OMM PRACTICAL EXAM Saroj Misra, DO, FACOFP Rachel Nixon, DO Marissa Rogers, DO Family Medicine Goals/Objectives

• Review Exam Day procedure

• Understand scoring process

• Discuss possible cases and 2 OMM techniques that may be used for each case Disclaimer: The material being presented is NOT necessarily identical to what will be tested upon. We are not afﬁliated with the actual exam. This is our approach to the practical exam material. EXAM DAY Exam day

• You will be assigned a time slot based on your last name

• You will select a partner within your time slot

• May not partner with a spouse or relative

• You will be asked to sign a waiver stating that if you choose to do HVLA you will not perform the corrective “thrust”

• You will then stand in line with your partner and await entering the testing room Exam day

• There will be two rooms - one in which you will review cases and the second where you will be tested

• Once you enter the ﬁrst room you will not be able to leave

• If you DO leave, both you and your partner will be given new cases Exam day

• You will be given 3 cases:

• Spine

• Extremities

• Systemic Disease

• You will enter your name, ID number and your partners ID number on each case before turning them over Exam day • Each case will have the following information:

• HPI

• PMH

• PSH

• FHx

• SocHx

• There will be multiple choice for the best answer for your diagnosis

• You will have 20 minutes to choose the best answer and plan a treatment strategy for each of your cases Exam day

• After the 20 minutes are complete, you will be moved into testing area and proceed to the ﬁrst testing station where you and your partner will present your ﬁrst cases

• If you selected the incorrect answer, you will be given the correct diagnosis and asked to do OMT for the correct dx

• You and your partner will each have 5 minutes to demonstrate and discuss OMT for your ﬁrst case

• You will then move with your partner to the next two stations where you will repeat the same process for your second and third cases Exam day

• You may be asked to diagnose the speciﬁed area on your partner

• Set up the treatment you would like to use and describe how you would perform the treatment

• You will not actually treat your partner

• They will check your hand placement so be sure to be accurate with placing your hands and with what you are feeling for Exam day

• Once you have completed your treatment…

• RECHECK

• And don’t forget to RECHECK!!! Scoring criteria

• For each case you will be scored on:

• Correct diagnosis

• Identiﬁcation of landmarks for your technique

• Implementation and demonstration of the technique

• Ability to discuss each technique

• To pass the exam, you must pass two of the three cases

• If you do an HVLA “thrust” you will immediately fail the exam Common questions…

• What if I don’t do the treatment correctly on a case?

• The proctor may ask you to perform an additional technique

• However, they may ask for another technique even if you did the ﬁrst correctly

• What if I don’t pass the exam?

• You will retake the exam later in the day Head Commonly Cervical Spine tested areas Thoracic Spine Lumbar Spine Ribs Extremities CASES Case 1: Head

• HPI: 31 year old female who is 29 weeks pregnant presents with facial pain, nasal drainage and a tender rib. Exam reveals tenderness to palpation over frontal and maxillary sinuses

• Dx: Sinusitis/Sinus Congestion

• DDx: Cephalgia, Rib dysfunction http://vitamin-resource.com/sinusitis-detecting-it.html Case 1: Sinusitis/Sinus congestion Treatment option 1

• OA Release - affects parasympathetic nervous system to thin nasal secretions and releases tension at OA

• Patient supine with examiner at head of table. Slide hands down posterior skull to where you feel the softening of the tissues at the OA junction. Apply a gentle tension towards the patient eyes while gently applying cephalward traction - allowing the occiput to fall into the palm of your hands. Respiratory effort may be added

• Hold until a release is felt or there is softening of the surrounding tissues

• RECHECK Case 1: Sinus congestion/Sinusitis Treatment option 2

• Sinus Eﬄeurage - decreases lymphatic congestion and assists in drainage

• Patient supine, examiner at head of table. Place the dorsal surface of your thumbs on the lateral sides of the middle of the forehead just above the glabella. Apply just enough pressure downward to compress the tissues against the deep fascia of the head. Stroke the thumbs laterally and down towards chin. Repeat 3-4 times over frontal and maxillary sinuses.

• RECHECK

• May want to mention that you would open the thoracic inlet ﬁrst so drainage has somewhere to go Case 2: Head

• HPI: A 47 year old female presents with jaw pain, HA, B/ L ear pain. She reports recently having a crown put in. Exam shows B/L tenderness anterior to tragus with difﬁculty opening the mouth.

