BOARD REVIEW

AXIAL
SKELETON
Cervical,Thoracic,Lumbar,Sacrum,Pelvis,Cranial

DENISE K. BURNS, DO, FAAO

PROFESSOR OMM
TOUROCOM
BASIC CONCEPTS
 SOMATIC DYSFUNCTION:
IS AN IMPAIRMENT OR ALTERED FUNCTION OF RELATED
COMPONENTS OF THE SOMAATIC ( BODY FRAMEWORK )
SYSTEM: ARTHROIDAL, MYOFASCIAL STRUCTURES AND
RELATED VASCULAR, LYMPHATIC AND NEURAL
ELEMENTS [ CLINICAL SCHEMATIC ROLE ]
DIAGNOSTIC CRITERIA: S/D
A = AYMMETRY
R = RANGE OF MOTION CHANGE
T = SOFT TISSUE CHANGES ART

T = TENDERNESS
A = ASYMMETRY
R = RANGE OF MOTION CHANGE
T = SOFT TISSUE CHANGES TART

S = SENSITIVITY STAR
 CRITERIA FOR SOMATIC DYSFUNCTION: (COM-OSU)

TENDERNESS
ASYMMETRY
• LANDMARK COMPARISON
• PALPATION & OBSERVATION
RESTRICTION OF MOTION
• MOTION TESTING ( ACTIVE / PASSIVE )
• LOOK FOR LOSS OF MOTION WITHIN THE NORMAL
ROM
• COMPARE MOTION BILATERALLY
• ASSESS QUALITY OF MOTION AND THE END POINT
TISSUE TEXTURE CHANGE
• TONE
• TENDERNESS
• TEMPERATURE
• TURGOR
• ACUTE vs CHRONIC ( NEW OR OLD )
 NORMAL JOINT

PASSIVE ROM

ACTIVE ROM

A E P N P E A
 RESTRICTIVE BARRIER
PASSIVE
ACTIVE

LOST ROM
- ACTIVE
ACTIVE
ACTIVE - PASSIVE

A E P N P E A
NOTE: MANY IGNORE A DISCUSSION OF THE ELASTIC
BARRIER IN THEIR DESCRIPTIONS OF BARRIERS BUT
HAVE IGNORED CAPSULES, LIGAMENTS & TENDONS
 ACUTE AND CHRONIC SOMATIC DYSFUNCTION:
ACUTE: CHRONIC:
TENDERNESS
• SEVERE DULL, ACHY,
• SHARPE BURNING
ASYMMETRY: PRESENT PRESENT
RESTRICTIONS:
• PRESENT PRESENT
• PAINFUL WITH MOVEMENT DEC. OR NO PAIN
TISSUE CHANGES:
• EDEMATOUS DEC. OR NO EDEMA
• ERYTHEMOUS NO ERYTHEMA
• WARM & BOGGY COOL & DRY
• HYPERTONIC MUSCLES DEC. MUSCLE TONE
FLACCID, ROPY
& FIBROTIC
TART
 S/D: ACUTE OR
CHRONIC
FINDINGS ACUTE CHRONIC

TENDERNESS SHARP, DULL, ACHY

SEVERE OR BURNING
ASYMMETRY PRESENT PRESENT

RESTRICTION PRESENT, PRESENT,

PAINFUL WITH DECREASED
MOVEMENT OR NO PAIN
EDEMATOUS, DEC. OR NO EDEMA, NO
TISSUE ERYTHEMA, COOL DRY
ERYTHEMOUS,
CHANGES BOGGY, MUSCLES
SKIN, MUSCLES
HYPOTONIC, FLACCID,
HYPERTONIC ROPY OR FIBROTIC
 PLANES OF MOTION
MOTION AXIS PLANE
FLX'N / EXT'N TRANSVERSE SAGITTAL

ROTATION VERTICAL TRANSVERSE

SIDEBENDING ANT. / POST CORONAL

 FACET ORIENTATION (SUPERIOR FACETS)

CERVICAL:
• BACKWARD
• UPWARD BUM
• MEDIAL

THORACIC:
• BACKWARD
• UPWARD BUL
• LATERAL

LUMBAR:
• BACKWARD
• MEDIAL BM

(B=BACKWARD, U=UPWARD, M=MEDIAL )

 SPINAL
MECHANICS
 KEY TO THE
UNDERSTANDING
TYPE I AND TYPE II
SPINAL MECHANICS

HOW MOTION TEST TO

II I II TELL IF IN THE
NEUTRAL OR NON-
NEUTRAL
COMPARTMENT ?
[ WITH SIDEBENDING
AND SEE WHICH WAY
THE VERTEBRA
ROTATES]
 SPINAL MECHANICS (FRYETTE”S LAW)

CERVICAL AREA:
• A/O AND A/A ATYPICAL
• C2-7 ALWAYS FOLLOW TYPE II LIKE MECHANICS
( MAY FOLLOW TYPE I MECHANICS FOLLOWING
A TRAUMA OR WHIPLASH INJURY)

THORACIC AREA:
• TYPE I MECHANICS
Q: WITH NORMAL
• TYPE II MECHANICS
CERVICAL MECHANICS…
FOLLOWING CERVICAL
LUMBAR AREA:
TRAUMA,….
• TYPE I MECHANICS
• TYPE II MECHANICS
NOTE: GREENMAN STATES C 3-7 FOLLOW TYPE II
MECHANICS
 SPINAL MECHANICS ( FRYETTE’S
LAWS )
TYPE II (NON-NEUTRAL) MECHANICS
ERS & FRS DYSFUNCTIONS
• OCCUR IN FLEXED OR EXTENDED
COMPARTMENT (NON-
NEUTRAL)
• ROTATION OCCURS BEFORE
SIDEBENDING [ ERS & FRS ]
• SIDEBENDING AND ROTATION GO
IN THE SAME DIRECTION
•Results from trauma
•Non physiologic motion
•Somatic dysfunction is named for the
freedom
• Can name for restriction
#6

#7

Right facet pair

will not open
with flexion
#8
flexion will be
Asymmetrical

T-7 ERS RIGHT

#6

#7

left facet pair

will not close
with extension
#8
extension will be
unsymmetrical

T-7 FRS RIGHT

 SPINAL MECHANICS
TYPE I TYPE II
ETIOLOGY POSTURAL TRAUMA
( MACRO / MICRO )
COMPARTMENT NEUTRAL FLEXED / EXTENDED

MAINTAINING LONG RESTRICTORS SHORT RESTRICTORS

# SEGMENTS SEVERAL TWO

SB / ROTATION OPPOSITE DIRECTIONS SAME DIRECTION

ROTATES PRODUCED CONVEXITY PRODUCED CONCAVITY

TOWARD

NOTE: TYPE I COMPENSATIONS TO TYPE II S/D

WILSON & MITCHELL: REPUTATIONS MADE TREATING TYPE IIs
 SPINAL MECHANICS
ETIOLOGY TYPE I TYPE II
POSTURAL TRAUMATIC
COMPARTMENT NEUTRAL FLEXED
EXTENDED

MAINTAINING LONG SHORT

RESTRICTORS RESTRICTORS

# OF SEVERAL TWO
SEGMENTS
SB / ROTATION OPPOSITE SAME
DIRECTION DIRECTION

ROTATES PRODUCED PRODUCED

TOWARD CONVEXITY CONCAVITY
 SPINAL MECHANICS: TREATMENT
ERSr = POSITIONAL DIAGNOSIS
• DIRECT Rx POSITIONING: ERSr SlRlF
• POSITION FOR MET OR HV/LA
• INDIRECT Rx POSITIONING: ERSr @ D.B.P.
• POSITIONING FOR FUNCTIONAL, S/CS, POSITIONAL
FACILITATED RELEASE(PFR) , LIGAMENTOUS
ARTICULAR STRAIN (LAS)
• FRSr = POSITIONAL DIAGNOSIS
• DIRECT Rx POSITIONING: FRSr SlRlE
• POSITION FOR MET OR HV/LA
• INDIRECT Rx POSITIONING: FRSr @ D.B.P.
• POSITIONING FOR FUNCTIONAL, S/CS,
POSITIONAL FACILITATED RELEASE(PFR) AND
LIGAMENTOUS ARTICULAR STRAIN (LAS)
 SPINAL MECHANICS (FRYETTE’S LAWS)
LAW III
• WHEN INTRODUCE MOVEMENT IN ONE PLANE, YOU
RESTRICT MOTION IN THE OTHER TWO PLANES
• WHEN YOU STACK A SECOND MOVEMENT INTO THE
SPINE, YOU RESTRICT THE OTHER TWO
MOVEMENTS

•APPLICATION: USE THE “PHYSIOLOGICAL LOCK”

WHEN UTILIZING HV/LA LOCKING. THIS REALLY
INVOLVES THE ELASTIC BARRIER AND THEREFORE
THERE WILL BE MINIMAL MUSCLE GUARDING.

•USE LAW III TO LOCATE THE AREA OF GREATEST

RESTRICTION (AGR)
 JOINT PLAY (MENNELL)

• NORMAL: WHEN TYPE III MECHANICS FUNCTIONING, YOU CAN

INTRODUCE A GLIDING TRANSLATORY MOTION (SIMULTANEOUSLY
ACROSS 3 PLANES OF MOTION) AND THERE WILL BE SOME
MOVEMENT, GLIDE OR YIELDING OF THE TISSUES
[ SOFT END FEEL, SPRING, YIELD]

• ABNORMAL (SOMATIC DYSFUNCTION): WHEN TYPE III

MECHANICS FUNCTIONING, YOU CAN INTRODUCE A GLIDING
TRANSLATORY MOTION (SIMMULTANEOUSLY ACROSS 3 PLANES OF
MOTION) AND THERE WILL NOT BE ANY MOVEMENT, GLIDE OR
YIELDING OF THE TISSUES.
[ HARD END FEEL, NO SPRING, NO YIELDING]

• APPLICATION: SCREENING EXAM FOR AGR

 “JOINT PLAY”
SIMULATNEOUSLY
CHALLENGING 3 PLANES
OF MOTION
• FLEXION / EXTENSION
• SIDEBENDING
• ROTATION

Q: END FEEL ?
• SOFT ?
• HARD ?
 MUSCLE CONTRACTIONS (TYPES)

ISOTONIC: MUSCLE CONTRACTION THAT RESULTS IN THE APPROXIMATION

OF THE MUSCLE’S ORIGIN AND INSERTION WITHOUT A CHANGE IN ITS
TENSION. PATIENT’S FORCE IS GREATER THAN THE OPERATOR’S FORCE

ISOMETRIC: MUSCLE CONTRACTION THAT RESULTS IN THE INCREASE IN

TENSION WITHOUT AN APPROXIMATION OF THE ORIGIN AND INSERTION.
THE OPERATOR AND PATIENT FORCES ARE EQUAL

ISOLYTIC: MUSCLE CONTRACTION AGAINST RESISTANCE WHILE FORCING

THE MUSCLE TO LENGTHEN.

