Cleveland Academy of Osteopathic Medicine

D.O.s: Treating Our Family & Yours

6th Annual OMT Seminar: January 24th, 2010
Core Concepts in
Osteopathic Manipulative Medicine
&
The Application To Board Examinations
Michael P. Rowane, DO, MS, FAAFP, FAAO
Associate Clinical Professor of Family Medicine and Psychiatry
Case Western Reserve University
Director of Medical Education
University Hospitals Richmond Medical Center
Director of Osteopathic Medical Education
University Hospitals Case Medical Center
 Outline

Review core concepts of OPP/OMM/OMT

Discuss general measures to prepare for board questions
involving Osteopathic Principles & Practices [OPP]

Examine the COMLEX Structural/OPP component to the
National Board of Osteopathic Medical Examiners [NBOME]

Present the 10 Basic Body Functions related to Osteopathic
Manipulative Medicine [OMM]

Explore the 5 Models involved in using Osteopathic
Manipulative Treatment [OMT]

Go over COMLEX practice questions involving OPP/OMM/OMT
Andrew Taylor Still, MD, DO

Born in 1828

Father = Minister &
Physician

MD in Kansas City, Mo

Abolitionists, moved to
Native American Reservation
in Indiana

Kansas Legislature

Children died of meningitis

MECHANICAL AGE

Discovered Osteopathy 1874

American School of
Osteopathy in Kirksville 1892
Key Concepts
 Somatic Dysfunction

Definition:

pathologic alteration of joint
function

mimic or aggravate organic
disease

involves “TART”

Tenderness

Asymmetry

altered Range of motion

Tissue texture abnormality
Barriers To Motion

Anatomic

Physiologic

Pathologic
 Indications/Contraindications
for Manipulation

Indications: alleviate somatic dysfunction

Contraindications:

trauma (fractures, lacerations, bleeding

pathologic bone disease (lytic / blastic)

poor patient cooperation

neurologic symptoms while positioning

severe RA, structural defects
Indications/Contraindications
of Manipulation
Contraindications
(cont.)

Bruits in carotids

Lens implants

Hemophilia

Medicolegal
situations
 “Red Flags” = RIFT

Radiculopathy

Infection

Fracture

Tumor
Types Of Manipulation:
Direct/Indirect
SOFT TISSUE TECHNIQUE

DEFINITION:
Procedure
directed toward
tissues other
than skeleton
while monitoring
response and
motion changes
using diagnostic
palpation.
 SOFT TISSUE TECHNIQUE
(con’t)
Usually involves
lateral
stretching, linear
stretching, deep
pressure,
traction, and/or
separation of
muscle origin
and insertion.
MUSCLE ENERGY
TECHNIQUE
DEFINITION:
A term first suggested by
Fred L. Mitchell, Sr, DO.

A form of Osteopathic
manipulative technique in
which the patient uses their
muscles, on request, from a
precisely controlled position,
in a specific direction, against
a distinctly executed
operator counterforce.
HIGH VELOCITY-LOW AMPLITUDE
(THRUST) TECHNIQUE
DEFINITION: A
type of direct
technique that
uses high
velocity-low
amplitude
forces.
COUNTERSTRAIN
TECHNIQUE
DEFINITION:

An indirect technique
developed by Lawrence
Jones, DO.

The operator moves the

patient or part passively
away from the motion
barrier always searching
for the position of
greatest comfort.
COUNTERSTRAIN TECHNIQUE (con’t)

Tender point associated
with somatic
dysfunction

Patient is held in
position of comfort for
90 seconds

Physician brings patient
back to neutral position

Tender point is
reassessed
Jones Tenderpoints
 OTHER MANIPULATIVE
TECHNIQUES

OSTEOPATHY IN THE CRANIAL FIELD

ARTICULATORY TECHNIQUE (Low
Velocity-High Amplitude)

BALANCE AND HOLD TECHNIQUE

EXAGGERATION TECHNIQUE

FIXED POINT ROTATION TECHNIQUE

FUNCTIONAL TECHNIQUE

GUIDING TECHNIQUE

INHIBITORY PRESSURE TECHNIQUE

FACILITATED POSITIONAL RELEASE
OTHER MANIPULATIVE TECHNIQUES (con’t)

MYOFACIAL RELEASE TECHNIQUE

RANGE OF MOTION TECHNIQUE

RESISTIVE DUCTION TECHNIQUE

(Ruddi Technique)

