OMM TECHNIQUES Semester II

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OMM TECHNIQUESSemester II

• Arnold E. Cuenca
• MS-I
• Western University/COMP
• Class of 2004

Screened and Edited by the D.O. Class of 2004
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ARTICULARY TECHNIQUES

• ?What is it?
• Direct, passive technique
• Engages barrier
• Gaps joints and separates facets

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ARTICULARY TECHNIQUES

• Why do it?
• Increase range of motion
• Prepare the patient for HVLA

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ARTICULATORY TECHNIQUERib Raising Scenario
1Bilateral technique

• ? For most acutely debilitated patient
• Patient supine
• Dr. rests fingers under ribs from transverse
  process to angles
• Dr. lifts superior and lateral with MCP joints as
  fulcrum
• After tissue relaxes, Dr. moves to adjacent
  groups, repeat, then do same on other side
• May apply additional traction inferiorly to
  encourage pump-handle inhalation
• May apply supero-lateral traction to encourage
  bucket handle inhalation

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ARTICULATORY TECHNIQUERib Raising Scenario
2Bilateral technique

• ? For debilitated patient with freedom of arm
  motion
• Pt. Supine
• Dr. places caudad hand under Pt. thorax
• Dr. grasps Pt.s wrist with cephalad hand
• Pt. Inhales while Dr. flexes arm and ribs
  SIMULTANEOUSLY
• Repeat technique to adjacent ribs, then to other
  side until ribs move easily

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ARTICULATORY TECHNIQUERib Raising Scenario
3Bilateral technique

• ? For convalescing Pt. with asthma, emphysema,
  pneumonia, etc.
• ? Treats Pectoralis and Serratus Anterior MM.
• Pt. Supine, Dr. at head of table
• Pt. reaches around and clasps hands around Dr.s
  waist or grabs belt
• Dr. places hands under both sides of Pt. rib
  cage, contacting rib heads with finger pads and
  with proximal phalanges
• As Pt. inhales, Dr. leans back and elevates ribs
  anteriorly
• Repeat for adjacent ribs until ribs move easily

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ARTICULATORY TECHNIQUERib Raising Scenario
4Bilateral technique

• ? For Pt. That cannot lie down comfortably (e.g.
  asthmatic attack)
• 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 heads of ribs
• As Pt. inhales, Dr. draws thorax to him/her,
  creating backward bending of thoracic spine at
  fulcrum of hands
• Repeat until ribs move easily

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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

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MUSCLE ENERGY

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

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MUSCLE ENERGY RIB 1INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Dr. at head of patient
• Patient SUPINE
• Place and localize thumb in supraclavicular fossa
  on rib of dysfunction
• Flex head up with opposite hand
• Pt. Exhales holds 3 sec and Dr. follows rib down
• Dr. adjusts to new restrictive barrier
• Repeat 3-5X

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MUSCLE ENERGY RIBS 2-5INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Same position of Dr. and Pt. as previous slide
• Localize dysfunctional rib with fulcrum of MP/PIP
  joint
• Flex head up with opposite hand
• Pt. Exhales holds 3 sec and Dr. follows rib down
• Dr. adjusts to new restrictive barrier
• Repeat 3-5X
• Final Stretch

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MUSCLE ENERGY RIBS 6-10INHALATION SOMATIC
DYSFUNCTION(RIBS UP)

• Same hand positions as previous BUT have the
  patient reach for his/her knee on side of
  dysfunction

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MUSCLE ENERGY RIB 1 EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• ? This technique is utilizing the scalenes
• Pt. SUPINE
• Pt. Places forearm (same side of rib dysfunction)
  on his/her forehead
• Dr. stands on OPPOSITE side of dysfunction
• Dr. grasps dysfunctional rib POSTERIORLY at rib
  angle

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MUSCLE ENERGY RIB 1 (continued)EXHALATION
SOMATIC DYSFUNCTION(RIBS DOWN)