CONCENTRIC CONTRACTION: ORIGIN & INSERTION APPROXIMATE DURING

CONTRACTION (SHORTEN)

ECCENTRIC CONTRACTION: LENGHTENS DURING CONTRACTION DUE TO

AN EXTERNAL FORCE
CERVICAL
SPINE
 CERVICAL AREA

A/O MOTION = NODDING FORWARD & BACKWARD

(50% OF CERVICAL: KAPLAN BOOK)
A/A MOTION = ROTATION ( 50% OF CERVICAL AREA )
 CERVICAL UNIQUENESS
• A/O MECHANICS: NODDING
• A/A MECHANICS: ROTATION
• C 2(3) - 7 : ALWAYS FOLLOWS TYPE II LIKE MECHANICS ( NORMAL
MECHANICS)
( TYPE I WITH POSSIBLE WITH WHIPLASH INJURIES)
• JOINTS OF LUSCHKA: SPURS AND FORAMEN SIZE
( STENOSIS )
 CERVICAL MUSCLES
SCALENIUS ANTICUS AND
MEDIUS:
• ELEVATE FIRST RIB WITH
INSPIRATION
SCALENIUS POSTERIOR:
• ELEVATES THE SECOND RIB
WITH INSPIRATION
STERNOCLEIDOMASTOID
•ATTACHES TO MASTOID AND
CLAVICLE
NOTE: IF UPPER RIBS ARE
DYSFUNCTIONAL, TORTICOLLIS
MAY DEVELOP
CERVICAL AREA: INNERVATION

• C 1 nerve root exits above C1

• C 2 nerve roots between the C1 and
the C2 segment
•The remaining nerve roots exit just
below the corresponding vertebra
RIB CAGE
 RIB CAGE PRINCIPLES:
ATYPICAL RIBS:
• R 1- ARTICULATES ONLY WITH BODY OF T 1
• R 2- LARGE TUBEROSITY FOR SCALENI POSTERIOR
• R 11- DOESN’T HAVE AN ANTERIOR ATTACHMENT
• R 12- DOESN’T HAVE AN ANTERIOR ATTACHMENT
(“FLOATING” RIBS)
TYPICAL RIBS:
• 3-10

TYPICAL RIBS: TWO TYPES

• 3-7: TRUE RIBS- ATTACH TO STERNUM DIRECTLY
• 8-10: FALSE RIBS- ATTACH TO STERNUM
INDIRECTLY
 PUMP HANDLE
• UPPER RIBS (1-5 )
• “CORONAL AXIS”
• INCREASE (A/P)
LONGITUDINAL SHAPE

BUCKET HANDLE
• LOWER RIBS
• “SAGITTAL AXIS”
• INCREASE LATERAL
DEMENSION
CALIPER MOTION
• INVOLVE RIBS 11 & 12
• FLARE IN & OUT
 RIB CAGE MECHANICS: DEFINITIONS
RIBS 1-6 IE. MOVE WELL INTO EXHALATION (POSITION Dx) BUT
POORLY INTO INSPIRATION (RESTRICTION Dx)
• EXHALATION RIB(S)
• EXHALATION DYSFUNCTION
• HELD IN EXPIRATION / EXHALED [ DEPRESSED RIB ]
• INSPIRATORY RIB RESTRICTION
•IINHALATION RESTRICTION
NOTE: IF THE WORD RESTRICTION IS NOT USED, THEY HAVE GIVEN
YOU THE POSITIONAL DIAGNOSIS,ie, WHAT IT CAN DO= SD
RIB MOTION PATTERNS: MIDDLE: COMBINATION
• PUMP-HANDLE: RIBS 1-5
• BUCKET-HANDLE: RIBS 6-10
• CALIPER: RIBS 11 & 12 ( GLIDE ANTERIOR / POSTERIOR,
SUPERIOR INFERIOR)
 RIB CAGE MECHANICS: PRINCIPLES
EXHALATION DYSFUNCTION: KEY RIB IS THE TOP OF
THE GROUP [ WILL GO INTO EXHALATION ]
INHALATION DYSFUNCTIONS: KEY RIB BOTTOM OF
GROUP [ WILL GO INTO INHALATION ]

INSPIR

EXPIR
THORACIC
SPINE
 TYPE I
NEUTRAL SOMATIC
DYSFUNCTION
• SB / R IN OPPOSITE DIRECTION
• R TOWARD PRODUCED CONVEXITY
• S/B PRECEEDS ROTATION [ NSRr ]
• LONG RESTRICTORS MAINTAIN
SPINAL MECHANICS (FRYETTE’S LAWS)

TYPE I (NEUTRAL) MECHANICS NSR

DYSFUNCTIONS
• IN THE NEUTRAL COMPARTMENT
• SIDEBENDING PRECEEDS ROTATION THEN
(PRODUCES R. CONCAVITY)
• ROTATION OCCURS TOWARD THE
CONVEXITY
• THEREFORE SIDEBENDING AND
ROTATION GO IN OPPOSITE DIRECTIONS
• NOTE: HOW TELL IF PATIENT IS IN
MAX
NEUTRAL ? SIDE BEND AND IF PALPATED
VERTEBRA ROTATES TOWARD THE PRODUCED ROTATION
CONVEXITY YOU KNOW THE PATIENT WAS IN
NEUTRAL
 TYPE II
NON-NEUTRAL SOMATIC DYSFUNCTION
( FLEXION & EXTENSION DYSFUNCTION)
( FLEXED & EXTENDED DYSFUNCTION)
• SB / R IN THE SAME DIRECTION
• R TOWARD THE PRODUCED CONCAVITY
• ROTATION PRECEEDS SIDEBENDING ( FRS & ERS )
• SHORT RESTRICTORS MAINTAIN
 COBB’ S ANGLE
( SCOLIOSIS )\

CURVES OF LESS THAN 10 DEGREES

•SHOULD BE CHECKED IN SIX MONTHS TO
A YEAR

CURVES OF MORE THAN 10 DEGREES

•SHOULD BE CHECKED q 4-6 MONTHS

CURVES OF 20 DEGREES
SHOULD BE CHECKED q 4 MONTHS

CURVES OVER 30 DEGREES

SHOULD BE TREATED
 SCOLIOSIS

NAMED BY SIDE OF THE CONVEXITY

ETIOLOGY:
• IDIOPATHIC
• FUNCTIONAL
• SOMATIC DYSFUNCTION
• SHORT LEG SYNDROME
• HEMI-VERTEBRA
• DENTAL ROLE
• FEMALES 7:1
• ONSET AT ABOUT PUBERTY
• STARTED ORTHODONTICS ?
• COMPRESSION FRACTURE

NOTE: BE SURE TO ALSO CHECK FORWARD

BENDING WHILE SITTING
 THORACIC AREA #1

RULE OF 3s( SP. PROCESS FOCUS )

• T1-3: THE SP. PROCESS (SP) IS AT
THE SAME LEVEL AS
CORRESPONDING VERTEBRA
• T4-6: THE S.P. IS AT THE LEVEL OF
THE BOTTOM OF THE
CORRESPONDING VERTEBRA
• T 7-9: THE S.P. IS AT THE LEVEL OF
THE VERTEBRA BELOW
• T 10: FOLLOWS T 7-9 PATTERN
• T11: FOLLOWS T 4-6 PATTERN
• T 12: FOLLOWS T 1-3PATTERN
 THORACIC AREA #2
RULE OF 3s( TR. PROCESS FOCUS )
• T1-3:T.P. AT THE SAME LEVEL AS THE
CORRESPONDING S.P.

• T4-6: THE T.P. IS ONE HALF

VERTEBRA ABOVE THE
CORRESPONDING S.P.

• T 7-9: THE T.P. IS AT THE SAME LEVEL AS

THE S.P. OF THE VERTEBRA ABOVE

• T 10: FOLLOWS T 7-9 PATTERN

• T11: FOLLOWS T 4-6 PATTERN
• T 12: FOLLOWS T 1-3PATTERN
 LANDMARKS
( ANTERIOR )
BODY OF T 2
BODY OF T 4

T 4 DERMATOME (5)
( NIPPLE )

T 10 DERMATOME
( NAVEL )

T 12 DERMATOME
( INGUINAL )
 LANDMARK
RELATIONSHIPS
( POSTERIOR )

BODY OF T 3

BODY OF T 7
R 12 / T 12
X
BODY OF L 4
 O/A

C/T

R. SHOULDER LOW

TOLERATE THIS PATTERN

T/ L

L/S

COMMON COMPENSATORY PATTERN (ZINK)

 COMMON S/D PATTERNS
• R. RIBS: EXPIRED
• L. RIBS INSPIRED
• T 12 FRS left
• R. PUBES CAUDAD
• L. PUBES CEPHLAD
• L. SACRAL FLEXION
• L/L SACRAL TORSION
• L/R SACRAL TORSION
• R. SACRAL EXTENSION
• R. ANT. INNOMINATE
• L. POST. INNOMINATE
[ DEPENDS ON AXIS
UTILIZED AT TIME ]

COMMON COMPENSATORY PATTERN (ZINK)

 O/A

C/T

NOT TOLERATED WELL

BY THE PATIENTS

T/ L

L/S

UNCOMMON COMPENSATORY PATTERN (ZINK)

 THORACIC OUTLET SYNDROME
PATHOGENESIS: ENTRAPMENT OF NEUROVASCULAR BUNDLE; AT VARIOUS SITES (
3 OPTIONS )
• BETWEEN ANT. & MEDIAL SCALENI ( RIB 1 & 2 ROLE )
• BETWEEN CLAVICAL & RIB # 1 [ SURGICAL SITE ]
• UNDER PECTORALIS MINOR ( RIB 3-5 ROLE )

COMPRESSION MAY BE DUE TO:

• CERVICAL RIB
• INCREASED ANT. & MEDIAL SCALENI TONE
• SOMATIC DYSFUNCTION OF RIB 1 OR CLAVICAL
• INCREASED TONE OF PECTORALIS MINOR

PAIN LOCATION: NECK OR RADIATING DOWN ARM

PAIN QUALITY: ACHING OR PARESTHESIAS
SIGNS & SYMPTOMS: LOCAL TENDERNESS, PULSES MAY BE ALTERED OR NORMAL.

