OMM Practical

Describe the movement of:

• Pump Handle

• Bucket

• Caliper

Pump Handle:

• R1-6

• Inhalation = Ant + Sup.

• in sagital plane

• Best felt in mid-clavicular

• Axis of motion: transverse (along the costovertebral/costotransverse line)

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Bucket:

• R7-10

• Inhalation = Lat + sup

• In Coronal Plane

• Felt at Mid Ax. Line

• AOM: AP

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Caliper:

• R11/12

• Inhaltion = Post + Lat

• Transverse Plane

• Felt @ 2-5cm lat. to transverse process

• Axis = vertical line

1. Which Ribs are A/Typical

2. What makes the ribs atypical

Typical: 3-9

Atypical: Rest

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Atypical:

• 1:

  • only one facet that articulates with T1.

  • Has internal tubercle for attachment of anterior scalene muscle.

  • no angle.

• 2:

  • large tuberosity on shaft for the serratus anterior muscle.

• 10:

  • only one facet that articulates with T10.

• Ribs 11 and 12:

  • articulates with only one vertebra

  • lacks tubercles and subcostal grooves.

how does the rib articulate w/ the vertebra

Rib articulation:

• @ 3 points:

  • Costotransverse facets

  • Sup/inf. costovertebral joint?

    • Inf/Sup facts

  • NOTE: Rib 3 articulates w/ Vertebra 2/3

Differentiate between respiratory and structural ribs

Structural:

• non-physiologic

• affects single rib

• treated before respiratory

• Superior/Ant/Post Somatic Dysfunction

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respiratory:

• Physiologic

• In groups

• Treated after structural

• Inhalation/Exhalation Somatic Dysfunction

Describe procedure for Structural ME

Rib 1 Superior:

• Knee on table, pt arm across knee on Contralateral side

• Pull trap posteriorly; push down and anteriorly on the First Rib

• Tilt Head towards affected side; Pt push contralateral side

• Reciprocal Inhibition

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Anterior:

• Patient Arm is flexed/adducted

• Thumb = medial to Angle → Pushed Laterally

• Patient will push laterally or Inferiorly

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Posterior:

• Pt. Arm is flexed/adducted

• Thumb = Lat to angle → Pushed Medially

• Patient will push Medially or Superiorly

What type of muscle energy technique is used to treat posterior/anterior ribs

joint mobilization using muscle force

What is the Key?

1. Jordan

2. Inhalation SD = Lowest Rib

3. Exhalation SD = Highest Rib

Which Muscles are treated for exhalation SD for each rib?

• Anterior and Middle Scalenes = Rib 1

• Posterior Scalene = Rib 2

• Pec Minor = Ribs 3-5

• Serratus = Ribs 6-8 (although it attaches to all 1-8)

• Lats = Ribs 9-12

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AMP targeted Minors using a Serrated knife in LA(T)

Explain how you would treat exhalation SD

How would you treat Inhalation SD

1: Flexed Neck

2-6: Neck/Shoulders Flexed and sidebent TOWARDS

6-10: Entire Pt is side bent TOWARDS

Describe type of muscle energy used for Inhalation/Expiration ribs

• Inhalation: Respiratory Assist

• Exhalation: Direct + Joint Mobilization

1. Define Articulatory Tech

2. How do You disengage the two joints

3. Where are your finger tips?

Low velocity, moderate to high amplitude technique where a joint is carried through its range of motion engaging a restrictive barrier

repeatedly with the goal of increasing that range of motion to the physiologic barrier

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CostoTransverse: Disengage by pushing down using the fulcrum

Costovertebral: Apply lat. traction to rib angle as cage is lifted

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Finger tips = medial to Angle

1. How to perform HVLA for posterior Ribs

2. NOTE: how do you localize?

1. Patient supine. Stand on the side opposite the posterior rib

2. Cross patient’s arms with the dysfunction side arm superior and their elbows close together.

3. Rotate patient’s dysfunction side shoulder toward you using your cephalad hand

4. Reach under your partner with your caudad hand’s thenar eminence to contact the rib angle

5. Roll patient back onto your thenar eminence.

6. Place patient’s crossed elbows in your abdomen (not rib cage or sternum)

7. Lift head and neck and flex partner down to the level of the dysfunctional rib

8. Side bend patient away from the dysfunction (toward you) to the level of the dysfunctional rib to open costovertebral joint

9. Further fine tune localization forces to the costovertebral articulation by applying force with your abdomen, through the patient’s arms. The angle needed to localize will vary between patients (in the direction you found previously).