• Dr. holds down patients forearm
• Pt. INHALES, HOLDS BREATH (2-3 seconds), and
  FLEXES head while Dr. provides counterforce on
  forearm
• After exhalation, Dr. adjusts to new restrictive
  barrier
• Repeat 3-5X
• Final Stretch

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MUSCLE ENERGY RIB 2EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same hand positions as previous BUT patient turns
  head AWAY from side of lesion 30 degrees, then
  lifts head toward ceiling

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MUSCLE ENERGY RIBS 3-5EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same positions of Dr. and patient as previous
  BUT
• Pt. has forearm (lesion side) flexed up beside
  lesion
• Dr. places hand on Pt.s elbow of forearm
• Pt. lifts elbow of affected side toward OPPOSITE
  ASIS (diagonally)

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MUSCLE ENERGY RIBS 6-10EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Same positions of Dr. and patient as previous
  BUT
• Pt. has arm (lesion side) straight out at 90
  degrees from body
• Dr. places hand on Pt.s elbow
• Pt. pushes elbow of affected side directly
  lateral pull your arm straight down to your
  side

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MUSCLE ENERGY RIBS 10-12EXHALATION SOMATIC
DYSFUNCTION(RIBS DOWN)

• Pt. prone, positioned CONVEX on the side of the
  lesion
• Abduct Pt. Arm on lesion side
• Dr. stands to side of patient (facing towards
  Pt.s head) OPPOSITE of lesion
• Dr. places hamate of cephalic hand on medial part
  of dysfunctional rib
• Dr. grasps ASIS on lesion side with caudal hand

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MUSCLE ENERGY RIBS 10-12 (continued)EXHALATION
SOMATIC DYSFUNCTION(RIBS DOWN)

• Dr. lifts ASIS off table and with cephalic hand
  pushes anterior, lateral, and superiorly on
  dysfunctional rib
• Pt. INHALES, holds breath 3 sec. and pushes ASIS
  down against Dr.s unyielding force
• After exhalation, Dr. adjusts to new restrictive
  barrier
• Repeat 3X
• Final Stretch
• Retest

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MUSCLE ENERGY Hamstring tightness

• ? Tight hamstrings may affect Standing Flexion
  Test
• Pt. supine, Dr. standing next to leg to be
  treated facing Pt.s head
• Dr. flexes Pt.s hip and knee fully with hands on
  Pts ankles while flexed, knee is extended to
  its limit
• Pt. flexes knee 3-5 sec. against unyielding force
  by Dr.
• Dr. extends knee to new barrier, repeat 3-5X
• Retest

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MUSCLE ENERGY Pubic Disengagement Part A

• Pt. supine, hips flexed 90 degrees, feet on
  table, knees together
• Dr. wraps arms around Pt.s knees
• Pt. spreads knees against unyielding force by Dr.
  3-5 sec.
• Repeat 2-3X

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MUSCLE ENERGY Pubic Disengagement Part B

• Pt. in same position, but knees APART
• Dr. places forearm between Pt. knees
• Pt. brings knees together against unyielding
  force by Dr.
• Repeat 2-3X

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MUSCLE ENERGY Anterior Innominate Rotation

• Pt. supine, Dr. on same side as dysfunction
• Dr. flexes Pt.s hip and knee toward abdomen to
  restriction barrier
• Dr. braces flexed knee against caudad shoulder
• Dr. places cephalad hand on rotated ASIS and
  caudad hand on ischial tuberosity

Note hand should be on Pt. ASIS, NOT on knee
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MUSCLE ENERGY Anterior Innominate Rotation
(continued)

• Dr. pushes posteriosuperiorly on ASIS and pulls
  ischial tuberosity inferiorly and anteriorly
• Pt. pushes against unyielding force by Dr. for
  3-5 sec.
• After Pt. relaxes, Dr. engages new restrictive
  barrier
• Repeat 3-5X

Note hand should be on Pt. ASIS, NOT on knee
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MUSCLE ENERGY Posterior Innominate Rotation

