The OMM Standardized Question

Lori A Dolinski, MSc, PhD, DO

Executive Director, Boards Boot CampPresident & 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 #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

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 #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

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

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 #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

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

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 #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

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 #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

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

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

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 CampPresident & Chairperson, Mindworks Corporation