OMM Techniques: MS1Fall Semester

1
OMM TechniquesMS1-Fall Semester

• Arnold E. Cuenca
• MS-II
• Western University of Health Sciences
• College of Osteopathic Medicine
• of the Pacific
• aecuenca_at_hotmail.com
• http//www.do2004.com

2
Disclaimer

• This is a STUDY AID, not a STUDY REPLACEMENT and
  should be used with discretion. The user is
  responsible for knowing all material presented in
  the classroom

Note There are some pictures missing
3
SOFT TISSUE TECHNIQUES

• What is the technique?
• Direct
• Passive
• Engages the barrier

4
SOFT TISSUE TECHNIQUES

• Why do you do this technique?
• Lengthen or relax the muscles
• Increase vascularity
• Increase circulation
• Prepare the patient for HVLA

5
SOFT TISSUE Cervical RegionLong-Axis Kneading

• Pt. Supine
• Dr. at head of the table
• Contact the posterior cervical muscles lateral to
  the spinous processes with your fingerpads
• First apply CAUDAD pressure, then apply an
  ANTERIOR, LATERAL, AND CEPHALAD oval, wave-like
  motion
• Do not slide fingers over the skin!
• Do this until you feel tissue changes
• RE-TEST

6
SOFT TISSUE Cervical RegionTransverse Push-Pull

• ? BI-LATERAL TECHNIQUE!
• Pt. Supine
• Dr. facing Pt. at side of table
• Place your CEPHALAD hand on top of your patients
  forehead
• Place your CAUDAD hand (fingerpads actually) on
  posterior cervical muscles lateral to spinous
  processes on opposite side of neck
• Gently push forehead away, rotating head to
  opposite side
• Gently pull cervical musculature toward you with
  your CAUDAD hand
• Do this while CEPHALAD hand is applying
  resistance on forehead
• Repeat several times in rhythmic motion
• RE-TEST

7
SOFT TISSUE Thoracic RegionProne Pressure

• Pt. Prone
• Dr. facing side of Pt.
• Pt.s head is facing toward the Dr.
• Place hands over paravertebral muscles on far
  side of Pt.s spine
• Apply pressure in Posterior -- Anterior, Lateral
  direction
• Continue applying pressure until tissue is taken
  as far as it will comfortably go
• Do not slide over the skin!
• Repeat in rhythmic fashion
• RE-TEST

8
SOFT TISSUE Thoracic RegionLateral Recumbent

• Pt. lying on side with hips and knees flexed
  slightly
• Dr. facing Pt.
• Contact uppermost paraverteberal muscles with
  finger pads, avoiding spinous processes
• Drape Pt.s arm b/w your 2 arms
• over your CEPHALAD arm when treating upper
  thoracics
• Over your CAUDAD arm when treating mid-thoracics
• Pull muscles anterolaterally with your finger
  pads as far as it will comfortably go
• Do not slide over the skin!
• Repeat in rhythmic fashion
• RE-TEST

9
SOFT TISSUE Lumbar RegionProne Pressure w/
Counter Leverage

• Dr. stands to side of PRONE Pt.
• Dr. reaches across Pt. To opposite ASIS w/ caudad
  hand
• Dr. contacts w/ heel of cephalad hand on
  paravertebral muscles of that side
• Dr. lifts ASIS POSTEROMEDIALLY and stretches
  paravertebral muscles ANTEROLATERALLY with
  cephalad hand using torquing motion
• Repeat in slow, rhythmic fashion until desired
  tissue response is achieved
• RE-TEST

10
SOFT TISSUE Lumbar RegionLateral Recumbent

• Dr. stands to side of lateral recubent Pt.
• Pt.s knees are flexed at abdomen
• Dr. pulls the uppermost lumbar paravertebral
  muscles laterally with both hands while applying
  counterpressure with thigh or groin at Pt.s
  flexed knees
• Repeat in slow, rhythmic fashion until desired
  tissue response is achieved
• RE-TEST

