cephalad (superior vertical strain)

1.992993

or caudad (inferior vertical strain) in relation to the occiput around the two transverse axes When is a lateral strain

When the sphenoid deviates

present?

lat e r ally (left or right) in relation

1.992993

to the occiput around two parallel vertical axes A lateral strain

Which strain pattern is associated with a "parallelogram-shaped head", a strain that often occurs to infants in utero or during the birthing process?

Superior view

Left

RighI

o

Left lateral strain

Right lateral strain

Figure 12-5.

Copyrighted Material

1.992993

146

Osteopathic Medicine Recall

Vertical and lateral strains

1.992993

What is an SBS compression

A strain where the occiput and

10.181

strain?

sphenoid have been forced

Which strains may be superimposed on other strains?

toge ther so tbat physiologic ,

flexion and extension are impaired

and even occasionally obliterated A compression strain

10.181

What type of situation can

Traumatic force to the back

1.993

cause a compression strain?

or front of the head, or

Which strain pattern can significantly reduce the rate and amplitude of the eRI?

circumferential compression of all sides of the head simultaneously, as in childbirth Which bones are referred

The parietals, temporals,

to as the paired bones of

maxillae, zygoma, palatines, nasal,

the skull?

and frontal

Why is the frontal bone

Because the metopic suture

viewed as a paired bone?

(running do\vn the center of the

10.171

10.171

frontal bone) frequently remains open throughout life What occurs during

The SBS flexes, the foramen

craniosacralllexion?

magnum elevates, and the base

10.172

of the sacrum moves posterior

(countemutates). What occurs during

The SBS extends, the foramen

craniosacral extension?

magnum moves inferior, and the

10.172

sacral base moves anterior (nutates). What are the three layers

1. Falx cerebri

of the dura?

2. Tentorium cerebeJli 3. Falx cerebelli

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10.176

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field What membrane separates the

147

The falx cerebri

10.176

The superior sagittal sinus

10.176

The tentorium cerebelli

10.176

The transverse sinus

10.176

At the junction of the falx cerebri

10.176

two cerebral hemispheres? Which vascular structure does the falx cerebelli enclose? What dural layer separates the cerebrum and the cerebellum? Which vascular structure does the tentorium cerebel1i enclose? Where is the reciprocal tension

(RTM) memb"ane

located?

and tentorium cerebelli; the RTM is also sometimes referred to as the "Sutherland fulcmm."

What layer separates the

The falx cerebelli

10.176

10.177

two hemispheres of the cerebellum? How does respiration

Inhalation enhances SBS flexion

enhance SBS flexion and

and exhalation enhances SBS

extension?

extension.

Which dural layer is viewed

The tentorium cerebelli

10.177

What happens to the

The tentorium cerebelli descends

tentorium cerebelli during

and flattens during inhalation, as

10.176177

inhalation?

a result of external rotation of the

as the "diaphragm" of the craniosacral mechanism?

temporal bones. What happens to the

With SBS extension, enhanced

tentorium cerebelli with

by exhalation, the tentorium

SBS extension?

cerebelli elevates because of the internal rotation of the temporal bones

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10.176177

148

Osteopathic Medicine Recall

What hold technique is

The Vault hold technique

10.179

1. Index fingers on the greater

10.179

used to evaluate the SBS mechanics by placing the hands and fingers over the skull, and is also used as an indirect treatment to balance membranous tension? How are the physician's fingers placed when using

wing of the sphenoid 2. Pinky fingers on the occiput

the Vault hold?

3. The ear bctwcen the middle

and ring fingers What are the goals of the

1. Balance the SBS motion

craniosacral techniques?

2. Reduce venous congestion

10.181182

3. Enhance both the rate and

amplitude of the CRI

4. Mobilize membranous

articular restrictions and ultimately correct them

What is the primary

Respiration (an inherent

activating force in

mechanism)

10.181182

craniosacral techniques? How is respiration used as

Voluntary inhalation can enhance

an activating force?

flexion of the midline bones and

10.183

external rotation of the paired bones within the craniosacraJ mechanism.

Which type of lower

Dorsiflexion

10.183

extremity movement, dorsiflexion or plantarflexion,

Note: Plantarflexion enhances

enhances flexion of the

extension of the SBS.

sphenobasllarjunction? A sensation experienced where

\Vhen using cranial techniques, what is a still

no motion is felt

point?

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10.183

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field

149

1. Enhance

10.182183

of the CRI movement

2. Enhance

3. Restore function to the

craniosacral mechanism

of the What is the venous sinus technique?

To enhance the flow of venous

'What technique is used to reshicted and impacted sutures?

The

What are some of the comillic::atjolrls associated with craniosacral treatments?

1. Alterations in heart rate, blood

blood

10.184

venous sinuses technique

10.179184

10.181184

2. 3.

What are the contraindications to craniosacral treatment?

1. Acute intracranial bleeding or

increased intracranial pressure

10.179184

2. Skull. trauma (fractures) 3. Seizures

Which cranial nerves (CN) are associated with " ...,,"'"""'" disorders and poor , 'o "'" in newborns?

Torticollis is associated with somatic dysfunction of which CN?

CN IX, X, and XII are associated with

CN XI, because it supplies the sternocleidomastoid muscle, the muscle

in torticollis

Dysfunction of the OA, A:\, or C2 affect the function which CN?

A lesion to which CN may cause of the heart, coordinating digestion stomach and bowels, and trouble with

11257, 1.667674

Ll257, 1.667674

U257, 1.667614

CN X

nerve)

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353

150

Osteopathic Medicine Recall

Dysfunction affecting the

eN IX, X, and XI all pass

jugular foramen can

through the jugular foramen.

