Study Guide for OPP 3

Written Exam 3 Fall 2020

 Osteopathic Concepts
• For ANY disease state, the patient must be STABLE before performing OMT***
• The sicker/weaker/more injured a patient is, use gentler techniques (examples include rib raising, myofascial release(MFR) soft tissue, etc.)
• Somatic dysfunction can occur anywhere in the body at

• Sympathetics levels
• Paraysmpathetic levels
• Soma (not autonomic related)
• Viscerosomatic reflexes occur at
• Sympathetics levels

• Parasympathetics levels
• Facilitated segments ONLY occur at
• Sympathetics
**** Know your sympathetic levels, parasympathetic levels. If sympathetic is not in your answer choices, see if a parasympathetic level to that
organ is present (lot of people tend to forget about the parasympathetics). For example, upper (proximal) ureters sympathetically are T10-T11,
and the parasympathetic innervation is vagus (so OA, AA (C1), C2 can affect the upper (proximal) ureters.
Test taking tip: Viscerosomatic reflexes can be both sympathetic and parasympathetic, but if a questions asks where you would see paravertebral
hypertonicity, keep in mind where the paraspinal muscles are. For example the sacrum does not have paraspinal muscles at S2-S4, but T12-L2
would.
Important Concepts
• If a spinous process is deviated to the right, the vertebra is rotated left. If a spinous process is deviated to the left, the vertebra is
rotated right
• Thoracic Pump with respiratory assist is CONTRAINDICATED in a patient with Asthmatic Flare Up or COPD exacerbation
• Thoracoabdominal diaphragm: Must evaluate neurological influence versus biomechanical influence
• Neurologically: Phrenic Nerve (C3, C4, C5)
• Biomechanically: Where the thoracoabdominal diaphragm attaches: lower ribs, thoraco-lumbar junction, T10-L3 are examples.
• If a patient has been sick recently and has had swollen glands/nodes in the neck and you suspect Mono, you worry about the person
developing splenomegaly. If they are injured in a trauma, such as a sport, they may get a referral pain to the shoulder and if the
spleen ruptures they can go into shock: low blood pressure/increased heart rate. They may lose consciousness. THIS IS A SURGICAL
EMERGENCY!
• Young males should not get recurrent urinary tract infections: must do imaging studies of the uro-genital anatomy
• Galbreath Technique: Great for treating otitis media, fluid in the ear, Eustachian tube somatic dysfunction
• Internal rotation of the temporal bone partially or completely closes the Eustachian tube and may result in the perception of a high-
pitched ringing in the ear.
• External rotation of the temporal bone may open the Eustachian tube and result in the perception of a low-pitched roar
• A parallelogram-shaped head in an infant is associated with a lateral strain cranial pattern
• B.I.T.E
• Bottom Rib is key rib in Inhalation dysfunction
• Top Rib is key rib in Exhalation dysfunction
• Remember, sometimes muscle hypertonicity, contraction, spasm can be caused by direct irritation of the what is overlying the
muscle:
• For example, if there is a renal lithiasis, it may cause the psoas to become hypertonic and you would have a positive Thomas test
• For example, if there is appendicitis, it may cause the psoas to become hypertonic and you would have a positive Thomas test
• For example, if there are inflamed lymph nodes, this may make the muscle they are touching to become hypertonic such as sternocleidomastoid causing torticollis
 Osteopathic Concepts: Please know
• If someone has a nocturnal cough at night, a couple things to think about is it may be due to asthma (pulmonary issue)
or reflux (GI issue) for example. Where you find somatic dysfunction may be a clue to which one it is and what
medication may be helpful.
• For example, if it is found at T2 you would think more pulmonary issue and maybe albuterol might be answer choice
• For example, if it is found at T8 you would think this is more GI and maybe omeprazole might be answer choice
• For example if it is found at T5 that could be either pulmonary or GI and you would need more information to get correct answer
• “Parallelogram” head = Lateral Strain
 Important Concepts
• Lumbar spine will side-bend towards the long leg side and rotate towards the short leg side
(Type I like mechanics)
• Most commonly used form of contraction in muscle energy is isometric contraction
• Take a history prior to physical examination
• Observation/observing the patient move is the first part of the physical examination
• Isometric contraction used in muscle energy tenses the Golgi Tendon organs causing a reflex
inhibition of the muscle allowing an increase in muscle length
• Translation to the right=left side-bending, translation to the left=right side-bending
• A heel lift for a leg length difference may help prevent osteoarthritis in a patient
• Feather’s Edge refers to the RESTRICTIVE BARRIER
 5 Osteopathic Models
• Biomechanical (structural, postural)
• Anatomy of muscles, spine, extremities; posture, motion
• OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis

• Neurological
• Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions
• Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions,
brain/CNS dysfunctions

• Respiratory/circulatory
• Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems
• Lymphatic techniques

• Metabolic/Nutritional
• Regulates through metabolic processes

• Behavioral (psychobehavioral)
• Focuses on mental, emotional, social and spiritual dimensions related to health and disease
Palpating Somatic Dysfunction
ACUTE CHRONIC
• Recent history (injury) • Long-standing
• Sharp or severe localized pain • Dull, achy diffuse pain
• Warm, moist, sweaty skin • Cool, smooth, dry skin
• Boggy, edematous tissue • Possible atrophy
• Erythematous • Fibrotic, ropy feeling tissue
• Local increase in muscle tone, • Pale/skin pallor
contraction, spasm, increased
muscle spindle firing • Decreased muscle tone,
contracted muscles, sometimes
• Normal or sluggish ROM flaccid
• May be minimal or no somatovisceral • Restricted ROM
effects
• Somatovisceral effects more often
present
“Old is cold, hot is not”
 Orientation of Orientation of
Superior Facets Inferior Facets
Region Facet Mnemonic Region Facet Mnemonic
Orientation Orientation

Cervical Backward, BUM Cervical Anterior, AIL

Upward, Inferior,
Medial Lateral
Thoracic Backward, BUL Thoracic Anterior, AIM
Upward, Inferior,
Lateral Medial
Lumbar Backward, BM Lumbar Anterior, AL
Medial Lateral
Somatic Dysfunction
• Somatic dysfunction is an impaired or altered
function of related components of the somatic
(body framework) system: skeletal, arthrodial, and
myofascial structures, and related vascular,
lymphatic, and neural elements.
• Diagnosed by T.A.R.T.
• T: Tissue Texture Changes
• A: Asymmetry
• R: Restriction of motion
• T: Tenderness
• Always named for the way it likes to go
• In axial spine, the reference point is the
superior/anterior aspect of the vertebra
• Not all somatic lesions are somatic dysfunctions.
Fractures, sprains, degenerative processes, and
inflammatory processes are not somatic
dysfunctions.
TYPES OF MOTION
terms describing motion
 Fryette Law 1
¡ When side-bending is attempted from

N
neutral (anatomical) position, rotation of
vertebral bodies follows to the opposite
direction.
¡ Typically applies to a group of vertebrae
(more than two)
¡ Occurs in a neutral spine (no extreme
flexion or extension) NO SAGITTAL
COMPONENT
¡ Side-bending and rotation occur to opposite
T2-6 RRSL
sides
¡ Side-bending precedes rotation
¡ Side-bending occurs towards the concavity T2-6 N RRSL
of the curve
¡ Rotation occurs towards the convexity of
the curve
¡ Diagnosed as a Type I dysfunction T2-6 N SLRR
Fryette Law 2
¡ When side-bending is attempted from non-

F
neutral (hyperflexed or hyperextended)
position, rotation must precede side-bending
to the same side.

E
¡ Typically applies to a single vertebra
¡ Occurs in a non-neutral spine (flexion or
extension of spine present) SAGITTAL
COMPONENT
¡ Side-bending and rotation occur to same
sides
¡ Rotation precedes side-bending T4 E RLSL
¡ Rotation of the vertebra occurs into the
concavity of the curve
¡ Diagnosed as a Type II dysfunction T4 E SLRL
¡ May be described as traumatic injury

T4 E SRL 12
 Cervical Spine

• OA (occipitoatlantal joint) side-bends to one

side and rotates to opposite , whether there is
a sagittal component or not (Type I like)
• OA Joint Accounts for 50% of Total C-Spine
FLEXION/EXTENSION
• AA (atlantoaxial joint) primarily rotational
• AA Joint Accounts for 50% of Total C-Spine
ROTATION

• C2-C7 rotate and side-bend to same side ,

whether there is a sagittal component or not
(Type II like)
 Neurological Exam of Upper Extremity

Root Sensation Motor Reflex

C4 Lateral Neck None None

C5 Deltoid Deltoid None

C6 Thumb, Index Finger Biceps Biceps

C7 Index and Mid Finger Triceps Triceps

C8 Ring Finger, Pinky Wrist Flexors None

T1 Medial Elbow Interossi None

 Tri-positional Diagnosis
• Determine which transverse process of the vertebra is posterior: this is the
side of rotation (should test with rotational component)
• Keep the side of rotation/posterior transverse process in your mind as you
move to the next step
 Tri-positional Diagnosis
• Monitor the posterior transverse process.
• Then, have the patient flex and extend to see if the posterior transverse process
moves more anteriorly (in other words: evens out, improves, becomes more
symmetrical, gets better) with either flexion or extension

• If a posteriorly rotated process moves anteriorly with flexion: it is F Rx Sx

• If a posteriorly rotated process moves anteriorly with extension: it is E Rx Sx
• If rotational component does not change with either maneuver (or gets worse
with flexion and extension), it is neutral: N Sx Ry
 Translational Motion
• Translation
• If a segment translates to the right, this induces left side-bending
• If a segment translates to the left, this induces right side-bending

L R

This segment is translating to the left, which is inducing right side-bending

 Tri-Positional Diagnosis
Screen the region.
Identify a transverse process that
feels posterior. (Posterior TP = X)

Have patient flex and extend his/her spine.

