Static Landmarks (ex.

OA SL RR)
Left transverse process (of C1) approximates left mastoid process (since youre sidebending them close together) Right transverse process separates from angle of jaw Right occipital condyle posterior

Deep occipital shelf

(it forms an awning)

Left occipital condyle anterior

Shallow occipital shelf

Chin points slightly to right of midline

Check static landmarks

Dx

TP closer to TP closer to Deep Occipital Shallow Mastoid Mandible Shelf Occipital Shelf

SLRR SRRL

Left Right

Right Left

Right Left

Left Right

Hands cradle occiput with fingertips of index and middle fingers over occipital articulation Test right and left translation (sideslippage) May also check forward and backward bending Somatic dysfunction named for the way

Hands cradle occiput with fingertips of index and middle fingers over occipital articulation Test right and left translation Also check in flexion/extension If more symetrical in flexion, then it has a flexion component If more symmetrical in extension, then it has an extension

OA SRRL

Place pads of fingers just beneath superior nuchal line in the soft tissues Lift head slightly so its entire weight is supported on fingers Pull forearms gently toward operator at 45 degrees

Rib raising: Anterior pressure on ganglia will initially produce a short-lived increase in sympathetic activity, but this is followed by long lasting sympathetic inhibition
Normalize sympathetic activity Improve lymphatic return Encourages maximum inhalation-more effective negative intrathoracic pressure

A. RIB RAISING - CHEST CAGE ARTICULATION Dysfunction: Decreased chest cage compliance.
Objective: Improve chest cage motion, ease of

respiration Discussion: This technique is useful for the hospitalized or bedridden patient with a chest cage exhibiting general decreased freedom or range of motion. It is also thought to help decrease sympathetic tone and improve respiration and gastrointestinal function.

Patient Position: Lying supine.

Physician Position: Standing or sitting at the patients side that is to be treated.

Procedure:
1. With the patient lying supine on the treatment table or in bed, the physician slides their hands, palms up, under the patient's thorax. The hands are positioned so that the finger pads contact the posterior aspect of the ribs (just lateral to the costo-transverse articulation area).

2. The fingers are then moderately flexed and held firmly against the patient's back. An upward springing force is then applied to the rib cage. This may be accomplished through hand/wrist effort. The technique may be more efficiently; and comfortably accomplished by the physician using their arms and trunk as a unit. This is done by holding your fingers, hands, wrists, and volar surfaces of your forearms as a fulcrum. 3. The position of the hands is shifted along the rib cage until each area has been satisfactorily treated. The physician then applies the same treatment to the opposite side.

Patient supine, Physician at head of table Cervical spine is flexed Physician places the thumb on the anterior, superior surface of the rib (between the heads of the SCM) Patient inhales deeply and holds for 3-5 sec Physician resists motion of rib (effecting an isometric contraction) Patient exhales Physician takes up the slack after a two-second pause The process is repeated 3-5 times

Grasp the inferior lateral rib cage. With thumbs pointed towards each other and caudad to the xiphoid process. Follow the diaphragm motion as the pt. exhales. (posterior/anterior) Hold the end position and resist movement during inhalation. During exhalation follow the diaphragm to a new barrier. Repeat three times, then move thumbs laterally along the costochondral margin to a new restriction and repeat.

15

Contact the inferior lateral rib cage. With thumbs pointed towards each other and caudad to the xiphoid process, move to the restriction (direct) balance point Alternatively or additionally, reposition with thumbs laterally along the costal margin to a new restriction balance point

16

17

Dysfunction: Lymphatic stasis Objective: Improve lymphatic flow and fluid exchange Discussion: The thoracic lymphatic pump technique utilizes the elastic recoil of the thoracic cage to create an abrupt inhalation. This inhalation creates a negative intrathoracic pressure which mobilizes lymph and intrabronchial phlegm. Patient Position: Supine Physician Position: Standing at the head of the table
19