674

Somatic dysfunction of

eN VIII (the vestibulocochlear

J.J257,

which eN can be associated

nerve)

674

interfere with the normal

1.1257, 1.667-

function of which cranial nerves?

with vertigo or hearing

1.667-

loss? Dysfunction of the ethmoid

eN I (olfactory) dysfunction can

1.1257,

bone is associated with

produce an altered sense of

somatic dysfunction of which

smell.

674

1.667-

eN? Which eN exit the skull

eN III (oculomotor), eN IV

through the superior orbital

(trochlear), eN V (trigeminal)

fissure?

division 1, and eN VI (abducens)

eN XII exits the skull

The hypoglossal canal

13.347

eN I (the olfactory nerve)

13.391

13.346

through which canal? Injury to the cdbifonn plate of the ethmoid bone may cause anosmia by injudng which eN? A lesion of which eN

eN II (optiC); this type of vision

13.391-

can cause bitemporal

loss would occur "vith a lesion of

392

hemianopsia, better known

eN II taking place at the optic

as "tunnel vision"?

c hias m

.

A lesion to which eN will

eN III (oculomotor); the ptosis is

cause the ipsilateral eye to

caused by paralysis of the levator

deviate downward and

palpebrae superioris muscle.

13.392393

laterally, and ptosis? A lesion of which eN as it

eN VII (the facial nerve)

exits the stylomastoid foramen can cause Bell's palsy?

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13.396

Chapter 12 I Cranial Techniques and Osteopathy in the Cranial Field

15 I

Which cranial nerve controls

eN v (the trigeminal nerve)

the afferent limb of the

division 1, the ophthalmic

corneal blink reflex?

division

Which division of the eN v

Division 2, the maxillary division

13.394395

A narrowing of the foramen

Division 3, the mandibular

ovale would possibly

division

13.394395

(trigeminal) exits the skull

13.394395

through the foramen rotundum?

compress what division of the trigeminal nerve? eN XII (the hypoglossal nerve)

13400

A lesion to which eN would

eN IX (the glossopharyngeal

13.398

eliminate the afferent limb

nerve)

A lesion to which eN would

cause dysphagia and deviation of the tongue to the injw'ed side?

of the gag rellex? A nerve lesion causing

CN IV (trochlear), because it is

inflammation and swelling

the only CN to emerge from the

that compresses the dorsal

dorsal aspect of the brainstem; it

aspect of the brainstem

is also the smallest eN!

would most likely result in injury to which eN?

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13.394

Chapter

13

Chapman Reflexes Chapman reflexes (points)

1.1051

Chapman reflexes

1.1051

Today anterior Chapman

To identify which organ is most

1.1051

points are most often used

likely dysfunctiollal

\\'hat is the name for a viscerosomatic reflex mechanism that has diagnostic and therapeutic importance? What type of reflex is described

as

a neurolymphatic

ganglifonn contraction that blocks lymphatic drainage, causing inflammation in tissues distal to the blockage, and causes both visceral and somatic tissues to suffer?

for what purpose? Where are posterior

In the paraspinal area, near

Chapman reflexes usually

transverse processes

L1051

located? On palpation, where are

Deep to the skin and

Chapman reflexes located?

subcutn1l('oUS areolar tissue, most

L1051

often on the deep fascia or periosteum

True or False: Chapman

False; Chapman reflexes are

reflexes are usually found

usually found paired on both the

unpaired,

ventral and dorsal surfaces of the

1.1051

body.

True or False: Compression

False; Chapman reflexes cause

of an anterior Chapman

greater pain than expected by

point reveals a finn, painless

both the patient and phYSiCian,

mass.

even with li ght compression.

152

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1.1051

Chapter i3 I Chapman Reflexes

EYE, EAR, NOSE, THROAT & NECK

CARDiOPULMONARY

(Z)

MYOCARDIUM

UPPER LUNG

LOWER LUNG

I------=�\'io:

UPPER

GASTROI NTESTI NAL

LOWER

GASTROINTESTINAL

o

INTESTINE

o

RECTUM

COLON

(BILATERAL)

(BILATERAL)

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153

154

Osteopathic Medicine Recall

EYE, EAR, NOSE, THROAT & NECK RETINA-CONJUNCTIVA CEREBRUM

ESOPHAGUS-BRONCHUS-THYROID (BILATERAL)

CARDIOPULMONARY MYOCARDIUM-UPPER LUNG

G)

LOWER LUNG (BILATERAL)

ARM UPPER GASTROINTESTINAL

ARMS&

PECTORALIS MINOR

LIVER &

GALLBLADDER

,

PANCREAS PYLORUS

o iINTESTINES­

APPENDIX

a

URASTHENIA

UPPER ARM

& PECTORALIS MAJOR

(BILATERAL)

PERISTALSIS

LOWER GASTROINTESTINAL

GENITOURINARY HEMORRHOIDAL PLEXUS KIDNEYS BLADDER URETHRA

fd\

RECTUM

HEMORRHOIDA

PLEXUS

UTERUS VAGINA-PROSTATE-UTERUS­ BROAD LIGAMENT FALLOPIAN TUBES-SEMINAL VESICLES INGUINAL GLANDS

(BILATERAL)

FALLOPIAN TUBES-SEMINAL VESICLES SCIATIC NERVE (BILATERAL)

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Chapter 13 I Chapman Reflexes

What are five distinguishing

Nodules that are

155

U051

L Small

characteristics of Chapman

2. Smooth

reflexes?

3. Firm 4.

5.

when To an

"'A"'UU"""i�

alone

UfiV:,lCllan

1.1051

how do feel?

2. 3. Circumscribed area of firm

edema 4. Fixed (cannot be

Are confluent areas of

Chronic; confluent (flowing and

Chapman I'eflexes acute

blended into one)

or chronic?

rare, are thought t o M,Haw",u,!'.

L1051

although

visceral and masses.

1.

