OMM practical#1

Pump Handle Ribs 2-5 Dx:

Inhalation SD Address the lowest rib in the group In this case Rib 5

Supine, Direct: Respiratory Cooperation (4821 Supine, Direct: Respiratory Cooperation (4821.12B) - “Pump Handle” InHalation SD Physician stands at head of table, Pt. supine. Contact the superior aspect of dysfunctional rib (or lowest rib of dysfunctional group) with the lateral margin of his/her thumb at the mid-clavicular line. Other hand slides under the patient with fingers hooked under the inferior margin of the posterior angle of rib.

Supine, Direct: Respiratory Cooperation (4821 Supine, Direct: Respiratory Cooperation (4821.12B) - “Pump Handle” Inhalation SD Flex the upper thorax up to the level of the dysfunctional rib. Apply cephalad tension on posterior angle of rib carrying it to restrictive barrier. Pt. Instructed to “Take a deep breath and let it out forcibly” Anterior hand carries anterior portion of dysfunctional rib caudad and holds rib at new restrictive barrier.

SUPine, Indirect: Respiratory Cooperation (4821 SUPine, Indirect: Respiratory Cooperation (4821.12C) “Pump Handle” Inhalation SD (Ribs 2-10) Pt is seated, with physician on side of dysfunction. Contact dysfunctional rib: Posterior: superior margin of the angle of dysfunctional rib. Anterior: interspace below dysfunctional rib. Lateral: Both thumbs contact rib shaft along the mid-axillary line.

SUpine, Indirect: Respiratory Cooperation (4821 SUpine, Indirect: Respiratory Cooperation (4821.12C) “Pump Handle” Inhalation SD (Ribs 2-10) Postion the hands on the lowest rib with pt rotating head and body away to free the rib head from the demifacets Use both hands simultaneously to move both the posterior angle and anterior end of the rib in the direction of inhalation to the point of balanced ligamentous tension Instruct patient to “inhale deeply and hold your breath as long as you can” Repeat x 2 and recheck

Treat the Highest Rib first in this case Rib 2 Exhalation SD Ribs 2-5

Supine, Direct: Muscle Energy (4821 Supine, Direct: Muscle Energy (4821.22B) “Pump Handle” Exhalation SD (Ribs 2-10) Pt supine, with doctor on side of dysfunction. Hooks fingers of caudad hand over superior margin of the angle of the dysfunction rib Apply caudad tension. Pt rotates head away from side of dysfunctional rib and places the forearm of the side of the dysfunction over his/her forehead.

Supine, Direct: Muscle Energy (4821 Supine, Direct: Muscle Energy (4821.22B) “Pump Handle” Exhalation SD (Ribs 2-10) Physician places other hand over the patient’s elbow and forearm Pt applies a contractile force against the physician’s hand Contraction is held for 3-5 second, while physician offers isometric counterforce Physician allows tissue to relax, and takes up the slack with the caudad hand at the rib angle to the new restrictive barrier Repeat x 2 and recheck

Pt is seated, with physician on side of dysfunction. SUpine, Indirect: Respiratory Cooperation (4821.22c) “Pump Handle” Exhalation SD (Ribs 2-10) Pt is seated, with physician on side of dysfunction. Contact dysfunctional rib: Posterior: inferior margin of the angle of dysfunctional rib. Anterior: interspace above dysfunctional rib. Lateral: Both thumbs contact rib shaft along the mid-axillary line.

SUpine, Indirect: Respiratory Cooperation (4821 SUpine, Indirect: Respiratory Cooperation (4821.22C) “Pump Handle” Exhalation SD (Ribs 2-10) Postion the hands on the highest rib with pt rotating head and body away to free the rib head from the demifacets Use both hands simultaneously to move both the posterior angle and anterior end of the rib in the direction of exhalation to the point of balanced ligamentous tension Instruct patient to “exhale deeply and hold your breath as long as you can” Repeat x 2 and recheck