evaluate if the asymmetry improves

Improves In No Improves In
Flexion Improvement Extension

FRSX NSYRX ERSX

Neutral (Type I)
Non Neutral (Type II)
Rule of 3’s
• T1-3: spinous processes project posteriorly therefore the tip of the
spinous process is in the same plane as the transverse process of that
vertebra
• T4-6: spinous processes project slightly downward, therefore the tip of
the spinous process lies in a plane halfway between that vertebra’s
transverse processes and the transverse processes of the vertebra
below it
• T7-9: spinous processes project moderately downward, therefore the
tip of the spinous process is in a plane with the transverse process
below it
• T10 follows rules of T7-9
• T11 follows rules of T4-6
• T12 follows rules of T1-3
Indirect and Direct treatment
• If INDIRECT treatment used: exaggerate/augment the dysfunction
• If DIRECT treatment used: engage the barrier/reverse the dysfunction
Indirect Technique
• Somatic dysfunction is exaggerated or augmented
• Somatic dysfunction is taken the way it likes to go
• Restrictive barrier is disengaged
• Dysfunction is taken into position of injury
• Uses inherent forces
• Uses a compressive, tractional, or torsional component
Direct Technique
• Somatic dysfunction is taken the way it does not like to go
• Restrictive barrier is engaged
• Uses external forces
 Examples of Indirect Techniques
• Counterstrain
• Facilitated Positional Release (FPR)
• Balanced Ligamentous Tension Technique (BLT)
• Functional Technique
• Myofascial Release (may also be direct)
• Cranial (may also be direct)
• Still Technique (combined indirect and direct)
• Initial positioning of Still Technique set up is indirect
• Ending positioning of Still Technique is direct
Counterstrain: Steps of Treatment
• Assess the “this is a 10” pain level
• Maintain finger contact at all times (NOT PRESSING FIRM constantly,
only monitoring!)(***continuous monitoring)
• this is to monitor tension, not to treat
• Find the position of comfort
• Retest by pressing with contact finger
• This is a passive treatment
• Hold it for 90 seconds (that’s the time for ALL counterstrain points,
including ribs)
• monitor tension and response
• Return patient to neutral position SLOWLY!!
• Recheck pain level
• should be a 3 or less
• The only time you press firmly is when finding the point, repositioning
the point. All other times you are keeping you contact finger on point
to just monitor location.
FPR
• Body part in NEUTRAL position (flatten the curve/spine)
• COMPRESSION applied to shorten muscle/muscle fibers
(some cases may have TRACTION instead)
• Place area into EASE of motion (INDIRECT) for 3-5
seconds
• Return body part to neutral
• THIS TECHNIQUE IS INDIRECT!!!!
Still Technique
• Tissue/joint placed in EASE of motion position (augments the somatic
dysfunction)
• Compression (or traction) vector force added
• Tissue/joint moved through restriction (into and through the
restrictive barrier) while maintaining compression (or traction) and
force vector
• THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!
 Examples of Direct Techniques
• Myofascial Release (May also be indirect)
• Soft tissue
• Articulatory
• Muscle Energy
• High velocity, low amplitude (HVLA)
• Springing
• Cranial (may also be indirect)
• Still Technique (combined indirect and direct)
• Initial positioning of Still Technique set up is indirect
• Ending positioning of Still Technique is direct
Soft Tissue Examples
• Stretching – a longitudinal or parallel traction technique in which the origin and insertion
of the myofascial structures being treated are longitudinally separated.
• Kneading – a perpendicular traction technique in which a rhythmic, lateral stretching of a
myofascial structure, where the origin and insertion are held stationary and the central
portion of the structure is stretched like a bowstring.
• Inhibition – a deep inhibitory pressure, which is a sustained deep pressure over a
hypertonic myofascial structure.
• Effleurage – Gentle stroking of congested tissue used to encourage lymphatic flow
• Petrissage – Involves pinching or tweaking one layer and lifting it or twisting it away from
deeper areas
• Tapotement – striking the belly of a muscle with the hypothenar edge of the open hand
in rapid succession in order to increase itʼs tone and arterial perfusion. A hammering,
chopping percussion of tissues to break adhesions and/or encourage bronchial secretions
 Muscle Energy Technique
Postisometric Relaxation Reciprocal Inhibition
• Procedure • Procedure
- Dysfunctional Structure Positioned at Feather Edge of Direct - Dysfunctional Structure Positioned at Feather Edge of
Barrier Direct Barrier

(Positioning is in All Three [3] Planes of Motion) (Positioning is in All Three [3] Planes of Motion)

- Physician Continuously Monitors Dysfunction - Physician Continuously Monitors Dysfunction

- Patient is Instructed to GENTLY Push AWAY From the Barrier - Patient is Instructed to GENTLY Push TOWARD the Barrier

- Physician Resists Patient’s Effort for 3 - 5 Seconds - Physician Resists Patient’s Effort for 3 - 5 Seconds

- Patient is Instructed to Relax - Patient is Instructed to Relax

- Physician Repositions Patient to Feather Edge of New Barrier - Physician Repositions Patient to Feather Edge of New
Barrier
- Repeat 3 - 5 Times or until Maximum Improvement
- Repeat 3 - 5 Times or until Maximum Improvement
- Passively Reposition to Neutral After Last Effort
- Passively Reposition to Neutral After Last Effort
- Recheck Area of Dysfunction for Change
- Recheck Area of Dysfunction for Change
Reflexes
• somatosomatic reflex, localized somatic stimuli producing
patterns of reflex response in segmentally related somatic structures.
For example, rib somatic dysfunction from an innominate dysfunction.
• somatovisceral reflex, localized somatic stimulation producing
patterns of reflex response in segmentally related visceral structures.
For example, triggering an asthmatic attack when working on thoracic
spine, or manipulating someone and causing constipation.
• viscerosomatic reflex, localized visceral stimuli producing
patterns of reflex response in segmentally related somatic structures.
For example gallbladder disease affecting musculature, or abdominal
pain from ovulation.
• viscerovisceral reflex, localized visceral stimuli producing
patterns of reflex response in segmentally related visceral structures.
For example, pancreatitis and vomiting or myocardial infarction and
vomiting.
• Remember, post ganglionic sympathetic fibers lead to tissue texture
changes such as hypertonicity, moisture, erythema, etc.
 Sympathetic levels
Head and Neck: T1 – T4 Appendix: T10 – T11
Heart: T1– T5/T6 Kidneys: T10 – T11
Respiratory: T1 –T6/ T2 – T7 Adrenal Medulla: T10
Esophagus: T2 – T8 Upper Ureters: T10 – T11
Upper GI Tract: T5 – T9 Lower Ureters: T12 – L1
– Stomach, Liver, Gall Bladder, Spleen,
Bladder: T12 – L2
Pancreas, Duodenum Gonads: T10 – T11
Uterus & Cervix: T10 – L2
Middle GI Tract: T10 – T11
Erectile tissue: T11 – L2
– Pancreas, Duodenum, Jejunum, Ileum, Prostate: T12 – L2
Ascending colon, Right Transverse
Colon, Kidney, Upper Ureter, Gonads Arms: T2 – T8
Legs: T11 – L2
Lower GI Tract: T12 – L2
– Left Transverse Colon, Descending
Colon, Sigmoid colon, Rectum,
Prostate, Bladder, Lower Ureter
Parasympathetic Levels
• Vagus Nerve (OA, AA/C1, C2)
Trachea, esophagus, heart, lungs, liver, gallbladder,
stomach, pancreas, spleen, kidneys, proximal ureter,
small intestine, ascending colon, and transverse colon up
to the splenic flexure

• S2-S4
Distal to the splenic flexure of the transverse colon,
descending colon, sigmoid colon, rectum, distal ureter,
bladder, reproductive organs, and external genitalia .

• Variations: Ovaries & Testes

Vagus Nerve
S2-S4
 Peripheral Sympathetic Supply
• Sympathetic Supply to Upper Extremity Vasculature
• T2 to T8 levels
• Sympathetic Supply to Lower Extremity Vasculature
• T11 to L2 levels

There are no parasympathetic supply to the upper or lower

extremities
Collateral Ganglia
 Collateral Ganglia
• Sympathetic Pre-ganglionics - T5 through L2:
Greater Splanchnic (T5-T9), Lesser Splanchnic (T10-11), Least Splanchnic (T12),
Lumbar Splanchnic (L1-L2) nerves
• Celiac Ganglion (T5-T9) Post-ganglionic to:
Distal Esophagus, Stomach (epigastric), Liver, Gallbladder (cholecystitis), Spleen,
portions of Pancreas, proximal Duodenum (foregut)
• Superior Mesenteric Ganglion (T10-T11) Post-ganglionic to:
Portions of Pancreas, Duodenum, Jejunum, Ileum, Ascending Colon, Proximal 2/3 of
Transverse Colon. (midgut); Adrenals, Gonads, Kidneys, upper ½ Ureter
• Inferior Mesenteric Ganglion (T12-L2) Post-ganglionic to:
Distal 1/3 Transverse Colon, Descending Colon, Sigmoid, Rectum (hindgut); lower ½
Ureter, Bladder, Prostate Genitalia
Sympathetic Innervation
• Greater Splanchnic Nerve (T5-9)
• Synapses at the Celiac Ganglion
• Stomach, Liver, Gall Bladder, Pancreas, Parts of Duodenum
• Lesser Splanchnic Nerve (T10-11)
• Synapses at the Superior Mesenteric Ganglion
• Small Intestines and Right Colon (appendix is found here)
• Least Splanchnic Nerve (T12) and Lumbar Splanchnic Nerve (L1-2)
• Synapses at the Inferior Mesenteric Ganglia
• Innervates the Left Colon and Pelvic Organs
Treating Lymphatics
(Thoracic inlet/outlet has to be cleared/opened/treated
BEFORE ANY other lymphatic treatment)

Thoracic inlet/outlet components:

• Supraclavicular space
• 1st rib

Treatment examples include:

• Anterior cervical fascia release
• Thoracic inlet myofascial release
• Pectoral Traction
 Chapman Reflex Points

• Adrenal glands
• Anterior: 1” lateral and 2” superior to umbilicus ipsilaterally
• Posterior: intertransverse spaces of T11 and T12 ipsilaterally midway between spinous and transverse
processes
• Kidneys
• Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally
• Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1
• Urinary Bladder
• Anterior: Umbilical Area (Periumbilical)
• Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2
• Urethra
• Anterior: Along superior margin of the pubic ramus about 2 cm lateral to the symphysis
• Posterior: L3 transverse processes
 Neurological Influences to the Chest
• Autonomics
• Sympathetics
• Heart: T1-6 with synapses in upper thoracic and cervical chain ganglia.