SPECIAL TESTS
MAY HAVE A POSITIVE ADSON’S, ROOS OR HYPERABDUCTION TESTS. [ SEE TESTS ]
PELVIC MECHANICS
 PELVIS
INNOMINATES:
• MADE UP OF ILIUM, PUBES AND ISCHIUS
• THEY FUSE @ ABOUT AGE 12
[ BALLET ISSUES ]
SACRUM: MADE UP OF 5 FUSED SEGMENTS
• IF TOP SEGMENT NOT FUSED = LUMBARIZATION
• IF L5 FUSED TO SACRUM= SACRALIZED LUMBAR
LIGAMENTS:
• SACROTUBEROUS: PREVENTS SACRAL FLEXION OR NUTATION
• SACROSPINOUS: DIVIDES THE GREATER AND LESSER SCIATIC
FORAMEN ( PIRIFORMIS )
• SACROILIAC: 3 LAYERS
• DEEP= HORIZONTAL (TRANSVERSE AXES)
• MIDDLE= OBLIQUE ( LOA AND ROA AXES)
• SUPERFICIAL: LONG DORSAL (PREVENTS SACRAL
EXTENSION OR COUNTERNUTATION
 POSTERIOR LIGAMENTS:
ROA
•DEEP: HORIZONTAL
•MIDDLE: OBLIQUE STA
•SUPERFICIAL: VERTICAL MTA
FOR STABALIZATION
ITA
• S/T: NUTATION
LOA
• LONG DORSAL:
COUNTER-NUTATION
[ 1990s ]

CORRELATE & EXPLAIN

THE AXES OF MITCHELL
?
GILETTE TEST “STORK TEST”

PURPOSE : TEST FOR S/I FUNCTION

UPPER POLE
LOWER POLE
TEST: THE PATIENT IS STANDING SO THEY CAN SUPPORT
THEMSELVES. THE OPERATOR PALPATES THE P.S.I.S. ON ONE SIDE
AND THE SACRAL BASE AT S 1 LEVEL. THE PATIENT IS INSTRUCTED
TO FLEX THE HIP ON THE PALPATED SIDE TO AT LEAST HIP LEVEL.
THE SECOND PART INVOLVES PALPATING THE P.S.I.S. AND
SACRAL APEX @ S 5. THE PATIENT AGAIN FLEXES THE HIP.

NORMAL: THE P.S.I.S SHOULD GLIDE POSTERIORLY, IF IT GLIDES

CEPHLAD IT IS A POSITIVE TEST.
 MUSCLES OF THE PELVIS
( PELVIC FLOOR )

LEVATOR ANI
• PUBOCOCCYGEUS
• PUBORECTALIS
PIR
• ILIOCOCCYGEUS
COCCYGGEUS

Pelvic floor
Important for
organ support
Circulation lower body
PIRIFORMIS: SIGNIFICANT WITH SCIATICA
• ORIGIN: ANT. INFERIOR ASPECT OF SACRUM
• INSERTION: GR. TROCHANTER OF FEMUR
• ACTION: THIGH EXTERNAL ROTATOR, THIGH EXTENDER AND
ABDUCTS THIGH WHEN HIP FLEXED
• INNERVATION: S1 AND S2 ROOTS
• CLINICAL: 11% SCIATIC NERVE RUNS THROUGH THE BODY
OF PIRIFORMIS 1-2% SCIATIC NERVE PASSES OVER PIRIFORMIS
 SUPERIOR INNOMINATE SHEAR
( UPSHEAR )
ETIOLOGY:
• FALL ON THE BUTTOCK
• JUMPING & LANDING WITH WEIGHT MORE ON ONE LEG
• MISSING A STEP
AXIS: ALL 3 TRANSVERSE ( STA, MTA & ITA IMPACTED)
FINDINGS:
• + STANDING F.B.T.
• PUBES - CEPHLAD
• ASIS - CEPHLAD
• CREST - CEPHLAD ( KEY DIFFERENTIAL LANDMARK)
• I / T CEPHLAD & LAX S/T LIGAMENT
• ROCKING TEST POSITIVE [ AXIS ISSUE / ALL 3 ]
 INFERIOR INNOMINATE SHEAR
( DOWN SHEAR )
ETIOLOGY:
• AFTER A DIFFICULT DELIVERY (RELAXIN)
• SKIING, TIP OF SKI GETS CAUGHT
• THROWN FROM HORSE, FOOT CAUGHT IN STIRRUP
AXIS: ALL 3 TRANSVERSE ( STA, MTA & ITA IMPACTED)
FINDINGS:
• + STANDING F.B.T.
• PUBES - CAUDAD
• ASIS - CAUDAD
• CREST - CAUDAD ( KEY DIFFERENTIAL LANDMARK)
• I / T CAUDAD & TIGHT S/T LIGAMENT
• ROCKING TEST POSITIVE [ AXIS ISSUE / ALL 3 ]
 SUPERIOR PUBIC SHEAR

ETIOLOGY: TRAUMA, TIGHT RECTUS OR

WEAK ADDUCTORS
AXIS: TRANSVERSE PUBES
FINDINGS:
• + STANDING F.B.T.
• PUBES - CEPHLAD [ SHEARED, NOT
ROATATED]
• A.S.I.S. - LEVEL OF SLIGHTLY CEPHLAD
• CRESTS LEVEL ( KEY DIFFERENTIAL
LANDMARK)
•MAY HAVE LONG LEG IPSILATERAL
 INFERIOR PUBIC SHEAR

ETIOLOGY: TRAUMA, TIGHT ADDUCTORS

OR WEAK ABDOMINALS
AXIS: TRANSVERSE PUBES
FINDINGS:
• + STANDING F.B.T.
• PUBES - CAUDAD [ SHEARED, NOT
ROTATED]
• A.S.I.S. - LEVEL OF SLIGHTLY CAUDAD
• CRESTS LEVEL ( KEY DIFFERENTIAL
LANDMARK)
• SHORT LEG (IPSILATERAL)
 ANTERIOR INNOMINATE ROTATION
ETIOLOGY:
• TIGHT QUADS &/OR WEAK ABDOMINALS
• WEAK HAMSTRINGS
AXIS: ITA
FINDINGS:
• + STANDING F.B.T.
• - SITTING F.B.T.
• A.S.I.S. CAUDAD
• P.S.I.S. CEPHLAD
• LONG LEG ( IPSILATERAL)
• PUBES: LEVEL[ ROTATED, NOT SHEARED ]
• CRESTS LEVEL
• ILA LEVEL

NOTE: KAPLAN; HAMSTRING TENDERNESS & S/I DISCOMFORT,

 POSTERIOR INNOMINATE ROTATION
ETIOLOGY:
• TIGHT HAMSTRINGS OR TIGHT
ABDOMINALS
• WEAK QUADS
AXIS: ITA
FINDINGS:
• + STANDING F.B.T.
• - SITTING F.B.T.
• A.S.I.S. CAUDAD
• P.S.I.S. CEPHLAD
• LONG LEG ( IPSILATERAL )
• PUBES: LEVEL[ ROTATED NOT SHEARED]
• CRESTS LEVEL
• ILA LEVEL

NOTE: KAPLAN; GROIN PAIN & TRANSMITTED ABNORMAL FORCES TO

KNEE,
 CONVEX
SI / J

INFLARED INNOMINATE OUTFLARED INNOMINATE

Rx: ADDUCTORS Rx: TENSOR FASCIA LATA

ILIACUS
SACRAL MECHANICS
 SACRAL MODELS: HISTORY
1938: STRACHAN @ CHICAGO COLLEGE OF OSTEOPATHY ( ANT. /
POST. SACRUMS )
1950’s: FRED L MITCHELL Sr.
• MITCHELL WAS A STUDENT OF STRACHAN !
•TRIED TO IMPROVE THE UNDERSTANDING OF THE PELVIS DUE TO
HIS WORK WITH OWENS
( CHAPMAN’S REFLEXES,ie, Rx BALANCE THE PELVIS AND THEN
TREAT THE CHAPMAN’S REFLEXES )
KIMBERLY: “NO ONE UNDERSTOOD PELVIC MECHANICS BUT
EVERYONE KNEW IT WAS VERY IMPORTANT AND FRED DECIDED TO
TRY TO EXPLAIN IT BETTER”
• TORSIONS INVOLVE INNOMINATES & SACRUM NOT BETWEEN L5
AND THE SACRUM
THIS IS THE BASIS OF THE TERMINOLOGY PROBLEMS
 ROA

STA

MTA

ITA

LOA

SACRAL AXES
• CORRECT
• INCORRECT
 SACRAL RULES
RULES OF L5 ON THE SACRUM:
• #1 WHEN L5 IS SIDEBENT, A SACRAL OBLIQUE AXIS IS
ENGAGED ON THE SAME SIDE AS THE SIDEBENDING
• #2 WHEN L5 IS ROTATED, THE SACRUM ROTATES IN THE
OPPOSITE DIRECTION AROUND AN OBLIQUE AXIS [ ROTATE IN
OPPOSITE DIRECTIONS (TORSION )
• #3 THE POSITIVE SEATED F.B.T. IS FOUND ON THE OPPOSITE
SIDE OF THE OBLIQUE AXIS

L/ L S.T. L/ R S.T.
• L5 SB l • L5 SBr
• L5 Rr • L5 Rr
• TYPE I • TYPE II
• - SPHINX +SPHINX
• - SPRING +SPRING
 TERMINOLOGY (CHICAGO )
ANTERIOR SACRUM: RIGHT
• ANTERIOR SACRAL BASE (SULCUS DEEP)
• L5 ROTATED IN THE SAME DIRECTION AS SACRUM ( ROTATED left )
• POSITIVE SITTING F.B.T. ON RIGHT
• ILA- INFERIOR AND POSTERIOR ON LEFT
• SHORT LEFT LEG [ L / L SACRAL TORSION ]

POSTERIOR SACRUM: LEFT

• POSTERIOR SACRAL BASE ON LEFT (SULCUS SHALLOW)
• L5 ROTATED IN THE SAME DIRECTION AS SACRUM (ROTATED left)
• POSITIVE SITTING F.B.T. ON LEFT
• ILA- INFERIOR AND POSTERIOR ON LEFT
• SHORT LEFT LEG [ L / R SACRAL TORSION ]

