Exam 2

Question 1

For ANY disease state, the patient must be STABLE before performing OMT

Answer 1

Cardiovascular, pulmonary, GI, GU, etc.
The sicker/weaker/more injured a patient is, use gentler techniques
New onset of chest pain or shortness of breath is not a time for OMT!

Question 2

Somatic dysfunction can occur anywhere in the body at

Answer 2

Sympathetics levels
Paraysmpathetic levels
Soma (not autonomic related)

Question 3

Viscerosomatic reflexes occur at

Answer 3

Sympathetics levels

Parasympathetics levels

Question 4

Facilitated segments ONLY occur at

Answer 4

Sympathetics

Question 5

If someone has a nocturnal cough at night, a couple things to think about is it may be due to asthma (pulmonary issue) or reflux (GI issue) for example. Where you find somatic dysfunction may be a clue to which one it is and what medication may be helpful.
For example, if it is found at T2 you would think more ___
For example, if it is found at T8 you would think ___
For example if it is found at T5 that could be ___

Answer 5

more pulmonary issue and maybe albuterol might be answer choice
think this is more GI and maybe omeprazole might be answer choice
be either pulmonary or GI and you would need more information to get correct answer

Question 6

Important to treat the thoracoabdominal diaphragm if flattened (indicates diminished zone of apposition). People with COPD are an example of people with a flattened diaphragm and diminished zone of apposition.

Answer 6

Treatment improves diaphragmatic excursion which improves the pressure gradient between abdominal cavity and thoracic cavity, which helps improve lymphatic flow
Treatment improves lymphatic flow also by relaxing the tension in the thoracoabdominal diaphragm

Question 7

When treating a group dysfunction with OMT

Answer 7

Go for the apex (middle) of the group curve

Question 8

A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. What is the most likely level of facilitation due to a viscerosomatic reflex in this patient?
A. OA
B. L2
C. T3 
D. T8
E. T11

Answer 8

C
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because facilitation occurs only at the sympathetic level!

Question 9

A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales.At which level would you expect her to have somatic dysfunction due to viscero-somatic reflex relating to her presentation?
A. OA
B. L2
C. T3 
D. T8
E. T11

Answer 9

In this case, both A and C would be correct answers, because both the parasympathetic and sympathetic nervous system would have viscerosomatic reflexes present in this patient’s clinical scenario!

Question 10

A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a sympathetic viscero-somatic reflex relating to her presentation?
A. OA
B. L2
C. T3 
D. T8
E. T11

Answer 10

C
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose C, because the question asks for the sympathetic level!

Question 11

A 78-year-old-female, with a history of congestive heart failure due to hypertension, presents to the emergency department with shortness of breath and swelling in the lower extremities for the past two hours. Lung auscultation reveals rales. At which level would you expect her to have somatic dysfunction due to a parasympathetic viscero-somatic reflex relating to her presentation?
A. OA
B. L2
C. T3 
D. T8
E. T11

Answer 11

A
In this case even though you have both parasympathetic and sympathetic levels which would be present in this patient’s presentation, you would only chose A, because the question asks for the parasympathetic level!

Question 12

Biomechanical (structural, postural)

Answer 12

Anatomy of muscles, spine, extremities; posture, motion
OMT directed toward normalizing mechanical somatic dysfunction, structural integrity, physiological function, homeostasis

Question 13

Neurological

Answer 13

Emphasizes CNS, PNS and ANS that control, coordinate and integrate body functions
Proprioceptive and muscle imbalances, facilitation, nerve compression disorders, autonomic reflex and visceral dysfunctions, brain/CNS dysfunctions

Question 14

Respiratory/Circulatory

Answer 14

Emphasizes pulmonary, circulatory and fluid (lymphatic, CSF) systems
Lymphatic techniques

Question 15

Metabolic/Nutritional

Answer 15

Regulates through metabolic processes

Question 16

Behavioral (Psychobehavioral)

Answer 16

Focuses on mental, emotional, social and spiritual dimensions related to health and disease

Question 17

Fryette Law 1

Answer 17

When side-bending is attempted from neutral (anatomical) position, rotation of vertebral bodies follows to the opposite direction.
Typically applies to a group of vertebrae (more than two)
Occurs in a neutral spine (no extreme flexion or extension) NO SAGITTAL COMPONENT
Side-bending and rotation occur to opposite sides
Side-bending precedes rotation
Side-bending occurs towards the concavity of the curve
Rotation occurs towards the convexity of the curve
May be described as a non-traumatic injury
Diagnosed as a Type I dysfunction when somatic dysfunction present

Question 18

Fryette Law 2

Answer 18

When side-bending is attempted from non-neutral (hyperflexed or hyperextended) position, rotation must precede side-bending to the same side.
Typically applies to a single vertebra
Occurs in a non-neutral spine (flexion or extension of spine present) SAGITTAL COMPONENT
Side-bending and rotation occur to same sides
Rotation precedes side-bending
Rotation of the vertebra occurs into the concavity of the curve of the spine
May be described as traumatic injury
Diagnosed as a Type II dysfunction when somatic dysfunction present

Question 19

If INDIRECT treatment used

Answer 19

exaggerate/augment the dysfunction

Take the dysfunction the way it likes to go

Question 20

If DIRECT treatment used

Answer 20

engage the barrier/reverse the dysfunction

Take the dysfunction the way it does not like to go

Question 21

Indirect Technique

Answer 21

Somatic dysfunction is exaggerated or augmented
Somatic dysfunction is taken the way it likes to go
Restrictive barrier is disengaged
Dysfunction is taken into position of injury
Uses inherent forces
Uses a compressive, tractional, or torsional component