11
ARTICULATORY TECHNIQUES

• What is the technique?
• Direct
• Passive
• Engages the Barrier
• Low Velocity, High Amplitude

12
ARTICULATORY TECHNIQUES

• Why do you to the technique?
• Gap the joints and separate the facets
• Increase range of motion
• Prepare the patient for HVLA

13
CERVICAL ARTICULATORY TECHNIQUES Flexion

• Pt. Supine
• Dr. facing Pt.
• Place one hand on Pt.s shoulder
• Place other hand cradling the occiput
• Lift the head until full flexion is obtained
• Repeat smoothly in a rhythmic fashion, each time
  increasing range of motion
• RE-TEST range of motion

14
CERVICAL ARTICULATORY TECHNIQUES Extension

• Pt. Supine
• Dr. facing Pt.
• Place one hand under Pt.s neck and use thumb and
  forefinger as fulcrum by pressing them against
  articular pillars of a vertebra
• Grasp Pt.s chin with other hand and lift fulcrum
  and chin to extend the neck
• Use smooth, rhythmic motion several times, on
  each vertebrae
• RE-TEST range of motion

15
CERVICAL ARTICULATORY TECHNIQUES Rotation

• Pt. Supine
• Dr. facing Pt.
• Grasp the chin with one hand and the occiput with
  the other
• Rotate the head to one side and engage the
  barrier, then return partway towards neutral
• Repeat several times, each time increasing range
  of motion (slow and rhythmic)
• RE-TEST range of motion

16
CERVICAL ARTICULATORY TECHNIQUES Sidebending

• Pt. Supine
• Dr. at head of table
• Place one hand on shoulder, using other hand to
  cradle the occiput
• Firmly sidebend neck towards opposite shoulder
• Engage the barrier and repeat several times using
  a slow, rhythmic motion
• RE-TEST

17
THORACIC ARTICULATORY TECHNIQUES

• Note
• For T1-T4, use the head and neck as a lever
• For T5-T12, use the torso as the lever

18
THORACIC ARTICULATORY TECHNIQUES Flexion

• Dr. stands behind (somewhat lateral) to Pt.
• Dr. puts arm across Pt.s chest w/ elbow resting
  on sternum and grasping the opposite shoulder
• Pt. Hooks hands over Dr.s arm
• Dr. stabilizes lower of 2 vertebrae by grasping
  fixating spinous process with thumb, index, and
  long fingers (or with thenar eminence)
• Using elbow as fulcrum, Dr. flexes Pt. 5-6X or
  until tissue changes occur
• RE-TEST

19
THORACIC ARTICULATORY TECHNIQUES Extension

• Dr. and Pt. In same position as previous slide
• Dr. uses same hand position to stabilize
  vertebrae in back
• 2 things are done simultaneously
• Hand in back presses a single segment anteriorly
• Arm in front extends the segments above
• Do this 5-6X or until tissue changes occur
• RE-TEST

20
THORACIC ARTICULATORY TECHNIQUES Rotation

• Dr. and Pt. in same position as previous slide OR
  Dr. passes one hand under Pt.s axilla and grasps
  the opposite anterior shoulder
• Dr. uses same hand position to stabilize
  vertebrae in back
• Dr. rotates the torso while stabilizing the
  vertebrae, allowing maximal rotational motion
  through the joint above
• Change to the opposite side and treat in other
  direction
• RE-TEST

21
THORACIC ARTICULATORY TECHNIQUES Sidebending

• Dr. stands behind Pt. And passses arm (axilla)
  over Pt.s shoulder, across the chest, and into
  opposite axilla (Dr. hand should be grasping near
  opposite axila)
• Dr. uses same hand position to stabilize
  vertebrae in back
• Dr. applies pressure to sides of Pt.s spinous
  process while simultaneously applying sidebending
  to Pt.s torso
• Repeat 5-6 X
• RE-TEST

22
LUMBAR ARTICULATORY TECHNIQUES Flexion (Seated)

• Dr. and Pt. in same position as Thoracic
  Articulatory Flexion
• Pt. Is seated or straddling the table
• You can use the stool if you wish
• Dr. leans Pt. backward slightly and using elbow
  as fulcrum, flexes and gaps the joint above the
  dysfunctional segment
• Repeat 5-6 X
• RE-TEST