1.1052

2. ExquiSitely 3. Sharp 4. 5.

gangliofonn contractions

True or False: Patients

U052

usually do not realize have Chapman reflexes

pressure. ""'here is the Chapman

Ll052

reflex located for pa'tients suffering from acute

question on the board examination.

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156

Osteopathic Medicine Recall

Frank Chapman, believing

Chapman su

in the interconnectedness

treatment of a pelvic

and interrelatedness of the

dysfunction initially noticeably

csted that

body as described by A. T.

enhanced the response to

Still's four basic osteopathic

subsequent treatment of

principles, suggested treat­

Chapman reflexes.

1.1052

ment of what area before addressing Chapman l-eflexes? How are Chapman reflexes

By flipping the colon 180" upon a

of the colon located and

h-ansvcrse axis through the (x'cum

correlated?

1.1053

and low Sigmoid regions, so that the right p roximal colon lies on the right femoral head, the light ascending colon runs along the anterior aspect of the femur, and the hepatic flexure lies just superior to the patella (with the same relationship for the descending colon upon the left femur)

A Chapman reflex located

The cecum

1.1053

The spleniC flexure

1.1053

The sigmoid colon and rectum

1.1053

Ovaries and urethra

1.1053

on the trochanter of the right hip is associated with dysfunction of what structure? A Chapman reflex located on the distal portion of the left: femur is associated with dysfunction of what structure? A Chapman reflex located on the proximal portion of the left femur is associated with dysfunction of what structure? An anterior Chapman reflex located just laterally to the superior sulface of the pubic symphysis is associated with dysfunction of what structures?

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Chapter 13 I Chapman Reflexes

The coracoid process

The anterior Chapman

157

L1053

reflex for cerebellar problems is located where? intercostal

The anterior

In the

reflex for the liver only is

between ribs 5 and 6

Ll052

located where? The anteriOl" Chapman

In the right intercostal space

reflex for tile liver and

between the ribs 6 and 7

U052

gallbladder is located where? The anterior Chapman

On the anterior surface of the

reflex for the pylol"Us and its

sternum

L1052

sphincter is located where? The anterior reflex for

In the left intercostal

","0."..,.

t{],n"'''h

between ribs 5 and 6

is

located where? The anterior Chapman

In the left intercostal space

reflex for stomach

between ribs 6 and 7

11052

is located where? The anterior Chapman

Below the inguinal

rellex for intestinal

lateral to the anterior inferior

peristalsis is located where?

"rr"n1,'nr

11053

(AnS)

The anterior '""""'.,,..,...

On the latera!

reflex for the

femur

U'U""'Ht::

broad ligament is located whel'e? Thyroid problems can cause

In the intercostal space between

an anterior Chapman reilex

libs 2 and .3

11053

located where? Somatic dysfunction of what

U053

stmctures, other than tile iliyroid, c,m cause anterior Chapman points in the intercostaJ space between the second and third rib?

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158

Osteopathic Medicine Recall The uterus

L10S3

The retina and

]]053

\Vhat anterior Chapman

L Nasal sinuses

liOS3

reflexes are located in the

2.

An anterior Chapman reflex located on the inf.. nor

structure? An anterior Chapman reflex located on the humerus, just superior to the deltoid tuberosity, is associated "lith dysfunction of what structures?

intercostal

between

ribs 1 and

:3. 4. 5. (1. Sinuses

Anterior Chapman reflexes

The small intestines

1.1053

The upper

L1DS3

The lower lung

lIOS3

The adrenals

L1D53

located in the intercostal spaces between ribs 8 and 9, ribs 9 and 10, and ribs 10 and 11 is associated with dysfunetion of what structnre? An anterior Chapman reflex located in the intercostal space between the third and fourth ribs is associated with dysfunction of what structure? An anterior Chapman reflex located in the intercostal space between the fourth and fifth ribs is associated with dysfunction of what structure? An anterior located 1 inch lan:OraJ1V 2 inches superiorly to umbiliclL is associated vdth dysfunction of what StruCtUl"e?

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Chapter 13 I Chapman Reflexes An antetior Chapman reflex

159

The kidneys

L1053

The bladder

1.l053

The spleen

L1053

The pancreas

1.l053

The adrenals

11054

1. Initially, pelvic function must

1.l055

located 1 inch laterally and 1 inch supetiorly to the umbilicus is associated with dysfunction of what structure? An antetior Chapman reflex located pet iumbilically is associated with dysfunction of what structure? An antetior Chapman reflex located in the left intercostal space between the tibs 7 and 8 is associated with dysfunction of what structu.-e? An antetior Chapman reflex located in the right intercostal space between tibs 7 and 8 is associated with dysfunction of what structw-e? A posterior Chapman reflex located near the transverse process of the eleventh thoracic vertebra is associated with dysfunction of what structure and known to be found in some hypertensive patients? How are Chapman points treated?

be normalized. Z. Apply heavy (even

uncomfortable) pressure to the gangliform mass. 3. Use slow, circular movements

with the finger in an effort to Hatten out the mass as if it were a localized fluid accumulation. 4. Continue to perform the

moving pressure for 10 to 30 seconds.

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160

Osteopathic Medicine Recall .5. Cease treatment when the

mass disappl;ars or the treatment can no longer be tolerated. Treatment of what posterior

The adrenal Chapman

Chapman reflexes aid in

decreased blood pressure, as well

decreasing blood pressure in patients?

!.lOS5

as deereased serum aldosterone levels, are seen as soon as 36 hours after the soft tissue treatment.

True or False: Chapman

This is accepted as true within

reflexes are highly efficient

the osteopathic research and

diagnostic tools, even among

literature.

more expensive diagnostic tools.

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1 1055

Chapter

14

Travell Trigger Points

What is a myofascial trigger

A hyperirritable spot in skeletal

point (TP)?

muscles associated with a

1103:;1037

hypersensitive palpable nodule in

a

taut band; it is painful upon

compression and can give rise to a characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. Yes; in fact, the term TP is

Do TPs refer pain?

