Exam 3 OPP

what joins at the bregma

what joins at the pterion?

what joins at the asterion

what joins at the lambda?

HEENT Lymphatic techniques in order

indications of mandivular drainage X2

contraindications of mandibular drainage

 *Ask if patient has anything in their mouth (know if loose objects as well)
 *Inform patient that they may experience drainage down the back of their throat
 Avoid treating over TMJ disorder
 Patient: Supine, head turned slightly toward DOc
 DOc: Seated at pt’s side (opposite of side to be treated), near the head of the
table
 Technique
 Have patient relax jaw open
 Stabilize head contralaterally with cephalad hand
 Engage ipsilateral mandible with third, fourth and fifth fingers of caudad hand along
posterior ramus of the mandible and hypothenar eminence along the body of the
mandible
 Gently move inferiorly, medially, and slightly anteriorly
 May maintain this position or may use a gentle milking motion until release felt (slow
rhythmic motion for 30 seconds to 2 minutes)
 Reassess: symptoms improved, reevaluate tissue texture, repeat otoscope exam

indications of auricular drainage technique (x3)

contraindications of auricular drainage technique

 *Ask if patient has anything in their mouth (know if loose objects as well)
 *Inform patient that they may experience drainage down the back of their
throat
 Avoid treating over TMJ disorder
 Patient: Supine, head turned slightly toward DOc
 DOc: Seated at patient’s side (opposite of side to be treated), near the
head of the table
 Technique
 Stabilize contralaterally with cephalad hand
 Place caudad hand with fingers pointing cephalad and the ear between the
3rd and 4th fingers
 Contact and engage anterior and posterior to auricle and gently massage in
rotary motion – clockwise, then counterclockwise (do not drag skin)
 Duration: 30 seconds to 2 minutes
 Reassess: symptoms improved, reevaluate tissue texture, repeat otoscope
exam

indications of trigeminal stimulation

 *Ask if patient has anything in their mouth
 (know if loose objects as well)
 *Inform patient that they may experience drainage down the back
of their throat
 Patient: Supine
 DOc: Seated at the head of the table
 Technique:
 Locate and palpate supraorbital foramina bilaterally
 With pad of middle finger of each hand, engage area you are treating
with firm rotary motion
 Repeat treatment at infraorbital and mental foramina
 Duration: 30 seconds to 2 minutes at each location
 Reassess: symptoms improved, reassess sinuses, tissue texture
change palpated

indication of maxillary drainage

 *Ask if patient has anything in their mouth (know if loose objects as
well)
 *Inform patient that they may experience drainage down the back of
their throat
 Patient: Supine
 DOc: Seated at the head of the table
 Technique:
 Engage area to bones overlying the sinuses being treated
 Maintain firm pressure during treatment – medial to lateral
motion as described
 Duration: 30 seconds to 2 minutes
 Reassess: symptoms improved, tissue texture change palpated,
reassess sinus exam, pharynx exam with postnasal drainage

indications of frontal drainage?

 *Ask if patient has anything in their mouth (know if loose objects as
well)
 *Inform patient that they may experience drainage down the back of
their throat
 Patient: Supine
 DOc: Seated at the head of the table
 Technique:
 Engage area to bones overlying the sinuses being treated
 2nd fingertips (may include 3rd fingers) immediately above and
medial to the eyebrows
 Maintain firm pressure during treatment – medial to lateral
motion as described, parallel to supraorbital ridge to pterion,
continue inferior toward TMJ to mandible
 Duration: 30 seconds to 2 minutes
 Reassess: symptoms improved, tissue texture change palpated,
reassess sinus exam, pharynx exam with postnasal drainage

structures passing through the superior orbital fissure

5 cranial concept principles

2 phases of cranial rhythmic movement

 Articulation between sphenoid and occiput
 The Angle of the SBS defines Flexion phase and Extension phase

what type of joint is the temporomandobular joint

tempororomandibular joint motions

what type of joints are the luschka joints

fx luschka joints

motion patterns of the cervical spine are larfely determined by these joinrs which are independent of doscs, liagemnts, and musculature

the occiput on C-1 exobts these mechanics

the C1 on C2 are only _______-

C2-6 exibit motion like these mechanics where sidebending and rptation are always coupled to the same side

clinicl considerations with the neck

Chronic systemic inflammatory dz
 Classic small peripheral joint involvement can be
coupled with axial (cervical) spine involvemen

what join can down syndrom result in instability im (neck joimt)

