Board Review I - Series A

CORE OMM Curriculum 

Board Review 

Developed for OUCOM CORE 

By: Janet Burns, D.O. 

Edited by: James Preston, D.O., 

Clay Walsh, D.O., and the 

CORE Osteopathic Principles and Practices Committee 

Series A, B, & C - Session #5 


for Students, Interns, & Residents ©2006

Overview 

• It is not the intention of this review to be comprehensive 

or exhaustive; that is best left to the several OMM board 

review books available. 

• The best use of your limited time is on high yield 

subject areas. 

• Current CORE residents provided the following 

recommendations for areas to focus on: 



Suggested Areas of Study 

1. Memorize Chapman’s Reflexes 

2. Dx and Tx of Sacral Dysfunctions via Muscle Energy 

model 

3. Know the difference between Direct and Indirect 

techniques 

4. Know contraindications to certain techniques 



Suggested Areas of Study - 

continued… 

5. Memorize Viscerosomatic reflex levels 

6. Memorize steps to Spencer Technique 

7. Diagnosis and treatment of somatic dysfunction in: 

cervical, thoracic, lumbar spine, sacrum, pelvis, ribs, 

and extremities; utilizing Direct and Indirect approaches 



Board Review Web Sites 

OMM Board Review, John D. Capobianco, D.O., F.A.A.O. 

http://www.md-do.org/NewOMMBoard%20Review02- 

REV.htm 

- A free 32 page outline format review. Excellent for last minute 

studying; includes mnemonics for recall, clinical correlations, 

functionally relevant anatomy. Highly recommended. 

60 multiple choice questions with key 

http://www.mommd.com/comlexsample.shtml 

- Free, good questions, but are not labeled as to whether they are 

Level I, II, or III 



Board Review Resources 

OMT Review 3rd edition - A Comprehensive Review in Osteopathic 

Medicine; Robert G. Savarese, D.O., 2003 

- $36 Suitable for Levels I - III, has updated COMLEX-style 

questions, includes a lot more relevant anatomy than 

previousedition. 

There are a few errors, if you own this book go to: 

http://www.omtreview.com/errata.htm 



OMM Terminology 

Major Resource for appropriate 

terminology: 

Found in the back of 

Foundations for Osteopathic 

Medicine, 2nd Ed. 



Sympathetic Innervations 



Barriers 

Physiologic – limit of active motion 

Anatomic – limit of passive motion 

Elastic – range between physiologic and anatomic motion 

Restrictive – limit within anatomic range which decreases 

Physiologic range 

Pathologic – permanent restrictive barrier associated with 

pathologic change in tissue 




for Students, Interns, & Residents ©2006 


Medicine, 2 nd Ed., pp. 575-576

Somatic Dysfunction 

Definition – impaired of altered function of 

related components of the somatic 

system: skeletal, arthrodial and 

myofascial structures and related 

vascular, lymphatic and neural elements. 



Naming/Diagnosing 

Somatic Dysfunction 

• All somatic dysfunctions are named according to the 

POSITION of the dysfunctional structural element. 

• The POSITION of the structural element EQUALS the EASE 

OF MOTION of that structural element. 

• Therefore RESTRICTION OF MOTION of the structural 

element is OPPOSITE the POSTION diagnosis 



Somatic Dysfunction: 

Physical Findings 

(T) A. R. T. 

T – Tissue Texture changes 

A – Asymmetry 

R – Range of Motion (ROM) 

(T) – Tenderness 

CARDINAL INDICATOR – R.O.M. 



Somatic Dysfunction: Acute 

Acute Chronic 

Temperature increased cool 

Texture boggy, rough doughy, thin 

Moisture increased decreased 

Tension increased sl. increased 

Tenderness Increased less tender 

Edema yes no 

Erythema yes, stays fades quick 



Contraction 

Concentric – shortening of muscle during contraction 

Eccentric – lengthening of muscle during contraction 

Isolytic – contraction while forcing to lengthening; 

operator>patient 

Isometric – inc. tension, length constant; operator= patient 

Isotonic – approximation without change in tension: 