Bucket Handle Ribs 6-10 Best palpated—lateral ribcage

Inhalation SD Address the lowest rib in the group In this case Rib 10

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.12A) - “Bucket Handle” Inhalation SD (Ribs 4-10) Physician stands at head of table w/ pt supine. Physician slides one hand under patient from above to mid-scapular region while letting the patient’s head rest on his/her forearm. Physician contacts the shaft of the dysfunctional rib at its mid-axillary line with the web between the thumb and index finger. We want to move the “stuck up” group down….so contact the inferior S/D rib CONTACT SHAFT WITH OUTSTRETCHED INDEX FINGER/THUMB IN MID-AXILLARY LINE Localize to maximize the Muscle Energy tx. DOC USES OTHER HAND TO LIFT, FB & SB TOWARDS THE LESION We ask the patient to attempt to return to a neutral position against doctors counterforce Muscles used will depend upon the rib(s) being treated.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.12A) - “Bucket Handle” Inhalation SD (Ribs 4-10) Pt. is lifted into forward bending and side bending toward side of dysfunctional rib until restrictive barrier is reached. Pt. is instructed to “bend body back to neutral position” against the physician’s resistance for 3-5 sec. After pt. relaxes, physician takes up slack with hand at mid-axillary line to the new restrictive barrier. Repeat x 2 and recheck.

SEated, Direct: Muscle Energy (4822 SEated, Direct: Muscle Energy (4822.12B) - “Bucket Handle” Inhalation SD (Ribs 2-3) Pt is seated with physician standing behind patient. Physician contacts shaft of dysfunctional rib in the mid-axillary line with the fingers of his/her caudad hand. Physician uses other hand to side bend and rotate away from side of dysfunctional rib. With patient seated, the axilla provides access to these ribs. Inspiratory (stuck up), so we want to contact the bottom rib in the group to help bring it down. GRASP SUPERIOR ASPECT ON SHAFT OF LOWEST S/D RIB in MID AXILLA DOC USES OTHER HAND TO POSITION PT HEAD. DOC PROVIDES ISOMETRIC COUNTER FORCE HERE. The force vector is provided by the patient -instructed to pull their head to the side against Doc hand.

Seated, Direct: Muscle Energy (4822 Seated, Direct: Muscle Energy (4822.12B) - “Bucket Handle” Inhalation SD (Ribs 2-3) Pt. is instructed to sidebend head towards side of dysfunction while physician offers isometric counterforce for 3-5 seconds After patient relaxes for 2-3 seconds, physician takes up slack with the hand at the mid-axillary line to the new restrictive barrier Repeat x 2 and recheck

Treat the Highest Rib first in this case Rib 6 Exhalation SD Ribs 6-10

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22A) - “Bucket Handle” ExHalation SD Ribs 4-10 Pt supine, with doctor on side of dysfunction. Physician hooks fingers of caudad hand over superior margin of the angle of the dysfunction rib or the lower rib of a group and applies caudad/lateral tension. Pt rotates head away from side of dysfunctional rib and places the forearm of the side of the dysfunction over his/her forehead. Supine. This time we want to think about moving the S/D rib(s) off of the lower ribs. CONTACT UPPER ASPECT OF SUPERIOR RIB ANGLE OF LESIONED RIB with FINGER PADS By placing the patient into the “fainting” position on the side of S/D, we can utilize muscle attachments to help us lift the offending ribs. Rotating the patient’s head away allows movement at the rib/vertebral articulation Doc maintains resistance on pt. elbow/forearm Patient provides contractile force, us per usual ME protocol.

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22A) - “Bucket Handle” ExHalation SD ribs 4-10 Physician places other hand over the patient’s elbow and forearm. Patient is instructed to apply a contractile force against the physician’s hand. Contraction is held for 3-5 second, while physician offers isometric counterforce. Physician allows tissue to relax, and takes up the slack with the caudad hand at the rib angle to the new restrictive barrier (Inferior, lateral force). Repeat x 2 and recheck The patient’s contractile force is directed as follows: upper ribs (ribs 2-4) towards the contralateral (opposite side) nipple middle ribs (ribs 5-7) towards the contralateral ASIS lower ribs (ribs 8-10) towards the ipsilateral (same side) hip

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22B) - “Bucket Handle” Exhalation SD (Ribs 2-3) Pt is seated with physician standing behind patient. Physician contacts shaft of the rib below the dysfunctional rib in the mid-axillary line with the fingers of his/her caudad hand. Physician uses other hand to side bend and rotate away from side of dysfunctional rib. Again axilla provides access to the expiratory SD rib ****NOTE: the rib contacted is the rib below the SD rib! How to grasp it? MID AXILLARY LINE Position patient? Why?_rotation away frees demifacet. Doc uses other hand to position head and neck to free SD rib head & maximize pull or the muscles Muscles activated by patient?______ Do you think that the scalenes may also be involved with rib 2 exhalation S/D muscle energy techniques? YES