23
LUMBAR ARTICULATORY TECHNIQUES Flexion (Lateral
Recumbent)

• Dr. faces lateral recumbent Pt.
• Flex Pt.s knees and rest against thighs or groin
• Dr. places hands on lumbar spine
• gently flex Pt.s knees/hips toward Pt.s chest
  while stretching joint space w/ both hands
• Repeat in slow, rhythmic motion 5-6X
• RE-TEST

24
LUMBAR ARTICULATORY TECHNIQUES Flexion (Supine)

• Dr. stands to side of supine Pt.
• Pt.s hips and knees are flexed
• Dr. rests his/her pectoral area on Pt.s knees
  and places hands below Pt.s lumbar region, one
  on each side of the spine
• Dr. presses toward the table through Pt.s
  knees/hips to spring lumbar joint space while
  pulling hands caudally
• Increase decrease degree of flexion to move
  focus up and down lumbar spine until desired
  changes occur
• RE-TEST

25
LUMBAR ARTICULATORY TECHNIQUES Extension (Seated)

• Dr. and Pt. in same position as Flexion Lumbar
  Articulatory Technique (Seated)
• Pt. Crosses arms with each hand grasping opposite
  shoulder
• With Pt. leaning forward slightly, Dr. lifts
  Pt.s elbows with one hand to induce lumbar
  extension and simultaneously applies anterior
  force at each segment level with the other hand
• Repeat in rhythmic fashion until ease of motion
  is increased, then move up or down lumbar spine
• RE-TEST

26
LUMBAR ARTICULATORY TECHNIQUES Extension
(Lateral Recumbent)

• Dr. and Pt. in same position as Lateral Recumbent
  Lumbar Articulatory Technique (Flexion)
• Dr. uses hands in lumbar region as a fulcrum
  applying an anterior pressure on successive
  segments
• Do this while inducing a backward bending lumbar
  motion through the long lever of Pt.s thighs
• Repeat in smooth, rhythmic fashion up and down
  lumbar spine
• RE-TEST

27
LUMBAR ARTICULATORY TECHNIQUES Sidebending
(Seated)

• Dr. and Pt. In same position as Sidebending
  Thoracic Articulatory Technique (Seated)
• EXCEPT hand on back is lateral to the spinous
  processes of the LUMBAR region

28
LUMBAR ARTICULATORY TECHNIQUES Sidebending
(Lateral Recumbent)

• Dr. faces lateral recumbent Pt. whose knees and
  hips are flexed 90 degrees
• Dr. places hand/forearm under Pt.s ankles
• Lift ankles to ceiling to induce sidebending

29
LUMBAR ARTICULATORY TECHNIQUES Rotation (Seated)

• Dr. and Pt in same position as Rotation Thoracic
  Articulatory Technique (Seated)
• EXCEPT hand on back is focused on the lumbar
  region

30
ARTICULATORY TECHNIQUESRIBS (Anterior)

• Dr. stands on side of SUPINE Pt.
• Grasp wrist with cephalad hand
• Stabilize anterior ribs with caudad hand (for
  females, have them cover their breasts)
• Use ulnar border and little finger, thumb and
  thenar eminence, or group the fingertips in a row
• Stretch arm upwards into flexion to point where
  elbow is straight and behind head
• Use respiratory cooperation as Pt. Inhales, flex
  
• During exhalation, return partly back to neutral
• This stretches pectoralis minor (ribs 3-5) and
  serratus anterior (ribs 6-10) to pull towards
  pump handle inhalation
• Repeat several times
• RE-TEST

31
ARTICULATORY TECHNIQUESRIBS (Posterior)

• Dr. stands at head of table with Pt. PRONE
• Grasp the Pt.s arm just proximal to elbow
• Stabilize each rib in sequence with thumb and
  thenar eminence at the rib angle
• Stretch arm into full abduction
• Use respiratory cooperation as Pt. inhales,
  abduct
• During exhalation, return partly back to neutral
• This stretches primarily serratus anterior (ribs
  1-9) toward bucket handle inhalation
• Repeat several times
• RE-TEST