SPENCER TECHNIQUE

SPRINGING TECHNIQUE
(Low Velocity-Moderate
Amplitude)

TRACTION TECHNIQUE

PROGRESSIVE INHIBITION OF
NEUROMUSCULAR STRUCTURES
(PINS)

STILL’S TECHNIQUE
 BOTTOM LINE

THERE ARE
MULTIPLE
MANIPULATIVE
MODALITIES

DIFFERENT
CONDITIONS
RESPOND TO
DIFFERENT
MODALITIES
 REFLEX ARCS

VISCERO-SOMATIC REFLEX

MI & arm pain

SOMATO-VISCERAL REFLEX

Fracture & vomiting

SOMATO-SOMATIC REFLEX

Tooth pain

VISCERO-VISCERAL REFLEX

MI & vomiting
 REFLEX ARCS
You must know all visero-somatic
relationships to specific body systems
& disease states
 OMM Board Preparation

Goal: To prepare the physician learner to
successfully understand OMM/OMT questions on
Complex/Specialty Board examinations.

Objectives:

To discuss salient topics that one must know to pass
the OMM/OMT questions on Complex/Specialty Board
examinations.

To review and discuss specific OMM/OMT questions
that one may encounter on Complex/Specialty Board
examinations.

Recommended strategy to prepare for doing well on
OMM/OMT section of the Complex/Specialty Board
examinations.
 COMLEX Structural/OPP component

Integrated within the fabric of the entire

examination

Osteopathic Principles and Practices [OPP]

NOT only applicable to musculoskeletal problems

Applicable to “human problems”

All Body systems

Various symptoms

15-20% of the exam is OPP-related

This does not include OPP distractors throughout the
examination.
 Osteopathically-Oriented
Question!

A DO view of the patient:

A whole person of integrated body, mind & spirit

Interactive and adapting to the environment as well as
internal stressors

Struggling to maintain the highest health status
obtainable [usually] having functional problems inter-
related with structural problems for which the patient is
trying to compensate.

Having self-healing and self-regulating capacities.

Functioning better when there is normal inherent
motion of the musculoskeletal and connective tissue
structure
 10 Basic Body Functions

1. Posture and Body Movement

2. Circulation
3. Pulmonary Respiration
4. Digestive, Absorption and
Elimination
5. Metabolism and Energy Balance
 10 Basic Body Functions
[con’t]

6. Regulation of Fluid and Electrolyte

Balance
7. Protective mechanisms
8. Sensory Systems
9. Reproduction
10. Consciousness and Behavior
 5 Models: Using OMT

Structural Model

Posture & Body Movement

Respiratory-Circulatory Model

Metabolic Model

Neurologic Model

Sensory & Protective

Behavioral Model

Reproduction, Consciousness and Behavior
When reading questions, keep
in mind the different models
that questions are based on.
 Structural Model
[Posture & Body Movement]

Biomechanical adjustment

Mobilization of Joints

Remove restrictive forces & enhance

Myofascialconnective tissue

Bony & soft tissues
 Structural Model
[Posture & Body Movement]

OMT Modalities

HV-LA

Muscle Energy

Counterstrain

Myofascial Release

Ligamentous
Articular
Techniques

Functional
Techniques
 Respiratory-Circulatory
Model

Goal: Improve all diaphragm restrictors in the

body

Diaphragms

“Transverse restrictors” of motion

Venous drainage

Lymphatic drainage

CSF
 Diaphragms:
“Conceptional Diaphragms”

Plantar fascia

Knee [popliteal fascia & cruciate]

Pelvic

Respiratory/T-L Diaphragm

Thoracic Outlet [cervicothoracic]

Suboccipital triangle

Tentorium Cerebelli

Diaphragm Sellae
 Respiratory-Circulatory
Model

OMT Modalities

Osteopathy in the
crainal field

Myofascial Release

Ligamentous
Articular
Techniques

Lymphatic pump
techniques
 Metabolic Model

Enhance self-regulatory & self-healing

mechanisms

Enhance energy conservation

Balance the body economy

Energy expenditure

Energy exchange

Foster Immune enhancement

Foster endocrine organ function
enhancement
 Metabolic Model

• OMT Modalities
• Lymphatic pump
techniques
• Other
osteopathically
oriented
management
considerations:
• Nutritional
counseling
• Diet
• Exercise
 Neurologic Model
[Sensory & Protective]

Goals:

Attainautonomic balance

Address neural reflex activity

Remove facilitated segments

Decrease afferent nerve signals

Achieve pain relief
 Neurologic Model
[Sensory & Protective]

OMT Modalities :

Counterstrain

Chapman’s Reflex
points
 Behavioral Model
[Reproduction, Consciousness and
Behavior]

Goal:

Improve the biological, psychological,
and social functional component of the
health spectrum.