Question 22

Examples of Indirect Techniques

Answer 22

Counterstrain
Facilitated Positional Release (FPR)
Balanced Ligamentous Tension Technique (BLT)
Functional Technique
Myofascial Release (may also be direct)
Cranial (may also be direct)
Still Technique (combined indirect and direct)
Initial positioning of Still Technique set up is indirect
Ending positioning of Still Technique is direct

Question 23

Counterstrain: Steps of Treatment

Answer 23

Assess the “this is a 10” pain level
Maintain finger contact at all times (NOT PRESSING FIRM constantly, only monitoring!)(***continuous monitoring)
this is to monitor tension, not to treat
Find the position of comfort
Retest by pressing with contact finger
This is a passive treatment
Hold it for 90 seconds (that’s the time for ALL counterstrain points, including ribs)
monitor tension and response
Return patient to neutral position SLOWLY!!
Recheck pain level
should be a 3 or less
The only time you press firmly is when finding the point, repositioning the point. All other times you are keeping you contact finger on point to just monitor location.

Question 24

Anterior Cervical CS Points
Anterior C 1
Location
Treatment Position

Answer 24

Mandible=Posterior aspect of the ascending ramus of the mandible at the level of the earlobe
Transverse process=Lateral aspect of the transverse process of C1
RA

Question 25

Anterior Cervical CS Points
Anterior C 2-6
Location
Treatment Position

Answer 25

On the anterolateral aspect of the corresponding anterior tubercle of the transverse process
FSARA

Question 26

Anterior Cervical CS Points
Anterior C 7
Location
Treatment Position

Answer 26

On the clavicular attachment of the SCM

FSTRA

Question 27

Anterior Cervical CS Points
Anterior C 8
Location
Treatment Position

Answer 27

At the sternal attachment of the SCM on the medial end of the clavicle
FSARA

Question 28

Posterior Cervical CS Points
PC1 Inion
Location
Treatment Position

Answer 28

On the inferior nuchal line, lateral to the inion

Marked Flexion

Question 29

Posterior Cervical CS Points
PC1 Occiput
Location
Treatment Position

Answer 29

On the inferior nuchal line at the splenius capitis (midway between the inion and mastoid)
Extended

Question 30

Posterior Cervical CS Points
PC2 Occiput
Location
Treatment Position

Answer 30

On the inferior nuchal line at the attachment of semispinalis capitis
Extended

Question 31

Posterior Cervical CS Points
PC2 Midline Spinous Process
Location
Treatment Position

Answer 31

On the superior aspect of the spinous process

Extended

Question 32

Posterior Cervical CS Points
PC3 Midline Spinous Process
Location
Treatment Position

Answer 32

At the side or inferolateral aspect of the spinous process of C2
FSARA

Question 33

Posterior Cervical CS Points
PC4-PC8 Midline Spinous Process
Location
Treatment Position

Answer 33

On the inferior or inferolateral aspect of the tip of the spinous process. Remainder of tender points follow this pattern.
ESARA

Question 34

Posterior Cervical CS Points
PC3-PC7 Lateral
Location
Treatment Position

Answer 34

On the posterolateral aspect of the articular process associated with the dysfunctional segment
ESARA

Question 35

Tender Point Anterior
AT1
Location
Classic Treatment Position

Answer 35

Midline or just lateral to the jugular (suprasternal) notch

Flexion to dysfunctional level

Question 36

Tender Point Anterior
AT2
Location
Classic Treatment Position

Answer 36

Midline or just lateral to the junction of manubrium and sternum (angle of Louis)
Flexion to dysfunctional level

Question 37

Tender Point Anterior
AT3-AT5
Location
Classic Treatment Position

Answer 37

Midline (or with some degree of sidedness) at level of corresponding rib
Flexion to dysfunctional level

Question 38

Tender Point Anterior
AT6
Location
Classic Treatment Position

Answer 38

Midline (or with some degree of sidedness) xiphoid–sternal junction
Flexion to dysfunctional level

Question 39

FPR

Answer 39

Body part in NEUTRAL position (flatten the curve/spine)
COMPRESSION applied to shorten muscle/muscle fibers (some cases may have TRACTION instead)
Place area into EASE of motion (INDIRECT) for 3-5 seconds
Return body part to neutral
THIS TECHNIQUE IS INDIRECT!!!!

Question 40

FPR Example

If C2 is extended, rotated right, side-bent right, you would

Answer 40

Place neck in a neutral position (flatten curve)
Add a compressive force
Then take C2 into extension, right rotation and right side-bending
Hold for 3-5 seconds
Return to neutral position and release compressive force

Question 41

Still Technique

Answer 41

Tissue/joint placed in EASE of motion position (augments the somatic dysfunction)
Compression (or traction) vector force added
Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector
THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!

Question 42

Still Technique

Answer 42

Tissue/joint placed in EASE of motion position (augments the somatic dysfunction)
Compression (or traction) vector force added
Tissue/joint moved through restriction (into and through the restrictive barrier) while maintaining compression (or traction) and force vector
THIS TECHNIQUE GOES FROM INDIRECT TO DIRECT!!!!