• When considering arrhythmias:

• Right and left-sided distributions
• Right- sinoatrial (SA) node and right deep cardiac plexus– predisposes to supraventricular
tachyarrhythmias. Sinus tach, A-fib, A-flutter, PACs
• Left-atrioventricular (AV) node and left deep cardiac plexus- predisposes to ectopic PVCs and
V fib and V tach
• Asymmetries in sympathetic tone may play a role in the generation of serious arrhythmias.
Neurological Influences to the Heart
• Autonomics
• Parasympathetic
• Right vagus-via SA node and hyperactivity
predisposes to sinus bradyarrhythmias.
• Left vagus- via AV node where hyperactivity
predisposes to AV blocks.
• Vagus nerves have fibers course to them from
the C-1 & C-2 nerve roots.
Parasympathetics to the Heart

• Parasympathetic Innervation to the Heart

• Cranial Nerve X (Vagus)
• Jugular foramen, Occipitomastoid (OM) suture,
OA, AA, C2
• Right and Left sided distribution
• Right side= SA node
• Left side= AV node

(PS: minimal and isolated peripheral arteriolar

innervation)
Cardiac Arrythmia Summary
• Sinus Bradyarrhythmia:
• OA, AA (C1), C2 will rotate towards the right (Right side is SA node)
• 1st, 2nd, 3rd degree AV Blocks:
• OA, AA (C1), C2 will rotate towards the left (Left side is AV node)

• Sinus Tachyarrhythmia, Atrial Fibrillation, Atrial Flutter, Premature Atrial

Contractions (PAC):
• Upper thoracic spine (T1-T5) will rotate towards the right (Right side is SA node)
• V-fib, V-Tach, Premature Ventricular Contractions (PVC):
• Upper thoracic spine (T1-T5) will rotate towards the left (Left side is AV node)
 Osteopathic Concepts
• Vagus nerve originates in the brainstem and exits through the jugular foramen. The
jugular foramen is formed from the occipitomastoid suture, which is made up from
the temporal bone and the occiput. So dysfunction affecting the vagus nerve could
come from occipitomastoid suture compression.
• Think what organs that might affect: If it comes from the right side of left side.
• For example how may it affect heart rhythms
• Right side: SA node
• Left side: AV node
 Atrial flutter 6:1

Thoracic vertebrae should be rotated to the right

Dry mouth (Xerostomia)
• Can be caused by Cranial Nerve VII
• (lacrimal glands, sublingual and submandibular glands). Remember CN VII is
associated with the Sphenopalatine (Pterygopalatine) ganglion and exits
through the stylomastoid foramen
• Can be caused by Cranial Nerve IX
• (parotid gland). Remember CN IX is associated with the Otic ganglion and
exits through the jugular foramen
Mandibular Drainage: Galbreath Technique

• Indications
• This technique is indicated for any dysfunction or
lymphatic congestion in the ENT or submandibular
region, especially dysfunction in the eustachian tubes.
Care must be taken in patients with active
temporomandibular joint (TMJ) dysfunction (e.g.,
painful click) with severe loss of mobility and/or
locking.
*** Great for treating otitis media, fluid in the
middle ear, Eustachian tube somatic dysfunction
Tender Point: Location Classic Treatment Acronym
Anterior Position
Midline or just lateral to the jugular F
AT1 (suprasternal) notch Flexion to dysfunctional level

Midline or just lateral to the Flexion to dysfunctional level F

AT2 junction of manubrium and
sternum (angle of Louis)
Midline (or with some degree of Flexion to dysfunctional level F
AT3-AT5 sidedness) at level of
corresponding rib;

Midline (or with some degree of

AT6 sidedness) xiphoid–sternal
junction
Anterior Cervical CS Points
Tender Point Location Treatment Position Acronym
Anterior Cervical 1 Mandible=Posterior aspect Markedly rotated away RA
of the ascending ramus of
the mandible at the level
of the earlobe

Transverse process=Lateral
aspect of the transverse
process of C1
Anterior Cervical 2-6 On the anterolateral Flexed, side-bent away, F SARA
aspect of the rotated away
corresponding anterior
tubercle of the transverse
process
Anterior Cervical 7 On the clavicular (lateral) Flexed, side-bent toward, F STRA
attachment of the SCM rotated away
Anterior Cervical 8 At the sternal attachment Flexed, side-bent away, F SARA
of the SCM on the medial rotated away
end of the clavicle
Trigger Points
****Sternocleidomastoid muscle (SCM) refers pain lateral and behind
the eye
****Splenius Capitus muscle refers pain to the vertex of the head
 Muscle Energy Technique
Postisometric Relaxation Reciprocal Inhibition
• Procedure • Procedure
- Dysfunctional Structure Positioned at Feather Edge of Direct - Dysfunctional Structure Positioned at Feather Edge of
Barrier Direct Barrier

(Positioning is in All Three [3] Planes of Motion) (Positioning is in All Three [3] Planes of Motion)

- Physician Continuously Monitors Dysfunction - Physician Continuously Monitors Dysfunction

- Patient is Instructed to GENTLY Push AWAY From the Barrier - Patient is Instructed to GENTLY Push TOWARD the Barrier

- Physician Resists Patient’s Effort for 3 - 5 Seconds - Physician Resists Patient’s Effort for 3 - 5 Seconds

- Patient is Instructed to Relax - Patient is Instructed to Relax

- Physician Repositions Patient to Feather Edge of New Barrier - Physician Repositions Patient to Feather Edge of New
Barrier
- Repeat 3 - 5 Times or until Maximum Improvement
- Repeat 3 - 5 Times or until Maximum Improvement
- Passively Reposition to Neutral After Last Effort
- Passively Reposition to Neutral After Last Effort
- Recheck Area of Dysfunction for Change
- Recheck Area of Dysfunction for Change
TMJ: Post Isometric Muscle Energy
• If patient can’t open mouth, physician opens patient’s mouth to
restrictive barrier and patient tries to close mouth against resistance
• If patient can’t close mouth, physician closes patient’s mouth to
restrictive barrier and patient tries to open mouth against resistance
• If patient’s jaw deviates to the left when the patient opens their
mouth, physician pushes the patient’s jaw to the right and the patient
tries to push their jaw to the left against resistance
• If patient’s jaw deviates to the right when the patient opens their
mouth, physician pushes the patient’s jaw to the left and the patient
tries to push their jaw to the right against resistance
 TMJ Masseter Counterstrain

• Indication for Treatment

• Somatic dysfunction of the
head/cranium and/or cervical region.
The patient may complain of pain in
the neck, face, jaw, ear, or
temporomandibular joint and have
difficulty opening mouth fully.
Mandible may deviate or shift to the
side of dysfunction.
• Tender Point Location
• Masseter: Just inferior to the zygoma
in the belly of the masseter muscle
typically found on the side of Fig. 9.225
mandibular deviation (Fig. 9.225).
 TMJ Masseter Counterstrain

• The patient lies supine, and the

physician sits at the head of the
table (Fig. 9.226).
• The physician gently glides the
patient's slightly opened
jaw/mandible laterally toward the Fig. 9.226
side of the tender point (Fig.
9.227).
• Fine-tune until the tenderness
is completely alleviated or reduced
as close to 100% as possible, but at
least 70%.
Fig. 9.227
 TMJ Medial Pterygoid Counterstrain

• Indication for Treatment

• Somatic dysfunction of the
head/cranium and/or cervical region.
The patient may complain of pain in
the neck, face, jaw, ear, or
temporomandibular joint and have
difficulty opening mouth fully.
Mandible may deviate or shift to the
side of dysfunction.
• Tender Point Location
• Jaw angle point or medial pterygoid:
On the posterior surface of the
ascending ramus of the mandible
about 2 cm. above the angle of the
mandible on the side opposite of Fig. 9.228
mandibular deviation (Fig. 9.228).
 TMJ Medial Pterygoid Counterstrain

• The patient lies supine, and the

physician sits at the head of the
table.
• The physician gently glides the
patient's slightly opened
jaw/mandible laterally away from
the side of the tender point (Fig.
9.229).
• Fine-tune until the tenderness
is completely alleviated or reduced
as close to 100% as possible, but at
least 70%. Fig. 9.229
 Cranial
nerves

http://cdn1.teachmeseries.com/tmanatomy/wp-content/uploads/20171222220133/CN-base-of-skull.jpg
Cranial Nerves**** Know these!!!!
• CN I ****
• Anosmia
• Cribiform plate through ethmoid bone
• CN V ****
• Trigeminal Neuralgia/Tic Douloureux
• May complain of sudden, severe facial, ear, and/or jaw pain
• CN VII ****
• Exits stylomastoid foramen
• Bell’s Palsy
• CN VIII ****
• Labyrinthitis, Tinnitus, Vertigo **** Temporal bone is associated with tinnitus, labyrnthitis, vertigo
• CN X ****
• Exits jugular foramen (formed by occipitomastoid suture)
• Can cause Nausea/Vomiting
• CN XI ****
• Exits jugular foramen (formed by occipitomastoid suture)
• Can cause Torticollis
• CN XII ****
• Hypoglossal canal
• Can cause nursing/latching problems in infants
Complaints associated with Cranial Nerve
Impingement

• Difficulty nursing/latching – CN XII

• Colic – CN X
• GERD – CN X
• Vomiting – CN X
• Torticollis – CN XI
• Asthma – CN X
• Otitis Media – CN VIII
 Rib Motions

• Pump-Handle motion
• Primarily ribs 1-5
• Palpation of Pump Handle Ribs:
best at Mid-clavicular Line

