COMLEX 3 Audio Crash Course - Complete Review for the Comprehensive Osteopathic Medical Licensing Ex

COMLEX Level 3

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TABLE OF CONTENTS Preface........................................................................................................ 1 About the COMLEX 3 Examination ............................................................. 5 Chapter One: Osteopathic Principles, Practice, and OMT ............................ 7 Direct and Indirect Techniques ....................................................................................... 7 Details of OMT ................................................................................................................. 9 Viscerosomatic Reflexes ................................................................................................ 15 Chapman Reflex Points.................................................................................................. 16 Jones CS Tender Points ..................................................................................................17 Musculoskeletal Testing ................................................................................................ 18 Key Takeaways ............................................................................................................... 25 Quiz ................................................................................................................................ 26 Chapter Two: Osteopathic Diagnoses and Management ............................ 30 Somatic Dysfunction in General .................................................................................... 30 What is the Barrier Concept?......................................................................................... 31 A Word about Fryette’s Mechanics ................................................................................ 32 Spinal Terminology in Somatic Dysfunction................................................................. 33 Cranial SD Management ................................................................................................ 34 Cervical SD Management .............................................................................................. 35 Thoracic and Rib SD Management ................................................................................ 38 Lumbar SD Management ............................................................................................... 41 Sacral SD Management .................................................................................................. 45 Pelvic SD Management .................................................................................................. 48

Extremity SD Management ........................................................................................... 50 Key Takeaways ............................................................................................................... 70 Quiz .................................................................................................................................71 Chapter Three: Osteopathic Management of Body Systems ....................... 75 HEENT ........................................................................................................................... 75 Cardiology ...................................................................................................................... 79 Pulmonology ..................................................................................................................80 Gastroenterology ............................................................................................................ 82 Urology and Gynecology ................................................................................................ 84 Obstetrics ....................................................................................................................... 86 Pediatrics........................................................................................................................88 Hospitalized Patients ..................................................................................................... 89 Key Takeaways ............................................................................................................... 91 Quiz ................................................................................................................................ 92 Chapter Four: Osteopathic Treatments and Techniques ............................ 96 Cranial Treatment .......................................................................................................... 96 Cervical Treatment....................................................................................................... 100 Thoracic, Diaphragm and Rib Treatment ................................................................... 103 Lumbar Treatment Techniques ................................................................................... 105 Pelvic and Sacral Techniques ...................................................................................... 107 Extremity Treatment ................................................................................................... 109 Systemic Disease Treatment ......................................................................................... 111 Key Takeaways .............................................................................................................. 114 Quiz ............................................................................................................................... 115

Chapter Five: Community Health and Patient Presentations Related to Wellness .............................................................................................. 118 Palliative Care ............................................................................................................... 118 Palliative Care in Cancer Patients and other Terminally Ill Patients ......................... 120 Attending to Physical Needs in Palliative Care ........................................................... 123 Patient Safety ............................................................................................................... 126 Workplace Safety ..........................................................................................................127 Automobile Safety ........................................................................................................ 128 Pediatric Safety Tips .................................................................................................... 130 Pedestrian Safety ......................................................................................................... 132 Older Adult Safety ........................................................................................................ 132 Public Health Issues .................................................................................................... 133 Patient Risk Assessment .............................................................................................. 136 Risk Factor Analysis for Heart Disease ........................................................................137 Addressing Cancer Risks ............................................................................................. 138 Assessing Adolescent Risk Factors ............................................................................... 141 Health Promotion and Disease Prevention ................................................................. 143 Lab and Imaging Testing in Community Health and Wellness .................................. 146 Key Takeaways ............................................................................................................. 148 Quiz .............................................................................................................................. 149 Chapter Six: Patient Presentations Related to Human Development, Reproduction, and Sexuality ....................................................................152 Normal Sexual Development and Sexual Maturation Delays ..................................... 152 Aging Milestones .......................................................................................................... 154 Developmental Delay ................................................................................................... 160

Congenital Anomalies .................................................................................................. 163 Primary and Acquired Immunodeficiency Disorders ................................................. 169 Failure to Thrive ...........................................................................................................172 Infertility .......................................................................................................................173 Contraceptive Techniques ........................................................................................... 176 Normal Obstetrics ........................................................................................................ 178 Labor and Delivery........................................................................................................ 181 Pregnancy Complications ............................................................................................ 187 Pregnancy Loss ............................................................................................................ 192 Neonatal Conditions .................................................................................................... 194 Birth Injuries ................................................................................................................ 196 Brain Hemorrhages...................................................................................................... 198 Neonatal Fractures....................................................................................................... 198 Premature Infants ........................................................................................................ 199 Impairment of Sexual Function ................................................................................... 201 Key Takeaways ............................................................................................................. 205 Quiz .............................................................................................................................. 207 Chapter Seven: Patient Presentations Related to the Endocrine System and Metabolism ........................................................................... 211 Abnormalities of Weight and Stature ........................................................................... 211 Undernutrition ............................................................................................................. 213 Obesity ..........................................................................................................................217 Short Stature ................................................................................................................ 223 Endocrine and Neck Masses ........................................................................................ 225 Hypothermia and Hyperthermia ................................................................................. 231

Heat-related Illnesses .................................................................................................. 232 Serotonin Syndrome .................................................................................................... 234 Diabetes and its Symptoms ......................................................................................... 235 Exam and Lab Findings in Endocrine Disorders ........................................................ 237 Key Takeaways ............................................................................................................. 242 Quiz .............................................................................................................................. 243 Chapter Eight: Patient Presentations Related to the Nervous System and Mental Health .................................................................................. 247 Anxiety ......................................................................................................................... 247 Mood Disturbances ...................................................................................................... 249 Bipolar Disorder........................................................................................................... 252 Behavioral and Perceptual Disturbances .................................................................... 254 Life Adjustment and Stressors..................................................................................... 257 Headache...................................................................................................................... 258 Speech and Language Disturbances ............................................................................ 261 Movement Disturbances .............................................................................................. 263 Seizures ........................................................................................................................ 266 Pain and Sensory Disturbances ................................................................................... 268 Sleep Disturbances....................................................................................................... 270 Substance Abuse .......................................................................................................... 273 Nervous System Trauma .............................................................................................. 274 Weakness ..................................................................................................................... 279 Key Takeaways ............................................................................................................. 282 Quiz .............................................................................................................................. 283

Chapter Nine: Patient Presentations Related to the Musculoskeletal System .................................................................................................... 287 Postural and Spine Deformities ................................................................................... 287 Back and Neck Pain ..................................................................................................... 291 Gait Disturbances......................................................................................................... 298 Joint Pain .....................................................................................................................304 Muscle Pain ..................................................................................................................309 Fibromyalgia ................................................................................................................ 310 Chest Wall Pain ............................................................................................................. 311 Temporomandibular Joint Pain .................................................................................. 312 Musculoskeletal Trauma .............................................................................................. 315 Sciatica and Radiculopathies ....................................................................................... 320 Musculoskeletal Tumors .............................................................................................. 323 Key Takeaways ............................................................................................................. 328 Quiz .............................................................................................................................. 329 Chapter Ten: Patient Presentations Related to the Genitourinary/Renal System and Breasts ............................................... 334 Anuria, Oliguria, Polyuria, and Edema ....................................................................... 334 Enuresis and Incontinence .......................................................................................... 338 Pelvic Relaxation Disorders ......................................................................................... 344 Urinary Symptoms ....................................................................................................... 345 Hematuria .................................................................................................................... 349 Amenorrhea ................................................................................................................. 351 Vaginal Bleeding .......................................................................................................... 353 Urethral Discharge ....................................................................................................... 354