•NOTE: WE WOULD CALL THESE TORSIONS WITH

AN UNCOMPENSATED L5
[ FLM,SR. TERMINOLOGY ]
 ANTERIOR SACRUM(R):
• SACRAL BASE WILL
ROTATE FORWARD
(TOWARD LEFT) AND
• SIDEBEND TOWARD
THE OPPOSITE SIDE
(RIGHT) OF THE
ROTATION
POSTERIOR SACRUM(L):
• SACRAL WILL ROTATE
BACKWARD (TOWARD
LEFT) AND
• SIDEBEND TO THE
OPPOSITE SIDE OF THE
ROTATION (RIGHT)
TRAP: USING SPINAL TERMINOLOGY TO EXPLAIN
PELVIC MECHANICS ( NO FACETS )
 LEFT ON LEFT SACRAL
TORSION
• ANTERIOR S.B. ( DEEP
RIGHT SULCUS )
• L5 ROTATED RIGHT
• ILA: INF. & POSTERIOR
ON THE LEFT
• + SITTING F.B.T. ON
RIGHT
• SHORT LEFT LEG
• LUMBAR CONVEXITY
TO THE RIGHT
• INC. LORDOSIS
• - SPRING TEST (L/S)
• - SPHINX TEST
MODIFIED RESTRICTIVE [ IF L5 ROTATED LEFT
SPRING TEST WOULD BE CALLED
ANT. SACRUM /RIGHT ]
+ + LEFT ON LEFT SACRAL
TORSION
• ANTERIOR S.B. ( DEEP
RIGHT SULCUS )
• L5 ROTATED RIGHT
• ILA: INF. & POSTERIOR
ON THE LEFT
• + SITTING F.B.T. ON
+ RIGHT
• SHORT LEFT LEG
• LUMBAR CONVEXITY
- TO THE RIGHT
• INC. LORDOSIS
+= WILL
• - SPRING TEST (L/S)
SPRING
• - SPHINX TEST
MODIFIED RESTRICTIVE [ IF L5 ROTATED LEFT
SPRING TEST WOULD BE CALLED
( TIME CONSUMING ) ANT. SACRUM /RIGHT ]
 LEFT ON RIGHT SACRAL
TORSION
• ANTERIOR S.B.
(SHALLOW LEFT SULCUS )
• L5 ROTATED RIGHT
• ILA: INF. & POSTERIOR
ON THE LEFT
• + SITTING F.B.T. ON
LEFT
• SHORT LEFT LEG
• LUMBAR CONVEXITY TO
THE RIGHT
• DEC. LORDOSIS
• ++ SPRING TEST (L/S)
• ++ SPHINX TEST
[ IF L5 ROTATED LEFT
MODIFIED RESTRICTIVE
WOULD BE CALLED POST.
SPRING TEST
SACRUM /LEFT ]
+ +
LEFT SACRAL FLEXION
• LEFT BASE GLIDES
ANTERIORLY AND
CAUDAD ( MTA
SHIFTS)
• DEEP LEFT SULCUS
• ILA: LEFT INF. AND
POSTERIOR
• L5 ROTATED LEFT
• INC. LORDOSIS
• LONG LEFT LEG
• LUMBAR CONVEXITY
- + TO LEFT
• + SITTING F.B.T. ON
LEFT
MODIFIED RESTRICTIVE
• - SPRING TEST (L/S)
SPRING TEST
• - SPHINX TEST
+ -
RIGHT SACRAL EXTENSION
• RIGHT BASE GLIDES
POSTERIOR AND
CEPHLAD ( MTA SHIFTS)
• LEFT SACRAL BASE
ANTERIOR
• SHALLOW RIGHT
SULCUS
• ILA: LEFT INF. AND
POSTERIOR
• L5 ROTATED LEFT
• DEC. LORDOSIS
• LONG LEFT LEG
+ + • LUMBAR CONVEXITY
TO LEFT
• + SITTING F.B.T. ON RIGHT
• + SPRING TEST (L/S)
• + SPHINX TEST
MODIFIED RESTRICTIVE
SPRING TEST
 GLOSSARY TERMS
SACRAL SULCUS: DISTANCE FROM THE P.S.I.S. TO
THE SACRAL BASE.

SHALLOW
SULCUS
DEEP SULCUS
SOMATIC DYSFUNCTION: ACUTE, IMMEDIATE, SHORT-TERM
IMPAIRMENT OR ALTERED FUNCTION OF RELATED
COMPONENTS OF THE SOMATIC (BODY FRAMEWORK) SYSTEM;
CHARACTERIZED IN EARLY STAGES BY VASODILATION, EDEMA,
TENDERNESS, PAIN AND CONTRACTION; IDENTIFIED BY T.A.R.T.
PALPATORILY DIAGNOSED BY ASSESSMENT OF TENDERNESS,
ASYMMETRY OF MOTION AND RELATIVE POSITION, RESTRICTIVE
MOTION AND TISSUE TEXTURE CHANGES.
LUMBAR SPINE
NEUROLOGICAL
 L/S ANAMOLIES:

SACRALIZATION: WHEN ONE OF

THE L 5 T.P. FUSE WITH THE
SACRUM. THEN HAVE ONLY 4
TRUE LUMBARS OR A 6
SEGMENTED SACRUM. CAN BE
BILATERAL ( BATWING )

LUMBARIZATION: WHEN THE S 1

SEGMENT DID NOT FUSE WITH
THE REST OF THE SACRUM.
THEN HAVE “6 LUMBAR
VERTEBRA” OR ONLY A 4
SEGMENTED SACRUM
 LUMBAR ANAMOLIES

SPINA BIFIDA: THREE TYPES

• SPINA BIFIDA OCCULTA: LAMINA
DIDN’T FUSE, THERE IS NO
HERNIATION THROUGHT THE
DEFECT [ HAIR OVER SITE ]
• SPINA BIFIDA MENINGOCELE:
LAMINAR DEFECT AND THE
MENINGES HERNIATE THROUGH THE
DEFECT
• SPINA BIFIDA MENINGOMYELOCELE:
LAMINAR DEFECT AND THE
MENINGIES AND NERVE ROOTS
HERNIATE THROUGH THE DEFECT
ANT. SPUR LAT.
STENOSIS

CENTRAL
STENOSIS

LATERAL
STENOSIS DISK
DEGENERATION
 SPINAL STENOSIS
DEFINITION: NARROWING OF THE SPINAL CANAL
(CENTRAL) OR FORAMEN (LATERAL) CAUSING
PRESSURE ON CORD (CENTRAL) OR NERVE ROOT
(LATERAL)
PATHOGENESIS: OSTEOARTHROSIS
• FACET JOINT DEGENERATIVE CHANGES (SPURS)
• DISK DEGENERATION
• SOFT TISSUE SPACE OCCUPYING STRUCTURES
LOCATION OF PAIN: LOW BACK TO LOWER LEG
QUALITY OF PAIN: ACHING, SHOOTING PAIN OR
PARESTHESIAS
SIGN & SYMPTOMS: PAIN ON STANDING & WALKING
RADIOLOGY: OSTEOPHYTES, DEC. INTERVERTEBRAL
SPACE
 CAUDA EQUINA SYNDROME

DEFINITION: PRESSURE ON THE NERVE ROOTS OF THE

CAUDA EQUINA USUALLY DUE TO A MASSIVE DISC
HERNIATION OR RUPTURE
LOCATION OF PAIN: LOW BACK
QUALITY OF PAIN: SHARP
SIGNS AND SYMPTOMS:
• SADDLE ANESTHESIA
• DECREASE OF DEEP TENDON REFLEXES ( DTR )
• DECREASE RECTAL TONE ( INCONTINENCE )
• LOSS OF BOWEL AND BLADDER CONTROL
TREATMENT: EMERGENCY SURGICAL
DECOMPRESSION OF THE CAUDA EQUINA IS
IMPERATIVE. IRREVERSIBLE PARALYSIS MAY
RESULT IF SURGERY DELAYED.
 SPINAL DISORDERS
• SPONDYLOLITIS: INFLAMMATION OF A VERTEBRA

• SPONDYLOSIS: DEGENERATION OF A VERTEBRA,ie,

SPINAL ANKYLOSIS

• SPONDYLOLYSIS: DEFECT OF THE PARS ARTICULARIS

WITHOUT ANY SLIPPING FORWARD

• SPONDYLOLISTHESIS: PARS DEFECT WITH SLIPPAGE

FORWARD. SCOTTY DOG SIGN PRESENT
 SPONDYLOLISTHESIS
DEFINITION: ANTERIOR DISPLACEMENT OF ONE
VERTEBRA IN RELATION TO THE ONE BELOW. OFTEN
OCCURS AT L4 OR L5 AND IS USUALLY SECONDARY TO
A FATIGUE FRACTURE OF THE PARS
INTERARTICULARIS
LOCATION OF PAIN: LOW BACK, POSTERIOR THIGH OR
LOWER LEG
QUALITY OF PAIN: ACHING
SIGN & SYMPTOMS: INCREASED PAIN WHEN IN THE
UPRIGHT POSITION [ GLIDES FORWARD]
RADIOLOGY: PARS DEFECT [ “SCOTTY DOG SIGN” ]
AND / OR ANTERIORLY DISPLACED VERTEBRA. “STEP
SIGN”
GRADE # 1 33%
GRADE # 2 66%
GRADE # 3 MORE THAN 66%
 OBLIQUE
LOW BACK
FILM

SCOTTY
DOG
SIGN
 HERNIATED NUCLEUS PULPOSUS

PATHOGENESIS: DUE TO NARROWING OF THE

POSTERIOR LONGITUDINAL LIGAMENT, A POSTERIOR LATERAL
HERNIATION OF THE DISC IS A COMMON PROBLEM.
• 98% OCCUR BETWEEN L4/5 OR BETWEEN L5/S1
• LUMBAR HERNIATION WILL EXERT PRESSURE ON THE NERVE OF
THE VERTEBRA BELOW. HERNIATION OF THE L5/S1 DISC WILL
AFFECT THE S1 NERVE ROOT
LOCATION OF PAIN: LOW BACK AND LOWER LEG
( BELOW KNEE & PAIN IS WORSE IN LEG THAN BACK: WADDELL)
QUALITY OF PAIN: SHARP, BURNING AND/OR SHOOTING PAIN
RADIATING DOWN THE LEG. WORSE WITH LUMBAR FLEXION
SIGNS & SYMPTOMS: WEAKNESS OR DECREASED D.T.R. SENSORY
DEFICIT OVER THE CORRESPONDING DERMATOME. POSITIVE
ST. LEG RAISING TEST.
RADIOLOGY: MRI IS THE GOLD STANDARD ( DISK / SOFT TISSUE ) CT
SCAN FOR STENOSIS OR BONE EVALUATION
TREATMENT: LESS THAN 5% REQUIRE SURGERY. PAIN MAY BE
FROM THE RELATED SOMATIC DYSFUNCTION AND NOT THE DISK
[ NEJM: 70-75 % OF DISKS ARE ASYMPTOMATIC]
 L 4 DISK

L5
NERVE
L5
DISK
S 1 NERVE

LUMBAR DISK
MANY ASYMPTOMATIC
TENSEGRITY
 WADDELL: DIAGNOSTIC LBP TRIADE
SIMPLE LOW BACK = 95 %
• 20 - 55 YRS OF AGE
• LUMBOSACRAL, BUTTOCK OR THIGH PAIN
• PAIN IS MECHANICAL ( ABOVE KNEE )
• PATIENT IS WELL
• R/O URINARY, G.I. & REPRODUCTIVE WITH PELVIC / RECTAL EXAM
NEUROLOGICAL / ROOT PAIN = 5 %
• UNILATERAL PAIN, WORSE IN THE LEG THAN IN BACK
• PAIN BELOW KNEE INTO FOOT OR TOES
• NUMBNESS OR PARESTHESIAS
• NERVE ROOT SIGNS
• MOTOR, SENSORY OR REFLEX CHANGES
“RED FLAG” LOW BACK = LESS THAN 1 %
• LESS THAN 20 OR OVER 55 YRS. OF AGE
• CONSTANT, PROGRESSIVE & NON-MECHANICAL PAIN
• SYSTEMICALLY NOT WELL
• Hx OF OTHER SERIOUS HEALTH PROBLEMS( HIV, R.A., STEROIDS,
MALIGNANCY, ETC.)
• ELEVATED ESR (SED. RATE)
 PSOAS PRINCIPLES