11037

reserved for only those myofascial points that have the potential to refer pain. Do TPs refer pain in any

No, TPs are known to refer

direction?

pain in a certain predictable

11037

distribution. What are the two types of

Active and latent TPs

U037

A TP that refers pain at rest,

1.1037

TPs, based on their ability to refer pain? What is an active TP?

with muscular activity, or with palpation What type of TP refers pain

Latent TPs

1.1037

Latent TPs

11037

only when p,'obed with a very steady pressure?

"Vhich type of TPs are often overlooked or misdiagnosed by novice palpatory examiners because they are difficult to identify?

161

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162

Osteopathic Medicine Recall

To where does the pain from

The external auditOly ear canal

aTP in the deep portion of

and into the middle ear; less

the masseter muscle radiate

radiating pain is felt on the

1.1035

lateral portion of the face

most strongly?

surrounding the muscle. VVhich TP is compressed if

The clavicular portion of the

a patient experiences

sternocleidomastoid TP

1.1035

radiating pain that migrates from the ipsilateral side of the face above the eye

across to the above the

eye?

The tibialis antelior TP

1.1036

The upper trapezius muscle

1.1038

What diseases and (or)

L ChroniC infections

11038

conditions seem to perpetuate

2. Allergic rhinitis

'WhatTP radiates pain over the entil-e "big" toe? In which muscle areTPs

most likely to develop?

3. Psychological stressors

TPs?

4. Endocline and metabolic

disorders, including hypothyroidism and hypoglycemia '¥hat is one of the strongest

Ovemse of somatic stmctures,

factors contributing to the

espeCially chilled muscles (caused

formation and perpetuation

by an improper warm-up peiiod

ofTPs?

before physical exertion or an

1.1038

improper cool dOlvn after a workout followed by a strenuous movement) Which two physicians are

Travell and Simon; much of their

credited with bringingTPs

public notoriety came from

into the public eye?

t reating President John F.

Kennedy.

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1.1038

Chapter 14 / Travell Trigger Points

163

The tenderness and pain

Prostaglandins, potassium,

associated with TPs are

substance P, bradykinins,

due to what chemical

serotonin, histamine, and

mediators?

leukotlienes

What manifests itself as a

A myofascial (TravelI) TP

1.1038

Wincing or withdrawal of the

1.1038

1.1038

nodular or spindle-shaped thickening of the tissues with alterations in cutaneous temperature and humidity? What is a "jump sign"?

patient due to pain and discomfort, seen with a resultant "local twitch" of a taut muscle band when compressed What causes a "jump sign"'?

A myofascial (Travell) TP

1.1038 1.1039

What kinds of mechanical

1. Muscle overload

abuse can lead to the

2, M yofascial postural stress

formation of a TP?

3, Leaving a muscle in a

prolonged shortened position, especially if the muscle is then quickly contracted from that position 4, Muscle chilling

Successful treatment of

Removing the primary myofascial

myofascial TPs depends on

TP, its associated satellite TPs,

what four elements'?

1.1039

related articular dysfunction, and any underlying or perpetuating factors

The local twitch response

The local twitch response , a

usually helps differentiate

transient contraction of the taut

which musculoskeletal

band of fibers hOUSing a TP, is

disorders?

usually absent in fibromyalgia but present in myofascial pain syndromes caused by TPs,

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1.1039

164

Osteopathic Medicine Recall 1. Correction of the associated

What factors ensure that treatment of a TP will last?

11040

somatic dysfunction 2. Educating patient to prevent

recurrences 3. Appropriate self-stretch

exercise programs 4. Correction of underlying

perpetual and facilitating factors What specific techniques have been used to treat myofasciaI TPs?

1. Inhibition soft tissue

techniques 2. Vasocoolant spray or other

intermittent cooling measures with stretch 3. Deep massage 4. Injection 5. Jones counterstrain 6. Isometric muscle energy

techniques 7. Myofascial release

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110401041

Works Cited

1. \;\lard HC, ed, F oundations for Osteopathic Medicine, 2nd ed, Philadelphia: Williams &

8, Hansen JT, Lambert DR, eds,

Netter's Clinical

NT: Icon

Novartis Medical

2005,

2,

2001. 3, Kuchera WA, Kuchera ML. eds,

Press, 4, The Manual, Millennium Kimberlv PE, Funk SL, eds, Kirksvill , MO: Kirksville of '-"0'''''fJ'''' 2000, 5,

7, Snell HS, Clinical Anatomv,

7th ed, Baltimore: Lippin ott

\Villiams & Wilkins, 2004,

9, Moore KL, AF, 5th ed, Oriented Baltimore: Lippincott Williams & Wilkins, 2006, 10, Greenman PE. of ed, Manual Medicine, Philadelphia: Lippincott Williams & Wilkins, 2003, 11. Jones LH, Kusunose R, Goering E. Jones Strain-CounterStrain, An1edcan Academy of Osteopathy. Boise, ID: fanes Strain­ CounterSt ain, Inc" 1995, 12, DiGiovanna EL, Schiowitz S, An Osteopathic Approach to Diagnosis and Treatment. 2nd ed, Philadelphia: , ,!,m''-'v 1997, 13,

165

Copyrighted Material

Figure Cred

Figures 1-1,2-2,

and all

in Chapters 12 and 13:

DiGiovanna EL, Schiovvitz S, Dowling DJ, eds. An Osteopathic

to

Diagnosis and Treatment. 3rd ed, Philadelphia: Lippincott Williams & Wilkins, 2005, 2-1 and all

in

7:

Modi RG, Shah NA. COMLEX Review Clinical MA: Blackwell

and Us'teapat.hic 2006.