Pelvic Pain .................................................................................................................... 356 Vulvar and Vaginal Discharge ..................................................................................... 357 Penile, Scrotal, and Testicular Diseases ...................................................................... 359 Prostate and Renal Masses .......................................................................................... 362 Prostate Cancer ............................................................................................................ 363 Breast Masses and Discharge ...................................................................................... 365 Breast Masses ............................................................................................................... 366 Breast Cancer ............................................................................................................... 367 Nipple Discharge .......................................................................................................... 369 Key Takeaways ..............................................................................................................371 Quiz .............................................................................................................................. 373 Chapter Eleven: Patient Presentations Related to the Gastrointestinal System and Nutritional Health ................................................................ 377 Jaundice ....................................................................................................................... 377 Ascites ..........................................................................................................................380 Involuntary Weight Loss.............................................................................................. 382 Nausea, Vomiting, and Hematemesis ......................................................................... 383 GI Bleeding................................................................................................................... 385 Disorders of Bowel Frequency ..................................................................................... 386 Chronic Abdominal Pain..............................................................................................390 Abdominal Cancers ...................................................................................................... 391 Esophageal Cancer ....................................................................................................... 391 Pancreatic Cancer ........................................................................................................ 392 Stomach Cancer ........................................................................................................... 393 Colorectal Cancer ......................................................................................................... 394

Anorectal Disorders ..................................................................................................... 395 Heartburn and Reflux .................................................................................................. 396 Mouth and Dental Pain ................................................................................................ 397 Abdominal Trauma ...................................................................................................... 401 Dysphagia and Odynophagia .......................................................................................404 Foreign Bodies in the GI Tract .................................................................................... 405 Abdominal Wall Abnormalities ...................................................................................406 Key Takeaways ............................................................................................................ 408 Quiz .............................................................................................................................. 410 Chapter Twelve: Patient Presentations Related to the Circulatory and Hematologic Systems .............................................................................. 415 Acute Coronary Syndromes ......................................................................................... 417 Palpitations and Arrhythmias......................................................................................420 Edema and Swelling..................................................................................................... 422 Lymphadenopathy ....................................................................................................... 424 Claudication and Peripheral Vascular Disease............................................................ 426 Dyspnea and Orthopnea .............................................................................................. 428 Bruising and Bleeding Disorders ................................................................................. 431 Hypercoagulability ....................................................................................................... 433 Shock ............................................................................................................................ 434 Hypertension................................................................................................................ 437 Chest Trauma ............................................................................................................... 439 Key Takeaways ............................................................................................................. 441 Quiz. ............................................................................................................................. 442

Chapter Thirteen: Patient Presentations Related to the Respiratory System .................................................................................................... 446 Cough ........................................................................................................................... 446 Sore Throat................................................................................................................... 448 Shortness of Breath in Lung Diseases ......................................................................... 451 Nasal Bleeding ............................................................................................................. 452 Airway Obstruction ...................................................................................................... 453 Nasal Discharge ........................................................................................................... 454 Ear Pain and Discharge ............................................................................................... 455 Respiratory Arrest ........................................................................................................ 458 Respiratory Cancers ..................................................................................................... 459 Head and Neck Cancer................................................................................................. 463 Key Takeaways ............................................................................................................. 465 Quiz .............................................................................................................................. 466 Chapter Fourteen: Patient Presentations Related to the Integumentary System ............................................................................ 470 Hair and Scalp Disorders ............................................................................................. 470 Seborrheic Dermatitis .................................................................................................. 472 Cyanosis ....................................................................................................................... 473 Pallor ............................................................................................................................ 474 Pigment Disturbances .................................................................................................. 475 Nail Disorders .............................................................................................................. 478 Skin Ulcers ................................................................................................................... 481 Stasis Dermatitis .......................................................................................................... 483 Pruritis ......................................................................................................................... 484

Rashes and Acne .......................................................................................................... 485 Burns ............................................................................................................................ 489 Wounds ........................................................................................................................ 492 Urticaria and Angioedema ........................................................................................... 495 Skin Presentations of Systemic Diseases ..................................................................... 497 Sweating Disorders ...................................................................................................... 499 Bites, Stings, and Infestations .....................................................................................500 Key Takeaways ............................................................................................................. 506 Quiz .............................................................................................................................. 507 Summary ................................................................................................. 511 Course Questions and Answers ............................................................... 516 Answers to Questions.............................................................................. 607 Chapter One ................................................................................................................. 607 Chapter Two .................................................................................................................609 Chapter Three ............................................................................................................... 611 Chapter Four ................................................................................................................ 612 Chapter Five ................................................................................................................. 613 Chapter Six ................................................................................................................... 615 Chapter Seven .............................................................................................................. 616 Chapter Eight ............................................................................................................... 617 Chapter Nine ................................................................................................................ 619 Chapter Ten .................................................................................................................. 621 Chapter Eleven ............................................................................................................. 623 Chapter Twelve ............................................................................................................ 625

Chapter Thirteen .......................................................................................................... 627 Chapter Fourteen ......................................................................................................... 628 Course Questions .........................................................................................................630

PREFACE The purpose of this course is to prepare you to take and successfully pass the Comlex Level 3 examination for osteopathic students. This is a national examination, required as part as three separate exams, for entry into an accredited allopathic or osteopathic residency program after graduation from an osteopathic college. The goal is to allow the generalist in osteopathy to demonstrate their skills in patient assessment and management of patients based on what they have learned in osteopathic curricula and clinical rotations.

There are different domains on the examination that cover the areas of osteopathy, including OMT, health and wellness, human development and sexuality, neurology and mental health, endocrinology and metabolism, gastroenterology, pulmonology, cardiology and hematologic conditions, the musculoskeletal system, the genitourinary and renal system, and disorders of the integumentary system. Through the learned material and sample questions, your knowledge in these areas will be refreshed and your test-taking skills will be honed.

Prior to studying the material, we will talk about the examination itself and what it entails so you can be better prepared for the rigors of taking it. While taking this examination generally means you have already passed the Comlex Level 1 and Comlex Level 2 examination, this Comlex Level 3 examination has a slightly different focus and examination formats that will test your knowledge and skills in a unique way.

Chapter one in the course introduces osteopathic principles and practice, reminding you of the things you have learned about the direct and indirect techniques used in osteopathic clinical medicine. We will talk about the viscerosomatic reflex, Chapman reflex points, and Jones CS tender points and will review the different types of osteopathic manual treatment and musculoskeletal testing. The goal is to review the foundations of osteopathy as it is used in clinical situations.

The focus of chapter two is the various somatic dysfunctions that exist in the spine, including how these are best diagnosed and how they are managed through OMT.

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Somatic dysfunctions of the cranium and spine manifest in several different ways so it takes skilled diagnostic skills and an understanding of the way these structures function under physiological conditions. The management is individualized to the specific somatic dysfunction, the details of which are covered in this chapter.