• Dx: TMJ Dysfunction http://www.physiownc.com/tmj-treatment/#.UshyGXl3TwI

• DDx: Tension Cephalgia, Dental abscess Case 2: TMJ Dysfunction Treatment option 1

• Counterstrain to muscles of mastication (Masseter): decreases tension of Masseter muscle

• Patient lies supine with examiner at the head of the table. Tenderpoint is found just inferior to the zygoma in the belly of the masseter muscle on the side of the mandibular deviation. The examiner gently opens the patients jaw slightly and gently glides the patients jaw toward the side of the tender point. Fine tune positioning until tenderness is alleviated or at least reduced by 70%

• Hold for 90 seconds or until a release is felt

• Return jaw to neutral and RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 2: TMJ Dysfunction Treatment option 2

• ME to jaw dysfunction: decrease pain/ tension at TMJ, improve ROM of jaw

• Jaw opening dysfunction: Patient supine, examiner at head of table. Hold patients mouth closed while patient attempts to gently open jaw against resistance. Repeat 3-5 times. RECHECK

• Jaw closing dysfunction: Patient supine, examiner at head of table. Hold patients mouth open slightly, while patient attempts to gently close against resistance. Repeat 3-5 times. RECHECK

• Jaw Lateral Deviation Dysfunction: Patient supine, examiner at head of table. Hold patients jaw slightly away from the affected side, while patient gently exerts force back toward neutral against resistance. Repeat 3-5 times. RECHECK Case 3: Cervical Spine

• HPI: 32 y/o male presents with 2 year history of cephalgia. No hx of trauma or neuro deﬁcits. On exam, C2- C6 prefers ﬂexion and does not want to rotate right.

• Dx: C2-6 FRLSL Somatic Dysfunction

• DDx: Tension Cephalgia, C- spine strain/sprain

http://www.advanced-wellness.net/blog/can-a-chiropractor-relieve-your-headache/ Case 3: Cervical dysfunction Treatment option 1

• Muscle Energy: decrease muscle tension, increase ROM

• Treatment will be ERS right. Patient supine, examiner at head of table. Place thumb on the margin of the right articular pillar and push to column to the left inducing right side bending. Use the other hand to hold the head and induce extension to localize. Have patient push head isometrically to the left against resistance. Take up slack and repeat 3-5 times.

• RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 3: Cervical dysfunction Treatment option 2

• Counterstrain to posterior cervical spine: decrease tension of associated cervical muscles

• Patient supine, examiner at head of table. Tenderpoint can be found along posterior lateral aspect of articular process of associated dysfunctional segement. Extend patients head and neck to level of dysfxn segment. Add side bending and rotation away. Fine tune position until tenderness is alleviated or there is 70% reduction.

• Hold for 90 seconds or until a release is felt.

• Return to neutral and RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 4: Cervical Spine

• HPI: 40 y/o male presents with neck pain after MVA 5 days ago. X-rays are negative. On exam, C3-6 are tender b/l and there is decreased lordosis. No increase of pain with addition of axial load.

• Dx: C3-6 Flexed

• DDx: C-spine strain, Tension cephalgia

http://www.lwcmanhattan.com/my-symptoms/neck-pain/ Case 4: Cervical ﬂexion Treatment option 1

• Muscle Energy: Decrease tension, increase ROM

• Patient supine, examiner at head of table. Place middle phalanx of index finger of one hand midline at the interspinous space of middle of dysfunctional segments. Reinforce with index finger of other hand. Rest patients head on table while inducing extension to restrictive barrier. Have patient gently flex head against resistance. Take up slack and repeat 3-5 times.

• RECHECK Case 4: Cervical ﬂexion Treatment option 2 • Counterstrain to posterior cervical spine: decrease tension of associated cervical muscles

• Hold for 90 seconds or until a release is felt.

• Return to neutral and RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 5: Thoracic spine

• HPI: 42 y/o male who presents with pain and tingling in the left shoulder and arm. He denies trauma and injury. Exam revelas Tinel’s, and Phalen’s tests are negative.