32
ARTICULATORY TECHNIQUESRIBS (Lateral)

• Dr. faces lateral recumbent Pt.
• Dr. grasps Pt.s elbow which is flexed
• Stabilize each rib in the mid-axillary line with
  thumb and thenar eminence
• Stretch shoulder into full abduction
• Use respiratory cooperation as before
• This stretches primarily serratus anterior (ribs
  1-9) toward bucket handle inhalation
• Repeat several times
• Repeat other side
• RE-TEST

33
ARTICULATORY TECHNIQUESRIBS (Elevation)

• Dr. stands to side of SUPINE Pt.
• Dr. lifts arm into full abduction so that wrist
  is held firmly in cephalad axilla
• Place one hand under Pt.s scapula
• Press tips of fingers anteriorly against angles
  of Pt.s ribs, and caudal
• Simultaneously stretch Pt.s arm superiorly and
  laterally
• This stretches primarily serratus anterior (ribs
  1-9) into bucket handle inhalation
• Repeat several times
• Repeat on other side
• RE-TEST

34
ARTICULATORY TECHNIQUESRIBS (Seated)

• Pt. seated, Dr. in front of patient
• Pt. crosses arms on Dr.s chest (or shoulders)
  with head resting on his/her arms
• Dr. places fingerpads on posterior rib angles
• Pull anteriorly and laterally to draw rib angles
  lateral
• At the same time, extend the spine and lift the
  arms (elbows) to flex the arms at the shoulders
• This articulates ribs toward pump handle
  inspiration
• Add respiratory cooperation to exaggerate range
  of motion of the ribs
• Repeat until ribs move easily

35
MYOFASCIAL RELEASE

• What is it?
• Either a Direct or Indirect technique
• Direct
• Load and Hold
• Engaging the restrictive barrier and is loaded
  until free movement is achieved
• Indirect
• Dysfunctional soft connective tissues are guided
  along a pathway of least palpatory resistance
  until free movement is achieved

36
MYOFASCIAL RELEASE

• Why do it?
• Release fascial tension and restore function to a
  somatic dysfunction
• Increase arterial, venous, and lymphatic
  circulation

37
MYOFASCIAL RELEASEThoracic Inlet Release

• ? This works on scalene muscles and continuations
  of cervical fascia in thorax (Sibsonfascia)
• ? DIRECT technique
• Pt. supine w/ arm abducted at 90 degrees to body
• Dr. sits to same side of abducted arm facing
  Pt.s head
• Support Pt.s elbow on knee with the cephalad
  hand supporting Pt.s wrist and caudal fingers
  placed on superior aspect of supraclavicular
  fossa
• Apply downward pressure to Pt.s wrist as caudal
  fingers wrap around clavicle applying gentle
  anterior pressure
• Move Pt.s wrist in arc back toward shoulder w/
  caudal hand following rotation of clavicle
  posteriorly until tension develops
• Hold this until some relaxation is noted
• Repeat arc enabling fingers to wrap around
  clavicle further
• Repeat 2-3X
• RE-TEST

38
MYOFASCIAL RELEASEThoracic Diaphragm Release

• ? INDIRECT technique
• Pt. Is seated
• Dr. stands behind Pt. and passes hands around
  thoracic cage (under arms of Pt.) and gently, but
  firmly, introduces fingertips, 5th finger-edge
  and hypothenar eminence, underneath costal margin
• Test for diaphragmatic restriction by passively
  rotating thorax gently to left and right until
  you feel tissue tension in ONE cycle
• Rotate diaphragm in direction of ease and follow
  tissue unwinding until it settles down into a
  free, rhythmic, vertical respiratory motion
• RE-TEST