Chapter three in the course focuses on the fact that osteopathic principles and practice do not simply apply to the musculoskeletal system. Somatic dysfunctions exist in each of the body systems, some of which are explainable by the various viscerosomatic reflexes.

Disorders related to the head and neck, heart, lungs, gastrointestinal tract, genitourinary system, pediatrics, obstetrics, and the hospitalized patient are covered as part of this chapter.

In chapter four, we talk about the different osteopathic treatments and techniques you will likely use in everyday practice. These are things learned at the bedside and in clinical rotations but may help jar your memory when you take the examination, especially as questions are asked about specific positioning recommendations and treatment options you will recommend as part of your clinical decision-making questions on the test. Things like cranial treatment, cervical treatment, management of all spinal OMT, extremity-related treatments, and therapies directed at the body as a whole will be explained in the chapter.

Chapter five in the course includes many aspects of the osteopathic physician’s role in community health, wellness issues, and end of life care. Many issues you will be asked to manage are not individual patient healthcare issues but are actually public health issues you may become involved in. A great deal of what you will do in the field of community health and wellness is education about disease risk factors, disease prevention, and health promotion. The Comlex-USA Level 3 examination will ask you about these issues and those things you as a practicing generalist should be able to identify and manage.

Chapter six covers the numerous issues dealing with normal and abnormal human development, including developmental delays in children, normal and abnormal sexual development, reproductive issues like contraceptive techniques, infertility, sexual dysfunction, normal obstetrical care, the care of high-risk pregnancies, pregnancy loss, labor and delivery, and congenital or acquired diseases of newborns. These issues

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involve the care of men, women, neonates, and children as they apply to their development, sexuality, and reproductive issues and are important aspects of the primary care of patients of all ages.

The two main topics in chapter seven in the course are endocrine system disorders and issues related to metabolism. Metabolic issues can cause issues regarding a person’s height or weight, although there are endocrine problems that can affect height, which will be discussed. The two most common endocrine diseases seen in primary care are thyroid disorders and diabetes mellitus—both of which require both short-term and long-term management. In this chapter, we will also talk about hormonal evaluation of patients as they relate to the common and less common endocrine disorder you might encounter.

Chapter eight combines issues related to both the neurological system and psychiatry.

The different psychiatric disorders frequently encountered in generalist practices include mood disorders, anxiety disorders, substance abuse disorders, schizophrenia, and adjustment disorders. Neurological diseases that are commonly seen and discussed in the chapter include the management of headaches, seizures, traumatic brain injuries, weakness, paralysis, and sleep disorders. These can be interrelated with similar symptoms that can often be evaluated and managed by the generalist in family medicine.

Chapter nine in the course mainly deals with the different musculoskeletal system complaints you will encounter as part of a generalist practice and talks about the allopathic approaches to musculoskeletal complaints. In the first part of the course, musculoskeletal issues from an osteopathic perspective will be discussed. You should also keep in mind, however, how these are evaluated and treated from an allopathic perspective so you can see where osteopathic principles and allopathic medicine can work together to help individuals with a variety of musculoskeletal disorders.

Chapter ten discusses the major presentations you will encounter related to the kidneys, other aspects of the genitourinary system in men and women, and the breasts. These include things like changes in the amount of urination, dysuria, hematuria, and urethral discharge as well as diseases of the penis, testes, and scrotum in men. Among women,

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common symptoms discussed in the chapter include those related to pelvic floor relaxation, vaginal discharge, vaginal bleeding, pelvic pain, and breast symptoms.

The focus of chapter eleven in the course is gastrointestinal and nutritional health, which are interrelated topics. Patients can present with a variety of GI related symptoms, such as reflux, abdominal pain, jaundice, nausea and vomiting, GI bleeding, disorders of stool frequency, and anorectal disorders. The chapter also talks about the manifestations of the different types of common gastrointestinal cancers. Disorders related to the teeth and mouth are covered as well as swallowing difficulties. Finally, the chapter talks about the manifestations and treatment of hernias of the inguinal area and the abdominal wall.

Chapter twelve places a focus on disorders of the circulatory system and hematologic system, including their presentation. Patients can present with chest pain, palpitations, edema, dyspnea or orthopnea, as well as symptoms suggestive of chest trauma.

Hematologic diseases can involve disorders of excessive bleeding, excessive clotting, or lymphadenopathy, which are also discussed as part of this chapter. Most of the treatment of these diseases depend on a solid understanding of how these are treated allopathically.

Chapter thirteen in the course covers patient presentations related to ENT diseases and respiratory illnesses. Common complaints you will encounter include things like cough, nasal congestion, dyspnea, ear pain, ear discharge, and sore throat. Related signs you might uncover include pallor and cyanosis, which are also discussed in this chapter.

Head and neck as well as lung cancer is covered so you know how to recognize these things and how to participate in their treatment.

The focus of chapter fourteen is the recognition, workup, and management of skinrelated diseases. This includes disorders related to the hair and scalp, nail disorders, skin ulcerations, rashes, and pigment diseases. Common skin complaints are also covered, such as pruritis and urticaria, which can also be a part of angioedema. Burn management, would care, and the management of bites, skins, and infestations are all a part of this chapter.

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ABOUT THE COMLEX 3 EXAMINATION The Comlex-USA Level 3 examination is similar to the other two Comlex examinations in that it is entirely a computer-based examination. Unlike the other tests, however, the Comlex-USA Level 3 exam is a two-day examination, while the others are just one-day examinations. The goal of the level 3 exam is to assess your competence in the different competency domains necessary for the osteopathic generalist to deliver safe and effective care in an unsupervised clinical setting.

You will need to keep in mind those things you have learned about osteopathic medical knowledge and its applications, patient care, communication, osteopathic principles and practice, ethical practices, and professionalism. The questions on the examination generally involve patient presentations and will test your knowledge with regard to the complete management of the well patient and those with medical and osteopathic concerns.

The Level 3 examination involves four separate computer-based question and answer sessions, each lasting 3.5 hours, taken within a 14-day window. The entire examination involves completing 420 multiple choice questions for which there will be one correct answer. Any given question will involve a test of your knowledge in ten clinical areas or one of seven competency domains in the field of osteopathy.

In addition, there are 26 clinical decision-making cases that each involve two to four questions per case. These are more complex and more difficult to study for because, not only could any given case involve any area of osteopathic medicine, but there will be an extended multiple choice format for which there will be more than one correct answer or a short answer response required. There may be audiovisual components to the clinical decision-making case questions.

While the multiple choice questions are fairly straightforward, the CDM or clinical decision-making cases, given in two separate sessions, are more difficult but better represent the kinds of decisions you will have to make as an osteopathic physician. The CDM cases will ask you about things like data acquisition or patient history,

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examination findings, and the ordering of tests, generating a diagnosis, and patient management, which could involve some type of OMT, the prescribing of medication, patient counseling, and follow-up care.

In each of the eight separate sections of the two-day exam, you must complete the section within the 3.5-hour timeframe. You can change your answers at any time during each section but, once you have completed the section, that part of the exam is closed and you will not be able to return to the section or change any answers you have already given.

All Comlex-USA examinations have questions that have equal weight in determining the raw score, which is the number of questions correctly answered. You will not know this number but will be given a pass-fail designation as well as a standard score that has been converted so that the mean test score will be between 500 and 550. A percentile rank is not given; however, you can go to the National Board of Osteopathic Medical Examiners website to convert your standard score into a percentile rank if you desire. In addition, each osteopathic college is provided with information comparing its students’ scores in relation to the national average.