• Pt. supine, Dr. stands on same side as
  dysfunction
• Dr. drops Pt.s affected leg off table to
  restriction barrier
• Dr. places one hand on affected anterior thigh,
  other hand on opposite ASIS
• Pt. raises thigh toward ceiling against Dr.s
  unyielding force 3-5 sec.
• Pt. relaxes Dr. engages new restrictive barrier
• Repeat 3-5X

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MUSCLE ENERGY OUTWARD ILIAL FLARE

• Pt. supine, Dr. stands on SAME side as
  dysfunction (e.g. on the R)
• Dr. flexes Pt.s leg at knee 90 degrees with one
  hand (R), lateral traction of posterior ilium
  with the other hand (L)
• Dr. adducts knee to barrier and patient abducts
  against unyielding force
• Repeat 3-5X

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MUSCLE ENERGY INWARD ILIAL FLARE

• Pt. supine, Dr. stands on OPPOSITE side of
  dysfunction
• Dr. positions affected leg in the sartorius
  muscle position
• Dr. places cephalad (L) hand on Pt.s ASIS on
  unaffected side
• Dr. places caudad (R) hand on Pts knee of
  affected leg and moves knee laterally to barrier
• Pt. adducts against unyielding force
• Repeat 3-5X

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MUSCLE ENERGY FORWARD SACRAL TORSION

• ? EXAMPLE L/L
• Pt. lies on side of involved axis (L)
• Dr. rotates Pt.s shoulders to face toward table
  (L)
• Pt. drops R arm off table
• Dr. flexes Pt.s knees and hips off table to
  localize
• Pt. inhales and during EXHALATION reaches toward
  for the floor (R arm)
• Repeat 3-5X

Part I
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MUSCLE ENERGY FORWARD SACRAL TORSION

• Dr. now applies unyielding force to patients
  ankles towards the floor while stabilizing Pt.
  with other hand
• Pt. Lifts ankles toward ceiling against
  unyielding force 3-5 sec.
• Pt. relaxes and Dr. engages new barrier
• Repeat 3-5X
• RETEST
• Note Patient can do both actions simultaneously

Part II
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MUSCLE ENERGY BACKWARD SACRAL TORSION

• ? EXAMPLE L/R
• Pt. lies on side of involved axis (R)
• Dr. extends Pt.s leg and flexes thigh off table,
  placing one hand on Pt.s knee
• Dr. places other hand on Pt.s shoulder and
  rotates Pt.s trunk to L down to L5
• Pt. raises upper leg toward ceiling against
  unyielding force
• Repeat 3-5X

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MUSCLE ENERGY UNILATERAL SACRAL FLEXION

• ? EXAMPLE Unilateral LEFT sacrum flexed
• Pt. prone, Dr. stands on affected (L) side and
  monitors L sacral sulcus
• Dr. abducts Pt.s L leg to area of maximum
  relaxation of SI joint
• Dr. springs L ILA with his/her R hand to find
  angle with greatest spring places palm of hand
  at angle
• During Pt. INHALATION, Dr. induces CEPHALAD and
  ANTERIOR force to L ILA
• Repeat 3-5X

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MUSCLE ENERGY UNILATERAL SACRAL EXTENSION

• ? EXAMPLE Unilateral RIGHT sacrum extension
• Pt. prone, Dr. stands on affected (R) side and
  monitors R sacral sulcus
• Dr. abducts Pt.s R leg to area of maximum
  relaxation of SI joint
• Dr. springs R sacral base with his/her L hand to
  find angle with greatest spring places palm of
  hand at angle
• During Pt. EXHALATION, Dr. induces CAUDAD and
  ANTERIOR force to R Sacral Base
• Repeat 3-5X

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MUSCLE ENERGY BILATERAL SACRAL FLEXION

• Pt. supine, Dr. stands to side
• Dr. abducts BOTH legs to area of maximum
  relaxation of BOTH SI joints
• Dr. springs over BOTH ILAs to find angle with
  greatest spring at the sulcus
• During Pt. INHALATION, Dr. induces a CEPHALAD and
  ANTERIOR force over the ILAs
• Repeat 3-5X