Emotional balancing

Compensatory mechanisms

Other items to consider

Reproductive processes

Behavioral adaptation/change
When reading questions, keep
in mind the different models
that questions are based on.
Practice Questions
 1. A female at 34 weeks’ gestation presents with
difficulty breathing while in the supine
position. Her lungs are clear to auscultation. All
other tests appear normal. In order to release
her diaphragmatic pressure, the most appropriate
management is to:
A. decrease her blood volume by initiating the use of
furosemide
B. induce her labor with artificial rupture of the membranes
C. place the patient in the Trendelenburg position
D. release her diaphragm using myofascial release technique
E. treat C6-C7 to affect the phrenic nerve
 1. A female at 34 weeks’ gestation presents with
difficulty breathing while in the supine
position. Her lungs are clear to auscultation. All
other tests appear normal. In order to release her
diaphragmatic pressure, the most appropriate
management is to:
A. decrease her blood volume by initiating the use of
furosemide
B. induce her labor with artificial rupture of the membranes
C. place the patient in the Trendelenburg position
D. release her diaphragm using myofascial release technique
E. treat C6-C7 to affect the phrenic nerve
 2. In a 22-year-old patient with asthma,
osteopathic manipulative treatment intended to
increase sympathetic stimulation to the lungs
would be directed to which of the following areas?

A. T1-T5
B. T3-T9
C. lumbar sympathetic plexus
D. suboccipital area
E. superior cervical ganglion
 2. In a 22-year-old patient with asthma,
osteopathic manipulative treatment intended to
increase sympathetic stimulation to the lungs
would be directed to which of the following
areas?
A. T1-T5
B. T3-T9
C. lumbar sympathetic plexus
D. suboccipital area
E. superior cervical ganglion
 3a. A 53-year-old male presents to the office
with severe numbness and tingling down the
lateral aspect of the left arm to the thumb and
the upper back. This began insidiously one
month ago, and no trauma is recalled. The
most likely diagnosis is
A. anterior disk herniation
B. brachial plexopathy
C. foraminal encroachment from osteoarthritis
D. posterior cervical muscle strain
E. spinal cord tumor
Question 1 of 2 in set
 3a. A 53-year-old male presents to the office
with severe numbness and tingling down the
lateral aspect of the left arm to the thumb and the
upper back. This began insidiously one month
ago, and no trauma is recalled. The most likely
diagnosis is
A. anterior disk herniation
B. brachial plexopathy
C. foraminal encroachment from osteoarthritis
D. posterior cervical muscle strain
E. spinal cord tumor
Question 1 of 2 in set
3b. The nerve root most likely
involved in this presentation is

A. C4
B. C5
C. C6
D. C7
E. C8

Question 2 of 2 in set
 “…severe numbness and tingling down the
lateral aspect of the left arm to the thumb and
the upper back.”
3b. The nerve root most
likely involved in this
presentation is
A. C4
B. C5
C. C6
D. C7
E. C8
Question 2 of 2 in set
 4. A patient presents with
vertigo. Dysfunction of which of the following
cranial bones is most likely involved?

A. ethmoid
B. maxilla
C. parietal
D. sphenoid
E. temporal
Inner Ear & Temporal Bone
 4. A patient presents with
vertigo. Dysfunction of which of the
following cranial bones is most likely
involved?

A. ethmoid
B. maxilla
C. parietal
D. sphenoid
E. temporal
 Summary

Reviewed core concepts of OPP/OMM/OMT Discussed general

measures to prepare for board questions involving Osteopathic
Principles & Practices [OPP]

Examined the COMLEX Structural/OPP component to the
National Board of Osteopathic Medical Examiners [NBOME]

Presented the 10 Basic Body Functions related to Osteopathic
Manipulative Medicine [OMM]

Explored the 5 Models involved in using Osteopathic
Manipulative Treatment [OMT]

Went over COMLEX practice questions involving
OPP/OMM/OMT