Figure 2-3: Ward RC. ed. Foundations for Us!teopathic Medicine. 2nd ed, .In'·>Inr'on

Williams &

2003.

167

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Index

Page numbers followed by for t indicate figures or tables, respectively. AA RR dysfunction, 112, 128, 129

Asymmetry. See TART

Abducted pubic bone, 122

Atlantoaxial (AA) subluxation, 14, 15, 149

ACL (anterior cruciate ligament), 47

Atlantoaxial subluxation. See AA subh'Gltion

A c tive motion, 10

Atypical ribs, 17

Active musc:le energy treatment

Autonomic nervous system. See ANS

technique, 107

Axis. See also Motion; Sacmm

Active treatment, 7

sacral oblique, left, 31, 32, 35

Active trigger pOints, 161 Adhesive capsulitis, 55 Adrenals, 73

Back strain/sprain, 23

Adson test, 45

Bell palsy, 150

Alar ligamrnts, 14

Bicipital tenosynovitis, 44

Allen test, 46

Bilateral sacral flexion dysfunction. 3&-37

Allostasis, 1

Bitemporal hemianopsia, 150

American Ostpopathic Association.

Bladder, 61-62, 64, 73

See AOA

Bone

Anatomic barrier, 2

ethmoid, 150

Ankle, 48, 50, 51, 55, 103

frontal, 146

Anosmia, 150

midline, 140, 141

ANS (autonomic nervous system), 57-76

paired, 140, 141, 146

Anterior cmciatc ligament. See ACL Anterior drawer tcst, 52, 53 Anterior-posterior axis of' motion, 11 Anteroposterior diameter of heads.

SCI' AP diameter of heads Antigens, 79

profunda, 39 Brachial plexus, 40 Brain and spinal cord, inherent motion of, 141

AOA (American Osteopathic

exhalation phase of, 139

Association), 1

respiration phase of, 140, 148

AP (anteroposterior) diameter of heads, 140,

pubic, abducted, 122 Brachial artery, 40

Brainstem, l.'51 Bucket handle lIIotions, of ribs, 18--20, 19f

141,142,143

Apley scratch test, 44

dysfunctions of, 117

AppendiCitis, acute, 155

Bunions, 53

Appendix,73 Arch lateral longitudinal, 50

C3 ERRSR dysfunction, 112

medial longitudinal, 50

C3 FSLRL dysfunction, 129, 130

transverse, 50

C6 ESRRR dysfunction, 130

Arms, 38, 42, 44, 74, 123, 153-1541

Calcanells technique, 102

Arrhythmias, of heart, 149

Caliper-like

Articular pillars, 13 Articulatory techniques, 81

CardiopulmonalY system, 1.5.)-.l54{ 4

Carpal tunnel syndrome, 43

Ascending colon, 70-71

Cauda equina syndrome, 26

Anterior supelior iliac spine (AS1S), 31-32

Central nervous system. See CNS

169

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170

Osceopachic Medicine Recall

Cerebellar problems, Chapman reflex for, 157

Cranial nerves, dysfunctions of, 149-151 Cranial rhythmiC impuls!'. See CRI

Cerebellum, 147

Cranial treatment technique, 6, 7,

Cerebral hemispheres, 147

139-151

Cerebrum, 147

Craniosacral extension, 141, 141f, 146

Cervical fascia, anteJior, 79 Cervical nerve roots, 14

Craniosacral flexion, 141, 146

Cervical segments, 14, 15

CRr (cranial rhythmiC impulse),

Cervical spine, 10, 12, 13-15,23, 24-25, 88,8 9f, 129

142, 146

Cribriform plate, 150

Cervical veliebrae, 13, JA

Crimping, 102

Chapman, Frank, 155

Crossed <"tensor reflex, 109

Chapman points, 152, 159

CV4 technique, 149

Chapman reflexes, 152-160 characteristics of, 152, 155 DEB (disengage, exaggerate,

neurolymphatic gangliform contraction, 152

and balance), 101

posterior, 152

Dermatome level, 16

treatment of, 7

Descending colon, 72

viscerosomatic, 59, 152

Diaphragms, 17, 29, 74,78,103, 104, 106

Chemical mediators, trigger points associated with, 163

Direct treatment, 5, 6, 7, 102, 103,104, 105,106, 107

Clavicle, 38, 105

Direction of ease, 5

Clitoris, 74

Distal duodenum, 71

CNS (central nervous system), 139

DorSiflexion, 148

Colon

Drop arm test, 44

ascendi ng, 70, 71

Dupuytren contracture, 56

Chapman reflexes of, 155

Dura mater, 139,146

descending, 72

Dural membrane, 139, 140

sigmoid, 72, 73

Dural strains, 78

transverse, 70, 71,72

Dysfunction. See SpeCific entries

Compartment syndrome, 49--50

Dysphagia, of tongue, 151

Compression strain, 146 Corneal blink reflex, 151 Elbow, 42

Coronal plane of motion, 11 Costochondritis, 105

Tennis, 43, 106

Counterstrain, spinal cord levels relating to, 8 9f, 90

Embryological gut, 68-69 Equina syndrome, 26

Counterstrain treatment technique, 6, 7, 85-97

Erb-Duchenne palsy, 40 Elythema test, 4, 5

Coxa valga, 48

Esophagus, 66,68

Coxa vam, 48

Ethmoid bone, 1.50

Cramping, 103

Extremities

Cranial field, osteopathy in, 139-1,')1

lower, 46--56

Cranial nerve III, 64-fiS

upper, ,38-46, 83

Cranial nerve IX, 65

Eye, 60, 62,65

Cranial nerve X, 65, 66, 75

ear, nose, throat, neck and, 153-154f

Cranial nerve XII, 150

ipSilateral, 150, 162

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Index

Facets, spine relating to, 10-11

Hallux valgus,,5,3

Facilitated positional release treatment

Hammer toes,53

techniqu<:. See FPR treatment

techniqlll;

171

Hand,41

Hearing loss, 150

Facilitation,definition of, 57,59

Heart,60,63, 65, 68

False ribs, 17

arrhythmias of. 149

Falx cerebelli, 146,147

Hemorrhoids, 106

Falx cere bri, 146, 147

Herniated disc, 23

Femoral artery,104

I-lip,47, 5], 155

Femoroacetabular joint, 52.