PRIMARY FLEXOR OF THE HIP

TIGHT PSOAS WILL PRODUCE
• EXAGGERATE LORDOSIS IF
BILATERAL
• SIDEBEND & ROTATE IF ONLY ONE
PSOAS IS TIGHT
• INCREASES FERGUSON’S
ANGLE
• A POSITIVE THOMAS TEST
• UPPER LUMBAR S/D DUE TO
INNERVATION
• T 12 FRS left S/D COMMON
• IF T 12 S/D PRESENT, INGUINAL
NOTE: BECOME REFERRAL COMMON
SHORTENED WITH • URETER UNDER FASCIA
ALOT OF SITTING
 DIAPHRAM: CRURA
• RIGHT: DOWN TO L 3
• LEFT: DOWN TO L 2 “ LIGHTER” / HIGHER
 THUMB = C 5
F 2-4 = C6-7
F5=C8

T12 = INGUINAL

ANT. THIGH = L2- 4

MEDIAL CALF = L4
LAT. CALF = L5
POST. THIGH &
CALF TO TOE = L #5
- S1
INNERVATION: ARM
NERVE ROOT SENSATION MOTOR REFLEX

C5 LAT. ARM & DELTOID & BICEPS

ELBOW BICEPS REFLEX

C6 LAT. FOREARM BICEPS & BRACHIO-

& THUMB WRIST RADALIS
REFLEX
C7 MIDDLE TRICEPS & TRICEPS
FINGER WRIST REFLEX
FLEXORS
C8 LITTLE FINGER WRIST NONE
MEDIAL FLEXORS &
FOREARM INTEROSSI
TI MEDIAL INTEROSSI NONE
ELBOW & ARM
DTR EVALUATION
GRADE DEFINITION

4/4 BRISK WITH SUSTAINED

CLONUS
3/4 BRISK WITH UNSUSTAINED
CLONUS
2/4 NORMAL

1/4 DECREASED BUT PRESENT

0/4 ABSENT
 MUSCLE STRENGTH
GRADE DIAGNOSIS DEFINITION

5 NORMAL FULL ROM AGAINST

GRAVITY AND FULL
RESISTANCE
4 GOOD FULL ROM AGAINST
GRAVITY OR SOME
RESISTANCE
3 FAIR FULL ROM AGAINST
GRAVITY WITH NOT
RESISTANCE
2 POOR FULL ROM WITHOUT
GRAVITY
1 TRACE EVIDENCE OF SLIGHT
CONTRACTION
0 ZERO NO EVIDENCE OF
CONTRACTION
CRANIUM
The 5 Cranial Phenomena
The fluctuation of CSF
The mobility of the CNS membranes (dura) and the reciprocal tension
membrane
The motion of the sacrum
The motion of the cranial bones
The motion of the central nervous system
FLEXION--MIDLINE BONES FLEX PAIRED BONES ER TRANSVERSE
DIAMETER WIDENS
EXTENSION-MIDLINE BONES EXTEND,PAIRED BONES IR,TRASNSVERSE
DIAMETER NARROWS
Reciprocal Tension Membrane
Falx Cerebrum and Tentorium Cerebelli change shape during each cranial
motion phase to accommodate the container change (intracranial and
intraspinal membranes)

It maintains balance of tension and forces

This fulcrum is suspended and occurs in the posterior cranium where these
membranes meet

Like ligaments that allow joints to move

The Sutherland Fulcrum

Cranial Patterns
Physiologic
◦ Torsions
◦ Sidebending rotations

Pathologic (traumatic)
◦ Lateral strain
◦ Vertical strain
◦ SBS compression
 Sidebending/Rotation
Sidebending Rotation
◦ When viewed from above, the ◦ When viewed from above, the
sphenoid and occiput rotate in sphenoid and occiput rotate in the
opposite directions on two vertical axis same direction on an AP axis
(moves left and right) ◦ (occurs to the side of the convexity
which is more caudad)
Torsion
The axis is AP from the opisthion to the nasion
Motion of the sphenoid and occiput is in opposite directions
Named for the superior aspect of the greater wing of the sphenoid
When the hands are in a vault hold, one hand will radially deviate while
the other deviates in an ulnar direction
Lateral Strain
Two vertical axis
A side to side shearing trauma
Motion of the occiput and sphenoid is in the same
direction
Named for the direction of the base of the sphenoid
The index fingers move laterally in 1 direction like a parallelogram
 Vertical Strain
•The axes consist of the two transverse axes of flexion and
extension
•Sphenoid will be in extension while the occiput is in flexion or
vice versa
•Named for the direction of the base of the sphenoid (superior
vertical shear vs. inferior vertical shear)

•When the hands are in the vault hold, both 2nd digits will move
caudad and both 5th digits will move cephalad, or vice versa.
SBS Compression
Unlike all other SBS Strains, it is NOT a combination of rotations about
axes
It is a base-to-base compression of the sphenoid and the occiput
When the hands are in the vault hold, there is a lack of full expansion of
the PRM
Clinical Applications:
Osteopathy in the Cranial Field
•Cephalgia/Pain Syndrome
•Vertigo/Dizziness
•EENT - Respiratory Tract Involvement
•TMJ & Occlusal Disorders
•Visceral dysfunction
•Pediatric health
•Post-partum blues
 Plagiocephaly: Parallelogram
Head
SBS Pattern
Normal Lateral Strain

Secondary to Birth Trauma/Asymmetric Pressures

Common Systemic Problems
OCF & the Respiratory System
Asthma
◦  Incidence: Extension Head

Ear cough
◦ Check OM-C2 somatic dysfnt

Earache (normal drum)

◦ Often OA or pterygoid SD

Eustachian tube dysfunction

◦ Medial pterygoid SD/OM suture CN 9 ,CN5
CLINICAL
APPLICATIONS
Infant suckling problem condylar compression of occiput
(CN 9,10,12)
Torticollis (CN11) compression
CN VI compression with medial deviation (strabismus) of
the eye from severe lesions of the sphenoid or temporal
bones and is associated with a lateral strain pattern
Headaches OM suture compression CN X and dural strain
Tic douloureux from dysfunction of palatines, sphenoid,
maxillae, temporals and mandible
Occipital Condylar
Compression
Condyles compressed on the atlas, and medial, restricting flexion and
extension
◦ Common in Newborns

Condyle forms the posterior medial part of the hypoglossal canal

XII-Responsible for sucking in Newborns

Membranous Dysfunctions
Consist of a fold in the dura
Similar to strains in any other connective tissues
Dura Mater is intimately adhered to the inside of the cranium, and a
strain in the dura will cause dramatic effects in the way the osseous
tissues move
Treatment is to balance the membranes
Sutural Dysfunctions
Often due to trauma
The compression of one suture into another prevents the full excursion
of the primary respiratory mechanism
Treatment includes the V-Spread technique in which the tide is directed
from the opposite side of the cranium to open the restriction
Secondary Sacral Restrictions
The RTM permits the sacrum to be the cause or a victim in any cranial
dysfunction
Trauma to the head can lead to low back pain
A dysfunction in the head may be resistant to treatment because there
is a sacral dyfunction
PRINCIPLES OF TREATMENT
Aim of Treatment:
◦ Establish free and uninhibited physiologic motion
◦ normalize nerve function
◦ counteract stress-producing forces
◦ eliminate circulatory stasis
◦ normalize cerebrospinal fluid function
◦ release membranous tension
◦ correct cranial articular lesions
◦ modify gross structural patterns
PRINCIPLES OF TREATMENT
The Point of
“Balanced Membranous Tension”
◦ The most “neutral” position possible under the influence of all the factors
responsible for the existing pattern---all attendant tensions having been
reduced to the absolute minimum
PRINCIPLES OF TREATMENT
Refinements in securing the point of balanced membranous tension:
◦ Exaggeration
◦ Direct action
◦ Disengagement
◦ Opposite physiologic motion
◦ Molding
OMT TYPES
 TECHNIQUE COMPONENTS
• DIRECT TREATMENT: TOWARD THE RESTRICTIVE
BARRIER
• INDIRECT TREATMENT: AWAY FROM THE
RESTRICTIVE BARRIER
• ACTIVE TREATMENT: PATIENT ASSISTS DURING THE
TREATMENT
• PASSIVE TREATMENT: PATIENT RELAXES DURING
THE TREATMENT
• MYOFASCIAL RELEASE: DIRECT OR INDIRECT, ACTIVE
OR PASSIVE
• COUNTERSTRAIN: INDIRECT PASSIVE
• FACILITATED POSITIONAL RELEASE: INDIRECT,
PASSIVE
• MUSCLE ENERGY: DIRECT, ACTIVE
• HV / LA: DIRECT, PASSIVE
• FUNCTIONAL: INDIRECT, ACTIVE (P/H, I/A), PASSIVE (I/P)
[ THESES ARE DESCRIBED FROM CLINICIAN VIEW ]
TECHNIQUE TYPES:
TREATMENT TYPE DIRECT OR INDIRECT ACTIVE OR PASSIVE
( PATIENT'S ROLE )
MYOFASCIAL RELEASE BOTH BOTH

COUNTERSTRAIN INDIRECT PASSIVE

FACILITATED INDIRECT PASSIVE

POSITIONAL REELEASE
MUSCLE ENERGY DIRECT (RARELY ACTIVE
INDIRECT )
HV / LA DIRECT PASSIVE

FUNCTIONAL / PCSOM INDIRECT PASSIVE (ALL)

 RESTRICTIVE BARRIER

LOST ROM
- ACTIVE
- PASSIVE

MUSCLE ENERGY - DIRECT

- PATIENT INTRODUCED FORCE[ ACTIVE]
(FUNCTIONALLY CHANGES ORIGIN & INSERTION OF
MUSCLE)
 RESTRICTIVE BARRIER

LOST ROM
- ACTIVE
- PASSIVE

HV/LA - DIRECT
- CLINICIAN INTRODUCED FORCE [PASSIVE]
(IMPULSE / THRUST)
 RESTRICTIVE BARRIER

LOST ROM
- ACTIVE
- PASSIVE
DBP

FUNCTIONAL - INDIRECT
- PATIENT “INTRINSIC FORCES” (GOLGI,
SPINDLES, PACINIAN, CHANGE SOFT-WARE, ETC)
 LUMBAR ROLL: SAVARESE