Question 43

There are many ways to ask how to diagnose C2 and once you figure out the diagnosis you can answer the treatment questions, for example:

Answer 43

C2 does not translate well to the right and becomes more symmetrical in extension
C2 translates easier to the left and becomes more asymmetrical in flexion
Both of these give you the diagnosis of C2 E RR SR

Question 44

Examples of Direct Techniques

Answer 44

Myofascial Release (May also be indirect)
Soft tissue
Articulatory
Muscle Energy
High velocity, low amplitude (HVLA)
Springing
Cranial (may also be indirect)
Still Technique (combined indirect and direct)
Initial positioning of Still Technique set up is indirect
Ending positioning of Still Technique is direct

Question 45

ME Technique

Postisometric Relaxation

Answer 45

Dysfunctional Structure Positioned at Feather Edge of Direct Barrier
(Positioning is in All Three [3] Planes of Motion)
Physician Continuously Monitors Dysfunction
Patient is Instructed to GENTLY Push AWAY From the Barrier
Physician Resists Patient’s Effort for 3 - 5 Seconds
Patient is Instructed to Relax
Physician Repositions Patient to Feather Edge of New Barrier
Repeat 3 - 5 Times or until Maximum Improvement
Passively Reposition to Neutral After Last Effort
Recheck Area of Dysfunction for Change

Question 46

ME Technique

Reciprocal Inhibition

Answer 46

Dysfunctional Structure Positioned at Feather Edge of Direct Barrier
(Positioning is in All Three [3] Planes of Motion)
Physician Continuously Monitors Dysfunction
Patient is Instructed to GENTLY Push TOWARD the Barrier
Physician Resists Patient’s Effort for 3 - 5 Seconds
Patient is Instructed to Relax
Physician Repositions Patient to Feather Edge of New Barrier
Repeat 3 - 5 Times or until Maximum Improvement
Passively Reposition to Neutral After Last Effort
Recheck Area of Dysfunction for Change

Question 47

Cardiac Autonomics
Sympathetics:
When considering arrhythmia:

Answer 47

Heart: T1-6 with synapses in upper thoracic and cervical chain ganglia.

Right and left-sided distributions
Right- sinoatrial (SA) node and right deep cardiac plexus– predisposes to supraventricular tachyarrhythmias.
Left-atrioventricular (AV) node and left deep cardiac plexus- predisposes to ectopic PVCs and V fib and V tach
Asymmetries in sympathetic tone may play a role in the generation of serious arrhythmias.

Question 48

Sympathetic Effects: Cardiac

Answer 48

Increases contractility
Increases force of contractility
Increases conduction velocity
Increases vasoconstriction
Increases peripheral vascular resistance
Increases arrhythmias (tachy-arrhythmias)
Decreases lymphatic drainage
Decreases development of collateral circulation

Question 49

Peripheral Sympathetic Supply
In addition to the direct effects on the organs, the sympathetic innervation also controls the vascular tone.

Sympathetic Supply to Upper Extremity Vasculature:
Sympathetic Supply to Lower Extremity Vasculature:

Answer 49

T2 to T8 levels

T11 to L2 levels

Question 50

Chapman Reflex Points
Myocardium, Thyroid, Esophagus, Bronchus
Anterior:
Posterior:

Answer 50

Anterior: 2nd intercostal space near sternum

Posterior: Midway between the spinous process and tips of the transverse process at T2

Question 51

Chapman Reflex Points
Upper Lung
Anterior:
Posterior:

Answer 51

Anterior: 3rd intercostal space near sternum

Posterior: Midway between the spinous processes and tips of the transverse processes of T3 and T4

Question 52

Chapman Reflex Points
Lower Lung
Anterior:
Posterior:

Answer 52

Anterior: 4th intercostal space near sternum

Posterior: Midway between the spinous processes and tips of the transverse processes of T4 and T5

Question 53

Chapman Reflex Points
Liver
Anterior:

Answer 53

Anterior: 5th intercostal space near sternum on R

Question 54

Chapman Reflex Points
Stomach (Acid)
Anterior:

Answer 54

Anterior: 5th intercostal space near sternum on L

Stomach Acid (think ulcers/NSAID use/Steroid use)

Question 55

Chapman Reflex Points
Liver, Gallbladder (Cholecystitis)
Anterior:

Answer 55

Anterior: 6th intercostal space near sternum on R

Question 56

Chapman Reflex Points
Stomach (Peristalsis)
Anterior:

Answer 56

Anterior: 6th intercostal space near sternum on L

Stomach Peristalsis (think of emptying time)

Question 57

Chapman Reflex Points
Pancreas
Anterior:

Answer 57

Anterior: 7th intercostal space near sternum on R

Question 58

Chapman Reflex Points
Spleen
Anterior:

Answer 58

Anterior: 7th intercostal space near sternum on L

Question 59

Chapman Reflex Points
Adrenal Glands
Anterior:
Posterior:

Answer 59

Anterior: 1” Lateral and 2” Superior to Umbilicus Ipsilaterally

Posterior: Intertransverse Spaces of T11 and T12 Ipsilaterally Midway Between Spinous and Transverse Processes

Question 60

Chapman Reflex Points
Kidneys
Anterior:
Posterior:

Answer 60

Anterior: 1” Lateral and 1” Superior to Umbilicus Ipsilaterally

Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of T12-L1

Question 61

Chapman Reflex Points
Urinary Bladder
Anterior:
Posterior:

Answer 61

Anterior: Umbilical Area (Periumbilical)

Posterior: Intertransverse Spaces Midway Between Spines and Transverse Tips of L1-L2

Question 62

Chapman Reflex Points
Appendix
Anterior:
Posterior:

Answer 62

Anterior: Tip of the right 12th rib

Posterior: At the transverse process of T11

Question 63

Cardiac Autonomics
Parasympathetics:
When considering arrhythmia:

