1. OMM practical#1

2. Pump Handle Ribs 2-5
Dx:

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

4. Supine, Direct: Respiratory Cooperation (4821
Supine, Direct: Respiratory Cooperation ( B) - “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.

5. Supine, Direct: Respiratory Cooperation (4821
Supine, Direct: Respiratory Cooperation ( B) - “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.

6. SUPine, Indirect: Respiratory Cooperation (4821
SUPine, Indirect: Respiratory Cooperation ( C) “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.

7. SUpine, Indirect: Respiratory Cooperation (4821
SUpine, Indirect: Respiratory Cooperation ( C) “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

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

9. Supine, Direct: Muscle Energy (4821
Supine, Direct: Muscle Energy ( B) “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.

10. Supine, Direct: Muscle Energy (4821
Supine, Direct: Muscle Energy ( B) “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

11. Pt is seated, with physician on side of dysfunction.
SUpine, Indirect: Respiratory Cooperation ( c) “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.

12. SUpine, Indirect: Respiratory Cooperation (4821
SUpine, Indirect: Respiratory Cooperation ( C) “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

13. Bucket Handle Ribs 6-10
Best palpated—lateral ribcage

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

15. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( A) - “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.

16. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( A) - “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.

17. SEated, Direct: Muscle Energy (4822
SEated, Direct: Muscle Energy ( B) - “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.

18. Seated, Direct: Muscle Energy (4822
Seated, Direct: Muscle Energy ( B) - “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

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

20. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( A) - “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.

21. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( A) - “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

22. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( B) - “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

23. Supine, Direct: Muscle Energy (4822
Supine, Direct: Muscle Energy ( B) - “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

24. Thoracic Spine

25. Upper Thoracic Spine

26. 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

27. Trunk Rotation Screen

28. 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

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

30. 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

31. Forward Bending

32. Backward Bending

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

34. - Soft Tissue: Prone, Direct, Kneading

35. Soft Tissue: Lateral Recumbent-Direct-Kneading

36. 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!

37. 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

38. 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

39. 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

40. 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

41. 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

42. Upper Thoracic Treatment

43. 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

44. 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.

48. 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

51. Middle Thoracic Spine

52. 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)

53. 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

57. Both Upper and Middle Thoracic
Neutral and Non Neutral

59. 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

60. 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.

61. 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

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

66. Non Neutral Treatments

67. 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

68. 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

69. 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

70. Alternative Hand Placements Ex: ERLSL
For ME or HVLA variation

71. 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

72. 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.

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

74. 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.