operator

Axes 

Transverse: Shoulder to shoulder 

Anterior-Posterior: Front to back 

Longitudinal: (Vertical) Head to toe 



Planes 

Transverse: Separates top from bottom 

Sagittal: Separates left from right 

Coronal: Separates front from back 



Flexion 

Def. – ends of arc approximate 

Sacral – base anterior 

Craniosacral –sacrum counter nutates 

(base posterior); sphenobasilar ascends 

Regional – cervical, thoracic, lumbar 



Sacral Flexion 




Medicine, 1st Ed., pp. 1130

Extension 

Def. – ends of arc move apart 

Sacral – base posterior 

Craniosacral – sacrum nutates (base 

forward) sphenobasilar descends 

Regional – cervical, thoracic, lumbar 



Sacral Extension 




Medicine, 1st Ed., pp. 1130

Fryette’s Principles 

Rules apply to thoracic and lumbar spine only 

Fryette’s I – with spine in neutral side – bending and 

rotation are opposite 

Fryette’s II – with spine hyperflexed or hyperextended 

sidebending and rotation are to the same side. 

Fryette’s III – motion in any plane of motion modifies 

motion in all other planes of motion. 



Thoracic Mechanics 

Non-neutral Mechanics 

Type II Rotation Before SB 

Non-neutral Mechanics 

Type II Rotation Before SB 

Kimberly Manual, 

millennium edition, 

pp. 11-12 



Facilitation 

Definition – area of impairment or restriction that 

develops a lower threshold for irritation and 

dysfunction when other areas are stimulated. 

Reflex hyper-excitability 

Hyper-irritable 

Hyper-responsive 



Spinal Motion 

• OA – Type I only with flexion/extension 

• AA – Rotation only 

• C2 – C7 – Type II only 

• Thoracic – Type I and Type II 

• Lumbar – Type I and Type II 



Gravitational Line 

• External auditory meatus 

• Lateral head of humerus 

• Third lumbar vertebrae (center) 

• Greater trochanter 

• Lateral condyle of knee 

• Lateral malleolus 



Gravitational Line 



Foundations for 

Osteopathic Medicine, 1st 

Ed., pp. 1131

Iliosacral Somatic 

Dysfunctions 

• Movement of ilium on sacrum 

• Standing Flexion test 

• Landmarks: ASIS, PSIS 

• Anterior rotation – ASIS down, PSIS up 

• Posterior rotation – ASIS up, PSIS down 

• Inflare – ASIS in 

• Outflare – ASIS out 

• Inferior shear – ASIS down, PSIS down 

• Superior shear – ASIS up, PSIS up 





DiGiovanna, 3rd Ed, p. 289







Sacral Somatic 

Dysfunctions 

• Extension – unilateral and bilateral 

• Flexion – unilateral and bilateral 

• Forward Torsions – L on L, R on R (rotation on 

an axis) 

• Backward Torsions – L on R, R on L 

• Sacral Shear 

• Anterior Sacrum (translated) 

• Posterior Sacrum (translated) 



Sacral Torsions 

Seated Flexion 

Test 

Axis (Oblique) 

Superficial 

Sulcus Right 

Superficial 

Sulcus Left 

------------------------ ------------------------ ------------------------ ------------------------ 

Positive Right Left Right on Left Left on Left 

(L5) 

(Sacral 

bending) 

L5 Left 

Rotation 

Backward 

L5 Right 

Rotation 

Forward 

------------------------ ------------------------ ------------------------ ------------------------ 

Positive Left Right Right on Right Left on Right 

(L5) 

(Sacral 

bending) 



L5 Left 

Rotation 

Forward 

L5 Right 

Rotation 

Backward

Pubic Somatic Dysfunction 

• Motion of pubic symphysis 

• Landmarks: pubic bone 

• Dysfunctions – superior, inferior 






Sacral Somatic 

Dysfunctions 

• Seated flexion test 

• Sphinx test (lumbar extension) 

• Spring test 

• 2 Landmarks – Sacral Sulcus – ILA 

(inferior lateral angle) 





Glossary of Osteopathic Terminology

Sacral Motion 

7 axes of motion 

– Vertical – rotation 

– A/P – sidebending 

– 2 Obliques (diagonals) R and L – torsions 

– 3 Transverse axes – flexion and extension 

• Superior transverse - respiratory axis 

• Middle transverse - postural axis 

• Inferior Transverse – Innominate rotation axis 



Sacral Axes 

1 Longitudinal axis 

1 Anterior-posterior axis 

2 Oblique axes 

• Right and Left 

3 Transverse axes 

• Superior, Middle, and 

Inferior 




Sacral Axes 

3 Transverse Axes 

– Superior: Respiratory 

axis 

• Motion relative to the pull 

of the dura occurs around 

this axis 

– Middle: Postural axis 

• Bilateral Flexion & 

Extension occur around 

this axis (motion during 

flexion/extension of spine) 