Answer 63

Heart: CN X (Vagus nerve): OA, C1, C2 somatic dysfunction can affect CN X

Right vagus-via SA node and hyperactivity predisposes to sinus bradyarrhythmias.
Left vagus- via AV node where hyperactivity predisposes to AV blocks.
Vagus nerves have fibers course to them from the C-1 & C-2 nerve roots.
Heart may be reflexively slowed by other organ visceral afferents.
Pulmonary branches have strongest influence

Question 64

Parasympathetic Innervation to the Heart

Answer 64

Cranial Nerve X (Vagus)
Jugular foramen, Occipitomastoid (OM) suture, OA, AA, C2
Right and Left sided distribution
Right side= SA node
Left side= AV node
(PS: minimal and isolated peripheral arteriolar innervation)
Minimal PS innervation: vasodilation of arterioles in periphery. Face blush, submax glands, parotid glands, tongue, penis

Question 65

Parasympathetic Effects: Cardiac

Answer 65

Decreases contractility
Decreases conduction velocity
Increases arrhythmia (brady-arrhythmias)

Question 66

Vagus nerve originates in the brainstem and exits through the jugular foramen. The jugular foramen is formed from the occipitomastoid suture, which is made up from the temporal bone and the occiput. So dysfunction affecting the vagus nerve could come from occipitomastoid suture compression.

Answer 66

Think what organs that might affect: If it comes from the right side of left side.
For example how may it affect heart rhythms

Question 67

What happens to Vagus nerve in heart transplant patient?

Answer 67

Which techniques would not be effective due to this following the surgery? Suboccipital Release because Vagus nerve is cut**

Question 68

Important Highlights

Answer 68

First rib elevation causes T1 to follow Type II mechanics to the opposite side
Example, if left rib is elevated, T1 would be RRSR

Feather’s Edge refers to feeling at Restrictive Barrier

After a History, you must do a Physical (for example observation, palpation, etc.).
Once these are done, along with any other diagnostic workup) then you can make an assessment and treatment plan.

Question 69

Important Highlights

Answer 69

Congestive Heart Failure (decompensated), Acute Myocardial Infarction
Do not use lymphatic pump techniques on patients

Congestive Heart Failure, COPD
Do not treat in supine position

The sicker the patient is, the weaker the patient is, the more frail the patient is:
Use gentle techniques, for example rib raising, soft tissue inhibition, myofascial release, counterstrain, etc.
Do not use techniques like muscle energy which can wear out the patient. Do not use HVLA

Question 70

Lymphatics

Answer 70

Heart and lungs drain predominantly to the right lymphatic duct

Question 71

Treating Lymphatics

Examples:

Answer 71

• **(Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment)
• ** Another way of saying this is that you have to open myofascial pathways at the transition zones

Examples include:
Anterior cervical fascia release
Thoracic inlet myofascial release
Pectoral Traction

Question 72

MI Somatic Diagnosis

Answer 72

Viscerosomatic reflexes T1-T6

Chapman reflex Myocardium:

• Anterior: 2nd intercostal space near sternum
• Posterior: between T2 and T3

Palpable changes left upper thoracic spine and ribs

Specific

• Anterior infarct: T2-3 L
• Inferior wall: T3-5L, C2

Right pectoralis major trigger point 5th intercostal space (ICS) associated with supraventricular tachyarrhythmia due to sympathetic nervous system

Question 73

Hypertension

Answer 73

Hypertension: a statistically significant correlation has been demonstrated between hypertension and C6,T2,T6 somatic dysfunction pattern.

A cause-effect relationship has not been established

Question 74

Hypertension: Common Functional Elements

Answer 74

Vascular and cardiac hypersensitivity to sympathetic stimuli

Prolonged sympathetic stimuli to the kidneys (T10-T11): THIS IS WHERE ACE INHIBITORS WOULD WORK
-Causes functional salt and water retention and increasing arterial pressure

Venoconstriction causing increased cardiac output with normal peripheral resistance
-Eventual increase in peripheral resistance to reduce cardiac output

Prolonged HTN causes baroreceptors in the carotid sinus to reset and maintain the increased arterial pressure

Question 75

Atrial fibrillation

HR ~150 to 110 (varies)

Answer 75

Thoracic vertebrae should be rotated to the right

Question 76

Sinus tachycardia rate 140

Answer 76

Thoracic vertebrae should be rotated to the right

Question 77

Acute anterior wall MI with ST elevations and Q waves in V1–V4 and aVL

Answer 77

Reciprocal inferior ST depressions

Question 78

3rd degree AV block

Answer 78

Cervical vertebrae should be rotated to the left

Question 79

Sinus bradycardia

Answer 79

Cervical vertebra should be rotated to the right

Question 80

1st degree AV block

Answer 80

Cervical vertebra should be rotated to the left

Question 81

Rib Raising Timing

Answer 81

Rib raising done for a short period of time (less than 2 minutes) will usually stimulate the sympathetic effects. For example, bronchodilation
Rib raising done for a longer period of time (greater than 2 minutes) will usually lessen the sympathetic effects.