Hip drop test,46

Femur,52.,155

Humerus, Chapman reflex on,158

Fibular lwad, 4!l,103, 138

HVLA (high velocity, low impulse or

Finkdstein test,45

mobilization with impulse)

Flexion test,87

treatment technique, 6, 7

seated, 32.,331, 35,36

contraindications for,133

standing, 31, 32.

respiratory phase relating to,12.7, 12.9

Flexioniextfnsion,8,11,14,16, 135

thrust technique rcbtin).\ to, 12.4,138

Floating ribs,18

Hypermobile JOint,12.5

Foot, 41>, 50

Hypertension, Chapman reflex relating

Foramen rotundum, 1.51

to, 160

Forearm, '12, 12..3

Hypertonicity,2.9

FPR (facilitated position,) I wll'ase)

Hypothenar eminBncl', 42.

treatment technique,6, 7, 98-100

Frontal bone, 146

Inferior lateral angles (ILAs),36, 37

Fryette bws,16

Iliacus musc:le, 96

of spinal mechanics

Iliolumbar ligament,2.9

usde, 2..3-24, 104

first, 9

Iliopsoas

second,9

Iliotibial band, 103

third,lO

Ilium, 70, 71

type I motion of,8, 9, 14

HI

Indirect treatment, 6, 7, 101-102.,

type II motion of, 8, 9, 10, 14

105,107 Inferior axis of sacrum,31

Infel-ior innominate shear, right, 32.

Gag reflex,151

Inferior pubic shear, 32.,12.3

Gallbladder, 66, 69, 70, 157

Inferior strain, 144f

G.mglions, 65, 70,71,72.,73

Innominate shear

Gastrointestinal tract. See GI tract

Genitourinary system. See GU system

Geriatric patients,12.

inferior, right, 32. supetior, tight,32. Innominates, 31-37

GI (gastrointestinal) tract, 61. 63,

anterior dysfunction of,31,12.1-12.2., 136-137

66,67,68,69,153-154f

Gbnds, 60, 63, 65

posterior dysfunction of, 31, 12.1-12.2.

Gl,'nohumeral joint , 38

upslipped , 137

Gonads, 74

Interossei,42.

Greater and lesser sciatic foramen, 2.9, 52.

Interstitial fluid pressure, decrf:1sfcl,78

GU (genitourinary) system, 74, 75,

Intestinal peristalsis, Chapman reflex

153-154f

for, 157

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172

Osteopathic Medicine Recall Lumbarization, 22

Intestines

Lumbosacral decompensation,29

large, 75, 76

small, 66, 74

Invertebral foraminal stenosis,14

Ipsilateral eye, 150, 162

Lumbosacral spring test, 34,35,36,37

Lungs, 61, 63, 65,66

Lymphatic duct, 77, 83

Lymphati c fluid movement,77-78 Lymphatic vesspls, 77, 79

Jejunum,70, 71

joint mobilization, 108

Lymphatics

congestion of, 78

Jugular foramen, 1.50

draina§,;l' of, 79, 83

Jump sign, 163

dysfunctions of, 80

treatm ent of, 6, 7,77

Key rib, 21, 114, 135 Kidneys, 62, 64, 73

Klu mpke palsy, 40

0

March fracture, 54

Masseter muscle, 162

Knee, 51-52,54,103

Maverick point, 88

McMurray test, 52

1.,3 ESn Rn dysfunction, 118

Medial col latera l ligament, 47

LAR (lig amentous articular strain)

Medial longitudinal arch, 50

Lachtman test, 52

treatment techniqu e, 6, 7

direct, 102, 103, 104, 105, 106

indirect, 101-102, 105

Large intes ti ne, 75, 76

Medial tepi<.:ondylitis, 44 Median

um

bilical ligament, 104

Meniscus, 103

Meralgia paresthetica, 55

Middle transverse axis of sacrum, 31

Lateral longitudinal arch, 50

Midline bones, 140, 141

Morton nt-'moma, 54--55

Lateral strain, 145, 145f Legs, 74, 1,5,3-154f

Lesser and greater sciatic foramen,29, 52 Ligament of Treitz, 76

Ligamentous articular strain treatment technique, See LAR treatment

technique

Ligaments. See also ACL; PCL

Motion. SCI' (Jlso Fryette laws active, 10

aAis of, 11

inherent, of spinal cord and brai n, 139, 140, 141, 148

of lumbar spine, 23 passive, 10

alar, 14

planes of, 11

medial collateral, 47

of ribs, H�-20, 19f 117

iliolumbar,29

restricted, of thoracic cage, 78

vertebral, .'5

median umbilical, 104

Muscle energy treatment technique, 6,7,

plantar, 51

posterior l o ngitudinal, 22

21, 107-123

spring, 51

active, 107

transverse, 14

Liver, 62, 64, 66, 69,70,78, 157 Lumbar roll, 135

Lumbar spine, 8,22-26, 35, 118

d<:, ellcrative changes in, 24--25 motion of, 23

tenderpoints in, 94-96, 94f, 95f

contraindications to, 111

direct, 107

indirect, 107

Muscles. See also SpeCific entries of respiration

plimary, 16

secondary, 16

Copyrighted Material

Index scalene, 13

Pancreas, 66, 69,70, 71

sternocleidomastoid, 13

Parasympathetic innervation, 74-75

Musculoskeletal, 163

173

Parasympathetic nervous system, 60-62,

Myofascial releus<: treatment technique, 6,7, 8,1-, 4,87, 102, 103, 10.5 Myofus('ial trigger point, 161, 164