LUMBAR ROLL TECHNIQUE

TYPE II DYSFUNCTION

IF POSTERIOR T.P UP, PULL LOWER ARM CAUDAD ( AND I

ANTERIOR)
IF POSTERIOR T.P. DOWN, PULL THE LOWER ARM CEPHLAD II
(AND ANTERIOR)
TYPE I DYSFUNCTION

IF POSTERIOR T.P. UP, PULL LOWER ARM CEPHLAD (AND II

ANTERIOR)
IF POSTERIOR T.P. DOWN, PULL LOWER ARM CAUDAD ( AND I
ANTERIOR)
 SAVARESE OPTIONS: L 3 ERS r

TYPE II
POST. T.P. UP

TECHNIQUE:
• PATIENT LAYS ON LEFT SIDE
• FLEX TOP HIP UP TO L 4; EXTEND LOWER LEG
• PULL LOWER ARM ANTERIOR [ ROTATES RIGHT ]
CAUDAD USING TYPE I [ SIDEBENDS LEFT ]
NOTE: TREATING ONLY THE S/B COMPONENT [OK]
USING TYPE I MECHANICS TO TREAT SIDEBENDING
COMPONENT OF TYPE II S/D
 SAVARESE OPTIONS: L 3 N Sl Rr

TYPE I
POST T.P. UP

TECHNIQUE
• PATIENT LAYS ON THEIR LEFT SIDE
• LOWER LEG IS EXTENDED
• UPPER LEG FLEXED TO L 4
• LOWER ARM IS PULLED ANTERIORLY
[ ROTATES RIGHT] AND CEPHLAD [SIDEBENDS RIGHT] NOTE: USING TYPE II
MECHANICS TO TREAT SIDEBENDING COMPONENT OF A TYPE I S/D [OK]
 SAVARESE OPTION: L 3 N Sl Rr

TYPE I
POST. T.P. DOWN
[ ANT. T.P. UP ]

TECHNIQUE:
• PATIENT ON THEIR RIGHT SIDE ( POST. T.P. DOWN)
• FLEX LEG TO LOCK TO L4 ( NOT L3 AS STATED )
• STRAIGHTEN THE LOWER LEG
• PULL LOWER ARM ANTERIOR AND CAUDAD TO USE TYPE I MECHANICS TO INDUCE
SIDEBENDING DOWN TO L 3 [ TREATING ALL 3 COMPONENTS ]
• INTRODUCE THRUST
NOTE: USING TYPE I MECHANICS TO REVERSE ALL COMPONENTS OF TYPE I S/D
QUESTIONS
Evaluation of the cranium utilizing the vault hold
includes all of the following EXCEPT:
A. Middle finger on the temporal bone
B. Fourth finger on the temporal bone
C. Thumb on the sagittal suture
D. Index finger on the sphenoid
E. Fifth finger on the occiput

122
VAULT HOLD
Answer: C

The vault hold includes all the following except that the
thumb(s) are over, but not touching, the sagittal suture.

124
The reciprocal tension membrane attaches to all of
the following bones EXCEPT:
A. Sacrum
B. Ethmoid
C. Temporal
D. Mandible
E. Occiput

125
Answer: D
The RTM has five points of attachment in the cranio-sacral mechanism:
Anterior superior pole attachment: Crista galli of ethmoid
Anterior inferior pole of attachment: Clinoid processes of the sella
turcica of the sphenoid
Lateral poles of attachment: Petrous ridges of temporal bones.
Posterior pole of attachment: Internal occipital protruberance and
transverse ridge of occiput
Inferior pole of attachment: S2 of the sacrum
The RTM does not attach to the facial bones per se.

126
An patient presents with low back pain of six week duration. She denies
any trauma, however, she does recall a “misstep” off the curb while
walking to work in the City. Examination reveals: A negative seated
flexion test. A positive standing flexion test on the right. The left ASIS and
left PSIS were found to be more inferior than the right. Which of the
following best describes the osteopathic treatment for this dysfunction?

A. Exert cephalad force on the ischial tuberosity with exhalation with

patient in the right sidelying position.
B. Exert cephalad force on the ischial tuberosity with the patient in the
left sidelying position
C. Exert caudad traction along the long axis of the right lower extremity
with patient in supine position.
D. Exert caudad traction along the long axis of the left lower extremity
with patient in the supine position.
E. Treat the anterior sacral base on oblique axis in the lateral Sims’s
position

127
Answer: C
This patient has a superior innominate (or upslipped
innominate) shear on the right as demonstrated by the
lateralization of the standing flexion test on the right. This
excludes a left innominate dysfunction. The negative
seated flexion test eliminates the possibility of a sacral
torsion thusly choice E is incorrect.
An superior innominate shear is treated by a “Tug” on the
involved extremity as the patient is supine, usually at the
end of exhalation.

128
A sixty four year obese male presents with chronic low back pain which
radiates into his medial thigh and groin. He is an industrial painter by
trade, working mostly on ceilings. His history and physical examination
are essentially benign except for liver disease “maybe hepatitis ”, high
cholesterol, an elevated Hemoglobin A1C. Osteopathic evaluation
reveals no exaggerated motion with the seated or standing flexion tests.
No recent weight loss. Recent x-rays reveal a Ferguson’s angle to be 45
degrees Which of the following are LEAST likely to be associated with
this patients condition?

A. Hepatocellular carcinoma
B. Spondylolisthesis
C. Right shoulder pain
D. Anterior sacral base on oblique axis
E Taut iliolumbar ligaments

129
Answer: A
This patient has decompensation of the Lumbar spine in the Sagittal
plane as demonstrated by an increased Ferguson’s angle (normal 25-35
degrees) suggesting an increased lumbar lordosis which is facilitated by
his obesity (anterior shift of gravity).

130
You are asked to attend to a head trauma victim in the ED. She
was boxing for a celebrity boxing match. The last thing she
remembers is being hit with a left hook from the opponent to the
side of her right frontal bone after a jab to the underside of the
chin. Osteopathic examination of the cranium reveals a left lateral
shear which occurs via:
A. Restricted motion of the sphenoid and occiput in opposite directions
about an A-P axis.
B. Restricted motion of the sphenoid and occiput in the same direction
about two vertical axes.
C. Restricted motion of the sphenoid and occiput in the same direction
about an A-P axis and two vertical axes.
D. Restricted motion of the sphenoid and occiput in the opposite
direction about an A-P axis and two vertical axes.
E. Restricted motion of the sphenoid and occiput in the same direction
about two physiologic transverse axes.

131
Answer: B
This patient has a left lateral strain of the cranium.
Lateral strains are pathologic and occur about two vertical axes, one
through the foramen magnum and other through the sella turcica.
The sphenoid and occiput rotate in the SAME direction. C
A torsion occurs about an A-P axis through the SBS joint in which the
sphenoid and occiput rotate in opposite directions.
A sidebending rotation strain occurs about an A-P axis through the SBS joint
and sidebend away from each other via two vertical axes, one through the
foramen Magnum and other through the sella turcica of the sphenoid.
Flexion or extension dysfunctions occur about the two physiologic axes,
however, the bones go in same direction. The cranial dysfunction is mostly
named per the relative position of the sphenoid bone.

132
A twenty five year old presents with symptoms of low back pain
which radiates below the knee. Numbness and tingling is reported
into the dorsum of the foot. Extensor hallucis longus does not
resist toe flexion. Which nerve root is affected?
A. L1
B. L2
C. L3
D. L4
E. L5

133
You decide to utilize FPR. Which of the
following are NOT true of the principle’s
of this technique?
A. Torsion
B. Compression
C. Neutral
D. Traction
E. Direct
.
Answer: E
Facilitated Positional Release is an Indirect, not direct, myofascial
technique which utilizes:
Neutral
Compression
Torsion
Traction (sometimes)
3-5 seconds

135
During your osteopathic structural examination you note
ropiness, asymmetry, diminished red reflex, altered motion
and sensitivity. Which of the following barriers are the
result of this phenomenon?
A. Anatomic
B. Elastic
C. Restrictive
D. Physiologic
E. Pathologic

136
Answer: C
According to the Osteopathic Glossary: The Restrictive Barrier is
indicative of Somatic Dysfunction (defined as Tissue Texture Changes,
Asymmetry, Restricted Motion and Tenderness). The Anatomic barrier
is the limit of human anatomy and end point of passive motion. The
Elastic Barrier is the range between the physiologic and anatomic
barrier of motion in which passive ligamentous stretching occurs before
tissue disruption. The Pathologic barrier is a restriction of joint motion
associated with pathologic tissues (osteophytes). The physiologic
barrier is the limit of active motion.

137
You decide to perform the further dynamic testing on your patient with low
back pain. With the patient in the supine position you take the hands and
compress their ASIS’s posteriorly and medially. This test will provide
valuable information about all of the following EXCEPT:

A. Lumbar spine
B. Ischium
C. Ilium
D. Sacrum
E. Pubes

138
Answer: A

This is the ASIS Compression Test which gives valuable information

about the pelvis and sacrum. The innominate is comprised of the ilium,
ischium and pubic bones. The sacrum and sacroiliac joint is also
assessed. This test, unlike the Spring Test, gives little information
concerning the lumbar spine.

139
Sutural Dysfunctions
Often due to trauma
The compression of one suture into another prevents the full excursion
of the primary respiratory mechanism
Treatment includes the V-Spread technique in which the tide is directed
from the opposite side of the cranium to open the restriction
Secondary Sacral Restrictions
The RTM permits the sacrum to be the cause or a victim in any cranial
dysfunction
Trauma to the head can lead to low back pain
A dysfunction in the head may be resistant to treatment because there
is a sacral dyfunction
PRINCIPLES OF TREATMENT
Aim of Treatment:
◦ Establish free and uninhibited physiologic motion
◦ normalize nerve function
◦ counteract stress-producing forces
◦ eliminate circulatory stasis
◦ normalize cerebrospinal fluid function
◦ release membranous tension
◦ correct cranial articular lesions
◦ modify gross structural patterns
PRINCIPLES OF TREATMENT
The Point of
“Balanced Membranous Tension”
◦ The most “neutral” position possible under the influence of all the factors
responsible for the existing pattern---all attendant tensions having been
reduced to the absolute minimum
PRINCIPLES OF TREATMENT
Refinements in securing the point of balanced membranous tension:
◦ Exaggeration
◦ Direct action
◦ Disengagement
◦ Opposite physiologic motion
◦ Molding
 CONSULT GI TRACT: PNS - MOUTH TO 1/2 TRANSVERSE COLON (VAGUS X );
REST OF PNS FROM SACRAL PLEXUS
SNS: ESOPHAGUS & STOMACH T 5-9
• LIVER AND GALL BLADDER T 7-9 (RIGHT)
• SPLEEN AND PANCREAS T 7 (LEFT)
• SM. INTESTINE & RIGHT COLON T 10-12 (AP. T12)
• LEFT COLON T 12-L2
CP-ESOPHAGUS IS2, LIVER IS 5,6 R,STOMACH IS5L,PANCREAS IS7R
COLON ANTERIOR IT BAND,APPENDIX TIP 12TH RIBR
 GLOSSARY TERMS

“GLOSSARY IS THE FINAL REFERENCE”

