Please help - OMT questions from a dummy

[DebDO]

Hi everyone,

I have an upcoming state licensing exam (practical) in OMT. Being an emergency room physician, the last time I practiced it would be nearly 10 years ago as a med student The only source I still have is the Savarese review book, as my notes are long gone. I have a few questions, so I figured I would venture back here (btw, impressive to see how expanded the osteopathic forums have become). I'd appreciate any advice you may have to offer:

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

Sorry if these questions seem overly technical - from what I remember there is variation. It's just that their grading seems to be based on specific checklists.

Thanks much

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[DocEspana]

Gonna give you the best I can. Thankfully I'm fresh out of OMM class for my first 2 years so I think I can actually be of service on most of these.

Hi everyone,

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

Of course the first question I can't be 100% certain on. I think MF/FPR/CS/Lymphatics are all soft tissue, though I know that specifically myofascial release and lymphatic drainage are definitely soft tissue techniques.

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

No reason to check each individually. You can "Screen" by feeling the entire area for both TART and particularly out of alignment areas. The specific technique we were given is to effectively apply a light "spring like" pressure with the thenar (or hypothenar) emminence against the TPs to quickly establish which ones are resistant to even slight rotation, and be able to test them 3 (or more if your hand is big) vertebrae at a time. If you find something definitely spend the time isolating it, but there is no reason to go into minute details on areas that are clearly in good shape.

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

Doesn't matter as long as they are able to flex and extend fully at that position. The legs (Which is what are eliminated by sitting) shouldnt effect lumbar and thoracic reads.

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

While this is true of most HVLA, in the neck we try not to engage both barriers due to the vertebral arteries having a higher risk of being kinked if you do so. So HVLA of the cervicals has you working into the natural tendancy to sidebend so that you can really act against the rotation restriction in isolation. To my knowledge you always do it against just the rotation since that is the primary motion of the HVLA anyway (aka: you never rotate the way it wants to go an sidebend against the restriction). And I've never extended for a cervical. I believe you either flex or do it neutral for the same reason why you only engage the rotational barrier.

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

Gotta imagine the chin cupping is a very stable hold, which you would want. Can't imagine anything but positive points would come from making sure your control of the head during HVLA was as secure and stable as possible.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

Treat the rotation. Its what I was taught. Lower in the neck you need to sidebend the entire neck more to work it into a position where you can best engage the rotational barrier... but your thrust is still in a rotational motion, not in a sidebending motion.

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

good question. I'd say yes, but I'm not 100% sure. I do think that you address lumbar before sacrum though.

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

I've been taught at least three HVLAs for the innominate and two for the sacrum. They're not in savarese? Hmmm. Perhaps they aren't widely used, but I use the hell out of them in my personal life. Having a GF with a bad hip from a car accident has made pelvic HVLA my bread and butter when I want to make her think OMM is cool . But despite my love of these techniques, if they're not in savarese, perhaps they are less important and less tested? Someone else will need to confirm that.

Thanks much

No problem. Glad to help.

 

[Pansit]

Hi everyone,

I have an upcoming state licensing exam (practical) in OMT. Being an emergency room physician, the last time I practiced it would be nearly 10 years ago as a med student The only source I still have is the Savarese review book, as my notes are long gone. I have a few questions, so I figured I would venture back here (btw, impressive to see how expanded the osteopathic forums have become). I'd appreciate any advice you may have to offer:

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

Sorry if these questions seem overly technical - from what I remember there is variation. It's just that their grading seems to be based on specific checklists.

Thanks much

Sorry but I am just curious...Do ALL DO's have to have practicals in OMM for licensing???...It sounds pretty stupid to be tested on something you dont ever use. It is like testing someone who is in Internal medicine how to do a well baby check for licensing.

 

[hawkeye pierce]

Umm i'm fairly certain licensing is based on USMLE OR COMLEX. Licensing is not your board specialty.

 

[DocEspana]

Sorry but I am just curious...Do ALL DO's have to have practicals in OMM for licensing???...It sounds pretty stupid to be tested on something you dont ever use. It is like testing someone who is in Internal medicine how to do a well baby check for licensing.

I'm sure the OP will respond as well, but yes: all AOA residencies have OMM as part of their licensing renewal requirements. Of course some field (Ophtho, derm) are notoriously pathetic with what they expect you to know. But anything where you could possibly treat someone with somatic dysfunctions tends to require you to be proficient in all of the musculoskeletal techniques and the diagnostic tools.

Umm i'm fairly certain licensing is based on USMLE OR COMLEX. Licensing is not your board specialty.

I believe you are confusing boarding with licensing. Boards and attaining a degree are based on COMLEX. (no 'or USMLE' our degree is based on our COMLEX. We take the USMLE for different residency options). You don't need to renew your degree just like you don't need to renew your High School diploma.

But you licensing is done by the state, and you need to pass the state osteopathic (or allopathic if youre in an ACGME residency) boards every so many years to remain able to practice medicine in that state. Also the testing is specialty specific. In this specific sense your residency training dictates which form of the test you take (your specialty + ACGME or AOA).