• Dx:

• Thoracic outlet syndrome

• DDx: First rib dysfunction, C- Spine dysfunction

http://www.howardluksmd.com/shoulder-faq/what-are-the- most-common-causes-of-shoulder-pain-rotator-cuff-labral-tears/ Case 5: Thoracic Outlet Syndrome Treatment option 1

• Thoracic Inlet Release: Releases facial tension, decreases pain

• Patient supine, examiner at head of table. Place hands over thoracic inlet with ﬁngers spread over anterior thorax and thumbs at posterior thorax. Gently carry the fascia into right/left rotation, right/left side bending, and ﬂexion/extension to balanced point. Respiratory effort can be added as enhancer

• Hold for 20-60 seconds or until release is felt

• Return to neutral and RECHECK Atlas of Osteopathic Techniques, Nicholas Case 5: Thoracic Outlet Syndrome Treatment option 2

• Muscle Energy to First Rib: Corrects inhalation dysfunction

• Patient supine, examiner at head of table. Place hands with thumbs on posterior margins of both 1st ribs and index ﬁngers over the anterior 1st ribs. Patient instructed to shrug shoulders while inhaling and drop shoulders down while exhaling. Physician maintains ﬁrm caudal pressure on the ribs during inhalation and follows caudally into exhalation. Repeat 3-5 times.

• RECHECK Case 6: Lumbar spine

• HPI: 30 y/o male which low back pain. Denies trauma. On exam radiation of pain down the right leg, tenderness at sacral base and low back. No incontinence or numbness. X- rays are negative.

• Dx: Piriformis Syndrome

• DDx: Lumbar strain, Sacral Torsion

http://www.biokineticspt.com/blog/uncategorized/skip-the-steroid-shots-for-back-pain.html Case 6: Piriformis Syndrome Treatment option 1

• Counterstrain to Piriformis: decrease tension of Piriformis muscle

• Patient prone, examiner at side of patient tenderpoint. Tenderpoint found midway between the ILA of sacrum and the greater trochanter. Drop patients leg off the edge of the table so hip is ﬂexed about 135 degrees. Abduct and externally rotate hip. Fine tune position until pain is alleviated or there is a 70% reduction. Rest patients knee on examiner leg

• Hold for 90 seconds or until a release is felt Atlas of Osteopathic Techniques, Nicholas • Return to neutral and RECHECK Case 6: Piriformis Syndrome Treatment option 2

• Muscle Energy to Piriformis Muscle: Decrease tension/improve ROM

• Patient prone, examiner at side of table. Palpate dysfxnl Piriformis with cephalad hand and grasps patients ankle with caudad hand. Flex patients knee to 90 degrees and slowly move patients ankle away from midline, internally rotating the hip to restrictive barrier. Patient pushes ankle towards midline against resistance. Take up slack and repeat 3-5 times

Atlas of Osteopathic Techniques, Nicholas • Return to neutral and RECHECK Case 7: Ribs

• HPI: 24 y/o male presents with pain in the chest wall after sneezing hard. Patient notes some numbness along lateral ribcage on the right. On exam, pain is elicited at the right 6th rib posteriorly and radiating around to anteriorly. Rib prefers inhalation.

• Dx: Inhaled 6th rib

• DDx: Costochondritis, Intercostal neuralgia

http://younglivingsingapore.com/2013/07/hairline-fracture-of-rib/ Case 7: Inhaled Rib Treatment option 1

• Muscle Energy to inhaled 6th rib: improve ROM of rib, decrease pain

• Patient supine, examiner sits on side of dysfunction. Hook the ﬁngers of one hand over the inferior margin of the angle of the rib. Place the other hand in the interspace above the rib. Thumbs meet at mid-axillary line. Together, move both the posterior and anterior ends of the rib into exhalation. Instruct the patient to inhale while holding the rib in exhalation and follow the rib further down during exhalation. Repeat 3-5 times.

• RECHECK Case 7: Inhaled Rib Treatment option 2

• Rib Raising: reset sympathetic nervous system and increase rib motion

• Patient supine. Stand/sit at patient side with patients arms crossed over the chest. Place ﬁnger pads on the posterior angles of the ribs. Lift the rib angles anteriorly until chest wall motion is noted. Hold the ribs up until the surrounding tissues relax. Allow ribs to fall Kimberly Manual posteriorly and repeat on the other side.