• Bucket-Handle motion
• Primarily ribs 6-10
• Palpation of Bucket Handle Ribs:
best at Mid-axillary Line

• Caliper motion
• Primarily ribs 11,12
 Inhalation Rib Somatic Dysfunction
• Somatic dysfunction usually characterized by a rib being held in a
position of inhalation
• Motion toward inhalation is more free
• Motion toward exhalation is restricted
• Patient may complain of pain with EXHALATION
• Synonyms:
• Exhalation rib restriction
• Inhalation strain
• Elevated rib
• Inhaled rib
 Exhalation Rib Somatic Dysfunction
• Somatic dysfunction usually characterized by a rib being held in a
position of exhalation
• Motion toward exhalation is more free
• Motion toward inhalation is restricted
• Patient may complain of pain with INHALATION
• Synonyms:
• Inhalation rib restriction
• Exhalation strain
• Depressed rib
• Exhaled rib
Rib information
• B.I.T.E
• Bottom Rib is key rib in Inhalation dysfunction
• Top Rib is key rib in Exhalation dysfunction
• Exhaled ribs are prominent posteriorly
• Inhaled ribs are prominent anteriorly
• Anterior Rib Counterstrain Points are associated with Exhalation Rib
Somatic Dysfunction
• Posterior Rib Counterstrain Points are associated with Inhalation Rib
Somatic Dysfunction
 Samples of how to diagnose ribs
• If pain increases when patient inhales: indicates exhalation rib somatic dysfunction
• If pain increases when patient exhales: indicates inhalation rib somatic dysfunction
• If left ribs 2-5 lag on exhalation as compared to the right side, then left ribs 2-5 are
dysfunctional and represent inhalation somatic dysfunction. The key rib would be rib 5 and the
muscle that may have caused this is pectoralis minor. Rib 5 is holding up rib 2, 3,4 and won’t
let them exhale. Rib 5 is the BOTTOM rib causing the dysfunction.
• Other findings that may be present:
• There may be posterior rib counterstrain points associated with inhalation rib somatic dysfunction
• Ribs would be prominent anteriorly with inhalation rib somatic dysfunction

• If left ribs 2-5 lags on inhalation as compared to the right side, then left ribs 2-5 are
dysfunctional and represent exhalation somatic dysfunction. The key rib would be rib 2. Rib 2
is holding down rib 3, 4, 5 and won’t let them inhale. Rib 2 is the TOP rib causing the
exhalation rib somatic dysfunction.
• Other findings that may be present:
• There may be anterior rib counterstrain points associated with exhalation rib somatic dysfunction
• Ribs would be prominent posteriorly with exhalation rib somatic dysfunction
 Samples of how to diagnose ribs, continued
• If right ribs have an increased 6th intercostal space (ICS), then at this point either rib 6 is
inhaled or rib 7 is exhaled.
• If right ribs have a decreased 6th intercostal space (ICS), then at this point either rib 6 is
exhaled or rib 7 is inhaled.
• Example: If right ribs have an increased 6th intercostal space (ICS), and they lag on
inhalation, then you know it is an exhalation somatic dysfunction and therefore rib 7 is
exhaled. Rib 7 would be the top rib over 8, 9, 10, etc.
• Example: if right ribs have an increased 6th intercostal space (ICS), and the patient has
pain when they exhale, then you know it is an inhalation somatic dysfunction and rib 6 is
inhaled. Rib 6 would be the bottom rib under 5, 4, 3, etc.
• Example: If right ribs have an increased 6th intercostal space (ICS), and there are anterior
rib counterstrain points found on exam, then you know this represents an exhalation
somatic dysfunction and rib 7 is exhaled. Rib 7 would be the top rib over 8, 9, 10, etc.
• Example: If right ribs have an increased 6th intercostal space (ICS), and the ribs are
prominent posteriorly, then you know it is an exhalation somatic dysfunction and rib 7 is
exhaled. Rib 7 would be the top rib over 8, 9, 10, etc.
Samples of how to diagnose ribs, continued
• Prominent ribs posteriorly would indicate exhalation somatic dysfunction
• Prominent ribs anteriorly would indicate inhalation somatic dysfunction
• Anterior rib counterstrain points would indicate exhalation somatic dysfunction
• Posterior rib counterstrain points would indicate inhalation somatic dysfunction
• Another sample question: If ribs 2-8 lag on exhalation, which muscle might have
caused this? So you know it is an inhalation somatic dysfunction and that 8 is the
key rib in inhalation somatic dysfunction (B.I.T.E). Muscles used to treat exhaled
ribs may become hypertonic and lead to an inhalation somatic dysfunction. Since
serratus anterior is associated with rib 8, that is the muscle that has now caused
the inhalation somatic dysfunction!
• Note: Piece all the findings giving to you from questions to formulate what the rib
diagnosis is, what muscles may have caused it, how do you set them up for
treatment if inhalation versus exhalation muscle energy, etc.
Strain-Counterstrain
Anterior Rib Tender Points
Indications
• Somatic dysfunction in ribs 1-6
(commonly exhaled ribs)
- Ribs 1-2
• Pain in anterior chest wall
- Ribs 3-6
• Pain in lateral chest wall

• Common causes of this dysfunction

include excessive coughing, sneezing,
or overuse of upper extremity
Strain-Counterstrain
Anterior Rib Tender Points
Tender Point Locations
• AR1
Below clavicle on 1st chondrosternal
articulation associated with pectoralis
major and internal intercostal muscles
• AR2
Superior aspect of 2nd rib in
midclavicular line
• AR3-10
On the dysfunctional rib at the anterior
axillary line associated with the
serratus anterior (AR3-8) and internal
intercostal muscles (AR9-10)
Strain-Counterstrain
Treatment of AR1-2 Tender Points - F STRT

1) The patient lies supine or seated and the

physician stands or sits at the head of the table.

2) The physician passively flexes patient's head

and neck to engage the dysfunctional rib level.

3) The patient's head and neck are side-bent and

rotated toward the tender point

4) The physician fine-tunes through small arcs of

motion (flexion, side bending, or rotation).

5) The physician holds this position for 90 seconds

6) Slowly return patient to neutral position

7) Reassess!
Strain-Counterstrain
Treatment of AR3-10 Tender Points – F STRT
1) The patient is seated with the hips
and knees flexed on the table on the
side of the tender point. The patient
may let the leg on the side of the
tender point hang off the front of
the table, the other leg crossed
under it.

2) The physician stands behind the

patient with the foot opposite the
tender point on the table and the
thigh under the patient's axilla
(induces side-bending toward tender
point).

3) The patient's thorax is slightly flexed

to the dysfunctional level.
Strain-Counterstrain
Treatment of AR3-10 Tender Points - F STRT
4) The patient's arm opposite the
tender point is draped over
physician's leg. The patient’s
arm on the side of the tender
point is extended and allowed
to hang off the edge of the
table behind the patient,
inducing rotation toward and
translation away (side-bending
toward) the tender point.
5) The physician fine-tunes
through small arcs of motion
(flexion, side bending, or
rotation).
6) The physician holds this
position for 90 seconds.
7) Slowly return patient to neutral
8) Reassess!
Strain-Counterstrain
Posterior Rib Tender Points
Indications
• Somatic dysfunction of ribs 1-6
(commonly inhaled)
- Rib 1:
• Pain in cervicothoracic
junction
- Ribs 2-6:
• Pain in upper to mid-thoracic
and/or periscapular region

• May be caused by trauma, overhead

sleeping position or sudden movement
of neck or thorax
Strain-Counterstrain
Posterior Rib Tender Points
Tender Point Locations
• PR1:
On the posterior superior angle of the
first rib just lateral to the
costotransverse articulation
• PR2-6:
On superior aspect of angle of
dysfunctional rib associated with the
levatores costarum and/or serratus
posterior superior muscles
• PR7-10:
On superior aspect of angle of
dysfunctional rib associated with the
levatores costarum
Strain-Counterstrain
Treatment of PR1 Tender Point – E SART
1) The patient is seated. The physician stands behind the patient.
2) The physician's foot is placed on the table on the opposite side as the tender
point.
3) The physician monitors the first rib tender point with the index finger pad, which
is on the tender point
Strain-Counterstrain
Treatment of PR1 Tender Point - E SART
4) With the other hand, the physician gently extends and side-bends the head and
neck away from the tender point, then, carefully monitoring the movement so it
is vectored to engage the first rib.
5) The physician rotates the head toward the tender point.
6) fine-tunes through small arcs of motion (extension, rotation, and side bending).
7) The physician holds this position for 90 seconds.
8) Reassess!
Strain-Counterstrain
Treatment of PR2-10 Tender Points - F SARA
1) The patient is seated with legs on the side of
table (for comfort, the patient may hang the
leg opposite the tender point off the table).
2) The physician stands behind patient with the
foot ipsilateral to the tender point on the
table with the thigh under the patient's
axilla.
3) The physician gently flexes patient's head,
neck, and thorax to engage the level of the
dysfunctional rib.
4) The physician elevates the patient's shoulder
with the axilla resting on the thigh, which
side-bends the trunk away from the tender
point.
Strain-Counterstrain
Treatment of PR2-10 Tender Points - F SARA
5) The patient is asked to slowly
extend the shoulder and arm
opposite the tender point and allow
the arm to hang down. This induces
side bending away (translation
towards) and rotation away from
the tender point.
6) The physician fine-tunes through
small arcs of motion (flexion,
rotation, and side bending).
7) The physician holds this position for
90 seconds.
8) Return patient to neutral position
slowly
9) Reassess!
Strain-Counterstrain
Treatment of PR2-10 Tender Points - F SARA