10. With each respiration, take up the “slack” and compress more until you are firmly at the barrier.

11. With all planes of available motion localized at the barrier of rib motion, at the end of partner’s exhalation, thrust posteriorly from your abdomen onto the dysfunctional rib. The direction of thrust matches that which you needed to localize at the fulcrum hand.

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Localization:

• Shift Body until elbow in abdomen → Vector = Superiorly (inhalation SD) or Inferiorly (Exhalation SD)

[REVIEW] BLT general Steps

Describe how to do BLT on Ribs

2-11:

• Pt supine → Physician on side w/ dysfunctional rib.

• stabilizes rib by grasping the rib shaft one hand anteriorly and one hand posteriorly.

  • arm of the patient lies between the physician’s arms.

• anterior and posterior compression is added to the dysfunctional rib to create disengagement.

• Then a lateral traction is added with both contacts.

• BLT time

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12:

Pt Supine:

• apply both middle fingers under the tip of the 12th rib.

• Disengage @ both joints by applying inferiolateral traction

• BLT time

Differentiate between type 1 and type 2 dysfunctions

Type 1: Neutral

Type 2: FRS/ERS

Describe the orientation of the articulation w/ the superior articular facets of various vertebras

Does a type 1 SD consist of one vertebral segment or multiple adjacent vertebral segments?

Multiple

[REVIEW] Contraindicatiosn of Lumbar HVLA

How do you do HVLA of the Lumbar

L2-FRS Left:

1. Pt lies on LEFT SIDE ( SAME SIDE THE PATIENT IS SIDEBENT TOWARD)

2. Phy monitors the interspinous space between L2 and L3

3. Phy induces extension @ interspinous space using the lower and upper extremeties (note, one hand has to be monitering space @ all time)

4. Pt. straighten bottom leg and right foot is placed in popliteal fossa

5. Pt. LEFT arm is used to pull left shoulder anterioly → Right rotation of Torso down to dysfunction segment

6. Phy grabs Pt Left Elbow → pulled cephalid → Right Side Bending above apex of dysfunction

7. NOTE: @ this time, pt is right rotated, right side bend, and extended

8. PHY places right forearm on anterior aspect of the patient’s right chest/shoulder .

9. PHY places left forearm on inferior aspect of the patients right iliac crest

10. HVLA TIME: Left FA → Ant + Sup Force; Right FA = counterforce

How do you do BLT of Lumbar Vertebra

BLT:

1. Disengage ligament articular structures by adding a slight compressive force

2. Stabilize Inferior Vertebra; move Superior vertebra (the one messed up):

   • Flexion: Move spinous process superiorly

   • Extension: Move spinous process inferiorly

   • Rotattion: (spine to right = left rotation)

3. BLT time

What is the structural relationships of the AL5 counterstrain point

• The obturator nerve (L2-4) courses anterior of the transverse processes of L3-L5 and pierces through the iliopsoas muscle. The posterior nerve bundle eventually pierces through the obturator externus muscle.

• This nerve can become compressed in this muscle and generate altered sensation to the pubic region via the cutaneous branch, a condition termed obturator syndrome.

Describe how to do Counter Strain

Anterior L1:

• Medial to ASIS

• Flexion to spinal level + Pelvis + ankles rotate towards (to sidebend towards)

  • This rotates Spinal Level AWAY

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Anterior L2-4:

• L2 = Medial to AIIS

• L3 = Lateral

• L4 = Inferior

• Flexion to spinal level + pelvis + ankles rotates away (sidebends away)

  • This rotates spinal level TOWARDS

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Anterior L5:

• Ant surface just below superior pubic rami

• Flex to spinal level + Pelvis Rotates Towards + Ankles Rotates Away (sidebends away)

  • This rotates spinal level AWAY

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Posterior L1-5:

• Inf. Lat side of spinous process

• Extension to spinal level by lifting thigh or pelvis

  • Rotates pelvis towards point and spinal level away

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Upper Pole:

• Superior Medial of PSIS

• Extension + adduction w/ fine tuning of int/ext rotation of hip

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Lower Pole:

• 2 cm below PSIS

• Hip flexion + adduction + int. rotation

[REVIEW] Rule of 3’s

• T1-3 + 12:

  • Spine and transverse = same level

• T4-6 +11:

  • Spine = ½ below transverse

• T7-9 +10:

  • Spine = 1 below Transverse