• RECHECK Case 8: Upper Extremity

• HPI: 80 y/o female with shoulder pain, stiffness and difﬁculty combing her hair/ reaching overhead or to get things from her back pocket. Exam reveals decreased ROM of shoulder in all planes

• Dx: Adhesive Capsulitis

• DDx: Rotator Cuff Tear, Biceps Tendonitis, Thoracic Outlet http://cheadleosteopathy.co.uk/portfolio-item/frozen-shoulder-adhesive-capsulitis-case-study-8/ Syndrome Case 8: Adhesive Capsulitis Treatment option 1 • 7 Stages of Spencer:

• Extension

• Flexion

• Circumduction w/ Compression

• Cirumduction w/Traction

• ABduction

• Rotation - Internal

• Pumping Atlas of Osteopathic Techniques, Nicholas Case 8: Adhesive capsulitis Treatment option 2

• Thoracic Inlet Release: Releases facial tension, decreases pain

• Patient supine, examiner at head of table. Place hands over thoracic inlet with ﬁngers spread over anterior thorax and thumbs at posterior thorax. Gently carry the fascia into right/left rotation, right/ left side bending, and ﬂexion/ extension to balanced point. Respiratory effort can be added as enhancer

• Hold for 20-60 seconds or until release is felt

• Return to neutral and RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 9: Upper Extremity

• HPI: 35 year old female presents with complaints of right lateral elbow pain for 2 weeks. She states it started after playing a game outside with her children. She denies numbness/tingling. No trauma to the elbow. On exam, patient has tenderness on the lateral epicondyle. No swelling noted. Negative Phalen’s. X-rays are negative.

• Dx: Lateral Epicondylitis http://maranicandronmt.ﬁles.wordpress.com/2010/12/elbow_pain.jpg • DDx: Posterior radial head, Elbow sprain Case 9: Lateral Epicondylitis Treatment option 1

• Counterstrain: decrease tension/pain at lateral epicondyle

• Patient seated. Examiner grasps wrist on dysfunction side with one hand and uses other hand to palpate tender point - usually found in the muscle extensor wad just anterior/inferior to lateral epicondyle. The elbow is moved in ﬂexion/extension, pronation/ supination until a point of ease is felt. Fine tune until pain is alleviated or there is 70% reduction. ris.nyit.edu/nycom/CME/treatment_upper_extremity.html • Hold for 90 seconds or until a release is felt

• Return to neutral and RECHECK Case 9: Lateral Epicondylitis Treatment option 2

• ME to posterior radial head: Patient seated. Examiner makes a handshake grip with the index ﬁnger contacting in distal radius. With the other thumb, anterior pressure is placed on radial head. The forearm is moved into extension/supination. The patient then gently pronates hand against resistance while examiner resists posterior motion of the radial head. Take up slack and repeat 3-5 times each times taking patient into further Atlas of Osteopathic Techniques, Nicholas supination.

• RECHECK CASE 10: Upper extremity

• HPI: 40 y/o male presents with pain and tingling in the right hand. States pain occurs mostly in the thumb and index ﬁnger. Pain has been waking him up from sleep. Exam reveals positive Tinel’s and Phalen’s tests

• Dx: Carpal Tunnel Syndrome

http://www.advancedintegrativehealthcenter.com/carpaltunneldallas.html • DDx: Thoracic Outlet Syndrome, C-spine somatic dysfunction Case 10: Carpal Tunnel Syndrome Treatment option 1

• Carpal Tunnel Release: release fascial restrictions, increase lymphatic drainage & decrease pain

• With patient seated, examiner sits facing patient. Interlock the 5th ﬁngers on each of your hands with the patients 1st and 5th ﬁngers. Use thumbs to apply lateral stretch over carpal tunnel. Repeat until softening of tissues is felt

• RECHECK Case 10: Carpal Tunnel Syndrome Treatment option 2

• Articulatory technique of wrist: decrease joint dysfunctions, increase ROM of wrist

• Patient seated, examiner sits facing patient. Grasp the patients wrist between hands. Patient squeezes examiners hand. As patient relaxes, examiner squeezes wrist to gap the inter-carpal joints. Carry the wrist through a ﬁgure 8 motion several times.

• RECHECK Case 11: Lower Extremity

• HPI: 18 y/o female presents with acute right ankle pain after she stepped off a curb and twisted her ankle. She is able to ambulate with slight limp. On exam, she has some tenderness along lateral ankle, but no joint instability. Pt also admits to some pain in right knee. X-rays negative.