Question 82

Sympathetics: T1-T6 (T2-T7): Lung, Trachea, Bronchi, Visceral Pleura

Answer 82

Bronchodilation
Vasoconstriction
Increased Goblet cell production
Decreased number of ciliated cells
Increased thick, sticky secretions
Dries the mucous membranes
Decreased lymphatic/circulatory drainage

Question 83

Sympathetics

Increased sympathetic outflow:

Answer 83

Bronchodilation

Vasoconstriction

• -> diminishes nutrient supply to the tissues (incl. medications)
• -> reduces lymphatic and venous drainage

increased number of goblet cells

• leads to thick and sticky respiratory epithelium (hyperplasia) = decreased mobility of the mucous
• inhibits secretion – leading to dryness and cracking of the mucosa allowing for secondary bacterial infections

Question 84

Parasympathetics

Answer 84

Vagus Nerve (CNX)

CN IX,X – Carotid Body
BP, CO2, O2 Regulation

Bronchial glands inhibited
Increased Ciliated/Goblet Ratio: Thinning of Mucous

Bronchial muscles constriction

Evaluate OA, AA/C1, C2 (close proximity of Vagus)

Vagus (CN X) for the respiratory airways:
-Right and left

Parasympathetic dominance is important to keep the mucous secretions clear and saliva-like (but sticky).

• Makes secretions thinner
• Ease ciliary clearance

Question 85

Parasympathetic Response

Answer 85

Contraction of bronchiolar smooth muscle (bronchoconstriction)
Thins secretions
Vasodilation (pulmonary)
Hering-Breuer reflex
-Unable to differentiate alveoli filled with air or fluid
-Respiratory excursion is limited
Respiratory centers sense low O2 levels and increase diaphragmatic rate
Overall response: Shallow Breathing at a Rapid Rate
Responsible for production of profuse, clear, thin secretions from mucosa of the nasopharynx and sinuses

Question 86

Increased Parasympathetic Activity

Answer 86

Bronchoconstriction
Increased clear, thin, watery secretions of glands
Improved/increased drainage

Question 87

Lymphatics

Response to Disease

Answer 87

Flattening of the diaphragm causes stagnation of lymph

• Increased tissue congestion
• Decreased cardiac output
• Associated with increased infection, mortality, prolonged healing time, fibrosis and scarring

Question 88

Treating Lymphatics

Examples:

Answer 88

Thoracic inlet/outlet has to be cleared/opened/treated BEFORE ANY other lymphatic treatment)

***Examples include:
Anterior cervical fascia release
Thoracic inlet myofascial release
Pectoral Traction

Question 89

Thoracoabdominal Diaphragm

Answer 89

Must evaluate neurological influence versus biomechanical influence

• Neurologically: Phrenic Nerve/C3, C4, C5
• Biomechanically: Where the thoracoabdominal diaphragm attaches: lower ribs, thoraco-lumbar junction, T10-L3 are examples.

Question 90

Rib Raising

Answer 90

Rib raising done for a short period of time (less than 2 minutes) will usually stimulate the sympathetic effects. For example, bronchodilation
Rib raising done for a longer period of time (greater than 2 minutes) will usually lessen the sympathetic effects.

Question 91

Thoracic Diaphragm: Physiology

Answer 91

Thoracic Diaphragm motion increases the volume of the thorax in Three Planes of Motion
*Inferior/Superior (limited by mediastinum)
*Transverse (Ribs 6-12, bucket-handle motion)
*Anterior/Posterior (Ribs 1-5, pump-handle)
Dome of the Diaphragm
*zone of apposition
Posture: Diaphragm’s greatest excursion is in the supine position

Question 92

Diaphragm - Lymphatic Pump

Answer 92

Lymphatic Drainage:
Affected by contraction of the diaphragm & thoracic cage motion
Assists in fighting infection
Prevents tissue congestion
Has a piston-like motion
*Flattens and moves inferior with inhalation when skeletal muscle contracts
*Domes upward and ascends with exhalation as skeletal relaxes

Question 93

Diaphragm

Consequences of Impaired Diaphragmatic Mobility:

Answer 93

Shortness of Breath
Less effective gas exchange in the lungs
Retention of Pulmonary Secretions
Constipation and Other Bowel Dysfunctions
Backache
Pelvic Congestion, Dysmenorrhea
Hemorrhoids
Leg Edema, Varicosities, Night Cramps
Headache, Irritability, Malaise, Dizziness, Confusion

Question 94

Bronchial Asthma: Signs / Symptoms

Answer 94

Dyspnea / Wheezing
Use of Accessory muscles
Positioning, patient will brace him/herself (Tripod position)

Question 95

Bronchial Asthma: Treatment

Answer 95

Acute attack

• Address immediate needs (monitor vitals)
• Oxygen
• Medications (β2 agonists, Anticholinergic, Steroids)
• Nebulizers

Once stable
-OMT
(NEVER use Thoracic pump WITH respiratory Assist during acute attack)

Between attacks
-Treat all components of respiratory system

Question 96

COPD: Musculoskeletal Changes

Answer 96

Barrel shaped chest 
↑ AP diameter
↑ Transverse diameter
Hypertophy of accessory muscles
May lead to neurovascular impingement (thoracic outlet syndrome)
What else may this lead to? For example, decreased lymphatic drainage
Decreased rib motion
Thoracic kyphosis

Restricted motion of the diaphragm
Flattened diaphragm (Diminished Zone of Apposition)
Decreased lymphatic drainage will occur because rib cage and diaphragm are not moving well

Question 97

Asthma/COPD

Answer 97

May be on steroids for extended periods of time

• What may be the side-effects? Osteoporosis, diabetes mellitus, adrenal insufficiency
• Where would you find viscerosomatic changes, Chapman points related to diabetes and adrenal insufficiency?
• What would you see on imaging, lab work for above side-effects?