 

[hawkeye pierce]

Docespana i was not. I was commenting on the comment directly above mine stating why would an IM doc need to knwo how to do a well baby exam for licensing (his example). Some states do not even require a specialty per se? Am I wrong here? At least one state accepts usmle for licensure http://www.hhs.state.ne.us/crl/medical/medsur/ost/exam.htm

 

[DocEspana]

Docespana i was not. I was commenting on the comment directly above mine stating why would an IM doc need to knwo how to do a well baby exam for licensing (his example). Some states do not even require a specialty per se? Am I wrong here? At least one state accepts usmle for licensure http://www.hhs.state.ne.us/crl/medical/medsur/ost/exam.htm

Well I'm not going to get into state-by-state stuff. My generalization apparently doesn't hold up across the board. Ah well. Trying to be helpful wherever I can though.

 

[DebDO]

Just to clarify, I'm applying for a state medical license. I need to have passed the COMLEX. However, in this particular state, if you are a D.O., they also require you to have passed an OMT practical. This is not an issue for most of you, as you have/will have passed the COMLEX PE/clinical skills exam which qualifies. However, for D.O.s like myself who took the COMLEX before the clinical skills component was in place, this particular state requires us to pass their practical OMT exam. This applies to any D.O. who wants a license in this state, regardless of the specialty.

 

[DebDO]

And DocEspana, thanks for the help with my questions!

 

[Roberie]

Just to clarify, I'm applying for a state medical license. I need to have passed the COMLEX. However, in this particular state, if you are a D.O., they also require you to have passed an OMT practical. This is not an issue for most of you, as you have/will have passed the COMLEX PE/clinical skills exam which qualifies. However, for D.O.s like myself who took the COMLEX before the clinical skills component was in place, this particular state requires us to pass their practical OMT exam. This applies to any D.O. who wants a license in this state, regardless of the specialty.

Thanks for the clarification. Reading this thread had me "sweatin' in my boots," so to speak, since I doubt my Army (ACGME) residency will offer much in terms of continuing OMT education.

 

[Pansit]

Just to clarify, I'm applying for a state medical license. I need to have passed the COMLEX. However, in this particular state, if you are a D.O., they also require you to have passed an OMT practical. This is not an issue for most of you, as you have/will have passed the COMLEX PE/clinical skills exam which qualifies. However, for D.O.s like myself who took the COMLEX before the clinical skills component was in place, this particular state requires us to pass their practical OMT exam. This applies to any D.O. who wants a license in this state, regardless of the specialty.

ok...I see. So just to clarify, the AOA or any state does not require OMT practicals for licensing or for any other type of recertification exam if you have done the COMLEX PE test.

 

[group_theory]

Just to clarify since there are some confusion

The "boards" can mean either "COMLEX/USMLE" or "Board Certification in Specialty" (such as internal medicine, pediatrics, surgery, neurology. psychiatry, etc)

You take the boards (COMLEX/USMLE) mainly for licensure purposes and they are required for state licensure in all 50 US states plus territories.

Board certification exams (to become board certified in a field) is optional. Granted, you may not get priviledges at any hospitals or be able to be accepted by any insurance companies (and it will be difficult to get malpractice insurance) but technically finishing residency and board certifications are optional.

Licensure is determined by each individual states. Some states want you to complete an AOA approved internship. Others do not. Some states require DOs to pass an OMT exam as part of the licensure requirement. Pennsylvania is one of them that requires an OMT exam for licensure. A few years ago, the state board of osteopathic medicine in PA ruled that the COMLEX 2-PE contains enough OMT to satisfy the OMT requirement for licensure. They also ruled that if your board certification exam contains a significant portion of OMT as part of the examination process (eg AOBFP), then that too would satisfy the OMT portion. My guess is the OP graduated from medical school before COMLEX 2-PE was implemented and now wants to obtain a license in a state that has an OMT requirement as part of licensure (likely Pennsylvania). So in addition to submitting AOA-approved internship, COMLEX scores, Medical School verification, NPDB-NIPDB self-query, verication of good standing from other state's medical boards, etc. the OP will also have to sign up and take a practical OMT exam administered by the state board (or a private company contracted by the state board). Unfortunately there is no central repository of states that require OMT for licensure (or other quirky requirements). You will have to check each individual states to see their requirements (and if it has an OMT requirement, whether COMLEX 2-PE or AOBFP certification counts towards the OMT requirement)

The licensure requirements for each state differs so it's important to read the rules/requirements of the states that you are interested in getting a medical license.

Just for further clarification - to renew your license is basically filling out an application, sending money, and making sure you have enough CMEs required by the states. There is no need to retake any examination or retake any OMT exam.

Now if you want to maintain your board certification, then you will have to retake another examination (in addition to a bunch of other hoops that you will have to go through to maintain your certification (ACGME) or "osteopathic continuous certification" (AOA).

 

[Styria]

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

Soft tissue techniques would fall under myofascial release. Counterstrain would too, though it's indirect instead. FPR is a functional technique (along with Still technique and functional method; any one of these would be excellent in the ER, by the way). Lymphatics vary; some are fluid techniques, some are myofascial (in that you're treating the source of a problem, something interfering with the thoracic duct), etc.