• Dx: Ankle Sprain

http://www.solpt.com/blog/2013/04/25/ankle-sprains/ • DDx: Posterior Fibular Head, Tibiotalar strain (medial side) Case 11: Ankle Sprain Treatment option 1

• Counterstrain to lateral ankle tenderpoint: decrease pain & tension at ankle

• Patient seated or lateral recumbent. Palpate tender point located anterior/inferior to lateral malleolus. Evert and dorsiﬂex ankle. Fine tune adding external rotation of foot until tenderness is alleviated or 70% reduced

• Hold for 90 seconds or until release is felt

• Return to neutral and RECHECK Atlas of Osteopathic Techniques, Nicholas Medial Ankle Treatment (Deltoid/Tibiotalar Ligament)

• Counterstrain to medial ankle tenderpoint: decrease pain & tension at ankle

• Patient laying in lateral recumbent position with pillow under medial aspect of distal tibia to create fulcrum. Palpate tender point located anterior/ inferior to medial malleolus. Invert and internally rotate ankle/ foot. Fine tune until tenderness is alleviated or 70% reduced

• Hold for 90 seconds or until release is felt

• Return to neutral and RECHECK

Atlas of Osteopathic Techniques, Nicholas Case 11: Ankle sprain Treatment option 2

• ME to posterior ﬁbular head: decrease tension, increase ROM, and decrease pain

• Patient seated with dysfunctional leg off the table. Examiner seated on side of dysfunction. Using cephalad thumb and index finger grasp the fibular head and apply anterior force. At the same time, using caudad hand grasp foot and place in dorsiflexion, eversion, and external rotation. Patient gently attempts to plantar flex and invert foot against resistance. Reposition to new barrier and repeat 3-5 times.

• RECHECK CASE 12: Lower Extremity

• HPI: 56 y/o male presenting with knee pain and swelling after golﬁng. On exam, knee is swollen, without joint instability. No neuro-vascular compromise noted. Negative drawer tests of knee. Pain elicited with full extension. MRI negative.

• Dx: Knee strain/sprain

http://gouldchiropractic.com/category/chiropractic-treatments/sport-injury-pain-treatment/ • DDx: Posterior ﬁbular head, Short leg syndrome Case 12: Knee Strain Treatment option 1

• Eﬄeurage to Knee: decrease lymphatic congestion

• Patient supine, examiner seated on side of dysfunction. Place hands around circumference of lower extremity. Apply gentle stroking motion of soft tissues distally to proximally towards pelvis in a wringing motion. Repeat this motion, each time starting more distally along edematous area.

• Return to neutral and RECHECK

• May want to mention that you would open the pelvic and thoracic http://derbysportsinjuries.co.uk/index.php/treatments diaphragms ﬁrst so lymphatics have somewhere to drain Case 12: Knee Strain Treatment Option 2

• ME to posterior ﬁbular head: decrease tension, increase ROM, and decrease pain

• RECHECK Case 13: Respiratory

• HPI: 25 y/o female presents with complaints of increasing cough, wheezing and mild shortness of breath. She recently had URI which seems to be improving. Has a history of asthma. Using inhaler 3-4 times per day. Exam reveals diminished breath sounds with wheezes throughout. Chest X- ray negative.

• Dx: Asthma Exacerbation

http://santamariamedicine.com/2013/03/ask-dr-santa-maria-pots-patient-with-shortness-of-breath/ • DDx: COPD exacerbation, Pneumonia Case 13: Asthma Exacerbation Treatment Option 1

• Rib Raising: reset sympathetic nervous system and increase rib motion

• Patient supine. Stand/sit at patient side with patients arms crossed over the chest. Place ﬁnger pads on the posterior angles of the ribs. Lift the rib angles anteriorly until chest wall motion is noted. Hold the ribs up until the surrounding tissues relax. Allow ribs to fall posteriorly and repeat on the Kimberly Manual other side.

• RECHECK Case 13: Asthma Exacerbation Treatment Option 2

• Redome Abdominal Diaphragm: Indirect: Increase movement of diaphragm, improve shortness of breath

• Patient supine, examiner stands at side of patient. Grasp patients lateral rib cage along the diaphragmatic myofascial borders. Take the myofascial structures into rotation, side bending and ﬂexion/extension to the point of BLT. Respiratory effort is added for several cycles. Return to neutral. http://www.lastsite.ca/wp-content/uploads/2012/03/diaphragm-1.jpg

• RECHECK Case 14: GI system

• HPI: 83 year old male presents with complaints of abdominal discomfort. States he has not had a normal bowel movement in several days. He is passing gas. He denies nausea/ vomiting, diarrhea. Last BM without mucus or blood. Exam reveals +BS, soft, and non- tender abdomen. +stool present in rectal vault. Abd X- ray reveals copious stool.

http://cancer.dartmouth.edu/focus/constipation_home_treatment.html • Dx: Constipation