Patient supine
2. DOc at head of table
3. DOc's finger pads within occipital sulcus
◦ Which is deeper?
◦ The deeper sulcus reflects a relatively posterior occiput on that
side... therefore this is the side to which the occiput is rotated
4. DOc confirms side bending with translation
5. Once back to neutral, DOc assess OA in flexion and
extension
◦ ONLY mobilize the segment in question and ONLY to the degree
of motion expected for that segment
◦ Does the sulcus become shallower in flexion, extension, or
neither?

what does diagnosing the OA test for?

1. Patient supine
2. DOc standing at head of table
3. DOc monitoring above AA to avoid
extension at OA
◦ Index on sulcus, 3rd finger on occiput
◦ If fingers "scissor," then OA is
inappropriately flexing or extending
4. DOc locking out C2-C7 by flexing the
lower cervical spine
5. Once locked out, rotate bilaterally to
determine which side is favored

1. Patient supine
2. DOc's finger pads on segmental ARTICULAR PILLARS
◦ Which is most posterior?
◦ The relatively posterior articular pillar is the side to which the
segment is rotated.
3. DOc confirms side bending with translation
4. Once back to neutral, DOc assess segment in flexion
and extension
◦ ONLY mobilize the segment in question and ONLY to the
degree of motion expected for that segment
◦ Do the articular pillars become more symmetrical in flexion,
extension, or neither?
◦ If yes, then that is considered the motion of ease

contraindications to cervical linear traction (x3)

1. Patient - supine
2. DOc is at head of table (Seated or standing)
3. DOc hand positions
◦ One hand cups the base of the skull/occiput with their palm, forearms parallel to table
◦ Second hand – 2 options
◦ Option A – hypothenar eminence at the base of the chin (Do not use of TMJ or
jaw/teeth disorder)
◦ Option B – palm over the patient’s forehead – far above eyebrows not to open their
eyes
4. DOc adds very minimum flexion at OA – chin tilt first and then gently provides
cephalad directed linear traction and hold until release if appreciated (parallel to table
and pt cervical spine)
◦ ~ 10-20 sec at time for total of 30-60 seconds
5. Very slowly release and return pt to neutral
6. Reassess

indications for cervical linear traction (x2)

1. Patient supine
2. DOc – head of the table (Seated or
Standing)
3. DOc places the patient's occiput on their
crossed forearms – starting parallel with
the OMT table
◦ DOc hands are on the contralateral shoulders
4. DOc gently lift forearms away from the
OMT table providing passive (midline)
cervical flexion until feel flexion barrier
5. Hold until a release if appreciated
6. Slowly return to neutral
7. Reasses

indications of cervical bilateral linear stretch

contraindications of cervical bilateral linear stretch (x3)

1. Patient supine
2. DOc next to patient at side of table
3. DOc's cephalad hand gently on the forehead
4. DOc's caudal hand on the contralateral cervical
paraspinal muscles
◦ Do not cross over midline - posteriorly
◦ Apply perpendicular (lateral-anterior) stretch
◦ Hold until release (up to 20 sec) or kneading fashion
◦ Release forces at that area
◦ Re-apply stretch to next area and then entirety of c-spine
◦ Repeat on other side
◦ DOc must switch to other side of table to complete properly
5. Reassess

1. Patient supine
2. DOc head of table
3. DOc’s hands B/L in posterior neck with fingertips lateral to
ipsilateral spinous processes and over paravertebral
musculature over articular pillars
4. DOc’s exerts ventral force to engage tissues, and a
longitudinal stretch cephalad cervical paraspinal muscles
◦ Apply parallel (cephalad-anterior) stretch
◦ Hold until release or kneading version
◦ Return to neutral
◦ Re-apply stretch to next area and then entirety of c-spine B/L
◦ Work way up and down c-spine level by level (rhythmic or Hold
technique)
5. Reassess

after completing hyoid motion testing, what do you treat with (x3)

1. Patient supine or seated
2. DOc explains to patient where the hyoid bone is and
what DOc will be doing
3. GENTLY grip each end of the body of the hyoid
bone
4. Motion test – laterally, superior/inferior
5. What's the position of ease?

