The OMM Standardized Question - American Academy of Osteopathy

The OMM Standardized Question - American Academy of Osteopathy

The OMM Standardized Question
Lori A Dolinski, MSc, PhD, DO
Executive Director, Boards Boot Camp
President & Chairperson, Mindworks Corporation
Goals
• Understand common OMM concepts for Levels 1, 2, and 3
• Appreciate common OMM areas of misunderstanding
Fryette Mechanics: Freedom
• Freedom = that movement involving the least facet and
ligamentous/bony interference
• Being more free on one side = being more restricted on the
other side! = somatic dysfunction
Fryette Mechanics: Types
• Applies only to T and L spine
• Neutral (type I): N  rotation and sidebending to the
opposite side
• Non-neutral (type II): F/E  rotation and sidebending to the
same side
Where is the freedom of the sagittal
plane?
• Whatever position allows for the most freedom of the
segment
• It is not the freedom for rotation
• It is not the freedom for sidebending
Case #1
A patient is found to have T4-5 rotate more to the right
than the left when flexed. What is the diagnosis?
T4-5 rotates more to the right  rotated right
This dysfunctional position is induced by flexion  flexion is
NOT the freedom
If it is T4-5 ERR, applying Fryette  T4-5 ERRSR
Cervical Motion Rules
• Cervical somatic dysfunction: guided by what segment it is,
and not by whether it is neutral or non-neutral
• Cervical segments do not follow standard Fryette mechanics
What is the dysfunction of THAT
cervical segment?
• C0-C1: rotation and sidebending are always to the opposite
side (type I-like)
• C1-2: rotation and sidebending are to the opposite side…but
rotation prevails (sidebending is not tested)
• C2-C7: rotation and sidebending are always to the same side
(type II-like)
But what are C0, C1, and C2?
C0 = occiput; refers to occipito-atlantal joint (OA)
C1 = atlas; refers to atlanto-axial joint (AA)
C2 = axis
Case #2
A patient is evaluated and the OA is determined to be stuck rotated
right when flexed. What is the somatic dysfunction?
Somatic dysfunction = freedom = nomenclature = diagnosis
OA  refers to actions of C0
C0 stuck rotated right  movement it does best = rotation right
C0 RR  therefore, C0RRSL
The dysfunction is induced by flexion  freedom = extension
Dysfunction = C0ERRSL
Case #3
On evaluation of a patient, C4 is found to be sidebend more to the left
than the right while in neutral. What is the restriction?
Restriction = opposite of freedom
Have to 1st know the freedom to determine restriction
SB more to left  freedom is SB left  C4 SL
C4 SL  C4 has rotation to same side  C4 RLSL
Neutral position induces the dysfunction  freedom is NON-neutral
So, freedom = C4 F/E RLSL
Restriction is the opposite of freedom  C4 NRRSR
Herniated Discs
• Intervertebral discs are named for the segment they support
or cushion
• If herniated, the nucleus pulposus ruptures through the
annulus fibrosus, creating a bulge that can potentially
impinge nearby nerve roots
• Not all herniated discs will cause impinged nerve roots
Which nerve root is impinged?
C spine: the next numbered nerve root
T spine: the same numbered nerve root
L spine: the next numbered nerve root
Herniated Discs
Case #4
A patient has a herniated C7 disc. What nerve root
risks impingement?
C7 disc (C7-T1 disc) supports C7 segment
C8 nerve root emanates from that level
C8 is the nerve root in jeopardy
Case #5
A patient has a herniated L4 disc. What nerve root risks
impingement?
L4 disc (L4-L5 disc) supports L4 segment
L4 nerve root exits at that level, but above disc
Lumbar discs herniate posterolaterally  impinging nerve roots of cauda
equina
Nerve root “lining up” for exit  first to be impinged
The larger the herniation  the more nerve roots impinged
Lumbar Pathologies
• There are numerous pathologies!
• Includes spondylolisthesis, spinal stenosis, osteoarthritis,
herniated disc
What causes achy lumbar pain?
Spinal stenosis
Osteoarthritis
Spondylolysis (chronic)
Spondylolisthesis
What causes sharp lumbar pain?
• Spinal stenosis
• Herniated disc
• Cauda equina syndrome
Important Upper Extremity
Disorders
• There are many!
• Includes thoracic outlet syndrome, carpal tunnel syndrome,
rotator cuff tear
Important Lower Extremity
Disorders
• There are many!
• Includes Osgood-Schlatter syndrome, Sprained ankle, Lateral
Femoral Patellar Tracking Syndrome
Signs of Cranial Dysfunction
• Bulging or sunken in eyes
• Protruding or close-to-head ears
• Headache
What do these outward findings
mean regarding cranial dysfunction?
• Bulging eyes: pushed out by B/L superiorly placed sphenoid
• Protruding ears: left “exposed” when occiput moves away
from the ipsilateral temporal bone
• Prominent mastoid process: appears more obvious when
occiput moves towards temporal bone
Case #6
You take one look at a conference attendee and notice immediately that
his right eye is bulging while his left eye is receded, AND his right ear is
sticking out while the left ear looks to be part matted down in his hair!
What is his diagnosis?
R eye bulge & L eye recession  sphenoid is superior on R and
inferior on L
R ear is prominent & left ear is close to head  occiput has
moved away from R temporal bone and is closer to L temporal
bone
Dx = right torsion
How about the mastoid process findings? Prominent L mastoid
Sympathetics, Facilitation, and
Reflex Arcs
• Sympathetic nervous system = fight or flight mechanism
• Activated when there is pathology, injury, illness, etc.
• If chronically or massively stimulated, can case facilitation
• Facilitation = decreased threshold to activation of spinal cord
• Facilitation  inappropriate outgoing impulses from that segmental level
of the cord
• Innervation of the remote tissue yields a reflex arc
Sympathetics,
Facilitation, and Reflex
Arcs
Sympathetics are Activated:
What’s the effect?
• Muscle Hypertonicity or Spasm
• Referred Pain
• Sympathetic response in remote tissues innervated by
same segmental spinal cord level
Autonomic
Nervous
System
Case #7
A patient complains of umbilical pain, though nothing
appears to be abnormal about the umbilicus. What could be
the cause?
Referred Pain!
Pain  T10 dermatome  Facilitation of T10 spinal cord
level  Pathology of ovary, intestine, or kidney
Case #8
A patient develops T2-4 spinal somatic dysfunction, with
accompanying muscle hypertonicity and spasms in the same
region. He also has fever, cough, and dyspnea. What could be the
cause of the musculoskeletal problems?
Reflex Arc involving motor neurons!
Muscle hypertonicity/T2-4 spinal SD  T2-4 facilitation 
Pathology of lungs, heart, aorta, esophagus
Cough, SOB, and fever point towards lung as the source
Case #9
A female patient presents with complaints regarding urinary
retention. She is recovering from diverticulitis. What could be
the cause of her urinary problems?
Barring any more serious complications from her
diverticulitis….probably Reflex Arc involving sympathetics!
Urinary retention  SNS activation of bladder  T12-L2 spinal
cord facilitation  Pathology of descending colon, sigmoid, or
rectum, or uterus
Hx of recent diverticulitis points to sigmoid colon as source
What else can help with
standardized OMM questions?
• Answer what the question is requesting
• Consider all answer options, and pick the one best one
• Think – avoid knee-jerk or memorized responses
The OMM Standardized Question
Lori A Dolinski, MSc, PhD, DO
Executive Director, Boards Boot Camp
President & Chairperson, Mindworks Corporation