– Inferior: Innominate 

rotation axis 




ME Sacral Diagnosis -Tips 

Similar to algebra, you will be expected to solve the equation for the 

unknown, you need to know the “rules” and algorhythms: 

(+) Spring or Sphinx (prone backward bending) tests reflect an 

extended sacral base (unilateral or bilateral extensions or backward 

torsions) 

Sacral torsion “rules” of L5 on S1 

– Sacrum rotates opposite L5 

– When L5 is sidebent, it forms an oblique axis on that side 

– The (+) seated flexion test is found on the side opposite the 

oblique axis 

– Forward Torsions occur in Neutral (Type 1) mechanics 

– Backward torsions occur in Non-neutral (Type 2) mechanics 



ME Sacral Diagnosis -Tips 

Using these rules, if you are given L5 FrSr: 

– There will be a (+) flexion test on L, sacrum rotated L on R 

oblique axis 

– You then extrapolate that this is a backward torsion (because 

forward torsions are named same on same, i.e. L on L, 

Backward torsions are vice versa) 

– Therefore the Spring or Sphinx tests would be (+) reflecting the 

extended (posterior) sacral base on the L 

– Deep Sulcus (DS) is therefore on the R, Posterior /Inferior ILA is 

on the L 



Forward Torsions - Review 

Findings for Left on Left: 

– (+) Standing flexion test on R 

– Deep sacral sulcus (DS) on R 

– Posterior/Inferior ILA on L 

– (-) Spring / Sphinx Test 

– Sacrotuberous Ligament taut 

on the L 



Mitchell, The Muscle Energy Manual, Volume III, p. 62

Forward Torsions: Causes 

Forward Torsions 

• Occurs when lumbar spine is in neutral 

mechanics 

• Exaggerated ambulation mechanics 

Sacrotuberous Ligament is taut on side of 

Posterior/Inferior ILA 



Backward Torsions - 

Review 

Findings for Right on Left: 

– (+) Standing flexion test on R 

– Deep sacral sulcus (DS) on L 

– Posterior/Inferior ILA on R 

– (+) Spring / Sphinx Test 

– Sacrotuberous Ligament taut 

on the R 


Mitchell, The Muscle Energy Manual, Volume III, p. 62 


Backward Torsions: Causes 

Backward Torsions 

How do these occur? 

• Physiologically during Non-Neutral Lumbar 

Mechanics 

Is backward torsional motion always 

dysfunctional? 

• No, only if it can’t return to neutral 



Backward Torsion: 

possible mechanism 

Mitchell, The Muscle Energy Manual, Volume III, p. 64 



L. Unilateral Sacral 

Flexion 

• L half of Sacrum has 

moved forward & down 

relative to R 

•(-) Sphinx test 

•(+) Seated flexion test on L 

•Sacrotuberous lig. taut on L 




Compare 




Unilateral Sacral 

Flexions / Extensions 

Deep Sulcus and Posterior/ Inferior ILA on Same side (i.e. both on L, 

could be L Flex or R Ext) 

What separates a L sacral Flexion from a R sacral 

Extension is: 

• the Sphinx test: (-) in flex (+) in ext 

• or the Seated flexion test (+) R on R Ext, (+) L on L Flex 

Some find it easier to think of it as a shear or combination of Sidebending 

and Rotational strains: 

• Sidebending and Rotation occur to opposite sides 

• Caused by unbalanced sacral base loading during trunk 

sidebending- same mech. that can cause innominate upslip, but 

trunk is sidebent, not upright 



Bilateral Flexion / Extension 

Extension Dysfunction 

PSIS’s level 

ILA’s level 

Bilateral shallow 

(posterior) sacral sulci 

(+) Spring / Sphinx test 

(restricted motion) 

Flexion Dysfunction 

PSIS’s level 

ILA’s level 

Bilateral deep (anterior) 

sacral sulci 

(-) Spring / Sphinx test 

(unrestricted motion) 