1. Patient: Seated or supine.
2. DOc locates the triangle formed by the sternal and clavicular heads of
the left SCM. Move head – slight flexion, and SB toward side being
treated to relax tissues
3. DOc using the thumb, index finger, or middle finger, presses deep into
this triangle.
4. This pressure should elicit a mild degree of pain (to tolerance) and be
maintained (may use rotary motion at area) for at least a minute after
the hiccups cease to break the reflex arc
5. If the technique is unsuccessful on the left, it may be repeated on the
righ

Restrictive barrier is DISENGAGED by DOc
Initially, the joint or tissue is positioned AWAY from the barrier
TOWARD relative ease/freedom of motion by DOc

Activating forces applied externally to the
patient

Activating forces that arise from
within the patient

indirect myofascial release is used to treat somatic dysfunction involving (x3)

who developed FPR

who developed counterstrain

Pt supine (nothing in their mouth, & proper exposure)
DOc is seated or standing at head of table
Neutralize by FLATTEN the axial curve at the level of the OA
Consider “tripod” hold to flatten c lordosis
Must MONITOR at the level treating (deep sulcus)
Gently COMPRESS longitudinally
Until you feel tissue soften at that segment
Move to the position of EASE (in all allowable planes)
i.e. into the diagnosis
HOLD for 5 full seconds
Gently/passively return to neutral
REASSESS (same as Dx)

AA is ALWAYS treated in NEUTRAL (not flexed)
Pt supine (nothing in their mouth, & proper exposure)
DOc is seated or standing at head of table
Neutralize by FLATTEN the axial curve at the level of the
AA
Consider “tripod” hold to flatten c lordosis
Must MONITOR at the level treating at TP of C1
Only treat AA in neutral (never flexed)
Gently COMPRESS longitudinally
Until you feel tissue soften at that segment
Move to the position of EASE (rotation only)
HOLD for 5 full seconds
Gently/passively return to neutral
REASSESS (flexed – same as Dx)

Pt supine (nothing in their mouth, & proper exposure)
DOc is seated or standing at head of table
Neutralize by FLATTEN the axial curve at the one level you
are treating
Consider “tripod” hold to flatten c lordosis
Must MONITOR at the level treating
Gently COMPRESS longitudinally
Until you feel tissue soften at that segment
Move to the position of EASE (in all allowable planes)
HOLD for 5 full seconds
Gently/passively return to neutral
REASSESS (same as Dx)

Position:
Patient supine. Patient’s
shoulder flexed to approx.
45o, abducted approx. 45o,
and then externally
rotated

counterstrain point for?

Position:
Patient prone. Patient’s ipsilateral leg is placed in
hip ABDuction to approx. 45o, hip flexion to approx.
60-90o, knee flexion to approx. 90o, then hip
external rotation.

what is this the counterstrain point for?

Position:
Patient supine. Patient’s ipsilateral elbow is fully extended and
forearm place in supination with minimal valgus

what is this the counterstrain point for

the still technique starts _______ and finishes ______-

Patient  Supine
DO  stands head of table
DO  control patient’s head, monitor OA/C2 junction or suboccipital junction
Neutral spine (not flexed like diagnosis), Patient’s head  Rotates indirect (ease of motion – diagnosis)  then Compress (axial to the level (< 5lbs))  Rotates to barrier  return to neutral.
Reassess

Patient  Supine
DO  head of table
DO  control patient’s head, monitor OA or C2-7 level
Neutral spine, Patient’s head  Rotates indirect (ease of motion – diagnosis, ALL planes)  then Compress (axial to the level (< 5lbs))  Rotates to barrier (ALL planes) return to neutral.
Reassess
Remember – Diagnosis (OA F/E/N Rx Sy, and C2-7 F/E/N Rx Sx)

Patient  Seated
DO  stands behind
DO  one hand control patient’s head & other hand monitor at diagnosis (T1-4)
Neutral spine, Patient’s head  Rotates indirect (ease of motion – diagnosis, ALL planes) until motion at the Dx (T1-4)  then Compress (axial/vertical to the level (< 5lbs))  Rotates to barrier (ALL planes) Return to neutral.
Reassess
Remember – Diagnosis (T1-4 made in seated position & Follows Fryette’s Principles)

Monitor the dysfunction
DOc passively engage the Restrictive barrier (all planes of motion)
Isometric contraction for 3-5 sec
Patient relaxes for 2 sec (2 sec pause)
DOc passively engage the new barrier (all planes)
Repeat steps 3–5 until you get them to the Physiologic barrier (approximately 3-5 times)
Return to neutral
Reassess!