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CHAPTER ONE: OSTEOPATHIC PRINCIPLES, PRACTICE, AND OMT This chapter introduces osteopathic principles and practice, reminding you of the things you have learned about the direct and indirect techniques used in osteopathic clinical medicine. We will talk about the viscerosomatic reflex, Chapman reflex points, and Jones CS tender points and will review the different types of osteopathic manual treatment and musculoskeletal testing. The goal is to review the foundations of osteopathy as it is used in clinical situations.

DIRECT AND INDIRECT TECHNIQUES While we will talk about the different osteopathic manual techniques in detail as we proceed through this course, it is a good idea to look at them all at once just to see how many of them there are and to recall which are direct techniques and which are indirect in nature. All direct techniques will engage a physiologically restricted joint, muscle, or tissue barrier and will try to break through that barrier directly.

All indirect techniques, on the other hand, position the body away from the barrier in order to allow the tissues that have become restricted to release inherently. After the affected tissues have been released, the barrier is no longer restrictive. Indirect techniques also do not necessarily address actual barriers but can instead be used to release reactive barriers that do not involve joint dysfunction.

The three main direct techniques are HVLA or high velocity-low amplitude, articulation or ART, and muscle energy or ME techniques. With both ART and HVLA, the patient’s role is entirely passive and the provider does all of the work in releasing the barrier. ME or muscle energy, on the other hand, involves some work by the patient and physician so it is both active and passive.

The three indirect techniques in OMT are facilitated positional release or FPR, strain and counterstrain, and balanced ligamentous tension. Areas of tenderness or

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tenderpoints are addressed using these techniques. MFR or myofascial release is used to address soft tissue dysfunction and may also address a restricted joint. MFR is both a direct and indirect technique. FPR and MFR are related but FPR uses a facilitating force to address the dysfunction.

With HVLA, you will need to find and work with a firm barrier. Also known as the thrust technique, HVLA is always used to remove a structural articular motion restriction but not to remove a barrier that stems from static asymmetry alone. You will position the patient in such a way that the dysfunctional joint first engages the restricted barrier before a quick, high-velocity thrust over a small distance and low amplitude is made.

With muscle energy or ME, the physician first engages the feather edge, which is the initial aspect of the resistance to a barrier, and involves asking the patient to provide a counterforce directed away from the barrier. The forces applied tend to be very light and you should always avoid applying a force that is too excessive. During the technique, the patient provides an active contraction of a muscle in order to directly mobilize a joint.

Alternatively, a postisometric relaxation period is created that will allow further stretching of the tissue.

With articulation or ART, which is another direct technique, the physician applies repetitive, gentle, and passive motion of the affected joint into its restricted barrier. The goal is to move the joint throughout its entire range of motion in order to find where it is restricted and to gradually loosen it. There are different techniques used for the different joints, such as the Spencer Technique on the shoulder or rib raising techniques, which need to be unique to the specific ranges of motion of the various joints.

Myofascial release or MFR is both direct and indirect, depending on the circumstances.

Tension is released from either the muscles or their surrounding fascia. If the technique is a direct one, there is rhythmic or static engagement of the tissue barriers prior to their release. If the technique is an indirect one, the tissues are instead taken to a position where the least amount of tension is present and then are held there until the natural release of the tissue occurs.

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In strain and counterstrain, this indirect approach involves positioning the patient’s body in order to provide a position of ease, where tenderness and tension are virtually eliminated, and then holding the position for about ninety seconds. It focuses on at least one of more than 200 tenderpoints, which tend to be small and discrete areas of marked tenderness often found within muscle tendons or within the belly of the muscle itself.

Some may also exist in the myofascial tissues rather than the muscle.

Remember that tenderpoints do not necessarily relate to the point of actual trauma but can be distant from the affected traumatized area. Often, multiple tenderpoints exist, with the goal of strain and counterstrain being to treat the most painful tenderpoints first. Those tenderpoints associated with traumatic injury should involve a position of treatment that mimics the position of trauma while maintaining maximal comfort.

When balanced ligamentous tension or BLT is used, there will be tension of the ligaments and of the membranous structures that are balanced through positioning of the joints. Because this is an indirect approach, this type of balance allows for the natural and inherent release of the affected tissues. The patient action of breathing itself is commonly used to facilitate the release of ligamentous tension.

In facilitated positional release, which is also indirect, the physician provides a facilitating force to release tissue tension over a shorter period of time. Often, this facilitating force involves either the application of tension or compression of the affected tissues. It is a technique that can be used for any tissue texture changes found or for joint restriction that has been caused by myofascial tension on the joint. The affected joint is first placed into a neutral position prior to adding the facilitating force.

DETAILS OF OMT In this section, we will talk further about the different OMT that can be applied, including the indications and contraindications of each procedure as well as the typical sequence you will be expected to know and follow as you apply the various techniques.

HVLA is a commonly applied OMT, in which you will apply a sudden and quick force to a restricted joint over a low amplitude so the actual movement of the joint is very small.

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This is a particularly common technique used when the restriction itself is articular in origin.

The main indication for HVLA is not going to be just the presence of a static asymmetry but must involve restriction of a given joint to both active and passive range of motion in at least one direction. Its main contraindications include any one of the following: •

Muscle contracture secondary to trauma

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Any bony fracture at the site

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The presence of a hypermobile joint, mostly because the application of HVLA can contribute to joint instability

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Ankylosis or advanced degenerative joint disease of the affected joint. In such cases HVLA will not be effective and can further damage the joint.

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Inability to relax the muscles around the affected joint, which could involve doing additional damage to the surrounding muscles and will decrease the effectiveness of the technique itself.

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The presence of an indistinct or rubbery tissue barrier, which generally means that HVLA will not be effective when applied to the joint. It may also mean that the patient has a viscerosomatic reflex.

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Osteoporosis by itself is not an absolute contraindication to HVLA but it means that you should probably try another technique first that is less forcefully applied to the affected joint.

During the HVLA sequence, you need to first position the patient so that the restricted joint is firmly engaged at the level of its restricted barrier. This is so that a small amplitude thrust will have the maximum impact. Perform the thrust maneuver over a very short distance until you have broken through the restrictive barrier, which often leads to a popping sensation. Then you should reassess the joint to see if the barrier has been released and that the joint is now more freely mobile.

Muscle energy or ME is also direct but involves the patient using active muscle force in order to affect a somatic change in the tissues. Specific positioning of the patient is necessary so that the physician can apply the appropriate counterforce to the force applied by the patient. It makes use of the feather edge, which is where you first feel

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there is restriction to motion. The restriction to motion is generally caused by soft tissue restriction rather than articular restriction and feels different from the restriction you would feel if you were applying HVLA. Because this is a soft tissue and not an articular restriction, very little force needs to be applied.

Indications for ME include muscle hypertonicity or joint motion asymmetry with the goal of the procedure being to lessen joint restriction, reduce restrictions to breathing, decrease hypertonicity of the muscles so the muscle fibers lengthen, and strengthen those asymmetries that are caused by muscle weaknesses.