PR2-6 Treatment Position – Back View

PR2-6 Treatment Position - Side View

 Muscle Energy
Inhalation Dysfunction Ribs 1 - 10
§ Patient is supine, physician at head
of table
§ Pump-handle ribs
§ Flex the patient’s head and neck
§ Bucket-handle ribs
§ Flex the patient’s head and neck and
side-bend the patient toward
dysfunctional rib
§ Physician places a hand, thumb, or
fingers on the anterior, superior
surface of the rib
 Muscle Energy
Inhalation Dysfunction Ribs 1 - 10
§ Patient inhales deeply and holds
for 3-5 seconds
§ Physician resists inhalation motion
of rib
— effecting an isometric contraction
§ Patient exhales, physician
guides/follows the rib into
exhalation
§ Physician takes up the slack, and
adjusts flexion/side-bending after
a 2 second pause
§ Pump handle rib treatment
§ The process is repeated 3-5 times
§ Reassess
Muscle Energy
Exhalation Dysfunction Ribs 1 – 10
[a general overview]
§ Patient supine, physician at head of table
§ The patient is instructed to place their arm in the correct position as
directed by the physician in order to use the correct muscle during the
treatment.
§ Physician contacts the key rib posteriorly at the rib angle.
§ Patient inhales while the physician applies an inferior force to the rib angle
§ At full inhalation, the patient is instructed to hold his/her breath while
performing an isometric contractions, pushing with their arm into the
physicians resistance, for 3-5 seconds.
§ The process is repeated 3-5 times and then rib motion is re-assessed.
Muscles used in Muscle Energy to treat
Rib Exhalation Somatic Dysfunction
• Rib 1: Anterior and mid scalene
• Rib 2: Posterior Scalene
• Ribs 3 – 5: Pectoralis Minor
• Ribs 6 – 8: Serratus anterior
• Ribs 9 – 11: Latissimus Dorsi
• Rib 12: Quadratus Lumborum

• NOTE: If these muscles become hypertonic, they can cause an inhalation somatic
dysfunction!!!!
• For example if you have a 4th inhalation rib somatic dysfunction, then pectoralis minor would
be the hypertonic muscle
• For example if a patient has a hypertonic pectoralis minor muscle on the right, what is the
likely rib(s) that may be inhaled? 3-5
• For example if rib 10 is an inhalation somatic dysfunction, latissimus dorsi would be the
involved muscle
 Muscle Energy
Exhalation Dysfunction Rib 1

§ Anterior and middle scalene muscles attach

to rib 1
§ Contraction of these muscles help mobilize
the exhaled rib
 Muscle Energy
Exhalation Dysfunction Rib 1
§ Patient supine, physician at head of table
§ The patient’s hand on their forehead palm up
§ Physician grasps rib 1 posteriorly at the rib angle
§ Patient inhales, physician applies an inferior
traction to the rib angle
§ At full inhalation, the patient is instructed to
hold his/her breath while lifting their head
anteriorly, physician resists this motion for 3-5
seconds.
§ The process is repeated 3-5 times and then rib
motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 2

§ Posterior scalene muscle attaches to rib 2

§ Contraction of this muscle help mobilize the
exhaled rib
 Muscle Energy
Exhalation Dysfunction Rib 2
§ Patient supine, physician at head of table
§ The patient’s hand on their forehead palm
up and rotates head away 30 degrees
§ Physician grasps rib 2 posteriorly at the rib
angle
§ Patient inhales, physician applies an inferior
traction to the rib angle
§ At full inhalation, the patient is instructed
to hold his/her breath while lifting their
head anteriorly, physician resists this
motion for 3-5 seconds.
§ The process is repeated 3-5 times and then
rib motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 3, 4, 5

§ Pectoralis Minor muscle

attaches to ribs 3, 4, 5
§ Contraction of these muscles
help mobilize the exhaled rib
 Muscle Energy
Exhalation Dysfunction Rib 3, 4, 5
§ Patient supine, physician at head of table
§ The patient’s hand on their forehead palm up
§ Physician grasps rib 3, 4, 5 posteriorly at the rib angle
§ Patient inhales, physician applies an inferior traction
to the rib angle
§ At full inhalation, the patient is instructed to hold
his/her breath and pushes their elbow to their
contralateral ASIS, physician resists this motion for 3-
5 seconds
§ The process is repeated 3-5 times and then rib motion
is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 6, 7, 8

§ Serratus Anterior muscle attaches to ribs 6, 7, 8

— It attaches to other ribs as well but the angle of
attachment to these ribs is what assists in the
treatment
§ Contraction of these muscles help mobilize the
exhaled rib
 Muscle Energy
Exhalation Dysfunction Rib 6,7, 8 – option 1
§ Patient supine, physician at head of table
§ The patient’s hand behind their head,
elbow pointing straight up
§ Physician grasps rib 6, 7, 8 posteriorly at
the rib angle
§ Patient inhales, physician applies an
inferior traction to the rib angle
§ At full inhalation, the patient is instructed
to hold his/her breath and pushes their
elbow toward the ceiling, physician resists
this motion for 3-5 seconds
§ The process is repeated 3-5 times and then
rib motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 6, 7, 8– option 2
§ Patient supine, physician at head of table
§ The patient’s hand on their forehead
palm up
§ Physician grasps rib 6, 7, 8 posteriorly at
the rib angle
§ Patient inhales, physician applies an
inferior traction to the rib angle
§ At full inhalation, the patient is
instructed to hold his/her breath and
pushes their elbow to their ipsilateral
ASIS, physician resists this motion for 3-5
seconds
§ The process is repeated 3-5 times and
then rib motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 9, 10 – option 1
§ Patient supine, physician at head of table
§ The patient’s hand on their forehead
palm up
§ Physician grasps rib 9, 10 posteriorly at
the rib angle
§ Patient inhales, physician applies an
inferior traction to the rib angle
§ At full inhalation, the patient is
instructed to hold his/her breath and
ADduct their arm, physician resists this
motion for 3-5 seconds
§ The process is repeated 3-5 times and
then rib motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 9, 10 – option 2
§ Patient supine, physician at head of
table
§ The patient’s arm is ABducted
§ Physician grasps rib 9, 10
posteriorly at the rib angle
§ Patient inhales, physician applies an
inferior traction to the rib angle
§ At full inhalation, the patient is
instructed to hold his/her breath
and ADduct their arm, physician
resists this motion for 3-5 seconds
§ The process is repeated 3-5 times
and then rib motion is reassessed.
 Muscle Energy
Exhalation Dysfunction Rib 9, 10

§ Latissimus dorsi muscle attaches to ribs 9, 10

§ Contraction of these muscles help mobilize
the exhaled rib
Rib HVLA 2-10 (Inhalation or Exhalation)
• Similar to Thoracic Supine HVLA (Kirkesville Crunch)
• Place thenar eminence (fulcrum) on posterior aspect of rib angle
instead of transverse process

• For exhalation rib HVLA, your thenar eminence on the rib angle will
pull downward (inferior/caudad) on rib angle
• For inhalation rib HVLA , your thenar eminence on the rib angle will
pusy upward (superior/cephalad) on rib angle
FPR
• Body part in NEUTRAL position
• COMPRESSION applied to shorten muscle/muscle
fibers (some cases may have TRACTION instead)
• Place area into EASE of motion (INDIRECT) for 3-5
seconds
• Return body part to neutral
• THIS TECHNIQUE IS INDIRECT!!!!
Still Technique
• Tissue/joint placed in EASE of motion position (augments the somatic
dysfunction)
• Compression (or traction) vector force added
• Tissue/joint moved through restriction (into and through the
restrictive barrier) while maintaining compression (or traction) and
force vector
• THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!
Short Leg syndrome
• Anatomical or functional
• Signs/symptoms
• Sacral base unleveling
• Anterior innominate on side of short leg
• Posterior innominate on side of long leg
• L-spine will side-bend away from and rotate towards short leg
• Lumbosacral (LS) angle will increase
• Stress on iliolumbar ligaments then SI ligaments
• Heel life can be used to help prevent arthritis in person with short leg
syndrome
Heel lift Guidelines
• Final lift height should be ½ – ¾ of the measured discrepancy
• If acute discrepancy (i.e. hip fracture), lift full amount