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MUSCLE ENERGY BILATERAL SACRAL EXTENSION

• Pt. supine, Dr. stands to side
• Dr. abducts BOTH legs to area of maximum
  relaxation of BOTH SI joints
• Dr. springs sacral base to find angle with
  greatest spring at the ILAs
• During Pt. EXHALATION, Dr. induces a CAUDAD and
  ANTERIOR force over the sacral base
• Repeat 3-5X

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TREATMENT FOR UP-SLIPPED INNOMINATE

• ? Direct action technique against the barrier
• Pt. supine, Dr. stands at Pt.s feet facing
  patient
• Dr. grabs ankle of affected leg and applies
  caudad traction, gently ab/adducting leg to
  determine most relaxed position for 30-60 sec.
• Short thrust IF NECESSARY

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TREATMENT FOR DOWN-SLIPPED INNOMINATE

• Pt. lies on side OPPOSITE side of dysfunction
• Dr. places one hand on inferior aspect of pubes
  other hand on ischial tuberosity of affected side
• Pt. Inhales and during EXHALATION, Dr. exerts
  cephalad force
• Short thrust IF NECESSARY or jump up and down on
  dysfunctional leg

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HVLA

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

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HVLA

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

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HVLA OA

• ? EXAMPLE SRRL
• SOFT TISSUE FIRST!!
• R hand cups chin, palm on zygoma
• L MP or PIP of index finger on bony calvarium of
  occiput
• Add a mild extension component limited to OA
• Rotate head to R
• Sidebend head to L and step slightly to the L of
  patient
• Approach the barrier
• Pt. inhales and at end point of exhalation, apply
  impulse toward R eye
• RETEST

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HVLA AA

• ? EXAMPLE RL
• SOFT TISSUE FIRST!!
• Same hand positions as previous slide BUT R hand
  cups chin with palm OR forearm (for stability) on
  zygoma
• Rotate Pt.s head to R and approach barrier
• Pt. inhales and at end point of exhalation, apply
  rotatory impulse at AA joint
• RETEST

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HVLA Typical Cervicals (Sidebending Focus)
(C2-C7)

• ? EXAMPLE C3 F SR RR
• SOFT TISSUE FIRST!!
• Same hand positions as before
• Flex patient down to C3/C4 joint space
• Add a mild extension component limited to C3
• Rotate head to R
• Sidebend head to L and step slightly to the L of
  patient
• Approach the barrier
• Pt. inhales and at end point of exhalation, apply
  impulse horizontally at C3 (towards opposite
  shoulder
• RETEST

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HVLA Typical Cervicals (Rotational Focus)
(C2-C7)

• ? EXAMPLE C3 F SL RL
• SOFT TISSUE FIRST!!
• Same hand positions as before, BUT
• Rotate AWAY and sidebend TOWARD restriction
• Apply thrust toward opposite eye

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HVLA RIBS

• ?Why do it with respects to Inhalation somatic
  dysfunction of rib 1?
• Due to anatomical relationships, the
  dysfunctional first rib has been implicated in
  several clinical syndromes, including
• Vascular compression
• Venous compression
• Lymphatic compression
• Nervous compression

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HVLA RIBS

• ?AS A RULE Diagnose and treat corresponding
  thoracic vertebral segment 1st BEFORE treating
  dysfunctional rib

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HVLA RIB 1 (SEATED)Inhalation Somatic
Dysfunction(Ribs up)

• SOFT TISSUE FIRST!!
• Pt. seated, Dr. behind patient
• Dr. places foot beside Pt. so that his/her knee
  is in Pt.s axilla OPPOSITE dysfunctional rib
• Dr. places MP joint of index finger on neck of
  dysfunctional 1st rib (like a karate chop)
• Dr. places other hand on top of Pt.s head with
  Pt.s neck resting on Dr.s forearm

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HVLA RIB 1 (SEATED)-ContinuedInhalation Somatic
Dysfunction(Ribs up)