There are different categories of ME, based on differing amounts of force necessary for the application of the technique. As you will see, these can range from a few ounces of force to up to 50 pounds of force. Let’s take a look at some of these: •

Crossed extensor reflex—just a few ounces of force are applied, involving the contraction of a flexor muscle in an extremity that causes relaxation of both the flexor muscle and contraction of the extensor muscle on the opposite side of the body.

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Reciprocal inhibition—just a few ounces of force are applied, in which an agonist contraction leads to reflex relaxation of the antagonist muscle group.

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Oculocephalogyric reflex—just a few ounces of force are involved in eye movements that will reflexively affect the muscles of the trunk and neck.

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Respiratory assistance—in this common technique, exaggerated breathing movements provide the necessary muscle force.

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Postisometric relaxation—this involves between 10 and 20 pounds of force.

Muscles are contracted and then are able to relax, which allows them to be stretched to a greater degree.

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Joint mobilization—this involves using between 30 and 50 pounds of force, in which the patient contracts a muscle in order to mobilize the affected joint.

The major precautions and contraindications to ME include the presence of any acute injury, a very young patient who cannot cooperate, muscle pain, and anything comorbid in the patient that prevents their cooperation in the procedure itself.

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In a typical ME sequence, you will position the affected body part at the feather edge, where the initial resistance is first felt. Have the patient contract a muscle or muscles in order to counteract the force you apply and then ask them to gradually release the contraction as you also release the force you have applied. Wait a few seconds until the muscles and tissues relax; then pick up the slack so that a new position of resistance is felt. This is repeated up to five times total so that there can be a gradual increase in joint range of motion.

The ultimate goal of ME is to provide some type of postisometric relaxation so that you will be able to further stretch the tightened tissues and muscles.

In the articulation technique, you essentially apply repetitive passive motion to the joint in a gentle manner in order to loosen the joint in the areas where there is restriction of motion. Often, the restriction itself is due to tightening of the connective tissue so that the goal is to restore the normal physiological motion of the affected area. Sometimes, this can be used for diagnostic rather than for therapeutic purposes.

Articulation can be used for any articulation movement restriction, including those often seen in patients who’ve been immobile for a period of time or who are postoperative. It is generally safe in most situations but should be used cautiously if there is significant soft tissue pain, areas of infection, burns, or sutures, bone fractures or traumatic muscle contractures, or areas involved in ankylosis or degenerative joint disease.

In an articulation sequence, you will maintain a comfortable position for the patient, while applying gentle range of motion of the joint to the point of tolerability or marked restriction. Repeat this after returning the joint to neutral and gradually increase the range of motion of the affected joint, which should be more easily accomplished over time. The procedure is done when maximum range of motion has been achieved. This will work well for old or very young patients as it is easily tolerated.

Myofascial release or MFR can involve release of tension in any muscle or fascia of the body. Direct or indirect forces are applied that will allow for the natural and inherent release of the affected tissue. Inhibition can be involved, which is the direct maintenance of pressure over a hypertonic tissue area until the area relaxes.

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The main indication for this technique is muscle or fascial areas of tension and restriction. Joint restriction can be involved but the restriction is not due to an articular problem by itself but to hypertonic tissues. This technique may be necessary prior to any attempt at doing HVLA to the joint.

MFR is largely considered safe; however, it cannot be used if there is moderate to severe pain in the affected area or if there are burns, wounds, infections, or sutures overlying the area to be treated.

In this procedure, you can directly engage the tissues with the appropriate amount of pressure applied. The move the area into a restricted barrier while holding the stretch on the tissues in order to help them relax. Do this again in a rhythmic fashion so that the area is maximally relaxed. You can engage the tissues through distraction, direct compression, rotation, or translation.

If you are using the technique indirectly, you will also engage the tissues using pressure and will move the tissues to an area of least resistance, waiting for the natural and inherent release of the tissues. The goal in the direct technique is to stretch the tissues using your own force, while the goal in the indirect technique is to wait for the inherent release of the affected tissues without direct force applied.

The basics of strain and counterstrain involve gentle positioning of the affected area in order to decrease the tenderness associated with certain tenderpoints so that somatic function can be restored. Remember the 200 tenderpoints that can possibly be involved, which can consist of muscles, ligaments, and tendons. It is mainly done when there are specific tenderpoints found.

Strain and counterstrain is largely a safe technique but, like similar techniques, it is avoided when there is moderate to severe pain involved or when there is overlying tissue damage from infections, wounds, burns, or sutures.

During this procedure, you will move the patient into a comfortable position, while looking for areas of tissue tension and relaxation. Light touch is maintained with increased touch when attempting to define a tenderpoint area. Find out how tender an affected area is and attempt to reduce the level of tenderness by directing pressure for about 90 seconds, while monitoring the area for evidence of tension release. Slowly let 13

up on the applied pressure until a neutral point is achieved before rechecking the area for additional tenderness. Ideally, you should aim for less than 30 percent of the original degree of tenderness.

In balanced ligamentous tension or BLT, there is the indirect positioning of a dysfunctional or abnormal joint so there is a balance of the membranous and ligamentous tensions. This balanced position will allow for inherent bodily forces to correct the dysfunction so that the tissues re-balance themselves. Breath is often used as the patient’s active movement in order to restore this balance and aid in the release of tension in the tissues. It is used if there is articular asymmetry or joint restrictions.

This is generally considered to be a safe procedure that should be used with caution if there is moderate to severe pain or if there are tissue injuries or infection overlying the treatment area. The act of inhalation will help to flatten the spine in the AP direction, while the act of exhalation increases AP spinal curvatures. The ligaments do not stretch or become overly lax, in part because the motion necessary for this technique is quite small.

The BLT sequence generally starts with finding an area of restriction about a joint and placing the patient’s body with respect to the joint so that there is a point of balance in the ligamentous tension around the joint. The patient engages in a relatively small movement that further tunes the balance, while you hold the joint’s position until there is a release noted. The sequence is complete when the dysfunction is corrected and the joint’s neutral position is more physiological.

In facilitated positional release or FPR, some type of torsion or compression is applied to lessen the time it takes for a tightened tissue to release itself. Any joint dysfunction from tissue hypertonicity or tissue texture change can be treated with this technique, although more than mild pain or the presence of injury or infection overlying the affected area are contraindications to doing it.

In an FPR sequence, you will place the dysfunctional joint into a neutral position, such as neither flexion nor extension of the spine. Some type of facilitating force is applied so that the tissues can be further placed into positions of relative freedom. There is natural relaxation of these tissues within seconds and the joint is returned to a more original

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and functional position. This technique relies on the natural and inherent release of the affected tissues.

VISCEROSOMATIC REFLEXES Viscerosomatic reflexes are commonly asked about on the Comlex-USA Level 3 examination. While there are a great many of these reflexes, it is probably the best and most high-yield option to memorize the various body areas associated with the different reflexes.

Viscerosomatic reflexes are somatic dysfunctions resulting from changes in the autonomic nervous system. These can be chronic or acute and generally represent overstimulation of one branch of the autonomic nervous system over another. This leads to a reflex reaction that affects the organ involved. The typical TART changes of tissue texture change, asymmetry, restriction of motion, and tenderness are seen in these organs when these can be appreciated.

