the omm standardized question - academy of...
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The OMM Standardized Question
Lori A Dolinski, MSc, PhD, DO
Executive Director, Boards Boot CampPresident & Chairperson, Mindworks Corporation
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Goals
• Understand common OMM concepts for Levels 1, 2, and 3
• Appreciate common OMM areas of misunderstanding
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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
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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
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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
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Case #1A 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
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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
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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)
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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
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Case #2A 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
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Case #3On 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
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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
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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
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Herniated Discs
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Case #4A 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
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Case #5A 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
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Lumbar Pathologies
• There are numerous pathologies!
• Includes spondylolisthesis, spinal stenosis, osteoarthritis, herniated disc
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What causes achy lumbar pain?
Spinal stenosis
Osteoarthritis
Spondylolysis (chronic)
Spondylolisthesis
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What causes sharp lumbar pain?
• Spinal stenosis
• Herniated disc
• Cauda equina syndrome
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Important Upper Extremity Disorders• There are many!
• Includes thoracic outlet syndrome, carpal tunnel syndrome, rotator cuff tear
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Important Lower Extremity Disorders• There are many!
• Includes Osgood-Schlatter syndrome, Sprained ankle, Lateral Femoral Patellar Tracking Syndrome
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Signs of Cranial Dysfunction
•Bulging or sunken in eyes
•Protruding or close-to-head ears
•Headache
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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
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Case #6You 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 LR ear is prominent & left ear is close to head occiput has moved away from R temporal bone and is closer to L temporal boneDx = right torsionHow about the mastoid process findings? Prominent L mastoid
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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
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Sympathetics, Facilitation, and Reflex Arcs
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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
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Autonomic Nervous System
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Case #7A 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
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Case #8A 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
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Case #9A 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
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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
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The OMM Standardized Question
Lori A Dolinski, MSc, PhD, DO
Executive Director, Boards Boot CampPresident & Chairperson, Mindworks Corporation