If someone has taken steroids for an asthma and hasn’t tapered off after heavy dosing for an extended time, what are you concerned about? For example adrenal insufficiency. The patient may present with fatigue, because adrenals aren’t working like they should. They stopped working because receiving exogenous steroids.

What are you concerned about with OMT in Asthma/COPD?

What treatment position is best avoided and why? Supine, they feel they can’t breathe.

What techniques should be avoided in an asthmatic attack or exacerbation of COPD? Thoracic pump with respiratory assist (recoil)

Question 98

Important Highlights

Answer 98

COPD
Do not treat in supine position (will feel like they are suffocating/can’t breathe)

The sicker the patient is, the weaker the patient is, the more frail the patient is:
Use gentle techniques, for example rib raising, myofascial release, counterstrain, etc.
Do not use techniques like muscle energy which can wear out the patient. Do not use HVLA, do not use lymphatic pump techniques.

Question 99

Rib Motions

Answer 99

Pump-Handle motion
Primarily ribs 1-5
Palpation of Pump Handle Ribs: best at Mid-clavicular Line

Bucket-Handle motion
Primarily ribs 6-10
Palpation of Bucket Handle Ribs: best at Mid-axillary Line

Caliper motion
Primarily ribs 11,12

Question 100

Pump Handle Motion

Answer 100

Predominantly ribs 1-5
Ribs move anterior and superior with inhalation
Motion predominantly in sagittal plane
Best palpated at mid-clavicular line
Axis of motion is costovertebral-costotransverse line

Question 101

Bucket Handle Motion

Answer 101

Predominantly ribs 6-10
Ribs move laterally and increase transverse diameter with inhalation
Motion predominantly in coronal plane
Best palpated at mid-axillary line
Axis of motion is a costovertebral-costosternal line

Question 102

Inhalation Rib Somatic Dysfunction

Answer 102

Somatic dysfunction usually characterized by a rib being held in a position of inhalation
Motion toward inhalation is more free
Motion toward exhalation is restricted
Patient may complain of pain with EXHALATION

Synonyms: 
Exhalation rib restriction 
Inhalation strain
Elevated rib 
Inhaled rib

Question 103

Exhalation Rib Somatic Dysfunction

Answer 103

Somatic dysfunction usually characterized by a rib being held in a position of exhalation
Motion toward exhalation is more free
Motion toward inhalation is restricted
Patient may complain of pain with INHALATION

Synonyms: 
Inhalation rib restriction 
Exhalation strain
Depressed rib 
Exhaled rib

Question 104

Rib Information

Answer 104

B.I.T.E
Bottom Rib is key rib in Inhalation dysfunction
Top Rib is key rib in Exhalation dysfunction
Exhaled ribs are prominent posteriorly
Inhaled ribs are prominent anteriorly
Anterior Rib Counterstrain Points are associated with Exhalation Rib Somatic Dysfunction
Posterior Rib Counterstrain Points are associated with Inhalation Rib Somatic Dysfunction

Question 105

If pain increases when patient inhales:
pain increases when patient exhales:
If left ribs 2-5 lag on exhalation as compared to the right side:

Answer 105

indicates exhalation rib somatic dysfunction

indicates inhalation rib somatic dysfunction

then left ribs 2-5 are dysfunctional and represent inhalation somatic dysfunction. The key rib would be rib 5 and the muscle that may have caused this is pectoralis minor. Rib 5 is holding up rib 2, 3,4 and won’t let them exhale. Rib 5 is the BOTTOM rib causing the dysfunction.
Other findings that may be present:
There may be posterior rib counterstrain points associated with inhalation rib somatic dysfunction
Ribs would be prominent anteriorly with inhalation rib somatic dysfunction

Question 106

If left ribs 2-5 lags on inhalation as compared to the right side,

Answer 106

then left ribs 2-5 are dysfunctional and represent exhalation somatic dysfunction. The key rib would be rib 2. Rib 2 is holding down rib 3, 4, 5 and won’t let them inhale. Rib 2 is the TOP rib causing the exhalation rib somatic dysfunction.
Other findings that may be present:
There may be anterior rib counterstrain points associated with exhalation rib somatic dysfunction
Ribs would be prominent posteriorly with exhalation rib somatic dysfunction

Question 107

Samples of how to diagnose ribs:

Answer 107

If right ribs have an increased 6th intercostal space (ICS), then at this point either rib 6 is inhaled or rib 7 is exhaled.

If right ribs have a decreased 6th intercostal space (ICS), then at this point either rib 6 is exhaled or rib 7 is inhaled.

Example: If right ribs have an increased 6th intercostal space (ICS), and they lag on inhalation, then you know it is an exhalation somatic dysfunction and therefore rib 7 is exhaled.

Example: if right ribs have an increased 6th intercostal space (ICS), and the patient has pain when they exhale, then you know it is an inhalation somatic dysfunction and rib 6 is inhaled.

Example: If right ribs have an increased 6th intercostal space (ICS), and there are anterior rib counterstrain points found on exam, then you know this represents an exhalation somatic dysfunction and rib 7 is exhaled.

Example: If right ribs have an increased 6th intercostal space (ICS), and the ribs are prominent posteriorly, then you know it is an exhalation somatic dysfunction and rib 7 is exhaled.