Remember that the sympathetic nervous system causes an acceleration of the activity of a given organ and generally arises from activity associated with the thoracolumbar spine segments. The parasympathetic nervous system, on the other hand, will decrease or inhibit an organ’s activity. The nerves involved are the high cervical segments of C0 to C2 but particularly to C2. This is because C2 is very specific for the vagus nerve, particularly on the left side.

Chronic VSR leads to the tissue texture change of firm, atrophied, dry, rubbery, ropy, and col tissues, while acute VSR leads to the tissue texture change of bogginess, moistness, and warmth. The restriction of motion will be more rubbery rather than the firmer feel of structural somatic dysfunction. When OMT is applied to somatic dysfunction from viscerosomatic reflexes, there will be a transient resolution but, unless the actual visceral problem is addressed, the somatic dysfunction will return.

The major body areas involved in viscerosomatic reflexes, include the following: •

For the head and neck, the sympathetic influence comes from T1 to T4, while the parasympathetic influence comes from C2.

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•

For the heart, the sympathetic influence comes from T1 to T5, while the parasympathetic influence comes from C2.

•

For the lungs, the sympathetic influence comes from T1 to T4, while the parasympathetic influence comes from C2.

•

For the GI tract, the sympathetic influence comes from T5 to L2, while the parasympathetic influence comes from C2, S2 to S4.

•

For the kidneys, the sympathetic influence comes from thoracolumbar junction, while the parasympathetic influence comes from C2 and from S2 to S4.

•

For the genitourinary tract, the sympathetic influence comes from the thoracolumbar junction, while the parasympathetic influence comes from C2 and from S2 to S4.

CHAPMAN REFLEX POINTS Chapman reflex points or CRP are also somatic representations of visceral disease.

These are also best memorized from a regional standpoint and represent areas on the anterior and posterior aspects of the body often used for diagnosis and treatment of disease states, although they are more often used diagnostically. They represent tiny areas of increased sensitivity and tenderness in the deep fascial layers due to increased sympathetic tone to a certain body area. As such, they are a subset of viscerosomatic reflex.

The two things that lead to these reflex points are increased sympathetic tone or lymphatic system blockages in a particular area. These tend not to be particularly specific because one spinal segment will often innervate several different organs.

Chapman reflex points are located mainly in the deep fascia and are small, firm 2 to 3 millimeter nodules with tissue texture changes similar to all TART changes. They are extremely tender but do not radiate from the point and may or may not be associated with a somatic dysfunction.

There are fifty different CP located on the front and back of the body from the head to the toes. Anterior CPs are located near the intercostal spaces near the sternum, with the

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level of the point correlating with the sympathetic inflow from the same vertebral segment as the corresponding visceral organ.

The head and neck are high on the thorax and along the lateral posterior spine, the lungs in the upper third of the thorax, the GI tract in the middle to low thorax, and the genitourinary tract on the abdomen. The posterior points tend to be in the paraspinal area near the transverse processes. Anterior points often have corresponding posterior points.

Lower extremity points are generally located on the anterior iliotibial band from just above the greater trochanter to just above the knee. Genitourinary points are in the pelvic and greater trochanter area, while the gastrointestinal points are along the femur.

Again, if an anterior point is noted, there will be a posterior component as well. These can generally help differentiate between a visceral and musculoskeletal pathology.

When used in the treatment of visceral disease, the general purpose is to decrease the sympathetic tone of the affected visceral area. Any point, anterior or posterior, can be accessed and used for diagnosis and treatment in osteopathy. Touch the point with the pad of the finger and apply firm circular pressure for about 15 seconds to two minutes at a time. When release is felt, you will notice a decrease in the tension of the fascia in the affected areas.

Two common points you should used in treatment are those used in appendicitis. The CRP for this is located at the tip of the twelfth rib on the right. The other CRP commonly used is for irritable bowel syndrome, for which the CRP is found along the iliotibial band.

JONES CS TENDER POINTS These are used for the counterstrain treatment techniques. There are many of these points that are difficult to memorize. For the examination, be mostly aware of the general regions of the body associated with these tenderpoints, knowing that the axial skeleton tenderpoints tend to be more important to remember and more successful in treatment than the extremity points.

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Look for areas of hypersensitivity and tenderness that are likely to have a direct relationship to a somatic dysfunction of a nearby area. They are primarily based on the neuromuscular basis of somatic dysfunction in general. They come from an imbalance in the proprioceptive activity leading to a reflex tenderpoint and a secondary somatic dysfunction.

Most of these are specifically located in a muscle body or near to the area of the body affected. There are several of them located along the sternocleidomastoid muscle that correspond to C2 to C6 spinal segments. Look also for tenderpoints linked to the supraspinatus muscle, the subscapularis muscle, the biceps brachii muscle, the rectus femoris muscle, and the gastrocnemius muscle, usually within the muscle belly or along one of the tendons.

In looking for Jones CS tenderpoints, seek out dime-sized, tense, and fibrotic tender areas with much more tenderness perceived by the patient than can be explained by the pressure actually applied to the site. These tenderpoints will be consistent from one person to the next and are much like CRPs because the pain will not radiate.

In treating these areas, place the patient in the position of greatest comfort. Use counterstrain in order to reduce the degree of tenderness by about two-thirds of the original tenderness. The patient is entirely passive during this treatment and is then returned to a neutral position.

MUSCULOSKELETAL TESTING You should know about the different musculoskeletal testing done in osteopathic manipulative medicine because these are commonly referred to during the Comlex-USA Level 3 examination. Some of these involve the upper extremities, while others involve the lower extremities. These are listed as follows: •

Adson Test—In the test, the radial pulse is palpated while the patient is asked to rotate and extend their head away from the side of their complaint. The patient then inhales and holds his breath. The test is repeated with the patient rotating and extending his head toward the side of the complaint. A positive finding

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involves the decrease or disappearance of the radial pulse on the side where thoracic outlet syndrome.

•

Spurling Test—in the test, a compressive force is transmitted by the provider down the axial spine through the top of the head. This compression is given with the neck in either the neutral, sidebent left, and sidebent right directions. The test is considered positive if there are radiating symptoms down the arms and into the hands, indicating a possible cervical nerve root impingement.

•

In the Apley Scratch Test of the Shoulder—the patient is asked to reach behind their back in order to touch the opposite shoulder blade. The patient will then reach above and behind their head toward the shoulder blades. This test determines the ranges of motion of the internal rotation, adduction, and abduction of the shoulder. If there are limitations, there will be asymmetry from one side to the other.

•

Apprehension/Relocation Test—with the patient’s elbow flexed to 90 degrees and the humerus abducted to 90 degrees, the glenohumeral joint is brought into passive external rotation. Pain will be elicited with apprehension of the patient when there is increased external rotation. When relocated by the stabilization of the humeral head, the patient will feel relief. This positive sign often indicates glenohumeral joint laxity.

•

Empty can test—this assesses the glenohumeral joint by abducting it to 90 degrees, horizontally flexing it to 30 degrees, and internally rotating it to 90 degrees so that the thumb points in the downward direction. The patient can resist a downward force exerted at the forearm by the examiner, while the examiner also stabilizes the glenohumeral joint. A positive test demonstrates an inability to resist the downward force applied and may drop more quickly compared to the other arm. Pain will be elicited at the greater tuberosity of the humerus, which indicates tendonitis or tear of the supraspinatus muscle.