• Start with 1/8” heel lift, then increase by 1/8” every two
weeks

• Frail patients should start with 1/16” heel lift, then increase by
1/16” every two weeks.
Heel Lift Guidelines
1. The heel lift should be applied to the side of the short leg
2. The final lift height should be ½ - ¾ of the measured leg length discrepancy, unless there was a
recent sudden cause of the discrepancy (hip fracture, prosthesis) then lift the full amount
3. The “fragile” patient (elderly, arthritic, osteoporotic, acute pain) should begin with a 1/16” (1.5
mm) heel lift and increase 1/16” every two weeks
4. The “flexible” should begin with 1/8” (3.2mm) heel lift and increase 1/8” every two weeks
5. A maximum of ¼” may be applied to the inside of the shoe (if >1/4” is needed, then this must be
applied to the outside of the shoe
6. Maximum heel lift possible = ½”. If more is needed, an ipsilateral anterior sole lift extending from
heel to toe should be used in order to keep the pelvis from rotating to the opposite side
• For example, if a patient has an 8 mm leg length discrepancy chronically (Long Term), your goal is
to lift to 4mm****
 Standing Flexion Test
• Patient standing with feet flat on floor and shoulder width
apart
• Physician monitors the inferior aspect of patient’s PSIS
• Patient forward bends maximally
• Positive: side PSIS moves more cephalad at the end range
of motion
• Purpose: identifies side of sacroiliac somatic dysfunctions
• “Gold Standard” Test for iliosacral SD
 ASIS Compression Test
• Apply a posterior-medial pressure
on one ASIS while stabilizing the
other.
• Imagine aiming the pressure
toward the SI joint.
• Repeat the test on the other side.
• The restricted side is the positive
side.
 Seated Flexion Test
• Patient seated on stool with feet flat on floor and shoulder
width apart
• Physician monitors the inferior aspect of patient’s PSIS
• Patient forward bends maximally
• Positive: side PSIS moves more cephalad at the end range
of motion
• Purpose: identifies side of sacroiliac somatic dysfunctions
• “Gold Standard” Test for sacroiliac SD
Somatic Dysfunction of the Pelvis
• Anterior Innominate Rotation
• Posterior Innominate Rotation
• Innominate Up-slip (Superior Innominate Shear)
• Innominate Down-slip (Inferior Innominate Shear)
• Innominate Out-flare (ABducted Innominate)
• Innominate In-flare (ADducted Innominate)
• Superior Pubic Shear
• Inferior Pubic Shear
Innominate Rotation
Anterior Posterior
• + standing flexion (on side of the • + standing flexion (on side of the
dysfunction) dysfunction)
• ASIS Compression test + (on side • ASIS Compression test + (on side
of dysfunction) of dysfunction)
• Inferior ASIS (on side of the • Superior ASIS (on side of the
dysfunction) dysfunction)
• Superior PSIS (on side of the • Inferior PSIS (on side of the
dysfunction) dysfunction)
• Superior ischial tuberosity (on • Inferior ischial tuberosity (on side
side of the dysfunction) of the dysfunction)
• Shallow sacral sulcus (on side of • Deep sacral sulcus (on side of the
the dysfunction) dysfunction)
• Equal iliac crest height • Equal iliac crest height
• Medial malleolus inferior (long • Superior medial malleolus (short
leg) (on side of the dysfunction) leg) (on side of the dysfunction)
Innominate Outflares/Inflares
Outflare (ABducted) Inflare (ADducted)
• + standing flexion (on side of • + standing flexion (on side of
the dysfunction) the dysfunction)
• ASIS Compression test + (on • ASIS Compression test + (on
side of dysfunction) side of dysfunction)
• ASIS lateral (on side of the • ASIS medial (on side of the
dysfunction) dysfunction)
• PSIS medial (on side of the • PSIS lateral (on side of the
dysfunction) dysfunction)
• Distance from ASIS to • Distance from ASIS to
umbilicus increased on umbilicus decreased on
dysfunctional side (is more dysfunctional side (is more
lateral) medial)
• ASIS further from midline • ASIS closer to midline
• Narrow sacral sulcus (on side • Wide sacral sulcus (on side of
of the dysfunction) the dysfunction)
Innominate Shears
Superior Innominate Shear Inferior Innominate Shear
Upslipped Innominate Downslipped Innominate
• + standing flexion (on side of the • + standing flexion (on side of the
dysfunction) dysfunction)
• ASIS Compression test + (on side of • ASIS Compression test + (on side of
dysfunction) dysfunction)
• Superior ASIS (on side of the • Inferior ASIS (on side of the
dysfunction) dysfunction)
• Superior PSIS (on side of the • Inferior PSIS (on side of the
dysfunction) dysfunction)
• Superior iliac crest height (on side of • Inferior iliac crest height (on side of the
the dysfunction) dysfunction)
• Superior pubic tubercle (on side of the • Inferior pubic tubercle (on side of the
dysfunction) dysfunction)
• Superior ischial tuberosity (on side of • Inferior ischial tuberosity (on side of the
the dysfunction) dysfunction)
• Superior medial malleolus (on side of • Inferior medial malleolus (on side of the
the dysfunction) dysfunction)
• Sacrotuberous ligament lax (on side of • Sacrotuberous ligament tight (on side of
the dysfunction) the dysfunction
Pubic Shears
Superior Pubic Shear Inferior Pubic Shear
• + standing flexion (on side of the • + standing flexion (on side of the
dysfunction) dysfunction)
• ASIS Compression test + (on side • ASIS Compression test + (on side
of dysfunction) of dysfunction)
• Superior pubic tubercle/ramus • Inferior pubic tubercle/ramus (on
(on side of the dysfunction) side of the dysfunction)
• Ipsilateral inguinal ligament tense • Ipsilateral inguinal ligament tense
and tender and tender
• ASIS may be even or may be • ASIS may be even or may be
superior (on side of the inferior (on side of the
dysfunction) dysfunction)
• PSIS may be even or may be • PSIS may be even or may be
inferior (on side of the superior (on side of the
dysfunction) dysfunction)
• Findings may look similar to a • Findings may look similar to an
posteriorly rotated innominate anteriorly rotated innominate
 Anterior Innominate Rotation
Muscle Energy
• Patient supine, stand/sit on dysfunctional side
facing cephalad.
• Use your medial hand to stabilize the
contralateral ASIS.
• Place patient’s leg against/on your shoulder.
Cup PSIS with your lateral hand.
• Flex hip and knee on side of dysfunction to
rotate the innominate posteriorly to the
restrictive barrier.
• Instruct the patient to gently push their knee
into your shoulder (they are extending their hip)
for 3-5 seconds while you resist their effort.
(Patient using hamstrings)
• Have the patient relax, then further flex the
patient’s hip to rotate the innominate
posteriorly into the new restrictive barrier.
• Repeat 3-5 times.
• Reassess.
 Posterior Innominate Rotation
Muscle Energy 1
• Patient supine, stand on dysfunctional side, facing caudad.
• Use your medial hand to stabilize the contralateral ASIS.
• Have the patient lay near the edge of the treatment table,
allowing their leg and the ischial tuberosity to hang off the
table.
• Place your hip against the patient so they do not feel
like they are going to fall off of the table.
• Place your hand on the patient’s thigh just proximal to the
knee. Gently push the patient’s leg toward the floor into
extension to rotate the innominate anteriorly to the
restrictive barrier.
• Instruct the patient to gently push their knee toward the
ceiling (they are flexing their hip) for 3-5 seconds while you
resist their effort. (Patient using quadriceps)
• Have the patient relax, then further extend the patient’s leg
to rotate the innominate anteriorly into the new restrictive
barrier.
• Repeat 3-5 times.
• Reassess.
 Posterior Innominate Rotation
Muscle Energy 2
• Patient prone, stand opposite the dysfunctional
side, facing toward the treatment table.
• Use your cephalad hand to induce a force into the
table at the PSIS.
• Place your caudad hand just proximal to the knee
and extend the hip to rotate the innominate
anteriorly to the restrictive barrier.
• You can have the patient flex their knee to decrease
resistance.
• Instruct the patient to gently pull their leg toward
the table (they are flexing their hip) for 3-5
seconds while you resist their effort. (Patient using
quadriceps)
• Have the patient relax, then further extend the
patient’s hip to rotate the innominate anteriorly
into the new restrictive barrier.
• Repeat 3-5 times.
• Reassess.
 Innominate In-flare (Adducted)
Muscle Energy
• Patient supine, stand opposite of the
dysfunctional side facing cephalad.
• Use your cephalad hand to stabilize the
contralateral ASIS.
• Flex and ABduct the patient’s hip and knee
and place the patient’s foot on the table
near the other leg.
• “Figure 4” or “frog leg” position
• Instruct the patient to gently push their
knee toward the ceiling for 3-5 seconds
while you resist their effort.
• Have the patient relax, then further ABduct
the patient’s leg into the new restrictive
barrier.
• Repeat 3-5 times.
• Reassess.
 Innominate Out-flare (Abducted)
Muscle Energy
• Patient supine, stand on dysfunctional side
facing toward the patient’s midline.
• Grasp the patient’s knee with the caudad
hand, and the medial aspect of the
ipsilateral PSIS with the cephalad hand.
• Flex the patient’s hip and knee, ADduct the
knee across the midline, engaging the
restrictive barrier.
• Instruct the patient to gently ABduct their
knee for 3-5 seconds while you resist their
effort. Gently apply a lateral force to the
PSIS.
• Have the patient relax, then further ADduct
the patient’s leg into the new restrictive
barrier.
• Repeat 3-5 times.
• Reassess.
 Superior Pubic Shear
Muscle Energy
• Patient supine, with the ipsilateral ischial
tuberosity near the edge of the treatment table.
Allow the leg to hang off the table.
• Stand between the table and the patient’s leg,
facing cephalad.
• Use your medial hand to stabilize the opposite
ASIS.
• ABduct the knee to gap the pubic symphysis.
• Gently push the patient’s leg toward the floor into
extension until you reach the restrictive barrier.
• Instruct the patient to gently push their knee
toward the ceiling for 3-5 seconds while you
provide a resist their effort.
• Have the patient relax, then further flex and
ABduct the patient’s leg into the new restrictive
barrier.
• Repeat 3-5 times.
• Reassess.
 Inferior Pubic Shear
Muscle Energy
• Patient supine, stand on dysfunctional side
facing cephalad.
• Flex the hip and knee and ABduct the thigh
to gap the pubic symphysis.
• Place the patient’s knee against your chest.
Use your cephalad hand to cup the ASIS
and your caudad hand to grasp the ischial
tuberosity.
• This rotates the innominate posteriorly to bring
the pubic symphysis superiorly.
• Instruct the patient to gently push their
knee into your chest for 3-5 seconds while
you resist their effort.
• Have the patient relax, then further flex and
ABduct the patient’s leg into the new
restrictive barrier.
• Repeat 3-5 times.
• Reassess.
Innominate Up-slip
(Superior Innominate Shear)
Muscle Energy
• Patient supine, stand at the foot of the table
facing cephalad.
• Grasp the lower extremity just proximal to
the ankle.
• Internally rotate and slightly flex the hip,
and ABduct to about 20°.
• Apply traction until the restrictive barrier is
reached.
• Instruct the patient to pull their hip
cephalad for 3-5 seconds while you resist
their effort.
• Have the patient relax, then add traction to
the patient’s leg until the new restrictive
barrier is met.
• Repeat 3-5 times.
• Reassess.
Muscle Energy treatment of Pubic Shears
• An inferior pubic shear is treated like an Anterior Innominate rotation
with the addition of ABduction.
• A superior pubic shear is treated like a Posterior Innominate rotation
with the addition of ABduction.
Sacral Somatic Dysfunctions
• B/L Flexed Sacrum (middle transverse axis)
• B/L Extended Sacrum (middle transverse axis)
• Forward Sacral Torsions (oblique axis)
• Backward Sacral Torsions (oblique axis)
• Unilateral Sacral Flexion (no axis)
• Unilateral Sacral Extension (no axis)
SACRAL ANATOMICAL AXIS
Transverse axis
• Superior:
• the cranial primary respiratory mechanism creates
motion around this axis
• Middle:
• sacral base anterior and posterior (FB/BB) occur
around this axis
• sacrum flexes and extends around this axis
(sagittal plane)
• Inferior:
• the innominates rotate around this axis relative to
the sacrum
 Sacral Somatic Dysfunction
(AKA Sacroiliac Dysfunction)

Physiologic: Non - physiologic:

Dysfunction that occurs Dysfunction that does not
around a Physiologic occur around an axis.
Axis Usually caused by trauma.