Question 108

Samples of how to diagnose ribs

Answer 108

Prominent ribs posteriorly would indicate exhalation somatic dysfunction

Prominent ribs anteriorly would indicate inhalation somatic dysfunction

Anterior rib counterstrain points would indicate exhalation somatic dysfunction

Posterior rib counterstrain points would indicate inhalation somatic dysfunction

Another sample question: If ribs 2-8 lag on exhalation, which muscle might have caused this? So you know it is an inhalation somatic dysfunction and that 8 is the key rib in inhalation somatic dysfunction (B.I.T.E). Muscles used to treat exhaled ribs may become hypertonic and lead to an inhalation somatic dysfunction. Since serratus anterior is associated with rib 8, that is the muscle that has now caused the inhalation somatic dysfunction!

Note: Piece all the findings giving to you from questions to formulate what the rib diagnosis is, what muscles may have caused it, how do you set them up for treatment if inhalation versus exhalation muscle energy, etc.

Question 109

Anterior Rib Tender Points
Tender Point Locations: 
AR1 
AR2 
AR3-10

Answer 109

AR1
Below clavicle on 1st chondrosternal articulation associated with pectoralis major and internal intercostal muscles

AR2
Superior aspect of 2nd rib in midclavicular line

AR3-10
On the dysfunctional rib at the anterior axillary line associated with the serratus anterior (AR3-8) and internal intercostal muscles (AR9-10)

Question 110

Treatment of AR1-2 Tender Points - STRT

Answer 110

The patient lies supine and the physician stands or sits at the head of the table.

The physician passively flexes patient’s head and neck to engage the dysfunctional rib level.

The patient’s head and neck are side-bent and rotated toward the tender point

The physician fine-tunes through small arcs of motion (flexion, extension, side bending, or rotation).

The physician holds this position for 90 seconds

Reassess!

Question 111

Treatment of AR3-10 Tender Points - STRT

Answer 111

The patient is seated with the hips and knees flexed on the table on the side of the tender point. The patient may let the leg on the side of the tender point hang off the front of the table, the other leg crossed under it.

The physician stands behind the patient with the foot opposite the tender point on the table and the thigh under the patient’s axilla (induces side bending toward tender point).

The patient’s thorax is slightly flexed to the dysfunctional level.

The patient’s arm opposite the tender point is draped over physician’s leg. The patient’s arm on the side of the tender point is extended and allowed to hang off the edge of the table behind the patient, inducing rotation toward and translation away (sidebending toward) the tender point.

The physician fine-tunes through small arcs of motion (flexion, extension, side bending, or rotation).

The physician holds this position for 90 seconds.

Reassess!

Question 112

Posterior Rib Tender Points 
Indications: 
Somatic dysfunction of ribs 1-6 (commonly inhaled) 
Rib 1 
Rib 2-6

Answer 112

Rib 1:
Pain in cervicothoracic junction

Ribs 2-6:
Pain in upper to mid-thoracic and/or periscapular region

May be caused by trauma, overhead sleeping position or sudden movement of neck or thorax

Question 113

Posterior Rib Tender Points
Locations: 
PR1: 
PR2-6: 
PR7-10

Answer 113

PR1:
On posterior superior aspect of 1st rib at cervicothoracic angle immediately anterior to trapezius

PR2-6:
On superior aspect of angle of dysfunctional rib associated with the levatores costarum and/or serratus posterior superior muscles

PR7-10:
On superior aspect of angle of dysfunctional rib associated with the levatores costarum

Question 114

Treatment of PR1 Tender Point - STRT

Answer 114

The patient is seated. The physician stands behind the patient.
The physician’s foot is placed on the table on the same side as the tender point.
The physician monitors the first rib tender point with the index finger pad, which is on the tender point
With the other hand, the physician side-bends the head and neck toward the tender point, then gently flexes or extends the head and neck, carefully monitoring the movement so it is vectored to engage the first rib.
The physician fine-tunes through small arcs of motion (flexion, extension, rotation, and side bending).
The physician holds this position for 90 seconds.
Reassess!

Question 115

Treatment of PR2-10 Tender Points - SARA

Answer 115

The patient is seated with legs on the side of table (for comfort, the patient may hang the leg opposite the tender point off the table).
The physician stands behind patient with the foot ipsilateral to the tender point on the table with the thigh under the patient’s axilla.
The physician gently flexes patient’s head, neck, and thorax to engage the level of the dysfunctional rib.
The physician elevates the patient’s shoulder with the axilla resting on the thigh, which side-bends the trunk away from the tender point.
The patient is asked to slowly extend the shoulder and arm opposite the tender point and allow the arm to hang down. This induces side bending away (translation towards) and rotation away from the tender point.
The physician fine-tunes through small arcs of motion (flexion, extension, rotation, and side bending).
The physician holds this position for 90 seconds.
Reassess!

Question 116

Supine Thoracic HVLA: T7 NSLRR

Answer 116

Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) under the posterior transverse process of the dysfunctional segment
Side-bend the patient to the right (away from you) engaging the restrictive barrier
The patient forms a “smiley” face from your viewpoint
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence)
Recheck your findings

Question 117

Supine Thoracic HVLA: T7 FSRRR

Answer 117

Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) under the posterior transverse process of the dysfunctional segment
Sidebend the patient to the left (toward you) engaging the restrictive barrier
The patient forms a “frowny” face from your viewpoint
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust straight down toward your fulcrum (thenar eminence)
Recheck your findings

Question 118

Supine Thoracic HVLA: T7 ESRRR

Answer 118

Patient is supine and physician standing on the left side of the patient (stand on the opposite side of the posterior transverse process)
Patient crosses arms opposite over adjacent
Physician places left thenar eminence (caudad hand) on the right transverse process below the dysfunctional segment
With your cephalad hand, flex the patient’s torso to the T7-T8 joint space
Side-bend the patient to the left (towards you) engaging the restrictive barrier (the patient forms a “frowny” face from your viewpoint)
Have the patient take a deep breath in and exhale out
At the end of exhalation, apply a HVLA thrust directed 45 degrees cephalad toward your fulcrum (thenar eminence)
Recheck your findings