• Pt. leans heavily on Dr.s knee (sidebend TOWARD
  restriction)
• Dr. SIDEBENDS Pt.s head TOWARD and ROTATE AWAY
  from dysfunctional rib
• Engage the barrier
• Pt. inhales and upon EXHALATION, Dr. applies
  impulse at ANGLE ACROSS THE BODY toward OPPOSITE
  COSTAL MARGIN

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HVLA RIB 1 (CROSS-ARM)Inhalation Somatic
Dysfunction(Ribs up)

• ? EXAMPLE Dysfunctional LEFT 1st rib
• SOFT TISSUE FIRST
• Pt. prone, Dr. at head of patient
• Pt.s head resting on chin Dr. places Pt.s chin
  toward side OPPOSITE (R) to dysfunctional rib and
  rotates head (with his/her Right hand) so it
  faces TOWARD dysfunction (L)
• Dr. places (L) thenar eminance on posterior
  aspect of Pt.s dysfunctional (L) rib (you should
  be crossing forearms at this point)

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HVLA RIB 1 (CROSS-ARM)-ContinuedInhalation
Somatic Dysfunction(Ribs up)

• Pt. inhales and during exhalation, Dr. takes up
  tissue slack
• At end point of EXHALATION, Dr. applies obliquely
  anterior, caudal, and lateral impulse against
  dysfunctional rib
• RETEST
• Note this technique is very effective for the
  upper two ribs

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HVLA TYPICAL RIBS (2-10)Inhalation Exhalation
Somatic Dysfunction

• SOFT TISSUE FIRST!!
• Pt. supine, Dr. stands to side OPPOSITE
  dysfunctional rib
• Pt.s arms crossed with OPPOSITE arm superior,
  elbows meeting in the middle
• Dr. places thenar eminence against rib angle
• Ribs UP BELOW inferior border pressing CEPHALAD
• Ribs DOWN ABOVE superior border pressing CAUDAD

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HVLA TYPICAL RIBS (2-10)-ContinuedInhalation
Exhalation Somatic Dysfunction

• Dr. places epigastrium over Pt.s elbows
• Dr. rolls patient BEYOND MIDLINE
• Pt. inhales and Dr. follows patient down during
  exhalation to restrictive barrier using his/her
  weight
• At exhalation end point, Dr. applies thrust
  through elbows to dysfunctional rib

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STRAIN/COUNTERSTRAIN

• ?What is it?
• Passive, positional technique that utilizes
  tender points
• Places a segment (spinal or other) in a position
  of comfort
• Technique treats the somatic dyfunction, NOT THE
  TENDER POINT

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STRAIN/COUNTERSTRAIN

• ?Why do it?
• Shortens involved muscles and connective tissue
• It arrests inappropriate nociceptive and
  proprioceptive activity that maintains the
  somatic dysfunction
• Inhibition of inappropriate strain reflex

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STRAIN/COUNTERSTRAINAnterior CervicalsLateral
1st Cervical (L1C)

• Pt. supine
• Dr. places index fingers on tip of transverse
  process of C1 (between angle of mandible and
  mastoid process)
• Dr. sidebends head toward tender point and finds
  point of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINAnterior CervicalsAnterior
1st Cervical (A1C)

• Pt. supine
• Dr. places index fingers on posterior edge of
  ascending ramus of mandible at the lobe of the
  ear
• Dr. rotates head away from tender point and finds
  point of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINAnterior Cervicals(A2C-A6C)

• Pt. supine
• Dr. places index fingers on anterior surface of
  tip of corresponding transverse process
• Dr. flexes head and neck to level of vertebra
  (45 degrees) with equal sidebending and rotation
  away (FSARA) and finds point of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINAnterior Cervicals(A7C)

• Pt. supine
• Dr. places index fingers 3cm lateral to the
  medial end of clavicle on posteriosuperior
  surface
• Dr. flexes head, sidebending toward and rotating
  head away (FSTRA) and finds point of least
  tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINAnterior Cervicals(A8C)