• Transverse 1. Unilateral Sacral Shear

• Oblique: Neutral and 1. Unilateral Sacral Flexion
Non-Neutral 2. Unilateral Sacral Extension
Important!!!!
• The side of the posterior ILA is also inferior
• Think Private Investigator
• Posterior and Inferior
• The side of the anterior ILA is also superior
• Think All Same
• Anterior and Superior
Sacral Torsion Rules
1. L5 Side-bends Towards the Oblique Axis
2. L5 Rotates Opposite of Sacral Rotation

Examples
• LOL: L5 SL RR
• LOR: L5 RR SR
• ROR: L5 SR RL
• ROL: L5 RL SL
****Refer back to sacral diagnosis to figure out what L5
diagnosis would be. Once you know this you can figure out
what the set up for HVLA or Muscle Energy for L5 would be:
Engage the barrier
 Sacral Chart
Seated Flexion Test +R Seated Flexion Test +L Seated Flexion Test ?,x
LOL ROR No SD
ROL LOR B/L Sacral Flexion
RUF LUF B/L Sacral Extension
RUE LUE

Lumbosacral Spring Test (Spring Test) Sphinx Test (Backward Bending Test)

Positive Negative Positive Negative

LOR LOL LOR LOL
ROL ROR ROL ROR
UE UF UE UF
B/LSacral Extension B/L Sacral Flexion B/L Sacral Extension
B/L Sacral Flexion
Sacral Patterns
A P P A Forward Sacral Torsion (LOL, ROR)
A P P A =
Backward Sacral Torsion (LOR, ROL)

A P P A Unilateral Sacral Flexion

P A A P =
Unilateral Sacral Extension

A A P P Bilateral Sacral Flexion

P P A A =
Bilateral Sacral Extension
 Bilateral Sacrum
Flexed Extended
• Negative Seated Flexion • Negative Seated Flexion
Test Test
• Negative Lumbosacral • Positive Lumbosacral Spring
Spring Test (Spring Test) Test (Spring Test)
• Negative Sphinx Test • Negative Sphinx Test
(Backward Bending Test) (Backward Bending Test)
• Deep Sacral Sulci • Shallow Sacral Sulci
• Anterior Sacral Base • Posterior Sacral Base
• Posterior ILA bilaterally • Anterior ILA bilaterally
• Tight Sacrotuberous • Loose Sacrotuberous
ligaments b/l ligaments b/l
 Sacral Torsions
Forward Sacral Torsion Backward Sacral Torsion
(Neutral) (Non-neutral)
LOL and ROR LOR and ROL

• Positive Seated Flexion Test (opposite • Positive Seated Flexion Test (opposite
side of axis) side of axis)
• Negative Lumbosacral Spring Test • Positive Lumbosacral Spring Test
(Spring Test) (Spring Test)
• Negative Sphinx Test (Backward • Positive Sphinx Test (Backward
Bending Test) Bending Test)
• L5 Neutral Mechanics • L5 Non-neutral Mechanics
• Anterior Base (Deep Sulcus) is on • Anterior Base (Deep Sulcus) is on
opposite side of Posterior/Inferior ILA opposite side of Posterior/Inferior ILA
• Sacrotuberous ligament tight on side • Sacrotuberous ligament loose on side
of posterior/inferior ILA of anterior/superior ILA
Unilateral Sacrum
Unilateral Sacral Flexion Unilateral Sacral Extension
(Sacral Shear) (Sacral Shear)

• Positive Seated Flexion Test (side of • Positive Seated Flexion Test (side of
dysfunction) dysfunction)
• Negative Lumbosacral Spring Test • Positive Lumbosacral Spring Test
(Spring Test) (Spring Test)
• Negative Sphinx Test (Backward • Positive Sphinx Test (Backward
Bending Test) Bending Test)
• Anterior Base (Deep Sulcus) is on • Anterior Base (Deep Sulcus) is on
same side of Posterior/Inferior ILA or same side of Posterior/Inferior ILA or
another way of saying this is Posterior another way of saying this is Posterior
Base (Shallow Sulcus is on the same Base (Shallow Sulcus is on the same
side of Anterior/Superior ILA side of Anterior/Superior ILA
 Forward Sacral Rotation RX on XOA
Prone, Physiologic response:
Operator springing, ME, or Resp. force
• Patient lateral recumbent and
physician facing patient
• Side of oblique axis toward table
• With knees bent, flex hips to greater
than 90 degrees with knees off table
• Physician seated, support patientʼs
knees with thigh
• While monitoring lumbosacral
junction, instruct patient to hug table
until motion localized at lumbosacral
junction
• Patient is lying face-down (hug
the table) with hips flexed greater
than 90 degrees

This is a LOL
Forward Sacral Rotation RX on XOA
Prone, Physiologic response:
Operator springing, ME, or Resp. force
• With forces localized at lumbosacral
junction, grasp spinous process of
L5 and pull away from table
• Apply activating force to the
patientʼs feet toward floor to
localize sidebending while
monitoring sacral base opposite of
axis
• LVMA springing
• ME
• Resp. force
• Repeat activating force until
adequate motion felt at sacral base
Backward Sacral Rotation RY on XOA
Lateral recumbent, Physiologic response:
Operator springing or ME
• Patient lateral recumbent and
physician facing patient
• Side of oblique axis toward
table
• With knees bent, flex hips to less
than 90 degrees with knees off table
• Draw shoulder on table forward to
induce rotation to lumbosacral
junction so patientʼs torso faces
upward
• Physician seated, support patientʼs
knees with thigh
• Maintain slight flexion at hips so
not to induce non-neutral sacral
mechanics
• Patient lies on their back and
hips are flexed less than 90
degrees

This is a ROL
Backward Sacral Rotation RY on XOA
Lateral recumbent, Physiologic response:
Operator springing or ME

• While monitoring sacral base

with cephalad hand, carry torso
with forearm into further
rotation to localize lumbosacral
base
• With patientʼs knees balanced
on thigh, apply activating force
on feet toward floor
• LVMA springing
• ME
• Repeat activating force until
adequate motion felt at sacral
base
Unilateral Sacral Flexion: ME
• Positional Diagnosis: R USF
• Treatment Position: Prone
• Place your left hypothenar eminence on patientʼs right ILA
• Ask patient to inhale and hold breath, while you push anterior and superior on the ILA
• Hold for 3-5 seconds
• Direct patient to exhale while you resist any posterior inferior movement of the sacrum
• Repeat 3-5 times and recheck findings
• Physician may add internal rotation to the patient’s hip with resistance from patient
 Unilateral Sacral Extension: ME
• Positional Diagnosis: R USE
• Treatment Position: Prone
• Place your left hypothenar eminence on the patientʼs right sacral sulcus
• Ask the patient to exhale and hold breath, while you push anterior and caudad on the superior
sulcus
• Hold for 3-5 seconds
• Direct the patient to inhale while you resist any anterior superior movement of the sacrum
• Repeat 3-5 times and recheck findings
• Physician may add internal rotation to the patient’s hip with resistance from patient
Psoas syndrome
• Condition that results from hypertonicity/spasm of the psoas
muscle
• Usually the result of being in a position that allows prolonged
shortening of the psoas followed by its sudden lengthening.
Examples:
• working at a desk or crawlspace
• road trips, plane trips
• sitting in a soft easy chair or recliner
• bending over from the waist for a long period of time
• weeding in the garden
• trauma (strain)
• May be precipitated by overuse, such as doing sit-ups with the lower
extremities fully extended
• Creates a neuromuscular imbalance that results in psoas
muscle hypertonicity. Psoas muscle and lumbar spine are
affected.
• Patient may complain of pain in the thoracolumbar region
and/or the anterior hip, thigh, or groin.
Psoas Syndrome
• Organic Causes of psoas tension of spasm must be ruled out by
history and/or physical examination and special tests:
• Femoral bursitis
• Arthritis of the hip
• Appendicitis
• Diverticulosis of the colon
• Ureteral calculi
• Prostatitis
• Cancer of the descending or sigmoid colon
• Salpingitis
• Psoas abscess
• Etc.
• Viscerosomatic reflex (ureteral calculi as an example)
• Direct irritation (ie, psoas fascia touches the sigmoid colon and
ureters)
• Ureteral calculi as an example
Diagnosis
• Patient may stand slightly flexed at
the waist and side-bent toward the
dysfunctional side (hypertonic psoas
muscle)
• Motion testing of the affected leg
will resist hip extension
• Tender points will be found at Psoas
Major muscle (may also find at
Psoas Minor and Iliacus if involved)
and may be found at contralateral
Piriformis muscle.
• Special test: Thomas Test will be
positive on side of hypertonic psoas
muscle
Diagnosis
• Positive Thomas test
• Psoas tender point (TP)
• Possibly contralateral
piriformis tender point
TP
• May or may not have
sciatic type pain down
the opposite leg
• Central low back pain
• May be significant
Psoas Syndrome
• The key somatic dysfunction initiating or perpetuating psoas syndrome is
believed to be a type II (non-neutral) somatic dysfunction (F Rx Sx) usually
occurring in the L1 or L2 vertebral unit, where “x” is the side of side-bending of
the somatic dysfunction. If this key somatic dysfunction remains, the patient’s
symptoms may progress to full-blown psoas syndrome. Osteopathic structural
exam findings indicative of this syndrome include:
• The key, nonneutral (type II) somatic dysfunction at L1 and/or L2
• Sacral somatic dysfunction on an oblique axis, usually to the side of lumbar side-bending
• Pelvic shift to the opposite side of the greatest psoas spasm
• Hypertonicity of the piriformis muscle contralateral to the side of greatest psoas spasm
• Sciatic nerve irritation on the side of the piriformis spasm
• Gluteal muscular and posterior thigh pain that does not go past the knee, on the side of the
piriformis muscle spasm
Special Tests
• Hip Drop Test
• Thoracolumbar/Lumbar Side-Bending Abnormality
• Trendelenburg Test
• Gluteus Medius Weakness
• FABERE/Patrick Test
• SI joint or hip pathology
• Ober Test
• Tensor fascia latae tightness
• Straight Leg Raising (SLR) Test
• Herniated Lumbar Disc (L1-L5, S1)
• Contralateral Straight Leg Raising
• Test Herniated Lumbar Disc (L1-L5, S1)
Special Tests
• Bragard Test
• Herniated Lumbar Disc (L1-L5, S1)
• Thomas Test
• Hip Flexion Contracture (Psoas Muscle Hypertonicity)
• Babinski Reflex
• Upper Motor Neuron Pathology
• Hoover Test
• Malingerer
 Trendelenburg Test
• Assessment of gluteus medius
muscle strength
• Pt stands on one foot while flexing
opposite knee and lifting foot off
floor
• Gluteus medius muscle on opposite
side of flexed knee should abduct
leg, keeping pelvis level
• Considered positive if pelvis tilts
toward side of flexed knee
• Not to be confused with hip-drop
test, which assesses ability of
lumbar vertebrae to side-bend
Hip Drop Test
• Assessment of lumbar spine compensation to sacral
base declination (Screening test)
• Patient bends one knee without lifting heel off floor
and allowing hip to drop downward
• Negative= Iliac crest on the unsupported side drops
20-25 degrees, and there is a smooth lumbar
curvature toward the weight bearing side of the body.
Indicates normal side-bending ability of the lumbar
and thoracolumbar spine
• Positive=Iliac crest does not drop 20-25 degrees on the
non-weight bearing side and there is a poor lumbar
spinal curve towards the weight bearing side. A
positive test indicates that the lumbar and/or
thoracolumbar spine has difficulty side-bending
toward the weight bearing side of the body (ie, the 142