65, 74 Passive motion, 10 Passive treatment, 7 Patellar-g,ind test, 53 Patellofemoral syndrome, 48

Nanoid, 142f

PCL (posterior cmciate ligament) , 47

Nerve roots, 22

Pediatlic patients, 11, 78

cef\ cal, 14

Pelvic diaphragm, 29, 78, 103

Nerves. See Specific entlies

Pelvic splanchnic nerve, 66-67, 75

Neurolymphatic gangliform contraction,

Pelvis, 13-37

152

Penis, 62, 64, 74

Neurovascular bunclJe,39

Peripheral nervous system. See PNS

Neutral mechanics, 8

Pes anserine bursitis, 55

\iippb,16

Pes planus, 54

Nonsteroidal anti-inflammatory dnlgs.

Piliformis muscle, 96-97, 96f, 97f Planes of motion, 11

See NSAIDs NSAIDs (nonsteroidal anti-inflammatory dmgs).39

Plantar fascia, 102 Plantar fasciitis, 54 Plantar ligaments, 51 Plantar flexion,148 PNS (peripheral nervous system), 57

OA ESLRn dysfunction, III OA FSRHI. dysf unction, 128

Pos telior cruciate ligament . See PCL

OA (occipitoatlantal) jOint, 14, 15, 149

Posterior drawer test, 52

Ober

Posterior longitudinal ligament, 22

test.