39
MYOFASCIAL RELEASEPelvic Diaphragm
ReleaseInhalation Somatic Dysfunction (Direct)

• DIRECT method
• Pt. is supine
• Dr. sits at side of pelvis to be treated, facing
  Pt.s head
• Flex Pt.s knee and hip and introduce index
  middle fingers medial to ischial tuberosity (the
  ischiorectal fossa)
• Instruct Pt. to inhale and during exhalation,
  press fingertips superiorly
• Maintain this position, ask Pt. to inhale and
  during exhalation, continue to follow and press
  fingers more superiorly
• Repeat several cycles
• RE-TEST

40
MYOFASCIAL RELEASEPelvic Diaphragm
ReleaseInhalation Somatic Dysfunction (Indirect)

• INDIRECT method
• Same hand positions but
• Ask Pt. to inhale to limit and maintain
  inhalation until FORCED to exhale
• At moment of forced exhalation or just before,
  the pelvic diaphragm descends
• Repeat several cycles
• RE-TEST

41
MYOFASCIAL RELEASEPelvic Diaphragm
ReleaseExhalation Somatic Dysfunction (Indirect)

• INDIRECT method
• Same hand positions but
• Ask pt. to inhale then exhale to the limit until
  FORCED to inhale
• At moment of forced inhalation or just before,
  the pelvic diaphragm ascends
• Repeat several cycles
• RE-TEST

42
LYMPHATIC TECHNIQUES

• What is it?
• Passive, direct techniques (except for myofascial
  indirect release techniques)
• Order of releasing the central lymphatic system
• 1. Thoracic inlet release
• 2. Thoracic diaphragm release (indirect
  myofascial)
• 3. Pelvic diaphragm release (indirect myofascial)
• 4. Release peripheral lymphatic system
• 5. Thoracic pump

43
LYMPHATIC TECHNIQUES

• Why do it?
• Re-establish maximum lymphatic fluid flow
• Increase removal of toxic products of metabolism
  and increase circulation of healing elements

44
LYMPHATIC TECHNIQUESAnterior Cervical Traction

• ? This works on anterior cervical fascia and SCM
  (Treat one side at a time!)
• Dr. sits at head of supine Pt.
• Pt.s head is slightly flexed with a pillow or
  manually
• Dr. places thumb along anterior margin and
  2nd-5th digits along posterior margin of SCM
• Starting in lower portion of SCM and anterior
  cervical fascia, gently lift anteriorly and
  laterally until relaxation is noted
• Move superiorly to middle portion, then to
  superior portion
• Repeat 3X
• RE-TEST
• Take care NOT to put pressure on the carotid
  bodies causing a vasovagal response!

45
LYMPHATIC TECHNIQUESCervical Lymph Drainage

• ? This works on jugular lymphatic chains
• Dr. sits at head of supine Pt.
• Pt. has head rotated away from side being treated
  with slight flexion via a pillow or manually
• Dr. places pad of thumb on anterior margin of SCM
  in inferior portion of neck
• Apply slow steady firm strokes along SCM margin
  to clavicle
• Repeat in middle portion
• Repeat in superior portion
• Repeat sequence 3X
• RE-TEST

46
LYMPHATIC TECHNIQUESLiver/Spleen Pump

• For Liver Dr. stands on right side of supine
  Pt., beside lower thorax and facing the head
• Pass left hand underneath lower ribs and right
  hand on abdominal wall immediately below the
  costal margin
• Ask Pt. To take in deep breath and identify
  border of liver with tips of fingers of right
  hand
• As exhalation occurs, fingers penetrate over
  liver and underneath thoracic cage
• Deep breath again, and during exhalation, apply a
  vibratory motion of right hand on liver
• Repeat 3-4X
• RE-TEST
• For spleen, treat other side