side opposite the positive test)

Sympathetic
Innervation
n T10-T11: Ovaries,
Testes
n T11-12: Fallopian
tubes, vagina
n T10-L2:Uterus and
cervix

Netter 386
Parasympathetic
Innervation
• S2-S4: Uterus, cervix,
vagina, clitoris, walls
of the urethra

Netter 386
The Pregnant Patient
• Sympathetic Innervation:
• T10 - L2 á Stimulation
• á vasoconstriction à poor
nutrition & O2 exchange
• á uterine contraction
• â threshold for pain
from the uterine body
• Parasympathetic Innervation:
• S2-S4 á Stimulation
• vasodilation
• á relaxation of uterine muscle
• â threshold for pain from the
cervix
Direct MFR (Myofascial release) of pelvic
diaphragm
• May be done supine or prone
• Identify ischial tuberosities by following gluteal fold medially.
****With thumbs medial to the tuberosities gently apply cephalad
pressure while maintaining contact with tuberosities at all times *
• Continue cephalad pressure until you gently engage the barrier as
tolerated.
• Hold your ground while patient inhales, then take up slack moving
cephalad during exhalation.
• Repeat until no further improvement.
• May be done after tuberosity spread or on its own
**** Great for lymphatics/addressing hypertonic pelvic floor
musculature
Absolute contraindications to OMT during pregnancy
• Abruptio placenta
• Ectopic pregnancy
• Placenta previa
• Undiagnosed vaginal bleeding
Osteopathic Considerations
• If a patient has been laboring on their back for an extended period of time
or if they have undergone cesarean section or other abdominal surgery,
consider what type of somatic dysfunctions you might encounter.
*** Note: For example if the sacrum is extended, the base would be
posterior and the apex anterior. If you were to do a Muscle Energy
treatment on this somatic dysfunction (even though you may never have),
you would apply the principles of Muscle Energy by engaging the barrier
(which in this case is pushing the base anteriorly). If the patient holds there
breath in exhalation this will help move the sacral base anteriorly
ALSO NOTE: If someone has had abdominal surgery recently, don’t put them
on their belly (prone)

http://www.surgico.co.nz/wp-content/uploads/2013/01/Trulife-Litho-Position.png
Occipital Condylar Compression

• The “most important” or most clinically

significant somatic dysfunction which should be
addressed in all newborns is occipital condylar
compression.
• Affecting cranial nerves 9, 10, 11, 12; it can be
the cause of poor suckling, swallowing
difficulties, colic, emesis/vomiting, hiccups,
congenital torticollis.
• OA decompression is useful in treating condylar
compression.
 Sympathetic levels
T10 – T11: Superior Mesenteric Ganglion: Lesser Kidneys: T10 – T11
Splanchnic Nerve Adrenal Medulla: T10
• Kidney, Upper Ureter, Gonads Upper Ureters: T10 – T11
Lower Ureters: T12 – L1
T12 – L2: Inferior Mesenteric Ganglion: Least and Bladder: T12 – L2
Lumbar Splanchnic Nerves Gonads: T10 – T11
• Prostate, Lower Ureter, Bladder Uterus & Cervix: T10 – L2
Erectile tissue: T11 – L2
Prostate: T12 – L2
Arms: T2 – T8
Legs: T11 – L2
Parasympathetic Levels
• Vagus Nerve (OA, AA, C2)
• kidneys, proximal ureter

• S2-S4
• distal ureter, bladder, reproductive organs, and
external genitalia

• Variations: Ovaries & Testes

• Vagus Nerve
• S2-S4
The Reproductive System
Sympathetics
• T10 – T11: Gonads
• Regulate hormonal secretions
• T12 – L2:
• Primary function in smooth muscle contraction and secretions
• Vasoconstriction
• Ejaculation
• Males: Penis, prostate, vas deferens, seminal vesicles
• Role in premature ejaculation
• Females: Uterus, uterine tube, cervix and vagina
Parasympathetics
• Vagus (OA, AA, C2): Gonads
• Unknown role in gonadal secretions
• S2 – 4
• Vasodilation and stimulation of erectile tissue
• Role in erectile dysfunction
Lymphatics
• Highly dependent on the motion of the thoracic and pelvic
diaphragms
• Obstruction of flow leads to pelvic congestion.
Sexual Dysfunction
• Impotence
• Organic and functional etiologies should be ruled out.
• Functional etiology derived from S 2 – S 4
• Pudendal Nerve: somatic input
• Parasympathic reflexes
• OMT should focus on SI somatic dysfunction
• Premature Ejaculation
• Primarily a sympathetically mediated event activated through L1-2 and
aided by somatic influence from S2-4
• Facilitation at L1-2
• Dyspareunia
• Etiology: spasm of pelvic floor or vagina, inadequate lubrication, genital
tract abnormality
• OMT: focus on pelvic diaphragm attachments and normalization of
parasympathetic tone (S 2-4)

*** Remember Point and Shoot: Parasympathetics for erection, Sympathetics for ejaculation
Osteopathic Considerations
Renal Physiology - Autonomics
• Sympathetic Effects on Renal Physiology
• Vasoconstriction of Afferent Arterioles
• Decreased GFR’Decreased Urine Volume
• Decreased Ureteral Peristalsis
• May Cause Ureteral Spasm (Ureterospasm)
• Relaxation of Bladder Wall (Detrusor Muscle)
• Hypersympathetic Tone Can Cause a Functional Urinary
• Retention / Obstruction (Incomplete Emptying)
• May Lead to Vesicoureteral Reflux
• Facilitates Contraction of Trigone Muscle
• Stimulates Internal Urethral Sphincter to Remain Tightly
Closed
• Inhibits Parasympathetic Stimulation
• Inhibits Micturition Reflex
• Response is Exacerbated by Emotional Stress
Autonomic Nervous System
Parasympathetic
• Vagus Nerve
• Affects: Kidney and Proximal Ureters
• Superior Vagal Ganglion Sits in the Jugular Foramen
• Inferior Vagal Ganglion Sits Around Body of C2
• S2-S4
• Affects: Distal Ureters and Bladder
• Via Pelvic Splanchnic Nerves
Osteopathic Considerations
Renal Physiology - Autonomics
• Parasympathetic effects on renal physiology
• Kidneys ?
• Ureters
• Maintain normal peristalsis
• Bladder
• Maintains bladder wall tonicity
• Excitatory to detrusor muscle
• Inhibitory to trigone muscle
• Works in concert with pudendal nerve in micturition
• Parasympathetic nerves control bladder wall musculature
• Voluntary pudendal nerve controls external urethral
sphincter
• Sympathetic relaxation of the internal urethral sphincter
• Must also occur for voiding to take place
Indications and Contraindications to OMT
• Remember indications and contraindications for techniques
• For example if a patient is too young or is not able to follow commands, you
can not do techniques such as muscle energy
• If a patient has lax ligaments such as Rheumatoid Arthritis or Trisomy 21, you
do not want to do HVLA, or ANY type of articulatory techniques in the upper
cervical spine. Remember Still Technique is an articulatory technique.
 Good luck!!!!
• For ANY clarifications, please refer to the Lecture/Lab material
• All concepts are cumulative: for example, Fryette principles, direct/indirect technique set up, etc.
• Please also review:
• C/T/L/Rib/Innominate/Sacrum somatic dysfunction DIAGNOSIS and TREATMENT set up for things like ME Muscle
Energy (ME)/HVLA/Counterstrain (CS), Still, FPR, etc.
• If they are not in this study guide refer to previous study guides and lecture/lab material
• Muscle energy/HVLA for rib somatic dysfunctions (set up, muscles used, etc.)
• READ QUESTION CAREFULLY IF TREATING INHALED OR EXHALED RIB SOMATIC DYSFUNCTION. Is the question asking how do you
treat an inhaled rib somatic dysfunction or how do you treat an exhaled rib somatic dysfunction.

****In ME, know which form of muscle energy is being used, what the patient’s activating force is, what the
physician’s resistive force is, etc.

****Goal of ME in innominate somatic dysfunction treatment is to restore joint motion

• Thank you for being a great class!!!!