DiGiovanna, 2nd Ed

Causes of Bilateral Sacral 

Flexion / Extension 

Bilateral Sacral 

Extension 

• Improper lifting techniques 

• Fall in a seated position 

Bilateral Sacral 

Flexion 

• Extremely common 

postpartum 

• Arched while holding 

heavy load 



Optional Activities 

1. Practice Diagnosing and Treating Sacral Dysfunctions 

according to ME model… 

2. Some Sacral ME treatments commonly found on exams 

are included in the following slides… 



1 of 3 

ME: Forward Torsion – 

Left on Left 

• Operator flexes the hips to at 

least 90 degrees, (Non-Neutral) 

guides the knees to the right side 

of the table and facilitates lumbopelvic 

rotation right. 

Pt.: Prone 

• Operator stands on the right side 

• Pt. is instructed to allow knees to 

be flexed & raise right hip. 



Kimberly Manual, p.203-204

2 of 3 

Forward Torsion – 

Left on Left 

• Sidebending is introduced by 

supporting the pt’s. knees on the 

operator’s thighs and lowering the 

feet off the table 

• Localized to L-S Junction 

• Pt is instructed to inhale, then 

reach to the floor with the right 

upper arm during exhalation while 

monitoring L5 

• Operator may assist this motion 

by pushing the shoulder toward 

the floor to achieve rotation of L5 

left 




3 of 3 

Forward Torsion – 

Left on Left 

• Pt. is instructed to lift the feet 

toward the ceiling against 

isometric resistance 

• Sufficient force is needed to feel 

the localization at of the muscle 

effort to the right sacral base. 

• Operator may additionally contact 

the spinous process of L5 to 

encourage rotation of that vertebra 

to the left. 

• This is usually not necessary. It 

is important to monitor the right 

sacral base simultaneously. 



• Hold for 3-5 seconds 

• Relax about 2 seconds, breathe 

as a reminder! 

• Repeat 

• Retest 


1 of 4 

ME: Right on 

Left Sacral Torsion 

• Patient in left lateral recumbent 

position 

• The right lower extremity is 

flexed until the vector of force is 

palpated at the right sacral base 

by the monitoring fingers 

• The right knee is supported 

between the operator’s two thighs 



Courtesy of David C. Eland, DO,FAAO - 

OUCOM

2 of 4 

Right on Left 

Sacral Torsion - continued 

The left lower extremity 

is extended by the 

operator 

– This encourages 

sacral base 

anterior motion 



Courtesy of David C. Eland, DO,FAAO - OUCOM

3 of 4 

Right on Left 


Trunk rotation to the right is 

accomplished via a pull through 

the left upper extremity. 

- This right rotation is carried down 

through L5, which, in turn, 

encourages the right sacral base to 

move anterior. 

Continue to support the right knee 

throughout the procedure 

– This helps maintain the 

fulcrum for change. 




4 of 4 

Right on Left 


-Carry the right ankle toward the floor 

-The patient is instructed to try to lift 

the ankle toward the ceiling – 

isometric contraction with operator 

resistance 

• This gaps the sacroiliac and 

allows the other forces 

acting upon the sacrum to 

carry the right base anterior. 

-Relax 

-Reposition ankle & knee according to 

response noted by monitoring hand 

-Repeat, Retest 




L. Unilateral Sacral Flexion; 

(Sacrum Sidebent L Rotated R) 

ME, LVMA 

- Patient prone, Doc on side of Dysfunction 

- ABduct & Int Rot Hip to gap SI Joint, brace with docs body 

- Apply anterior pressure to Inferior/Posterior ILA to move (DS) base 

posteriorly; Cephalad to side bend it Right. Can spring it or use 

respiratory assist: Pt inhales deeply and holds-should feel Base move 

posterior 

Kimberly Manual, p.214 



L. Unilateral Sacrum Extended; 

LVMA 

•Heel of Caudad hand on 

Inferior Ischial Tuberosity 

•Hypothenar eminence of 

cephalad hand on Sacral Base 

•Carry Ischial Tuberosity 

SUPERIORLY 

– This produces an anterior 

rotation of the innominate 

to help engage the barrier 

•Carry Sacral Base Anterior and 

Inferior to barrier 



Kimberly Manual, p.214

1 of 2 

ME: Bilateral Sacral Flexion 

Pt. Sits with feet & knees 

apart 

Operator: 