Procedure: Place your hands on the patients thoracic wall with the thenar eminence of each hand just distal to the respective clavicle, with the fingers spreading out over the chest wall. NOTE: In the female patient it is important not to apply heavy pressure to the breast tissue. Alternative hand placement is best lateral to the breasts and will require your force to be directed medially and posteriorly. Have the patient turn their head turned to one side with their mouth open. As the patient exhales apply a compressive force through your arms, following the patient into full exhalation. While keeping compression that prevents the patient from inhaling, apply a rhythmic pumping action for ten cycles. Upon completion of the tenth compressive cycle, quickly remove your hands from the patients chest allowing the patient to take a deep inspiration. As the patient quickly inhales, this creates a vacuum or negative intrathoracic pressure within the thoracic cavity. You should hear a suction or vacuum release. Allow the patient to take several normal breaths then repeat this process four additional times. NOTE: A patient with secretions within the bronchial tree may go into a spasm of coughing. This is beneficial in clearing the secretions and further 20 enhances the flow of lymph. Allow the patient to catch his/her breath

F. Supine--direct method-respiratory force (pectoralis lift) ( . F) Diagnosis: Lymphatic congestion Physician places his/her hand over the pectoralis muscles . and grasps their inferior margins (anterior axillary folds) between his/her fingers and palms Physician leans backwards and pulls the pectoralis muscles . superiorly and medially putting superior and anterior tension on its muscular attachments to the sternum and costal cartilages of ribs sometimes enhance - and to inhalation Patient is instructed, Breathe in and out very deeply. The . physician holds continued pectoral traction throughout repeated respiratory cycles (average is about minutes) Recheck lymphatic status .

C1- Inion C1- Muscle mass lateral to nuchal line C2- articular pillar C3- articular pillar C4 articular pillar C5 articular pillar C6 articular pillar C7 articular pillar

C1- Inion Flex C1- Extend & SARA

C2- Extend & SARA C3- Flex & STRAw C4 Extend & SARA (off the table) C5 Extend & SARA (off the table) C6 Extend & SARA (off the table) C7 Extend & SARA (off the table)

C1 Posterior edge of the ascending mandible C2 C3 C4 C5 C7 lateral attachment of SCM to C8 medial tip clavicle of clavicle C6

C1 Rotate Away C2 Flex & SARA C3 Flex & SARA C4 Flex SARA (might extend) C5 Flex & SARA C6 Flex & SARA C7 Flex & STRAw C8 Flex & SARA

Rib raising: Anterior pressure on ganglia will initially produce a short-lived increase in sympathetic activity, but this is followed by long lasting sympathetic inhibition
Normalize sympathetic activity Improve lymphatic return Encourages maximum inhalation-more effective negative intrathoracic pressure

A. RIB RAISING - CHEST CAGE ARTICULATION Dysfunction: Decreased chest cage compliance.
Objective: Improve chest cage motion, ease of

respiration Discussion: This technique is useful for the hospitalized or bedridden patient with a chest cage exhibiting general decreased freedom or range of motion. It is also thought to help decrease sympathetic tone and improve respiration and gastrointestinal function.

Patient Position: Lying supine.

Physician Position: Standing or sitting at the patients side that is to be treated.

Procedure:
1. With the patient lying supine on the treatment table or in bed, the physician slides their hands, palms up, under the patient's thorax. The hands are positioned so that the finger pads contact the posterior aspect of the ribs (just lateral to the costotransverse articulation area).

2. The fingers are then moderately flexed and held firmly against the patient's back. An upward springing force is then applied to the rib cage. This may be accomplished through hand/wrist effort. The technique may be more efficiently; and comfortably accomplished by the physician using their arms and trunk as a unit. This is done by holding your fingers, hands, wrists, and volar surfaces of your forearms as a fulcrum. 3. The position of the hands is shifted along the rib cage until each area has been satisfactorily treated. The physician then applies the same treatment to the opposite side.

Direct Contact

Use pad of the finger

Gentle rotary motion over the point

Approximately 15 seconds Pressure should be firm Do NOT make the patient grimace!