47
LYMPHATIC TECHNIQUESLymphatic Drainage of
Upper Extremities

• Dr. stands to side of supine Pt.
• Tuck Pt.s hand into axilla and hold it there
• Take hold of upper arm close to shoulder and with
  hand on either side of limb, apply a rotatory
  wringing motion
• Move a hands width closer to elbow and repeat
  wringing motion
• Continue wringing proximal to distalwhen you get
  to elbow, repeat process 3-4X until adequate
  drainage is achieved
• Go to forearm and place thumbs on ventral surface
  between flexor and extensor muscle masses and
  rest of digits around other side
• Gently squeeze muscle masses simultaneously, then
  relax
• Repeat 3-5X moving proximal to distal
• RE-TEST

48
LYMPHATIC TECHNIQUESLymphatic Drainage of
Lower Extremities

• With Pt. supine, sit on table facing Pt. with leg
  balanced on shoulder
• Flex Pt.s hip and knee to right angles
• Place palmar surface of both hands on opposing
  sides of leg and perform wringing motion
• As tissue changes take place, move distally down
  thigh towards knee, one hands width at a time
• Repeat sequence 3-5X
• Go to lower leg and place hands on either side w/
  thumbs pressing deeply b/w two gastrocnemius
  heads
• Rock body backward during each squeezing motion
• Work progressively toward foot and repeat 3-5X
• RE-TEST

49
LYMPHATIC TECHNIQUESThoracic Pump Technique

• Dr. stands at head of supine Pt.
• Place hands on thoracic wall w/ thenar eminence
  of each hand just distal to respective clavicle,
  fingers spreading over chest wall
• Induce rhythmic pumping action by alternating
  pressure and release with hands

50
MUSCLE ENERGY

• ?What is it?
• Active, direct technique
• Applied unyielding force by physician
• Isometric contraction by patient in all 3 planes
• Joints are positioned at the restrictive barrier

51
MUSCLE ENERGY

• ?Why do it?
• Decrease muscle tightness
• Decrease muscle hypertonicity

52
MUSCLE ENERGY AA

• Flex neck to lock out cervicals
• Introduce rotation towards leading edge of
  restrictive barrier
• Place hand on patients cheek and have Pt.
  perform isometric contraction towards neutral for
  3-5 seconds
• Ask Pt. to stop, then take up slack in tissues by
  repositioning toward leading edge of new
  restrictive barrier
• Repeat 3-5X
• RE-TEST

53
MUSCLE ENERGY OA

• Dr. positions Pt.s head into restrictive
  barriers
• Repeat isometric contractions as described in
  Muscle Energy AA
• RE-TEST

54
MUSCLE ENERGY TYPICAL CERVICALS

• Dr. supports head with one hand on posterior
  lateral surface opposite side of restriction
• Other hand placed w/ MP joint and index finger
  held against articular pillar of restricted
  vertebral segment as a fulcrum
• Position neck against barrier at that segment
  level and rotation in same direction around the
  fulcrum
• Perform isometric contractions as described in
  Muscle Energy AA
• RE-TEST

55
MUSCLE ENERGYThoracic Type I Group Dysfunction

• Dr. stands behind/beside seated Pt.
• Dr. is on opposite side where sidebending will be
  induced
• Place your shoulder underneath Pt.s axilla and
  grasp Pt.s opposite shoulder
• Have Pt. rest hands inside your elbow w/ arms
  hanging in relaxed manner
• Palpate posterior transverse process of
  dysfunctional vertebra
• Sidebend Pt. by lifting your shoulder and rotate
  Pt. towards you while applying pressure on
  posterior transverse process
• Perform isometric contractions and reposition
• RE-TEST

56
MUSCLE ENERGYThoracic Type II Group Dysfunction

• Dr. stands behind/beside seated Pt.
• Place axilla on shoulder where sidebending will
  be induced (towards restriction) and grasp
  opposite shoulder
• Have Pt. Rest hands inside your elbow w/ arms
  hanging in relaxed manner
• Position Pt. toward leading edge of restriction
• Perform isometric contractions and repositioning
• RE-TEST

57
MUSCLE ENERGYLumbar Type I and II Group
Dysfunction

• Same positioning as Thoracic Muscle Energy except
  hand is place on posterior transverse processes
  of lumbar region