47

Occiput, 14lj: 142f, 143

Postisometric relaxation, 108, 110

Oculocephalog)'1ic reflex, 109

Primary respiratory mech'1nism. See PRM PRM (primary respirat ory mechanism ) ,

O'Dolluhue triad, 50 OMT (osteopathic manipulative therapy ) ,

139, 144

11,12,39,55,56,77 Orbital fissure,superior, 150

Profunda brachial artery, 39

Osteopathic manipulative therapy. See

Pronation, of ankle, 51

OMT

Pronator muscles, 42

Osteopathic pri nCiples , 1, 155

l°rostate, Chapman reflex for, 157

Osteopathic tn:utlllcnts, 7

Proximal duodenum, 69, 70

Osteopathy

Poste-rior supelior iliac spine (PSIS), 31-J2

basics of. 1-12

Psoas muscle, 104

in cranial field, 139-151

Pubic bone, abducted, 122

Otitis media, 79

Pubic rami Chapman rellex relating to, 158 right, 32 Pubic shear

Pain

inferior, 32, 12,3

in type I dysfunction, 9

superior, 32, 123

in type II dysfunction, 9, 10 Paired bones, 140, 141, 146

Pubic symphysis, 155

Palpat ory P<:[('('ption, of movement or

l°ump handle motions, of ribs, 18-20, 19f

rC'sistance, III

Pyloru s, 157

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174

Osteopathic Medicine Recall

de Quervain syndrome, 56

Ropiness, 3

Rotation, 8, 9, 14, 16,26, 114,

143, 144

Radial artery, 40

Rotator cu ff muscles, 38

Radial head, 42, 123, 137-138

Radial nerve,.39, 41

Rational therapy, 1

Sacral base,140, 141

Reciprocal inhibition,108

Sacral extension, 119

Reciprocal tension membrane system,

Sacral flexion dy sfunction, 36-37,

141f, 142f, 147

118, 136

Rectum, 72, 73

Sacral oblique ax.is, left, 31, 32, 35

Reflex. See also Chapman reflexes

corneal blink, 151

Sacral sulci, 36,37

Sacral torsion, 32, 34-36, 34f, 119,120

crossed extensor, 109

Sacralization, 22

gag, 151

Sacroiliac dysfunction, 119

oculocephalogyric,109

Sacroiliac joint. See SI joint

somatovisceral, 60

Sacrum, 28-37,30f, 139, 141f

spinal,57

axis of, 29, 31

somatic dysfunctions of, 29, 37

viscerosomatic, 59, 152

Reproductive system, 66,67, 75

Sagittal plane of motion, 11

Respiratory assistance technique, 109

SBS (sphenobasilar synchondrosis), 140--Wi

Respiratory phase

of brain and spinal cord, 140, 148

Scalene muscles, 13,39

HVLA treatment technique relating to,

Scapula, 40

127, 129

Scapulothoracic jOint, 38

Respiratory system, 68

Sciatic nerve, 29, 54

muscles of, 16

Sciatica, 53

Restriction. See TART

Sternocleidomastoid muscle (SCM), 89f

Restrictive barrier,2,2f

Scoliosis,26-213, 27f

Rib(s), 18f, 78, 105, 130

Segmental sympathetic innervation, 67

anterior, 92, 93

Short leg syndrome, 28

atypical, 17

Shoulder joints,.38, 56, 105-106

Chapman reflex relating to,

SI (sacroiliac) jOint, 29

156, 157, 159

Sidebending, 8, 9, 11, 14,15, 16,26,114,

143, 144

dysfunctions of, 19--21

exhalation, 19-20, 114, 117, 1.34

SigmOid colon, 72,73

inhalation, 19-20, 114,115, 116,

Skeletal muscles, 61,64

Skin, 61, 63, 79

l.33-135

false, 17

Small intestines, 66,74

floating, 18

Somatic dysfunctions, 2, 78, 110,125,

key, 21,114, 135

127, 150,157

motions of, 18--20, 19f, 117

posterior, 93

acute moisture in, 4

tenderpoints in, 92--93, 93f

TART relating to, ,3, 4

treatment of, 12

temperature in, 4

true, 17

tension in,4

typical, 17

Rib cage, 1.3, 16--21 Rib raising, 82--83

treatment of, 12

chronic edema relating to, 5

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Index

moisture in, 4

175

Strain. See also LAR

TART relating to,3, 4

back,23

temperature in, 4

compression, 146

knsion in, 4

dlrral,78

definition or, 1

inferior, 144f

of sacrum, 29, 37

lateral, 145,14,5f

Somatovisceral reflex, 60

superior, 144f

Spencer technique, 55, 81-82

torsion, 143, 143f

Sphenobasilar synchondrosis. See SBS

Stmin patterns, 144, 145, 146

Sphenoid, 1411, 1421, 143

Strains at SBS, types of, 143

Spina bifida cystica, 22

Stringiness, 3

Spina binda occulta, 22

Subclavian artery, 39

Spinal cord and brain, inherent motion or, 139,140, 141,148

Subclavian vein, 39

Superior innominate shear, right, 32

Spinal cord levels, 67-74, 76

Superior orbital fissure, 150

counterstrain relating to, 89f, 90

Superior pubic shear, 32, 123

Spinal mechanics, Fryctte laws or,9, 10

Superior strain, 144f

Spina l reflex, 57

Superior transverse axis of sacrum,29

Spinal stenosis, 24-2.5

Supinator muscles, 41

Spine,9, 78, 135

Supraspinatus tendonitis, 39

cef\ cal, 10, 12, 13-15, 23, 24--25, 88,

891, 129

Sy mpa thetic innervation, 58t, 67-74,76 Sympathetic nef\'OUS system,62-64,

facets relating to, 10-11

77,83

lumbar, 8, 22-26,35,94-96, 94f, 951,

118

thoracic, 8, 11, 12, 1,5-16,911, 92, 130

T3 EH[,SL dysfunction, 113

Spine of scapula, 16

T4 ERLSL dysfunction, 114

Spleen, 69, 70, 79

T5 FSRRH dysfunction, 132

Splenic flexure, 76

T7 ER[,SL dysfunction, 113

Spondylolisthesis, 25

T7 FSRRR dysfunction, 131-132

Spondylolysis, 25--26

T7 NSLRR dysfunction, 132-133

Sprains

no ERnSH, 9

of back, '2..3

no FRRSn, 9

of lower extremities, 49, 51, 55

T10 NSH RL, 8

Spring ligament, 51

Talus, 102

SeRA diagllosis, 131

TART

Sternal anp;le of Louis, 16

asymmetry, 1

Sternal notch, 16

in somatic dysfunction, acute, 3

Sternocleidomastoid muscles, 13

in somatic dysfunction, chronic, 3

Sternomanubrial-clavicular complex, 78

Stern 11m, 105

in somatic dysfunction, acute, 3

ShU, A T, 1, 101, 155

in somatic dysfunction, chronic,:3

Still point, 148

tenderness, 1, 2

Stomach, 66, 69, 70

in somatic dysfunction, acute, 3

Stomach acidity, Chapman reflex

for, 157

Stmight-Ieg raising t('st, 46

in somatic dysfunction, cluonic,4

tissue texture changes, 1

Stomach peristalsis, Chapman reflex

for, 1,57

restriction, 1, 2

in somatic dysfunction, acute, ,3 in somatic dysfunction, chronic, .3

Tenderness. See TART

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Osteopathic Medicine Recall

Travell trigger points, 161-165

Tenderpoints, 85-97 in cervical spine, 88, 89f

activc'. 161

in lumbar spine, 94--96, 94f, 95f

chemi('al mediators associated with, 163

in piriformis muscle, 96-97, 96f, 97f

disrase associated with, 162

in ribs, 92-93, 93f

latent, 161

in thoracic spine, 91f, 92

myofasciaJ, 161, 164

Tennis elbow, 43, 106

Trendelenburg test, 46

Tentorium cerebelli, 146, 147

Trigeminal ne-rve, 151

Tests. See Specific entries

True Jibs, 17

Thenar eminence', 42

Tunnel vision, 1.50

Therapeutic pulse, 87

Typical Jibs, 17

Thomas test, 47 Thoracic cage motion, restricted, 78 Thoracic lesion, 130-1.31

Vlnar arte r)" 40

Thoracic nerve, 40, 41

Umbilicus, 16

Thoracic outlet syndrome, 39

Chapman reflex relating to,

Thoracic segments, 15

1.5'1-159

Thoracic spine, 8, 11, 12, 15--16, 91f,

UnilateraJ sacral flexion, 37 Ureters, 62, 64, 73

92, 130

Thoracic vertebrae, 16, 159

Vrinary system, 66, 67

Thoracoabdominal diaphragm, 104

Uterus, 62, 64, 74

Thrust techniques, of HVLA, 124--138 Tibia, 102 Valgus stress test, 53

Tibiotalar joint, 50 Tissue bOgginess, 3

Varus stress test, 053

Tissue texture changes. See TART

Vault hold, 148

Toe

Venous return, from head, 78

big, trigger points associated wit.h,

Venous sinus technique, 149

hammer, 53

Vertebrae, 8

Tongue, dysphagia of, lSI

cervical, 13, 14

Torsion strain, 143, 143f

thoracic, 16, 159

Torticollis, 13, 149

Vertebral motions, 5

Toxins, 79

Vertebral segment 5

Transverse arch, 50

Vertebral unit,S, 10

Transverse ru..i s of motion, 11

VeJtical axis of motion, 11

Transverse axis of sacrum

Vertigo, 150

.

.

middle, 31

Visceral organs, 76

superior, 29

Visceral vessels, 61, 63

Transverse colon, 70, 71, 72

Viscerosomatic reflex, 059, 152

Transverse ligaments, 14 Tn1l1sverse plane of motion, 11 Transverse process, 1.5

Yerguson test, 405

Copyrighted Material