Treatment can last from 15 sec to 2 minutes End point is achieved when the physician notes the softening of the firm nodule

POSTERIOR The space between the transverse processes of T2 and T3 midway between the spinous process and the tip of the transverse process

Myocardi um (Bilateral)

ANTERIOR 2nd intercostal space at the Sternal Border

An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna, 3rd ed, pp 113-117

POSTERIOR
Intertransverse spaces on both sides of T11 and T12 midway between the spinous processes and transverse processes

ANTERIOR Adrenals (Bilatera l)

Lateral Aspect of rectus abdominus at the level of the inferior margin of the costal margin

An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna, 3rd ed, pp 113-117

F. Supine--direct method-respiratory force (pectoralis lift) ( . F) Diagnosis: Lymphatic congestion Physician places his/her hand over the pectoralis muscles . and grasps their inferior margins (anterior axillary folds) between his/her fingers and palms Physician leans backwards and pulls the pectoralis muscles . superiorly and medially putting superior and anterior tension on its muscular attachments to the sternum and costal cartilages of ribs sometimes enhance - and to inhalation Patient is instructed, Breathe in and out very deeply. The . physician holds continued pectoral traction throughout repeated respiratory cycles (average is about minutes) Recheck lymphatic status .

Place pads of fingers just beneath superior nuchal line in the soft tissues Lift head slightly so its entire weight is supported on fingers Pull forearms gently toward operator at 45 degrees

Forth ventricle contains Medulla which regulates respiration Used to treat fluid motion/potency:

Through promotion of movement of nutrients into cells Metabolic wastes out of the cells

Indications: Normalize PRM Reduce tone in sympathetic nervous system Reduces fevers Venous congestion Promotes uterine contraction i.e. induction of labor Arthritic/autoimmune disorders Contraindications: Acute CVA Aneurysm Malignant HTN Skull fracture Pregnancy from 7th month because my induce labor

CV-4 means compression of the 4th ventricle, i.e. that space in between the cerebellum and the brainstem filled with cerebrospinal fluid. The brainstem underlying the 4th ventricle consists primarily of the pons and upper medulla. Sutherland believed that compression of the 4th ventricle affected all the vital nerve centers located throughout this region of the brainstem. CV-4 is one of the most important techniques you will learn. According to Viola Frymann, DO, it is thought that CV-4 technique stimulates the bodys inherent therapeutic potency to overcome whatever dysfunction is present. In this sense it is a general technique. It seems to have a global influence on a lot of different body systems. CV-4 seems to decrease overall

Patient lies Supine Physician seated at head of the table With both forearms resting on the table to establish a fulcrum Place one hand in the palm of the other so that the thenar eminences lie uppermost and parallel to each other Slip them under the occipital squama. Fig 4-3 Make sure they lie medial to the occipitomastoid suture! Thumbs are at the level of C2 The weight of the head rests on the thenar eminences and thereby gently compresses the lateral angles of the occiput. Become aware of the CRI motion of the occiput. The occiput will press against your thenar eminences in flexion, and will move away in extension. Follow the motion into EXTENSION by maintaining bilateral medial force. Discourage (inhibit) flexion. The amplitude of the motion gets progressively smaller with each cycle until a STILL POINT is reached. At the still point, the CRI will seem to stop. You may feel a sensation of a fine vibration which builds in a crescendo fashion to a peak, and then starts to diminish in a decrescendo fashion. At the end of the still point, there is a sense of softening and warmth in the occiput and a gentle rocking motion of flexion/extension returns like a boat on quiet water. At the same time, thoracic respiration should be diaphragmatic at about the same

The still point may last only a few moments or several minutes. You may observe in some patients a gentle perspiration on the forehead. The patient may have a deep sigh in the respiration as the still point releases. You must be patient and wait for it to complete itself. You may feel the head move through more than one still point. The CV-4 technique can also be performed by following the temporals or even lower extremities into internal rotation, or the sacrum into extension, holding through a still point, and then releasing.

Soft tissue paraspinal inhibition (lumbar)

Normalize sympathetic activity to help prevent ileus

Celiac, superior & inferior mesenteric ganglia releases

Normalize sympathetic activity

Both hands palms up at L1-2 under supine patient Finger tips on distal erector spinae masses (ESM) & thenar eminences on proximal ESM Hands are then closed approximating ESM

So THIS is the one where you reach BEYOND the spine

Tensions balanced in rotational component Further balance achieved by moving one forearm towards or away from operator

 COLLATERAL GANGLION TECHNIQUE

Dysfunction: Increased sympathetic input to abdominal viscera. Objective: Normalize sympathetic tone through inhibitory pressure of the collateral ganglia. Discussion: The three collateral sympathetic ganglia are located between the xiphoid process and the umbilicus. Cephalad to caudad they are the celiac, superior mesenteric and the inferior mesenteric ganglia.