58
MUSCLE ENERGY LATERAL RECUMBENT

• Pt. lies on side of posterior transverse process
• While monitoring lesion with cephalad hand, Dr.
  flexes Pt.s knees until motion is achieved at
  restricted joint
• Pt.s bottom leg is straightened with foot of top
  leg cupped in popliteal fossa of bottom leg
• Dr. changes hands to monitor with caudad hand
• Pt. grasps Dr.s cephalad elbow with arm laying
  on table, while Dr. hold onto Pt.s arm with
  his/her hand
• Type I pull arm caudad
• Type II pull arm cephalad

59
MUSCLE ENERGY LATERAL RECUMBENT

• To treat rotational component, place cephalad
  hand on Pt.s upper shoulder and have Pt. Perform
  isometric contractionsreposition
• To treat sidebending component, flex Pt.s
  bottoms leg until it is even w/ top legthen
• Type I bring Pt.s ankles down off table until
  barrier is engaged. Have Pt. lift feet toward
  ceiling with isometric contractions and
  reposition
• Type II lift Pt.s ankles to ceiling until
  barrier is engaged. Have Pt. push feet toward
  floor with isometric contractions and reposition
• RE-TEST

60
HVLA

• ?What is it?
• Passive, Direct, High Velocity/Low Amplitude
  technique
• Engages the barrier

61
HVLA

• ?Why do it?
• Increase range of movement
• Restore normal joint receptor activity
• Decrease muscle spasm and hypertonicity
• Stretch connective tissue

62
HVLA Kirksville KrunchExtension Restriction

• Dr. stands on side of supine Pt. facing Pt.s
  head
• Cross Pt.s arms over chest w/ hands over outside
  portion of each shoulder and arm on Pt.s
  opposite side superior to the other
• Using cephalad hand, grasp Pt.s opposite elbow
  to rotate Pt. toward you
• Using caudad hand, in a bilateral fulcrum hand
  position, contact skin 1 superior to flexed
  vertebra and pull skin inferiorly
• Support Pt.s head and neck while gently flexing
  Pt. to engage barrier
• Pt. inhales and at end of exhalation, apply
  short, quick thrust straight down toward floor by
  dropping weight
• RE-TEST

63
HVLA Kirksville KrunchFlexion Restriction

• Same positioning as Kirksville Krunch Extension
  Restriction EXCEPT
• Apply thrust 45 degrees cephalad from the A-P axis

64
HVLA Texas TwistType I Dysfunction

• Dr. stands on side of prone Pt.s posterior
  transverse process
• Pt.s head is turned away from Dr.
• Contact skin superior to posterior TP with
  hypothenar eminence with CEPHALAD hand and pull
  skin caudad until hand contacts TP
• Contact skin just inferior to opposite TP of
  segment BELOW dysfunctional joint space with
  thenar eminence of CAUDAD hand and draw skin up
  until hand contacts the TP
• Have Pt. inhale then exhale, to localize forces
  with some rotation
• Apply HVLA thrust through wrists and elbows held
  rigid as Pt. reaches maximum end-exhalation
• RE-TEST

65
HVLA Texas TwistType II Dysfunction

• Same as Type I except reverse hand placement and
  direction of rotation localization

66
HVLA Lumbar Roll

• Positioning is same as Muscle Energy Lumbar
  Lateral Recumbent
• Instruct Pt. to fold arms across their chest or
  side, or have Pt. clasp their forearms together
• Slip cephalad hand beneath Pt.s left arm and
  contact Pt.s anterior axilla (pectoral area) w/
  your forearm
• Place caudad forearm on Pt.s left buttock across
  SI area, while your hand grasps spinous process
  of dysfunctional vertebra
• While maintaining localization, roll the Pt. as a
  unit toward you
• Have Pt. Inhale/exhale and at end-exhalation,
  thrust in a rotatory motion anteriorly (toward
  the groung) with forearm
• RE-TEST

67
Special Thanks to

• Greg Kogan-MS II Photographer
• Shahab Mahboubian-MS II OMM model
• Brian Tran-MS II OMM model

68
GOOD LUCK!!