Heel of sacral hand contacts 

below the middle transverse 

axis 

Cephalad hand monitors & 

maintains trunk flexion via 

contact with the mid to lower 

thoracic area 




2 of 2 

Bilateral Sacral Flexion 

- Pt. is instructed to ‘push 

the lumbosacral junction 

posterior’ while operator 

maintains isometric 

counterforce 

-3-5 second contraction 

followed by about 2 second 

relaxation 

-Repeat 

-Recheck 




ME: Bilateral Sacrum 

Extended 

Pt. Seated on stool 

– Feet together, knees apart, 

arms crossed 

Operator: 

– Hand on sacral base 

– Other hand across chest 



Pt. Positioning Refinement: Pt. Is instructed 

to arch the back by pushing the abdomen 

toward the knees 

Operator maintains compressive force on 

sacral base 

3-5 repetitions of pt. Attempted trunk flexion 

(isometric), relax between efforts 

Innate Force: 

Exhalation assists in 

Carrying the sacral 

base anterior 

Greenman, 3 rd Ed., p. 383

Ribs 

Atypical – Ribs 1, 2, 10, 11, 12 

Typical – Ribs 3 – 9 

Pump handle – upper ribs 

Mixed – middle ribs 

Bucket handle – lower ribs (to rib 10) 

Caliper – Ribs 11 and 12 





Foundations for Osteopathic Medicine, 1st Ed., pp. 1128




Rib Somatic Dysfunction 

• Exhalation Rib – free motion in exhalation 

other: exhalation strain, depressed rib, anterior 

rib tenderpoint 

• Inhalation Rib – free motion in inhalation other: 

inhalation strain, elevated rib, posterior rib 

tenderpoint 









Rule of Three’s (Thorax) 

Refers to the position of a spinous process relative to its 

vertebral segment level. 

T1 –T3–same level 

T4 – T6 – ½ segment below 

T7 – T9 – 1 segment below 

T10 – 1 segment below 

T11 – ½ segment below 

T12 – same level 



What are Chapman’s 

Reflexes? 

A system of predictable anterior and posterior fascial 

tissue texture abnormalities described in the 1920’s 

by Frank Chapman, D.O.: 

• They indicate increased functional activity of the sympathetic 

nervous system 

• Thought to reflect visceral dysfunction or pathology 

• They follow Sympathetic afferent pathways 

– Do NOT reflect parasympathetic nervous system 

• Treating them may alter sympathetic influences on the 

corresponding viscera 



Chapman’s vs. 

Viscerosomatic Reflexes 

Similarities 

Differences 

– Somatic result of a visceral 

input 

– Will return if underlying 

problem is not corrected 

– Tx of Somatic Component 

can improve Visceral 

homeostasis 

– Chapman’s are 

neurolymphatic reflexes; 

viscerosomatic are neural 

reflexes 

– Chapman’s manifest in the 

same place all of the time; 

viscerosomatic manifest 

within a range of vertebral 

segments, and of varying 

intensity 



Chapman’s Reflexes: 

Anterior Points 

Kuchera ML, Kuchera WA. 

Osteopathic Considerations in 

Systemic Dysfunction. 2nd 

ed. Columbus OH: Greyden 

Press: 1994: pp. 232-3. 

or 

Ward R. Foundations for 

Osteopathic Medicine. 2nd 

ed. Philadelphia: Williams & 

Wilkins: 2002: pp. 1053-4. 



Chapman’s Reflexes: 

Posterior Points 

Kuchera ML, Kuchera WA. 

Osteopathic Considerations 

in Systemic Dysfunction. 

2nd ed. Columbus OH: 

Greyden Press: 1994: pp. 

232-3. 

or 

Ward R. Foundations for 

Osteopathic Medicine. 2nd 

ed. Philadelphia: Williams & 

Wilkins: 2002: pp. 1053-4. 