HARRIET SHAW, D.O. 1999 @ PCSOM
 TERMS: KAPLAN

• STRESS: FORCE
• STRAIN: DEFORMATION
• ELASTIC: RESISTS DEFORMATION
• PLASTICITY: EASILY DEFORMED
• ELASTIC DEFORMATION OF TISSUES: DEFORMATION
WHICH RETURNS TO ORGINAL
• PLASTIC DEFORMATION: DEFORMATION WHICH DOES
NOT RETURN TO NORMAL
• VISCOELASTIC PROPERTIES OF COLLAGEN:
COLLEGEN HAS PROPERTIES OF A SOLID AND A FLUID
 GLOSSARY TERMS:
• ACCESSORY MOVEMENTS: MOVEMENTS USED TO
POTENTIATE, ACCENTUATE OR COMPENSATE
FOR AN IMPAIRMENT IN A PHYSIOLOGICAL
MOTION (EX:MOVEMENT NEEDED TO MOVE A
PARALYZED LIMB)
• ACCOMMODATION: A SELF REVERSING AND
NONPERSISTENT ADAPTATION
• ALLOPATHY:
• SUBSTITUTION THERAPY, A THERAPY SYSTEM IN
WHICH A DISEASE IS TREATED BY PRODUCING A
SECOND CONDITION WHICH IS INCOMPATIBLE OR
ANTAGONISTIC TO THE FIRST [DISEASE PROCESS]
• TRADITIONAL MEDICAL PRACTICE AS
DISTINGUISHED FROM HOMEOPATHY AND
OSTEOPATHY
 GLOSARY TERMS:
FERGUSON’S ANGLE: TWO TYPES

LUMBO-LORDOTIC LUMBO-SACRAL ANGLE

( 39 +/- 2 DEGREES )
 GLOSSARY TERMS:
AXIONIC TRANSPORT (NEUROTROPHIC AXIONIC
FLOW): THE ANTEGRADE MOVEMENT OF SUBSTANCES
( PROTEIN & LIPID; ESSENTIAL FOR HEALTH OF END-
ORGAN) FROM THE CELL / NUCLEUS ALONG THE AXON
TOWARD THE TERMINALS AND THE RETROGRADE
MOVEMENT FROM THE TERMINALS TOWARD THE CELL.
NOTE: 30 mm HG PRESSURE ENOUGH TO STOP THE
FLOW. [ KORR: CROSS NEURO-MUSCULAR JUNCTION ]
[ 30 mm HG PRESSSURE IMPEADS FLOW ]
ABNORMAL JOINT BARRIERS:
• RESTRICTIVE: ALTERS ACTIVE AND PASSIVE RANGE
OF MOTION [ REVERSIBLE ]
• PATHOLOGICAL: A RESTRICTIVE BARRIER THAT IS
IRREVERSIBLE( FUSION, OSTEOPHYTE,
CONTRACTURE)
 GLOSSARY TERMS
BIND: RELATIVE PALPABLE RESISTANCE TO MOTION OF AN
ARTICULATION OR TISSUE. SYNONYM: RESISTANCE ANONYM:
EASE, COMPLIANCE, RESILIENCE
BOGGINESS: A TISSUE TEXTURE ABNORMALITY
CHARACTERIZED PRINCIPALLY BY A PALPABLE SENSE OF
SPONGINESS IN THE TISSUE,
INTERPRETED AS RESULTING FROM CONGESTION DUE
TO INCREASED FLUID CONTENT OF TISSUES [ VENOUS,
LYMPHATIC ]
CONTRACTURE: A CONDITION OF FIXED HIGH RESISTANCE
TO PASSIVE STRETCH OF A MUSCLE, RESULTING FROM
FIBROSIS OF THE TISSUES SUPPORTING THE MUSCLES OR THE
JOINT, OR FROM DISORDERS OF THE MUSCLE FIBERS. EX:
DUPUYTREN’S CONTRACTURE OF PALMAR FASCIA
 GLOSSARY TERMS
CONTRACTION: SHORTENING AND / OR DEVELOPMENT OF TENSION
IN A MUSCLE [ REVERSIBLE ]
• CONCENTRIC: APPROXIMATION OF ENDS / SHORTENING
• ECCENTRIC: LENGTHING OF MUSCLE [ ISOLYTIC ]
• ISOLYTIC: CONTRACTION OF A MUSCLE AGAINST RESISTANCE
WHILE FORCING THE MUSCLE TO LENGTHEN. OPERATOR
FORCE IS GREATER THEN THE PATIENT FORCE [ EX: STRETCHING
HAMSTRING ] ( ECCENTRIC )
• ISOMETRIC: CHANGE OF TENSION OF THE MUSCLE WITHOUT
APPROXIMATION OF MUSCEL ENDS. PATIENT AND OPERATOR
FORCES / RESISTENCE ARE EQUAL (BUILDS MASS )
• ISOTONIC: APPROXIMATION OF THE MUSCLE ENDS WITHOUT
CHANGE IN TENSION. OPERATOR FORCE OR RESISTENCE IS LESS
THAN THE PATIENT FORCE ( BUILDS STRENGTH )
(CONCENTRIC )
 GLOSSARY TERMS
“CORE LINK”: THE CONNECTION OF THE SPINAL DURA MATER FROM THE
OCCIPUT AT THE FORAMEN MAGNUM TO THE SACRUM. IT CORDINATES
THE SYNCHRONOUS MOTION OF THESE TWO STRUCTURES.
CRANIAL RHYTHMIC IMPULSE (CRI): PALPABLE RHYTHMIC FLUCTUATION
BELIEVED TO BE SYNCHROMOUS WITH THE PRIMARY RESPIRATOY
MECHANISM [ A MODEL PROPOSED BY WILLIAM G. SUTHERLAND, D.O. TO
DESCRIBE THE INTER-DEPENDENT FUNCTIONS AMONG FIVE
COMPONENTS ] AS FOLLOWS:
• THE INHERENT MOTILITY OF THE BRAIN & SPINAL CORD
• FLUCTUATIONS OF THE CEREBRAL SPINAL FLUID (CSF)
• MOBILITY OF THE INTRACRANIAL AND INTRASPINAL
MEMBRANES [ RTM ]
• ARTICULAR MOVEMENT OF THE CRANIAL BONES [ SUTURES ]
• THE INVOLUNTARY MOBILITY OF THE SACRUM BETWEEN THE
INNOMINATES (STA)
 GLOSSARY TERMS
DECOMPENSATION: A DYSFUNCTIONAL, PERSISTENT PATTERN, IN
SOME CASES REVERSIBLE, RESULTING WHEN HOMEOSTATIC
MECHANISMS ARE PARTIALLY OR TOTALLY OVERWHELMED
DERMATOMES: SEE PICTURE
PAIN PATTERNS BY: BY TISSUES INVOLVED
• DERMATOME: SKIN SUPPLIED BY CUTANEOUS BRANCHES OF A
SINGLE NERVE. NEIGHBORING DERMATOMES MAY OVERLAP
• MYOTOME: ALL MUSCLES DERIVE FROM ONE SOMITE AND
INNERVATED BY ONE SEGMENTAL SPINAL NERVE ( MUSCLE
PAIN /ACHING )
• SCLEROTOME: PATTERN OF INNERVATION OF STRUCTURES
DERIVED FROM EMBYONIC MESENCHYME (JOINT CAPSULE,
LIGAMENTS AND BONE ) (PAIN IS DEEP, DULL & ACHY)
 GLOSSARY TERMS
- ED (SUFFIX): DESCRIBES STATUS, POSITION OR
CONDITION, ie, FLEXED, EXTENDED, ROTATED OR
RESTRICTED [ SEE -ION )
ENTHESITIS: TRAUMATIC DISEASE OCCURING AT THE
INSERTION OF A MUSCLES WHEN RECURRING
CONCENTRATION OF MUSCLE STRESS
PROVOKES INFLAMMATION WITH A STRONG
TENDENCY TOWARD FIBROSIS AND
CALCIFICATION; INFLAMMATION OF THE
MUSCULAR OR TENDENOUS ATTACHMENT
FACET ASYMMETRY: NOT BILATERALLY
COMPARABLE (TROPHISM):
INCREASES POTENTIAL
FOR DISK DEGENERATION ON
SIDE OF CORONAL FACET
 GLOSSARY TERMS
FACILITATION:
1. THE MAINTANCE OF A POOL OF NEURONS [ 90 % NEURONES ] IN A
STATE OF PARTIAL OR SUBTHRESHOLD EXCITATION; IN THIS
STATE, LESS AFFERENT STIMULATION IS REQUIRED TO TRIGGER
THE DISCHARGE OF IMPULSES.
2. A THEORY REGARDING THE NEUROPHYSIOLOGICAL MECHANISMS
UNDERLYING THE NEURONAL ACTIVITY ASSOCIATED WITH
SOMATIC DYSFUNCTION
3. FACILITATION MAY BE DUE TO SUSTAINED INCREASE IN
AFFERENT INPUT, ABERRANT PATTERNS
OF AFFERENT INPUT, OR CHANGES WITHIN
THE AFFERENT NEURONS THEMSELVES OR
THEIR CHEMICAL ENVIRONMENT. ONCE ESTABLISHED
FACILITATION CAN BE
SUSTAINED BY NORMAL CNS ACTIVITY.
 GLOSSARY TERMS
GRAVITATIONAL LINE: LATERAL VIEW “PLUMB-LINE”
• EXTERNAL AUDITORY MEATUS
• TIP OF THE SHOULDER
• CENTER OF BODY OF L3
• ANTERIOR 1/3 OF BASE OF THE SACRUM
• GREATER TROCHANTER
• LATERAL CONDYLE OF THE KNEE
• SL. ANTERIOR TO LATERAL MALLEOLUS
HYPERTONICITY: A CONDITION OF EXCESSIVE
TONE OF THE SKELETAL MUSCLES;
INCREASED RESISTANCE OF MUSCLES TO PASSIVE
STRETCHING [ SEE CONTRACTURE ]
INTERSEGMENTAL MOTION: DESIGNATES RELATIVE MOTION TAKING
PLACE BETWEEN TWO ADJACENT VERTEBRAL SEGMENTS
( VERTEBRAL UNIT ); DESCRIBES THE UPPER SEGMENT MOVING ON
THE LOWER ONE.
 GLOSSARY TERMS
INHIBITION REFLEX:
1. IN OSTEOPATHIC USAGE, A TERM THAT DESCRIBES THE
APPLICATION OF STEADY PRESSURE TO SOFT TISSUES TO
EFFECT RELAXATION AND NORMALIZE REFLEX ACTIVITY.
[ DICKEY / TCOM RESEARCH PROJECT ]
2. EFFECT AN ANTAGONIST MUSCLE DUE TO RECIPROCAL
INNERVATION WHEN THE AGONIST IS STIMULATED [EX:
HAMSTRING STRETCH: MET ]
INTRINSIC CORRECTIVE FORCES: VOLUNTARY OR
INVOLUNTARY FORCES FROM WITHIN THE PATIENT THAT ASSIST
IN THE MANIPULATIVE TREATMENT PROCESS. [ FUNCTIONAL
TECHNIQUES ]
- ION (SUFFIX): DESRIBES A PROCESS OR MOVEMENT
( EXTENSION, FLEXION, ROTATION, RESTRICTION)
 - ION (SUFFIX): DESRIBES A PROCESS OR MOVEMENT
( EXTENSION, FLEXION, ROTATION, RESTRICTION)
“WHAT IT CAN DO”
- ED (SUFFIX): DESCRIBES STATUS, POSITION OR
CONDITION, ie, FLEXED, EXTENDED, ROTATED,
RESTRICTED
INTRINSIC CORRECTIVE FORCES: “NEW MEANING”
• SPINDLE INPUT
• GOLGI INPUT
• PACINIAN INPUT
• BALANCE FASCIA
• BALANCE MUSCULATURE
• BALANCE LIGAMENTOUS STRUCTURES
• ENABLES CRANIAL IMPACT
• MOVEMENT STIMULATES MECHANORECEPTORS
WHICH THEN INHIBIT THE NOCICEPTORS
• TENSEGRITY
 GLOSSARY TERMS
FUNCTIONAL TECHNIQUES: AN INDIRECT TREATMENT METHOD IN WHICH
THE PHYSICIAN GUIDES THE MANIPULATIVE PROCEEDURE WHILE THE
DYSFUNCTIONAL AREA IS BEING PALPATED IN ORDER TO OBTAIN A
CONTINUOUS FEEDBACK OF THE PHYSIOLOGICAL RESPONSE TO
INDUCED MOTION; THE PHYSICAIN GUIDES THE DYSFUNCTIONAL PART SO
AS TO CREATE A DECREASED SENSE OF TISSUE RESISTANCE
(INCREASED COMPLIANCE)
[ INDIRECT / ACTIVE ; YOU LEARNED INDIRECT / PASSIVE OR
“STILL TECHNIQUES”]
LIGAMENTOUS ARTICULAR STRAIN:(LAS) MYOFASCIAL RELEASE
TECHNIQUES DESCRIBED BY DRs HOWARD & REBECCA LIPPINCOTT, DO
(BOTH)
[ INDIRECT / POSITION AND HOLD AT DBP ]
( SUTHERLAND TAUGHT THEM TO LAUGHLIN )
 FUNCTIONAL TECHNIQUE TYPES