Supine, Direct: Muscle Energy (4822 Supine, Direct: Muscle Energy (4822.22B) - “Bucket Handle” Exhalation SD (Ribs 2-3) Pt. instructed to “pull your head to the side against my hand” while physician offers isometric counterforce for 3-5 seconds. After patient relaxes for 2-3 seconds, physician takes up slack with the hand at the mid-axillary line to the new restrictive barrier. Repeat x 2 and recheck

Thoracic Spine

Upper Thoracic Spine

Trunk rotation screen Main motion of T-Spine is rotation Hands on shoulders Induce a rotary motion (90 each way) If less than 90, indicates restriction to rotation in thoracolumbar spine Follow with segmental evaluation when pt. prone. Monitor T12

Trunk Rotation Screen

Upper trunk side-bending Patient Still Seated Upper trunk side-bending Upper T-Spine Hands at CT junction Induce inferomedial force Compare sides Side with less motion  possible SD upper spine Middle T-Spine Hands between CT junction and acromion (midclavicular) Inferomedial force Compare each side Lower T-Spine (“Acromion Drop Test”) Hands at AC joint Depress shoulder in inferomedial direction Normal >25 (negative test) Abnormal <25 (positive test)  restriction of lower T-spine to side-bend toward the side of the positive test

Upper T-spine-sidebending Upper Group(T1-4) Base of Neck(CT junction)

Backward Bending Forward Bending At the same time observe T & L spine for muscle fullness, rib hump, and how far fingers are from floor Looking for areas of restricted motion or asymmetry Backward Bending

Forward Bending

Backward Bending

Soft Tissue These are taken from the Lumbar lecture I am assuming the same technique engaging the thoracic spine

- Soft Tissue: Prone, Direct, Kneading

Soft Tissue: Lateral Recumbent-Direct-Kneading

Prone Longitudinal Stretching 1) Patient is lying prone 2) Patient standing at side opposite of treated side 3) Both hands on same side, just lateral of spinous process; one hand goes cephalad, other goes caudal ***Gentle force HOLD FOR THREE SECONDS Found Online!

FB (F) Somatic Dysfunction Spinous Processes of FORWARD BENT segments are more gapped (exaggerated kyphosis) SP will not approximate well during extension. They stay gapped and will not backward bend. BB restriction = FB freedom of motion = Flexion SD extended Remember that somatic dysfunction is the way it “likes to go”-the position of ease

BB (E) Somatic Dysfunction SP of BB segments tend to stay closer together. (flattened or reduced kyphosis) SP will not separate well during flexion. They remain approximated and will not forward bend. FB restriction = BB somatic dysfunction = Extension SD flexion

Testing Forward/Backward Bending Test by palpating between the tips of the SP FB and BB the patient down to the segments being monitored Note the ability of the SP to approximate and separate Use the head to test motion in the C-T junction

Testing Rotation Place thumbs over TP and sink through subcutaneous tissue (Take your time, especially on patients with more subcutaneous tissue!) Increase pressure, applying an anterior force, over one TP (while monitoring movement of the contralateral TP) Repeat for other TP Rotation is determined by the direction of ease of motion and named by movement of a point on the superior/anterior surface of the vertebral body Rotation: occurs around a vertical axis, in a horizontal plane

Testing Sidebending Operator on side of dominant hand Slide thumbs inferior and medially from the TP to the intervertebral space below the lesioned body (Remember the Rule of 3’s!) Apply an (antero)medial force- noting the motion of Sidebending Sidebending is determined by the direction of ease of motion and named for the side of concavity Remember that translating to the left induces right sidebending. Sidebending: occurs around an A/P axis, in a coronal plane

Upper Thoracic Treatment

CT Flexion SD with Neutral variation Seated Direct Articulatory/Springing Pt sits on stool or table with physician at side or towards the front of the patient. Pt crosses arms at shoulder level and places their forehead on their own forearm, resting

CT Junction Direct, Springing Phys. flexes their index finger- to use finger and thumb placed over opposite transverse processes of segments to be treated. Phys supports the patient’s arms with his arm and places the other treating hand over the involved transverse processes. Phys induces springing by lifting the pts. arms and putting anterior pressure , inducing BB at the segment treated.