Craniosacral 

Discoverer – Sutherland 

Midline Bones – Flex/Extend 

Paired Bones – External/Internal Rotation 

Inspiration – Cranial Flexion + Ext. Rotation 

Expiration – Cranial Extension + Internal Rotation 

CV4 – Gently hold cranial extension forces CSF distally 

Still point - Sutherland 



Cranial Concept: 

5 Components 

1. The intrinsic motility of the brain and spinal cord 

2. The fluctuation of the cerebrospinal fluid 

3. The mobility of the intracranial and intraspinous 

membrane as functional system known as the 

reciprocal tension membrane 

4. The sutural mobility of the cranial bones 

5. The involuntary movement of the sacrum between the 

ilia 





Foundations for Osteopathic Medicine, 1st Ed.

? 




Flexion at SBS 

? 




Cranial Flexion 

Flexion Phase: Sphenobasilar 

symphysis rises pulling the sacral base 

superior/posterior 



Magoun, Osteopathy in the Cranial Field, 3 rd Edition, p. 39

Cranial Flexion/Extension 



Upledger, Cranial Sacral Therapy

Strain Patterns 

There are essentially six strain patterns to concern yourself 

with. They are: 

1. Flexion & Extension 

2. Torsion 

3. Sidebending, Rotation 

4. Vertical Strain 

5. Lateral Strain 

6. Compression 



Flexion and Extension 



Pratt-Harrington, 

“Except for OMT”, , p 37

Torsion 





Sidebending/Rotation 





Vertical Strain 





Lateral Strain 





SBS Compression 




Direct Techniques 

HVLA 

LVLA 

Muscle Energy - Mitchell 



Indirect Techniques 

Counterstrain – Lawrence Jones 

Facilitated Positional Release – 

Schiowitz 

Functional Technique 



Direct/Indirect Techniques 

Myofascial 

Cranial – Sutherland 

Still Technique 



Facilitated Positional 

Release 

• Schiowitz 

• Patient relaxed 

• Flatten A/P curve 

• Place in position of ease 

• Facilitated force – compression, traction, torsion 

• Hold 3 – 4 seconds 



Counterstrain 

Lawrence Jones, D.O. 

• Patient relaxed 

• Position of least discomfort (70 % better) 

• Hold 90 sec. (120 sec. – ribs) 

• Slowly release 



Contraindications 

There is no single definitive reference for these: 

The Savarese review book has lists that are compiled from major 

Osteopathic texts including: DiGiovanna, Greenman, Foundations, 

and Kuchera & Kuchera. 

Know the absolute vs. relative contraindications for different 

techniques, when noted. 

– Not all techniques have nice, clear-cut lists of relative vs. 

absolute. 

– Board questions tend to ask about contraindications that are 

commonly agreed upon, not the controversial ones. 



Contraindications: HVLA 

Absolute 

Osteoporosis 

Osteomyelitis, incl. Pott’s Dz 

Bone Metastasis 

Fractures in area of thrust 

Tx of C-Spine in patients w/ 

severe RA or Down’s 

Syndrome 

– Weakened ligament of 

Dens 

Relative 

Acute Whiplash 

Pregnancy 

Post- surgical conditions 

Herniated nucleus pulposus 

Hemophiliacs, 

anticoagulated patients 

Vertebral artery ischemia 



Contraindications: ME 

Absolute 

• Fractures & severe 

neuromuscular injuries to 

potential Tx sites 

• Inability of patient to 

cooperate 

Relative 

• Patients w/ low vitality, 

who could be further 

compromised by active 

muscular exertion: 

– Post surgical 

– ICU /CCU patients 

– These pts may tolerate 

gentler forms of ME 

such as reciprocal 

inhibition 



Contraindications: 

Counterstrain 

Absolute 

Relative 

Inability to relax muscles 

– Disease 

• Physical 

• Emotional 

– Severe pain 

– Age 

– Drugs 

Severely debilitated patient 

– Decrease DOSAGE 

(intensity of treatment) 

• Do less than six points 

• Position for less than 

maximal relief of TP 

- Avoid positions of 

extreme thoracolumbar 

flexion in osteoporotic 

patients 



Osteopathy in the Cranial Field: 

Indications & Contraindications 

Indirect Action / Exaggeration 

Commonly used in ages 5 thru adult 

– Overriding sutures 

NOT used in: 

– In acute head trauma when exaggeration could cause 

or increase intracranial bleeds 

– In young children who do not yet have a developed 

sutural pattern 




Indications & Contraindications 

Direct Action 

Recommended in ages 5 and under 

used in: 

– Overriding sutures 

– In acute head trauma when exaggeration could cause 

or increase intracranial bleeds 

– In young children who don’t have a developed sutural 

pattern yet 

NOT used when it could cause or increase intracranial 

bleeds, or tissue trauma. 