•

Hawkins-Kennedy Impingement Test—in the test, the glenohumeral joint is set at 90 degrees of abduction and at 30 degrees of forward flexion. The elbow is flexed to 90 degrees and then the humerus is internally rotated. A positive test will be

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seen as pain indicating impingement of the rotator cuff tendons, often the supraspinatus tendons.

•

Neer sign—this is also a shoulder test in which the elbow is extended and the glenohumeral joint is internally rotated. The glenohumeral joint is passively brought into full forward flexion. If there is pain, this is a positive test often indicating impingement of the rotator cuff tendons, often meaning the supraspinatus tendons.

•

Speed test—in the test, the elbow is extended with the palm facing upward. The patient is asked to resist the flexion of the glenohumeral joint. A positive test leads to pain with resistance to flexion, which often indicates tendonitis of the long head of the biceps or sometimes a labral injury.

•

Sulcus sign—in the test, the patient’s arm is held at the elbow and downward traction is applied by the physician. A sulcus or depression is seen below the glenoid fossa, indicating inferior glenohumeral laxity.

•

Yergason test—this is a shoulder test in which the elbow is flexed to 90 degrees, while the patient resists as the examiner brings the glenohumeral joint into external rotation, pulling the elbow inferiorly. A positive test is seen as a pop or snap in the bicipital groove, indicating laxity of the transverse humeral ligament.

If there is pain without a popping sensation, this could indicate bicipital tendonitis.

•

Finkelstein test—this is a test of the forearm by having the patient making a fist and tucking the thumb inside the fingers, while the wrist is actively moved into ulnar deviation. A positive test involves pain on the radial side of the forearm, indicating tenosynovitis of the extensor pollicis brevis and abductor pollicis longus tendons, also referred to as de Quervain tenosynovitis.

•

Phalen test—this is a test for carpal tunnel syndrome done by placing the dorsal aspect of both wrists together so the wrist is hyperflexed for a minute. A positive test involves tingling of the median nerve areas of the hand from carpal tunnel syndrome. The reverse Phalen test involves placing the palms together in order to alleviate symptoms.

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•

Tinel sign—this is another test for carpal tunnel syndrome in which the median nerve is tapped on at the level of the transverse carpal ligament. A positive test shows tingling that radiates along the median nerve distribution as would be seen in carpal tunnel syndrome.

•

Patrick test or the FABERE sign—this is a test of the SI joint by having the patient lie supine, resting the affected foot on the opposite thigh to bring the hip into flexion, internal rotation, abduction, and extension. The opposite ASIS is stabilized while the examiner pushes downward on the affected knee. A positive test is seen when there is sacroiliac pain, although pain in the anterior femur indicates pathology of the hip.

•

Iliac compression/distraction test—this is a test for SI joint pathology by having the patient lie supine with force applied laterally at the ASIS bilaterally. This compresses the SI joints. Then the examiner exerts a medial force at the ilium bilaterally, which gapes the SI joints. A positive test involves pain with compression of the SI joints plus relief of pain when spreading these joints, which mean there is SI joint pathology.

•

Backward bending test—the patient stands and lifts one leg, while extending at the waist. This is repeated on the opposite side. Pain in the lumbar spine will indicate some type of pathology of the posterior elements of the spine, such as degenerative joint disease, spondylolisthesis, or spondylolysis.

•

Straight leg raising—the patient lies supine with the affected leg extended. The heel is grasped and the leg is raised with the knee completely extended. The hip is then flexed. A positive test indicates pain and paresthesias down the leg with moderate flexion and indicates some type of irritation in the sciatic nerve or other lumbar nerve root. This can be from disc disease or pyriformis syndrome.

•

Thomas test—this involves the supine patient with buttocks at the end of the table. One knee is drawn toward the chest, while the other leg is passive. The knee of the tested leg cannot flex to 90 degrees, indicating a tight rectus femoris muscle. If the thigh of the tested leg raises off the table, there is likely a tight iliopsoas muscle.

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•

Trendelenburg test—the patient stands and raises the opposite leg to the side being examined. A positive test involves the iliac crest of the non-weight-bearing test falling below the level of the iliac crest of the standing leg, which is seen in weakness of the gluteus medius of the standing leg.

•

The Valsalva test—this involves the seated patient bearing down with the glottis closed in order to increase intrathecal pressure. A positive test involves spinal pain usually from a herniated disc at the level of the perceived pain.

•

Anterior drawer test—this is a test of the knee. The patient lies supine with the knee flexed at 90 degrees and hip flexed at 45 degrees. The examiner will sit at the foot and will pull forward at the knee by grasping it behind the leg just below the joint line. Increased anterior tibial displacement compared to the opposite side is a positive sign of an ACL tear.

•

Apley Compression test—the patient lies prone with the knee flexed to 90 degrees. The examiner presses downward on the calcaneus with pressure extending through the tibia while also internally and then externally rotating the knee. A positive sign is pain with compression, which indicates a tear of the meniscus or the collateral ligaments.

•

Apley distraction test—the patient lies prone with the knee flexed at 90 degrees.

The examiner grabs the ankle with one hand while also stabilizing the femur with the other hand. A distraction force is applied through the ankle, while also externally and internally rotates the knee. A positive test involves pain with distraction seen in a collateral ligament tear. The alleviation of pain with the Apply compression test indicates some type of meniscal injury.

•

Lachman test—the patient lies supine with passive flexion of the knee at 20 degrees. The examiner grabs the tibia with one hand and stabilizes the femur with the other. The tibia is translated anteriorly while the femur is pushed in the posterior direction. Increased anterior tibial translation indicates a positive test when this is compared to the opposite side and indicates an ACL tear.

•

McMurray test—the patient lies supine while the examiner monitors the joint line with one hand while holding the distal tibia with the other hand. Passive flexion of the knee happens with internal and external rotation of the tibia. A valgus

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stress is placed on the knee while externally rotating the tibia during slow but passive knee extension. Popping or clicking of the knee along with pain along the joint line is a positive test, indicating a meniscus tear of some kind—usually a medial meniscus tear.

•

Ober test—this involves the side-lying patient with the affected side up and both the knees and hips flexed at 90 degrees. The examiner maintains pelvic stability with one hand while lifting and extending the top hip and then returning it to neutral. The hip is allowed to then drop to the table. A positive test involves an inability of the knee to drop to the table in an iliotibial band tightening problem.

•

Posterior drawer test—this involves the same setup as the anterior drawer test but the tibia is pushed posteriorly rather than anteriorly. Increased posterior tibial translation during this maneuver indicates a PCL tear.

•

Valgus stress test—the patient lies supine and the examiner grabs the tibia with one hand, exerting a valgus stress on the knee with the other hand. It is performed at complete extension and when the knee is flexed at 20 to 30 degrees.

Increased laxity at the medial knee is a positive test indicating an MCL tear.

•

Varus stress test—the patient lies supine with the examiner grabbing the distal tibia and exerting a varus or lateral stress on the joint line of the knee at complete knee extension and at about 20 to 30 degrees of knee flexion. A positive test is increased laxity of the lateral knee at the joint line, indicating an LCL tear.

•

Anterior drawer test of the ankle—this assesses the lower leg. The lower leg dangles off the table and the foot is kept at slight plantar flexion. The examiner pulls the talus and calcaneus forward while stabilizing the distal tibia. A positive test is indicated as increased laxity of the joint, which could mean a tear of the anterior talofibular ligament, a common ligament involved in an ankle sprain.