Question 119

Muscle Energy

Inhalation Dysfunction Ribs 1 - 10

Answer 119

Patient is supine, physician at head of table
Pump-handle ribs
Flex the patient’s head and neck
Bucket-handle ribs
Flex and Side-bend the patient towards dysfunctional rib
Physician places a hand, thumb, or fingers on the anterior, superior surface of the rib
Patient inhales deeply and holds for 3-5 seconds
Physician resists inhalation motion of rib
effecting an isometric contraction
Patient exhales, physician follows the rib into exhalation
Physician takes up the slack, and adjusts flexion/side-bending after a 2 second pause
The process is repeated 3-5 times
Reassess

Question 120

Muscle Energy

Exhalation Dysfunction Ribs 1 – 10

Answer 120

Patient supine, physician at head of table
The patient is instructed to place their arm in the correct position as directed by the physician in order to use the correct muscle during the treatment.
Physician contacts the key rib posteriorly at the rib angle.
Patient inhales while the physician applies an inferior force to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while performing an isometric contractions, pushing with their arm into the physicians resistance, for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is re-assessed.

Question 121

Muscles used in Muscle Energy to Treat Rib Exhalation Somatic Dysfunction

Answer 121

Rib 1: Anterior and mid scalene 
Rib 2: Posterior Scalene
Ribs 3 – 5: Pectoralis Minor
Ribs 6 – 8: Serratus anterior 
Ribs 9 – 11: Latissimus Dorsi 
Rib 12: Quadratus Lumborum 

NOTE: If these muscles become hypertonic, they can cause an inhalation somatic dysfunction!!!!

Question 122

Muscle Energy

Exhalation Dysfunction Rib 1

Answer 122

Anterior and middle scalene muscles attach to rib 1
Contraction of these muscles help mobilize the exhaled rib

Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 1 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while lifting their head anteriorly, physician resists this motion for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is reassessed.

Question 123

Muscle Energy

Exhalation Dysfunction Rib 2

Answer 123

Posterior scalene muscle attaches to rib 2
Contraction of this muscle help mobilize the exhaled rib

Patient supine, physician at head of table
The patient’s hand on their forehead palm up and rotates away
Physician grasps rib 2 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath while lifting their head anteriorly, physician resists this motion for 3-5 seconds.
The process is repeated 3-5 times and then rib motion is reassessed

Question 124

Muscle Energy

Exhalation Dysfunction Rib 3-5

Answer 124

Pectoralis Minor muscle attaches to ribs 3, 4, 5
Contraction of these muscles help mobilize the exhaled rib

Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 3, 4, 5 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow to their contralateral ASIS, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.

Question 125

Muscle Energy

Exhalation Dysfunction Rib 6-8

Answer 125

Serratus Anterior muscle attaches to ribs 6, 7, 8
It attaches to other ribs as well but the angle of attachment to these ribs is what assists in the treatment
Contraction of these muscles help mobilize the exhaled rib

Option 1
Patient supine, physician at head of table
The patient’s hand behind their head, elbow pointing straight up
Physician grasps rib 6, 7, 8 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow toward the ceiling, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.

Option 2
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 6, 7, 8 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and pushes their elbow to their ipsilateral ASIS, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.

Question 126

Muscle Energy

Exhalation Dysfunction Rib 9-10

Answer 126

Latissimus dorsi muscle attaches to ribs 9, 10, 11
Contraction of these muscles help mobilize the exhaled rib

Option 1
Patient supine, physician at head of table
The patient’s hand on their forehead palm up
Physician grasps rib 9, 10 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and ADduct their arm, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.

Option 2
Patient supine, physician at head of table
The patient’s arm is ABducted
Physician grasps rib 9, 10 posteriorly at the rib angle
Patient inhales, physician applies an inferior traction to the rib angle
At full inhalation, the patient is instructed to hold his/her breath and ADduct their arm, physician resists this motion for 3-5 seconds
The process is repeated 3-5 times and then rib motion is reassessed.

Question 127

HVLA Seated Inhaled Rib 1

Answer 127

Physician stands behind and places his contralateral foot onto the table
Patient drapes contralateral arm over physician’s leg and leans against the leg
Physician places ipsilateral 2nd MCP joint (thrusting hand) over the rib head
Physician places the contralateral hand to sidebend the cervical spine towards the dysfunctional rib and rotates head away from dysfunctional rib
Slack is taken up (patient exhales)
Thrust is directed caudal and medial as the sidebending is exaggerated
NOTE: Apply ONLY about 5% of your force to the patient’s head or neck!!!

Question 128

Rib HVLA 2-10 (Inhalation or Exhalation)

Answer 128

Similar to Thoracic Supine HVLA (Kirkesville Crunch)
Place thenar eminence (fulcrum) on posterior aspect of rib angle instead of transverse process

For exhalation rib HVLA, your thenar eminence on the rib angle will pull downward (inferior/caudad) on rib angle
For inhalation rib HVLA , your thenar eminence on the rib angle will push upward (superior/cephalad) on rib angle

Question 129

Please look over indications/contraindications for indirect and direct techniques:

Answer 129

For example if a patient is unable to follow commands (ie: due to language barriers, dementia(confusion), delirium (confusion) they can not participate in M.E. because they can not follow commands to push against resistance, etc.