Absolute 

Relative 

• Acute intracranial bleed 

• Increased intracranial 

pressure 

• Skull fracture 

• Traumatic brain injury 

• In patients with Hx of 

seizures or dystonia, great 

care must be used in order 

to not exacerbate any 

neurological Sx 



Contraindications - Articulatory 

Techniques: Springing, Low 

Velocity/Moderate Amplitude (LVMA) 


• Acutely inflamed joints, especially if due to infection or 

fracture 

• Recent surgery to Tx area 

• Repeated hyper-rotation of an extended upper Cervical 

spine may damage the Vertebral Art. 



Contraindications: Facilitated 

Positional Release (FPR) 

None listed in Savarese or the FPR chapter in Foundations 2 nd ed.. 

If it shows up on boards, apply fundamental principles to reason it out: 

– It uses compression (usually) or distraction as its activating 

force; after putting patient in position of ease 

– Think of things that can’t tolerate compression, i.e. injured discs, 

etc. 

– Therefore it would not be the Tx of choice in an acute whiplash 

injury 




Myofascial Release 

No absolute vs. relative, no discussion found about 

Direct vs. Indirect contraindications 

In general: 

– Nearby surgical wound or infection 

– Fracture 

Specific Contraindications to Celiac, Inf., & Sup. 

Mesenteric Ganglia releases: 

– Aortic Aneurysm 

– Nearby surgical wound 




Lymphatic Techniques 

No clear distinction currently made between Relative and 

Absolute. 

– The term “Absolute” is therefore generally not used 

with regard to Lymphatic Treatment. 

Be aware of the difference between Lymphatic “Pump” and 

other lymphatic techniques. 




Lymphatics 

There are many different kinds of Lymphatic Techniques; 

rather than try to memorize a separate contraindication 

list for every one, it is simpler to think about what 

category a specific technique falls under. 

– i.e., rib raising is a direct Articulatory technique and 

therefore shares the same list of contraindications 

– redoming the diaphragm shares those of the other 

direct myofascial release techniques 



Relative Contraindications: 

Lymphatic Pump Tx 

• Fractures 

• Bacterial infections with a temp > 102 o F 

• Abscesses or localized infection 

• Thromboses 

• Fragility of nearby organs 

• Certain stages of Carcinoma, or Malignancy of Lymphatic System 

– Controversial Area 

– No clinical evidence to support this as a contraindication 



Relative Contraindications: 

Lymphatic Tx 

Physiologically, there is a difference between: 

• Merely restoring normal motion and function to the components of 

the lymphatic system i.e. diaphragm/ fascial release and 

• Actively pumping lymph around, augmenting its flow, i.e. pedal, 

abdominal, or thoracic pumps. 

For sake of boards, on a lymphatic contraindication question, it’s safest 

to go with malignancy as a contraindication; 

– unless they make you choose between several types of 

lymphatic tech., in which case techniques in category # 2 would 

be “more contraindicated” than techniques in # 1. 



A. T. Still 

1828 – 1917 

1874 – announced osteopathic tenets 

1892 – established first school 



Seven Stages of Spencer 

Purpose: improve glenohumeral joint restrictions 

Some schools include a warm-up sequence with 

the Spencer Technique. For the sake of boards, 

the warm-up exercises do not officially count 

toward the 7 stages. 




• Spencer Technique has undergone modification; may be 

done passively or Muscle Energy Techniques may be 

used at each of the restrictive barriers. 

• Depending on reference, the stages may be labeled 

differently (i.e. I, II, III, IVa, IVb) however, the basic 

sequence is still the same. 




I: Shoulder Abduction with traction /compression 

II: Extension / Flexion (elbow bent) 

III: Flexion / Extension (elbow straight) 

IVa: Circumduction w/ Compression (elbow bent) 

IVb: Circumduction w/ Traction (elbow straight) 

V: Adduction & Ext Rotation (elbow bent) 

VI: Abduction & Int. Rotation – Arm behind back 

VII: Repeat Stage I 



Ward R. Foundations for Osteopathic Medicine. 2nd ed. 

2002: pp.850-52.

THE END 

GOOD LUCK!

Board Review I - Series A

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