•

Bump test—the patient is seated with the foot off the examining table. The examiner takes the palm of the hand and bumps the calcaneus with increasing force. Pain in the talus, calcaneus, tibia or fibula can indicate an advanced stress fracture of this area.

•

Kleiger test—the lower leg dangles from the table and the foot is rotated laterally but not everted or inverted, while the tibia is kept still. A positive test means a

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sprain of the deltoid ligament, while pain above the medial malleolus indicates a sprain of the syndesmosis.

•

Squeeze test—the examiner takes the proximal tibia and fibula and squeezes them together. Pain distally in the leg indicates a tibia or fibular fracture or a sprain of the syndesmosis.

•

Thompson or Simmonds test—the patient is prone or sitting with the foot off the table. The examiner squeezes the calf. A positive test involves no plantar flexion of the foot, which indicates an Achilles tendon tear.

•

Talar tilt test—the lower leg dangles from the table, while the examiner grabs the calcaneus in order to invert and evert it. A positive test involves increased tilting and indicates sprains of the calcaneofibular ligament and the deltoid ligaments, respectively.

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KEY TAKEAWAYS •

OMT involves techniques considered direct techniques, indirect techniques or both.

•

The major OMT techniques must be learned as the major ways an osteopath can use their unique skills to affect musculoskeletal and visceral conditions of the body.

•

Viscerosomatic reflexes connect aspects of the spine to abnormalities of the body’s viscera.

•

Chapman reflex points are anterior or posterior tenderpoints most often used in confirming a diagnosis of a visceral somatic dysfunction.

•

Jones CS tenderpoints are small areas of tenderness that can be treated with strain and counterstrain techniques in order to reduce the degree of tenderness.

•

There are multiple musculoskeletal tests an osteopath can do that can, from head to toe, define certain structural abnormalities of the different aspects of the musculoskeletal system.

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QUIZ 1.

The patient you are evaluating is complaining of chronic back pain. While the range of motion of the spine appears normal on the examination, you find multiple tenderpoints near the lateral aspect of the thoracic spine on the left.

Which technique might you decide to apply first? a. HTLV b. Strain and counterstrain c. Balanced ligamentous tension d. Muscle energy e. Articulation

2.

Which technique would you most likely apply to the patient with rotation of an upper cervical spinal segment and restriction at the affected area on the left when the patient is complaining of a left-sided headache? a. HTLV b. Strain and counterstrain c. Balanced ligamentous tension d. Muscle energy e. Articulation

3.

The patient is a 30-year-old female with increased frequency of urination and occasional dysuria, even though cystoscopy and urine cultures are always negative. You suspect a viscerosomatic reflex and direct your OMT to what area of the spine? a. T8 b. T12 c. L1 d. C4 e. S3

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4.

You identify a Jones tenderpoint along the sternocleidomastoid muscle on the left side. Which OMT will you most likely apply to this area in order to relieve the patient’s symptom? a. HTLV b. ME c. Strain and counterstrain d. BLT e. MFR

5.

You tap on the volar aspect of the patient’s wrist in order to elicit tingling of the hand in the median nerve distribution. What test are you doing in this examination? a. Tinel test b. Phalen test c. Yergason test d. Finkelstein test e. Speed test

6.

You strongly suspect that the patient you are evaluating has de Quervain tenosynovitis. What test will you do in order to assess this possibility? a. Tinel test b. Phalen test c. Yergason test d. Finkelstein test e. Speed test

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7.

The patient received a blow to the knee playing soccer so you evaluate the structures of the knee. Which test will you do in order to evaluate the patient for a medial collateral ligament tear? a. Posterior drawer test b. Anterior drawer test c. Valgus stress test d. Varus stress test e. McMurray test

8.

In evaluating the painful knee, you have the patient lying supine while you monitor the joint line with one hand while holding the distal tibia with the other hand. A valgus stress is placed on the knee while externally rotating the tibia during slow but passive knee extension. Popping or clicking of the knee along with pain along the joint line is a positive test, indicating a meniscal tear. What test are you doing? a. Posterior drawer test b. Anterior drawer test c. Valgus stress test d. Varus stress test e. McMurray test

9.

You perform a test of the ankle, in which the lower leg dangles from the table, while you grab the calcaneus in order to invert and evert it. A positive test involves increased tilting and indicates sprains of the calcaneofibular ligament and the deltoid ligaments, respectively. What test are you performing? a. Bump test b. Kleiger test c. Talar tilt test d. Squeeze test e. Thompson test

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10.

Which test of the foot and ankle might you do if you suspect an anterior talofibular ligament sprain? a. Anterior drawer test of the ankle b. Kleiger test c. Talar tilt test d. Thompson test e. Squeeze test

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percent of cervical rotation happens because of this joint, which also flexes and extends little. Figure 2 shows the relationship between the atlas and axis:

Figure 2.

In making a somatic dysfunction diagnosis at this level, you will need to flex the neck in order to lock C2 to C7 in their positions and to isolate just the rotation of this joint.

Rotate the head to either direction, looking for restrictions. If the rotation is more to the right than to the left, for example, the atlas is said to be rotated to the right.

There are several treatment options. You can do HTLV, muscle energy techniques, indirect techniques, or facilitated positional release. We will talk more about this in a few chapters.

For somatic dysfunctions of C2 to C7, remember that sidebending and rotation always occur to the same side, regardless of the actual position of the neck. Assess the range of motion in flexion and extension, rotation, and sidebending. Techniques that can be applied include HVLA, muscle energy, indirect techniques, and facilitated positional release.

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Figure 3.

Scoliosis is named for its convex side; it can be idiopathic, which is most common, congenital, or gradually acquired if there is a problem such as a shortened limb. Surgery is reserved for curvatures greater than 50 degrees because it can compromise the patient’s cardiorespiratory function. Functional curvatures can be corrected with things like a heel lift. This cannot help in structural curvatures. Things like HVLA, muscle energy, and FPR can help to address specific segments.

With regard to the ribs, there are three major types. The true ribs are ribs one through seven. These are fully attached anteriorly to the sternum. The false ribs are ribs eight through ten, which are not attached to the sternum but are attached to costal cartilage anteriorly. Ribs eleven and twelve are called floating ribs, because they have only a posterior attachment to the spine and no anterior attachment.

There are three possible rib motions. The upper ribs are involved in pump handle motion, in which the anterior parts of the ribs will move upward during inspiration with the goal of increasing the AP diameter of the thorax. The lower ribs are involved in 39

The major ligament to know about in the lumbar area is the iliolumbar ligament that starts at the iliac crest and inserts along the transverse processes of L4 and L5. This ligament will decrease the lower lumbar mobility and often contributes to referred pain in the lumbar area.

The spinal cord itself ends at L2 with the cauda equina passing through the canal lower than this. The iliopsoas muscle is important here because several major nerves pass near this muscle. Directly through the psoas major muscle is the genitofemoral nerve, which can lead to anterior thigh or groin pain should there be psoas muscle tension.

Another potential problem is pyriformis syndrome, which can lead to sciatica if this muscle is tight or dysfunctional. Figure 5 demonstrates pyriformis syndrome:

Figure 5.

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