• Pt. supine
• Dr. places index fingers on medial end of
  clavicle in suprasternal notch, pressing
  laterally
• Dr. flexes head and neck to level of vertebra
  (45 degrees) with equal sidebending and rotation
  away (FSARA) and finds point of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINPosterior Cervicals(1CI
Inion)

• Pt. supine
• Dr. places index fingers on medial border of
  posterior muscle mass on occiput 2cm below
  External Occipital Protuberance
• Dr. flexes at base of occiput and finds point of
  least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINPosterior Cervicals(PC1)

• Pt. supine
• Dr. places index fingers 2 cm lateral to muscle
  mass, low on the occiput
• Dr. extends at base of occiput and finds point of
  least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

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STRAIN/COUNTERSTRAINPosterior Cervicals(PC2)

• Pt. supine
• Dr. places index fingers on muscle mass lateral
  to spinous process of C2
• Dr. extends head to C2, slight rotation away,
  slight sidebending away (ESARA) and finds point
  of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

TP 2 should be here
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STRAIN/COUNTERSTRAINPosterior Cervicals(PC3)

• Pt. supine
• Dr. place index fingers on INFERIOR SURFACE OF C2
  muscle mass
• Dr. flexes 45 degrees, sidebends head away,
  rotates away (FSARA) and finds point of least
  tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

62
STRAIN/COUNTERSTRAINPosterior Cervicals(PC4-PC8)

• Pt. supine
• Dr. places index fingers on muscle mass lateral
  to respective spinous processes of each vertebrae
• Dr. extends head OVER END OF TABLE to level of
  vertebra using light pressure on top of occiput,
  rotation, and sidebend away (ESARA) finds point
  of least tenderness
• Hold for 90 seconds
• Slowly bring head back to neutral
• Retest

63
STRAIN/COUNTERSTRAINAnterior Thoracics(A1T)

• Pt. seated w/ hands on top of head
• Dr. stands behind Pt., places arms under axilla
  around Pt.s chest with index finger pushing
  caudad into center of suprasternal notch
• Dr. has Pt. lean on his/her chest causing flexion
  and finds point of least tenderness
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

64
STRAIN/COUNTERSTRAINAnterior Thoracics(A2T)

• Pt. seated
• Dr. places index finger on middle of manubrium in
  midline
• Follow treatment protocol used for A1T

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STRAIN/COUNTERSTRAINAnterior Thoracics(A3T-A4T)

• Pt. seated with arms dropped back
• Dr. places forearms under Pt.s axilla and grasps
  medial side of Pt.s forearms to add internal
  rotation (cuff em)
• Dr. pulls backwards on Pt.s arms, creating
  fulcrum at desired level
• Dr. uses his/her chest and abdomen to force Pt.s
  thoracic spine into flexion.
• Dr. WILL NOT be able to monitor the tender point
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

66
STRAIN/COUNTERSTRAINAnterior Thoracics(A5T-A8T)

• Dr. pulls supine Pt. far enough table and applies
  strong force by pushing his/her femur and hip
  against Pt.s upper thoracics (Stuff em)
• Dr. places index finger on Tender Points (all
  close to midline)
• A5T 1 above xiphoid junction
• A6T at xiphoid junction
• A7T at tip of xiphoid
• A8T 1 below xiphoid
• Dr. fine tunes position to point of least
  tenderness
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

67
STRAIN/COUNTERSTRAINAnterior Thoracics(A9T-A12T)

• Pt. supine
• Dr. places pillow under Pt.s hips to flex lower
  thoracics and upper lumbars.
• Dr. places index finger on tender points
• A9T 1 cm above umbilicus
• A10T 1-2 cm below umbilicus
• A11T 3 cm below umbilicus
• A12T Iliac crest at mid-axillary line on
  superior/medial surface of ilium
• Pt.s knees and hips are flexed 135 degrees
• Dr. stands on side of tender point and pulls
  knees slightly toward tender side 20 degrees
• Dr. fine tunes position to point of least
  tenderness
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