Patient  Supine
DO  head of table
DO  control patient’s head, monitor OA
Patient’s head  into all barriers (minimal motion) sidebending and rotation and F/E/N
Isometric contraction 3-5 sec
Patient relaxes, (DOc takes 2 sec pause)  engage new barrier in all planes
Repeat isometric ctx, relax/2 sec pause/new barrier for 3-5 times
Return to neutral.
Reassess

Patient  Supine
DO  stands head of table
DO  control patient’s head, monitor OA/C2 junction or suboccipital junction
Neutral spine (not flexed like diagnosis), Patient’s head  Rotates direct (into barrier)  Isometric contraction 3-5 sec  Patient relaxes, 2 sec pause  engage new barrier  Repeat isometric ctx, relax/2 sec pause/new barrier 3-5 times  return to neutral.
Reassess

Patient  Supine
DO  head of table
DO  control patient’s head, monitor C2-7 level (or OA if treating OA)
Neutral spine (not flexed like diagnosis), Patient’s head  Rotates direct (into barrier - ALL planes)  Isometric contraction 3-5 sec  Patient relaxes, 2 sec pause  engage new barrier (ALL planes)  Repeat isometric ctx, relax/2 sec pause/new barrier 3-5 times  return to neutral.
Reassess

what does this show

Cause = hypertonic piriformis
Patient: supine
DOc – Opposite side as dysfunction (contralateral side)
Flex pt hip and knee, & ankle crosses opposite knee
Monitors ilium – side of dysfunction (ipsilateral side)
DOc pulls knee towards - IR hip
Pt attempts to ER hip– Isometric contraction
Hold 3-5 sec, relax, 2 sec pause, go to new barrier,
Repeat 3-5 times
Return to neutral
Reassess

Cause = hypertonic Psoas
Patient: prone
DOc – Same side as dysfunction (ipsilateral side)
Flex pt knee,
Monitors ilium – side of dysfunction (ipsilateral side)
DOc pulls knee towards ceiling - extension hip
Pt attempts to flex hip – toward table– Isometric contraction
Hold 3-5 sec, relax, 2 sec pause, go to new barrier,
Repeat 3-5 times
Reassess

The distance over which the force is applied

The speed with which the force is applied.

The force that results in the therapeutic effect of the technique

types of direct techniques

what is the post treatment reacyion to direct treatmet

what are directions given to a patient post direct treatment procedures

myofacical relese, velocity and amplitide

goal of myofacicval release

goal of articulatory treatment

velocity and amplitude articulatory treatment (ART)

A low velocity / mod. amplitude
The restrictive barrier is engaged repeatedly
Therapeutic goal: increased articular ROM

who digitized and referenced the still technique

indivcations still technique

contraindications still technique

Start in Neutral then place in Position of Ease (away from barrier) & Monitor
Choose the body part to use as a lever for articulation (neck, extremity, etc)
Apply a vectored force parallel to the lever
Compression (< 5lbs) or Distraction
Position into the barrier while maintaining the compression.
The lever is used to move the dysfunctional segment through its barrier and then back to neutral while the parallel force is maintained
Return to neutral
Reassess

who invented muscle energy

indications muscle energy

contraindications to muscle energy technique

Type of eccentric
Contraction of a muscle against resistance while operator force causes muscle to lengthen.