• DDx: Ileus, Bowel obstruction Case 14: Constipation Treatment Option 1

• IT band Chapman points: reset viscerosomatic reﬂex of the colon

• Patient supine. Examiner stands at patients side. Identify tender Chapman points along the IT band bilaterally. Using your thumb or ﬁnger apply rotary press to the chapman point for 10-30 seconds. Continue down IT bands. w.studyblue.com/notes/note/n/chapmans-reﬂex-pts/deck/8608369

• RECHECK Case 14: Constipation Treatment Option 2

• Mesenteric release: increase gastric motility, improve lymphatic/ venous drainage

• Patient prone, examiner at side of patient. Gently examiner uses both hands to pull/push colon towards mesenteric attachment point (center) and hold until release is felt. Repeat for all parts of the colon. For small intestine gently pull/push towards RUQ which is the mesenteric attachment point for the small intestine. Again, hold until release is felt.

• RECHECK Atlas of Osteopathic Techniques, Nicholas Case 15: Lymphatics

• HPI: 65 year old male presents with complaints of bilateral leg swelling and pain. States he noticed this AM that there was a sore on his leg that had some clear drainage. Denies fevers, chills or LE weakness. He has a known history of uncontrolled diabetes and CHF. Exam reveals a 1cm stage 2 ulceration on right LE with minimal serous sanguineous drainage. +reddish brown skin discoloration with 1-2+ edema of http://healthool.com/venous-stasis-ulcer/ both LEs extending to about 2inches below the knee.

• Dx: Venous stasis ulcer

• DDx: Cellulitis, Venous Dermatitis Case 15: Venous Stasis Ulcer Treatment Option 1

• Lower extremity effleurage: Increase lymphatic return from the lower extremity, decrease inflammation and mobilize venous blood flow

• Patient supine, examiner seated on side of dysfunction. Place hands around circumference of lower extremity. Apply gentle stroking motion of soft tissues distally to proximally towards pelvis in a wringing motion. Repeat this motion each time starting more distally along edematous area. Foundations of osteopathic medicine, 2nd edition, Figure 68.32 • Return to neutral and RECHECK

• May want to mention that you would open the pelvic and abdominal diaphragms ﬁrst so drainage has somewhere to go Case 15: Venous Stasis Ulcer Treatment Option 2 • Popliteal Fascia release: Improve lymphatic drainage from lower extremities and to release any fascial restricion(s) of the popliteal fossa

• Patient supine with legs extended. Physician sitting on side to be treated and places hands on either side of the knee so ﬁngers are grasping the medial and lateral aspects of the popliteal fossa. Palpate for any fascial restrictions in all directions. Apply anterior pressure through ﬁngertips while engaging any additional barriers through a direct MFR. Hold until a release is felt http://www.eastlandpress.com/preview/las.pdf

• RECHECK

• May want to mention that you would open the pelvic and abdominal diaphragms ﬁrst so drainage has somewhere to go Pelvic Diaphragm Release

• Improves motion of the pelvic diaphragm allowing for increased venous and lymphatic drainage from the pelvis

• Patient prone, physician standing at patient side. Place thumbs medial to ischial tuberosities bilaterally. Apply cephalad and lateral pressure until resistance is met. As patient inhales resists motion of diaphragm; as exhales follow further cephalad. Repeat with several respiratory cycles.

• RECHECK Atlas of Osteopathic Techniques, Nicholas Other possible Cases:

• Otitis Media

• Tx: OA release, Auricular Drainage, Galbreath Technique

• Gastro-esophageal reﬂux

• Tx: OA release, Chapman points for stomach, Ganglion release

• Plantar Fasciitis

• Tx: Plantar fascia stretch/release, Counterstrain to calcaneal tender point Key points:

• Practice, Practice, Practice

• Stay CALM

• Do not rush

• Talk your way through your treatment so proctor is less likely to ask questions Questions??? Resources

• The 5 Minute OMM Consult by Channell and Mason • OMT Review by Savarese, Capobianco, and Cox • Foundations of Osteopathic Medicine • Principles of Manual Medicine by Greenman • Atlas of Osteopathic Techniques by Nicholas • Osteopathic Medicine Recall by Mosier & Kohara • The Kimberly Manual • Pediatric Manual Medicine: As Osteopathic Approach by Carreiro • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486778/ References

• Dreyer, Laura DO: Preparing for OMM Practical ppt presentation

• Nicholas, A et al: Atlas of Osteopathic Techniques, 2nd edition. Philadelphia, PA. 2012