68
STRAIN/COUNTERSTRAINPosterior Thoracics(P1T-P3T)

• Pt. prone with arms hanging over sides of table
  (1,2,3..hug a tree)
• Dr. supports Pt.s head by cupping point of chin
  in hand
• Dr. applies force straight posterior, bringing
  neck into extension
• Dr. monitors greatest tenderness very close to,
  or on midline, of spinous process of
  corresponding vertebral level
• Dr. fine tunes position to point of least
  tenderness by Extending, Side bending Away,
  Rotating Away the head (ESARA)
• Hold for 90 seconds
• Slowly bring back to neutral
• Retest

69
STRAIN/COUNTERSTRAINPosterior Thoracics(P4T-P6T)

• Pt. prone with arms extended overhead (4,5,6arms
  like sticks)
• Same technique as previous slide (ESARA)

70
STRAIN/COUNTERSTRAINPosterior Thoracics(P7T-P9T)

• Pt. in same position as previous slide, but
  pillow is placed under chest
• Same technique (ESARA)

71
STRAIN/COUNTERSTRAINPosterior Thoracics(P10T-P12
T)

• 10, 11, 12be like Pelv
• Dr. diagnoses rotation on tender point
• Dr. stands on OPPOSITE side of rotated direction
  of ease
• Dr. grasps ASIS on OPPOSITE side and rotates
  pelvis towards him/her 45 degrees

72
STRAIN/COUNTERSTRAINAnterior Ribs(AR1)

• Pt. seated
• Dr. places index finger on 1st costal cartilage
  adjacent to the sternum
• Dr. has Pt. lean and relax against his/her chest.
  Dr. induces on Pt.s head and neck (as a lever) a
  mild forward bending, sidebending towards, and
  MARKED ROTATION TOWARD tender point (FSTRT)
• Dr. fine tunes position to point of least
  tenderness
• Hold for 2 minutes
• Slowly bring back to neutral
• RETEST

73
STRAIN/COUNTERSTRAINAnterior Ribs(AR2)

• Same treatment as AR1 but Tender Point is at
  mid-clavicular line on rib 2

74
STRAIN/COUNTERSTRAINAnterior Ribs(AR3-AR6)

• Pt. seated
• Dr. places index finger on tender points located
  on the anterior axillary line, on INFERIOR rib
  margins
• Dr. places Pt.s axilla OPPOSITE lesion over
  his/her thigh.
• The Pt.s arm on the side of the lesion is
  suspended behind his/her back (off the table)
• Technique is FSTRT, but use the chest as the
  articulating lever fine tune position to point
  of least tenderness
• Hold for 2 minutes
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINPosterior Ribs(PR1)

• Pt. seated
• Dr. places index finger on tender point of first
  rib posterolateral aspect located beneath margin
  of trapezius
• Dr. places Pt.s axilla ON SAME SIDE of lesion
  over his/her thigh
• Using Pt.s neck as the articulating lever, Pt.
  is slightly extended, Sidebent away, slight
  rotation toward lesion (ESART)
• Dr. fine tunes technique and holds for 2
  minutes
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINPosterior Ribs(PR2-PR12)

• Pt. seated
• Pt. crosses arms over chest to move scapula in
  order to expose rib angles
• Dr. places index finger on tender point of
  superior margins of rib angles
• Same positioning of patient from previous slide
  BUT add Pt.s arm opposite lesion suspended
  behind back (off the table)
• Technique is same as PR1 the neck is used as
  well as thoracics for a lever, BUT NOW we do
  ESARA (no longer ESART).
• Dr. fine tunes technique and holds for 2
  minutes
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINAnterior Lumbars(A1L)

• Pt. Supine
• Dr. is on same side as tender point (medial to
  ASIS)
• Dr. flexes Pt.s legs to level of L1 with knees
  and ankles towards him/her (Dr.)
• Sidebend towards and rotate away from tender
  point (FSTRA)
• Dr. fine tunes technique and holds for 90
  seconds
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINAnterior Lumbars(Abd2L)