Type of concentric
Contraction against resistance in which the angular change of joint motion is at the same rate.

inactivity increases with age with women being (greater/less) active then men

what is the recomended excercise for adults (wk/CDC)

components of exercse rx (FITT VP)

best outcomes for exercise incorporate the following elemets (x4)

Indications for exercise Rx

how can reciprocal inhibition work for you/in your favor?

how can reciprocal inhibition work against you

normal sequence of motion of hip extension (x6)

how many exercises should you limit to in an exercise rx?

how odten should exercise rx be perforned (frequency of how often written on a script)

psoas hypertonic
-pelvis tilted posteriorly ten leg leaned forwared

lats stretched out
-lean backward into knees

stretch caused by posterior pelvic tilt
-kep back streigh
-hold for 20sec
-let off for 5sec
-hold for another 20sec
-done

keep the back streiaght and hip neutral with hip and knees tofether and heel to buttocks
-hold for 20sec
-let off for 5sec
-hold for 20 sec

-extensor sirface of antebrachium on table
-stretch is achieved as torso is pulled towards the heel
-keel the back streaigh
-hold for 20 seconds
-let off for 5
-hold for 20
-done

-keep back straight and pelvis and head down
-hold for 20sec
-let off for 5 sec
-hold for 20 more sec
-done

stages of spender ME/Springing in order

test

test

Tests for Long head of biceps tendonitis
Patient is sitting or standing
Shoulder flexed to 90°
Elbow fully extended (but not hyperextended)
Forearm supinated (palm up)
Examiner places one hand on the patient's forearm and the other hand over the bicipital groove
Examiner resists the patient's attempt to actively flex the humerus (not biceps/elbow)
POSITIVE = In the setting of tendonitis, this will produce pain in the bicipital groove

test?

Test of supraspinatus strength
ABduct the arms to 90 degrees
Flex shoulder to 30 degrees
Alternative – Flex to 90d, and ABD to 30d
Internally rotate the arms with the thumbs pointing down, as if emptying a can
Ask patient to resist downward pressure on the arms
Apply pressure on one arm at a time and note any weakness
POSITIVE = Weakness = Suspect supraspinatus injury

Test infraspinatus and teres minor
Patient
Have the patient slightly abduct (20-30 degrees) their shoulders
Keep both elbows flexed to 90 degrees.
Examiner places hands on the outside of patient’s distal forearms. (lateral)
Examiner directs patient to push their wrists outward (externally rotate) against the examiner’s resistance.

Evaluates Subscapularis
Patient
Patient internally rotates shoulder
Place the back (dorsum) of their hand against the small of the back (mid-lumbar region)
Examiner instructs patient to lift off their back – extension of shoulder (may maintain or increase IR shoulder)
Examiner resists patient's attempt to force their arm away from their back

Medial Epicondyle
Patient
Asked to actively flex wrist, while forearm in pronation
Examiner
Stabilize the elbow,
Monitor medial epicondyle
Resist patient’s active flexion of wrist
POSITIVE = pain or symptoms at medial epicondyle

Lateral Epicondyle
Patient
Asked to actively extend wrist, while forearm in pronation, wrist w/slight radial deviation
Examiner
Stabilize the elbow
Monitor lateral epicondyle
Resist patient’s active extension of wrist
POSITIVE = pain or symptoms at lateral epicondyle

Elbow
Cubital Tunnel
Ulnar Nerve
Examiner – locate medial epicondyle and olecranon
Tap over ulnar nerve b/w the 2 landmarks
POSITIVE = pain, symptoms in ulnar n distribution

Examiner
Instruct patient to flex at the wrists
> 90 degrees
Hold
Symptoms
Carpal Tunnel
Median Nerve
POSITIVE = pain, symptoms in median n distribution

Wrist
Carpal Tunnel
Median Nerve
Examiner
Tap over the retinaculum at the median nerve
Must be over medial nerve in canal – distal to palmer crease
POSITIVE = pain, symptoms in median n distribution

De Quervain’s tenosynovitis
Examiner
Instruct patient to actively make first with thumb inside fingers
Wrist neutral position
Stabilize forearm/wrist and passively ulnar deviate the wrist
POSITIVE = pain at the radial side of the wrist at the tendons

Collateral Circulation of the Hand
Radial a
Ulnar a
Used – prior to any arterial sampling/line, hand surgery
Examiner
Ask the patient to make a fist (A)
Occlude both arteries
Ask patient to open fist (B)
Remove occlusion from one artery and see if circulation returns to the hand while other artery is still occluded (C)
Release both arteries
Repeat and open the opposite artery the second time

osteopathic salute: of a patient has type 1 dysfunction how many arms over patient