POSITION & HOLD (P/H) @ D.B.P.

• LAUGHLIN: MONITOR TISSUES RESPONSE
• JONES / STRAIN-COUNTERSTRAIN: MONITOR
TENDER POINT
• FACILITATED POSITIONAL RELAEASE: ADD
COMPRESSION
• GREENMAN BOOK
INDIRECT / ACTIVE (I / A): START @ D.B.P. BUT THEN
OPERATOR ACTIVELY FOLLOWS THE PATH OF LEAST
RESISTENCE
• GLOSSARY DEFINITION
• “ STILL TECHNIQUES “ VAN BUSKIRK
• GREENMAN BOOK
INDIRECT / PASSIVE (I / P): START @ D.B.P. AND ADD
COMPRESSION AND LET “ DO-DAD DO ITS THING”
[ WHAT LAUGHLIN TAUGHT ME, SUTHERLAND TAUGHT LAUGHLIN ]
 GLOSSARY TERMS
LYMPHATIC PUMP: TERM COINED BY C.EARL
MILLLARD ( MILLER) , DO. TO DESCRIBE THE IMPACT
OF INTRATHORACIC PRESSURE CHANGES ON
LYMPHATIC FLOW; THIS WAS THE NAME ORIGINALLY
GIVEN TO THE THORACIC PUMP TECHNIQUE
BEFORE THE MORE EXTENSIVE PHYSIOLOGICAL
EFFECTS OF THE TECHNIQUE WERE RECOGNIZED.
PERCUSSION VIBRATORY TECHNIQUE: AN
OSTEOPATHIC MANIPULATIVE TECHNIQUE
DEVELOPED BY ROBERT FULFORD, DO
INVOLVING THE SPECIFIC APPLICATION OF
MECHANICAL VIBRATORY FORCE TO TREAT
SOMATIC DYSFUNCTION
[ MECHANISM: PACINIAN RECEPTOR / VIBRATION
RESPONSE ?]
I GOT A FREE ONE @ AAO MEETING
 GLOSSARY TERMS

OSTEOPATHIC PHILOSOPHY: ( KCOS 1953 )OSTEOPATHIC MEDICINE

IS A PHILOSOPHY OF HEALTH CARE AND A DISTINCT ART,
SUPPORTED BY EXPANDING SCIENTIFIC KNOWLEDGE;

ITS PHLOSOPHY EMBRACES THE CONCEPT OF UNITY OF THE LIVING

ORGANISM’S STRUCTURE (ANATOMY) AND FUNCTION (PHYSIOLOGY).
ITS ART IS THE APPLICATION OF THE PHILOSOPHY IN THE PRACTICE
OF MEDICINE AND SURGERY IN ALL BRANCHES AND SPECIALTIES.
ITS SCIENCE INCLUDES THE BEHAVIORAL, CHEMICAL, PHYSICAL,
SPIRITUAL AND BIOLOGICAL KNOWLEDGE RELATED TO THE
ESTABLISHMENT AND MAINTANCE OF HEALTH AS WELL AS THE
PREVENTION AND ALLEVIATION OF DISEASE.
 GLOSSARY TERMS
OSTEOPATHIC PHILOSOPHY (CONT)
OSTEOPATHIC CONCEPTS EMPHASIZE THE FOLLOWING
PRINCIPLES:
1. THE HUMAN BEING IS A DYNAMIC UNIT OF
FUNCTION.
2. THE BODY POSSESSES SELF-REGULATORY
MECHANISMS WHICH ARE SELF HEALING IN NATURE
3. STRUCTURE AND FUNCTION ARE INTER- RELATED AT ALL
LEVELS TISSUE TENSION / STRETCH CAN CHANGE BOTH THE
BIOCHEMICAL AND GENETIC FUNCTIONAL PATTERNS.] [ CAPRA:
STRUCTURE = NETWORK / TENSEGRITY ]
4. RATIONAL TREATMENT IS BASED ON THESE
PRINCIPLES
 GLOSSARY TERMS
ISOKINETIC EXERCISES: EXERCISING USING CONSTANT SPEED OF
MOVEMENT OF THE BODY PART
LAWS: OF OSTEOPATHIC SIGNIFICANCE
• HEAD’S: WHEN A PAINFUL STIMULUS IS APPLIED TO A BODY PART
OF LOW SENSITIVITY( ie VISCUS) THAT IS IN CLOSE CENTRAL
CONNECTION WITH A POINT OF HIGHER SENSITIVITY (ie SOMA), THE
PAIN IS FELT AT THE POINT OF HIGHER SENSTIVITY RATHER THAN AT
THE POINT WHERE THE STIMULUS IS APPLIED
[V/S REFLEX]
• WOLFF’S: EVERY CHANGE IN FORM AND FUNCTION OF A BONE, OR
IN ITS FUNCTION ALONE, IS FOLLOWED BY CERTAIN DEFINITE
CHANGES IN ITS INTERNAL ARCHITECTURE, AND SECONDARY
ALTERATIONS IN ITS EXTERNAL CONFORMATIONS [BONE IS LAID
DOWN IS LINES OF STRESS] ( JOE SHAW, MD PLASTICITY OF
INNOMINATES; “SMALL HEMI-PELVIS” )
 GLOSSARY TERMS
MANDIBULAR DRAINAGE: SOFT TISSUE MANIPULATIVE
TECHNIQUE USING PASSIVELY INDUCED JAW MOTION TO
EFFECT INCREASED DRAINAGE OF MIDDLE EAR
STRUCTURES VIA THE EUSTACHIAN TUBE AND LYMPHATICS
[GALBRAITH TREATMENT]
FACILITATED POSITIONAL RELEASE (SCHIOWITZ) THE
RESTRICTED SEGEMENT IS PLACED IN NEUTRAL [ DBP ]
POSITION, DIMINISHED TISSUE AND JOINT TENSION, IN ALL
PLANES, AND AN ACTIVATING FORCE (COMPRESSION OR
TORSION) IS ADDED.
[ POSITION & HOLD WITH COMPRESSION ]
FASCIAL UNWINDING: INVOLVES A CONSTANT FEEDBACK TO THE
PHYSICAIN WHO IS PASSIVELY MOVING A PORTION OF THE
PATIENT’S BODY IN RESPONSE TO THE SENSATION OF
MOVEMENT. FORCES ARE LOCALIZED USING THE
SENSATION OF EASE AND BIND OVER WIDE REGIONS.
[ INDIRECT / ACTIVE IS DESCRIBED; YOU ALSO LEARNED
INDIRECT / PASSIVE WHERE THE BODY’S INTRINSIC FORCES
CORRECT THE PROBLEM ]
 GLOSSARY TERMS
RECIPROCAL INHIBITION: THE INHIBITION OF
ANTAGONIST MUSCLES WHEN THE AGONIST IS
STIMULATED. [ FRS MET MANAGEMENT / Tx
HAMSTRINGS Rx MET ]
RECIPROCAL TENSION MEMBRANE: THE
INTRACRANIAL AND SPINAL DURAL MEMBRANES
INCLUDING THE FALX CEREBRI, FALX CEREBELLI,
TENTORIUM AND SPINAL DURA.
REFLEXES:
• SOMATO-VISCERAL
• VISCERO-SOMATIC
(MYOCARDIAL INFARCT)
• VISCERO-VISCERAL
(CHOLECYSTO-
CORONARY SYNDROME)
• SOMATO-SOMATIC
( JONES POINT )
 SOMATIC DYSFUNCTION: CHRONIC, IMPAIRMENT OR
ALTERATED FUNCTION OF RELATED
COMPONENTS OF THE SOMATIC (BODY
FRAMEWORK) SYSTEM, CHARACTERIZED BY
TENDERNESS, ITCHING, FIBROSIS,
PARESTHESIAS, CONTRACTURE; IDENTIFIED T.A.R.T.
STILL POINT: A TERM USED BY WILLIAM .G
SUTHERLAND, D.O. TO IDENTIFY AND DESCRIBE THE
BRIEF CESSATION OF RHYTHM (CRI) ATTRIBUTED TO THE
FLUCTUATION OF CEREBRAL SPINAL FLUID
( A COMPONENT OF THE PRIMARY RESPIRATORY
MECHANISM) OBSERVED BY PALPATION DURING
OSTEOPATHIC MANIPULATIVE TREATMENT WHEN A
POINT OF BALANCE MEMBRANOUS TENSION (OR
BALANCED LIGAMENTS) IS ACHIEVED
Thank you!