• Pt. Supine
• Dr. same side as tender point and places finger
  on tender point (abdominal wall 2 ½ lateral to
  umbilicus and ½ inferior)
• Dr. flexes Pt.s hips 90 degrees and rotates
  knees 60 degrees toward him/herself
• Dr. pushes Pt.s ankles away from physician and
  elevates them above Pt.s knees
• Dr. Flexes, sidebends away and rotates away from
  tender point (FSARA)
• Dr. fine tunes technique and holds for 90
  seconds
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINAnterior Lumbars(A2L)

• Pt. Supine
• Dr. stands OPPOSITE tender point and places
  finger on tender point (medial and inferior to
  AIIS)
• Dr. flexes Pt.s knees and hips 90 degrees and
  rotates 60 degrees toward him/herself. Or
• To level of L2
• When relief of pain is reached
• Dr. sidebends away and rotates toward tender
  point (FSART)
• Dr. fine tunes technique and holds for 90
  seconds
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINAnterior Lumbars(A3L)

• Pt. Supine
• Dr. is OPPOSITE tender point (lateral side of
  AIIS)
• Dr. flexes Pt.s knees to 90 degrees with MINIMAL
  rotation
• Marked sidebend away to level of L3 Sidebend
  away, rotate MINIMAL (SARM)
• Dr. fine tunes technique and holds for 90
  seconds
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINAnterior Lumbars(A4L)

• Same positions for Dr. and Pt. As previous slide
  BUT
• Sidebend to L4 SARM
• Tender point is beneath AIIS

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STRAIN/COUNTERSTRAINAnterior Lumbars(A5L)

• Pt. Supine
• Dr. is SAME side as tender point and places
  finger on tender point (front of pubic bone 1cm
  lateral to pubic symphysis)
• Dr. flexes Pt.s hips 135 degrees and rotates
  Pt.s knees toward him/herself slightly
• Flex, rotate away (FRA)
• Dr. fine tunes technique and holds for 90
  seconds
• Slowly bring back to neutral
• RETEST

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STRAIN/COUNTERSTRAINPosterior Lumbars(P1L)

• Pt. Prone
• Tender point is the spinous process and posterior
  surface of transverse process of L1
• Diagnose rotation of ease
• Dr. stands on opposite side of rotation, grasps
  the ASIS opposite him/her and rotates pelvis 45
  degrees

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STRAIN/COUNTERSTRAINPosterior Lumbars(P2L-P5L)

• Pt. Prone
• Tender points is same as previous slide except
  now with L2-L5 (respectively)
• Treatment is same as previous slide

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UNFINISHED POSTERIOR LUMBAR STRAIN/COUNTERSTRAIN
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Strain/CounterstrainPelvis and Hip

• SEE HANDOUT GIVEN IN CLASS

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MYOFASCIAL RELEASE

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

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MYOFASCIAL RELEASE

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

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CERVICAL MYOFASCIAL RELEASESuboccipital Release

• ? DIRECT technique
• Pt. Supine
• Dr. seated at head of table
• Dr. contacts suboccipital soft tissue between the
  occiput and spinous process of C2 with fingers
• Dr. applies deep pressure bilaterally by the use
  of patients head onto fingertips
• Dr. uses a GRADUAL traction until a resistance
  barrier is met
• Hold until palpable stretch and relaxation is
  achieved

90
CERVICAL MYOFASCIAL RELEASELigamentum Nuchae
Regional Technique

• ? INDIRECT technique
• ? Useful to balance regions covering greater than
  2-3 segments
• Example F SR RR C4-C7
• Pt. Supine, Dr. at head of table
• Dr. cradles Pt.s occiput in palm of one hand
  (fingertips in suboccipital region) and flexes
  neck to C4-C5
• Dr.s other hand grasps C4-C7 fascia overlying
  articular pillers
• Dr. applies gentle traction superiorly w/
  cephalad hand
• Motion test in all 3 planes
• Move tissue in direction of ease and follow
  tissues as they unwind
• Wait at least 90 seconds or until tissue is no
  longer changing
• Re-check range of motion

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GOOD LUCK ON YOUR EXAM!!!