Neutral C7-T3 Seated Direct ME N SB left, Rotated right-example “osteopathic salute” vs using patient’s head to localize SB and rotational components 1st: Physicians thumb on right transverse process of involved segment Physician SB patients head to the right (reverse the SD)- localized to the segment Physician Rotates the patients head to the left (using a hand on top of patients head)- localized to the segment Instruct the patient to turn to the right, or to straighten head back to midline. Usual ME protocol

Middle Thoracic Spine

Sagittal Plane FB – Sitting Direct: Springing (4311.11B) Pt seated and facing physician Pt crosses forearms on head Dr passes both arms under patient’s forearms and over shoulders to dysfunctional area Place pads of fingers at the level of the lesioned segment If possible, have pt with their feet on the ground (use the stools or ladderbacks)

Sagittal Plane FB – Sitting Direct: Springing (4311.11B) Flex the pt’s hips by leaning them forward With Dr’s fingers acting as a fulcrum, BB (extension) is induced to restrictive barrier LVMA springing applied (directly anterior) for correction Recheck

Both Upper and Middle Thoracic Neutral and Non Neutral

Direct Muscle Energy Seated: Ex: NSRRL Pt sits on table with doc standing behind pt. Pt placed in “Osteopathic salute” position on side of rotation DO places R thumb or thenar eminence against apex of lesioned group

Direct Muscle Energy Seated: Ex: NSRRL Doc reaches beneath pt’s arm to grasp opposite arm (“under & over”) Pt is slightly extended, SB Left & rotated Right until all planes of motion are localized under thumb or thenar eminence Pt uses isometric ME force to straighten up reposition pt in all 3 planes after relaxation (engage the new lesion barrier). repeat 3X or until SD is corrected.

Direct HVLA – Seated Ex: NSRRL Set up pt. in same position as ME treatment, engaging restrictive barrier Place hypothenar eminence on posterior TVP Brace your elbow against hip Doc should have wide stance and be well-balanced Apply HVLA thrust antero-superiorly through hand on back Recheck

Note! Note: these techniques can be utilized in the upper T spine by adding some extension at the region being treated!

Non Neutral Treatments

Direct Muscle Energy Seated: Ex: ERRSR #1 Direct Muscle Energy Seated: Ex: ERRSR Pt sits on table while D.O. stands behind pt. Pt. does “osteopathic salute” D.O. contacts posterior transverse process of NN segment – Right transverse process

Direct Muscle Energy Seated: Ex: ERRSR Arm of D.O. over pt’s arm and grab opposite arm Slightly flex, sidebend L and rotate L until all planes of motion are localized under monitoring thumb Use isometric ME force to straighten up Pt relaxes, reposition pt in all 3 planes. Repeat 3x or until SD is corrected

Direct Seated HVLA: Ex: ERRSR #2 Direct Seated HVLA: Ex: ERRSR Set up like seated ME: may be used as a follow-up technique if full correction is not achieved with ME. Arm of D.O. over pt’s arm and grab opposite arm Slightly extend, sidebend L and rotate L until all planes of motion are localized under monitoring thumb or thenar/hypothenar eminence Thrust is in an superoanteromedial direction Check

Alternative Hand Placements Ex: ERLSL For ME or HVLA variation

Indirect Respiratory Force – Supine Ex: ERRSR #4 Indirect Respiratory Force – Supine Ex: ERRSR Pt supine. D.O. sits on side of convexity, L side. D.O. reaches under pt. contacting opposite side (R) side of spinous process of involved segment. Cephalad

Indirect Respiratory Force – Supine Ex: ERRSR DO pulls on spinous process and adds slight anterior lift to induce R Sidebending, R Rotation, extension Pt may aid by moving R shoulder toward R hip.

T4-T10 Non-Neutral Supine Indirect Respiratory Force Ex: ERLSL

Indirect Respiratory Force – Supine Ex: ERRSR D.O. instructs pt to take breath, monitor inhalation and exhalation to find phase that increases ligamentous balance Pt holds breath in proper cycle phase until air hunger or until DO feels the release Recheck pt.