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

Evaluate the neck first via active motion: have the patient look up, down, left, right, sidebend. A standardized patient will not move as far in the direction of the barriers and will complain of pain when doing it, or say that that reproduces the pain. Palpate quickly for tenderness or tissue texture changes. If it's simulated, muscle energy is good and quick and non-specific. If you're going to do HVLA for real, evaluate each level. And don't forget contraindications.

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

I'm used to seated, but either works. If you have to, a deep breath flattens the spine (thoracic extension and lumbar flexion) and exhaling does the opposite.

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

This is a use of Fryette's third law: motion in one plane will restrict motion in the other two. So when you sidebend to the right, you've further restricted the ability of C6 to rotate left, which means you don't have to move it as far to engage the barrier. That makes it easier to palpate and less awkward for the patient. We don't HVLA the neck in extension anymore, but there is at least one book out there with instructions on how to do it (on the OA, no less).

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

I don't cup the chin for anything, including the AA. It's actually part of a different hold; the chin is cupped, while the top of the head is stabilized against your belly.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

It's supposed to be easier to do a rotational thrust higher up and sidebending lower. I'm better at rotation and tend to use that top and bottom. If you're going to do sidebending, you would rotate in the direction of ease and then sidebend towards the barrier. The cervicals follow type II mechanics but the HVLA setup in the cervicals is type I.

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

Muscle energy is not just a technique type, but also a model Mitchell made. The terms for sacral torsions, shears, etc. actually come from that model. Under that model, you always treat the innominates and lumbars before the sacrum.

Treat pubic symphysis > innominates > lumbar > sacrum.

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

This book has 4 different HVLA techniques for the innominates, none of which are in Nicholas and Nicholas. Don't forget that the traction tugs for the innominates (anterior, posterior, and superior shear) are HVLA techniques too.

http://www.amazon.com/Manipulation-Spine-Thorax-Pelvis-DVD/dp/0702031305/ref=sr_1_1?ie=UTF8&s=books&qid=1306955176&sr=8-1

It will explain the chin cupping better too and uses it extensively. Makes me wonder what's in Greenman's text.

 

[BobBarker]

Hmm..

I would look at just taking the Comlex PE. It would definitely be easier than trying to relearn that.. stuff.

 

[redeye57]

Just to clarify on this old thread. Myofascial Release and Ligamentous Articular Strain/Release, and lymphatics ARE osteopathic manipulative techniques. They were not taught as "soft tissue" techniques at my school. Soft tissue is stretching, kneading, effleurage, petrissage, and tapotement. There are some very famous quotes by A.T. Still about the centrality of treating lymphatics, and fascia, to osteopathy. As an aside, historical data suggest that MR/LAS are the techniques that Still used. See William Sutherland, DO, Rollin Becker, DO.

 

[redeye57]

Just to clarify on this old thread. Myofascial Release and Ligamentous Articular Strain/Release, and lymphatics ARE osteopathic manipulative techniques. They were not taught as "soft tissue" techniques at my school. Soft tissue is stretching, kneading, effleurage, petrissage, and tapotement. There are some very famous quotes by A.T. Still about the centrality of treating lymphatics, and fascia, to osteopathy. As an aside, historical data suggest that MR/LAS are the techniques that Still used. See William Sutherland, DO, Rollin Becker, DO.

Forgot to mention that I passed the AOBFP OMT practical using only LAS/MR and lymphatics. I don't think that it was just by a hair because the examiners had very few questions for me.

 

[Madicap12]

[
I know thAt you posted this sometime ago, but I am in the same position you were in. I was hoping you could provide some insight into how intensely I need to study for this exam. Thanks for the help if you get this message.



QUOTE="DebDO, post: 11047198, member: 401031"]Hi everyone,

I have an upcoming state licensing exam (practical) in OMT. Being an emergency room physician, the last time I practiced it would be nearly 10 years ago as a med student The only source I still have is the Savarese review book, as my notes are long gone. I have a few questions, so I figured I would venture back here (btw, impressive to see how expanded the osteopathic forums have become). I'd appreciate any advice you may have to offer:

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

Sorry if these questions seem overly technical - from what I remember there is variation. It's just that their grading seems to be based on specific checklists.

Thanks much [/QUOTE]

 

[Madicap12]

I know that you posted this sometime ago, but I am in the same position you were in. I was hoping you could provide some insight into how intensely I need to study for this exam. Thanks for the help if you get this message.





="DebDO, post: 11047198, member: 401031"]Hi everyone,

I have an upcoming state licensing exam (practical) in OMT. Being an emergency room physician, the last time I practiced it would be nearly 10 years ago as a med student The only source I still have is the Savarese review book, as my notes are long gone. I have a few questions, so I figured I would venture back here (btw, impressive to see how expanded the osteopathic forums have become). I'd appreciate any advice you may have to offer:

1. We are expected to know HVLA, muscle energy, and soft tissue techniques. Out of myofascial/FPR/counterstrain/lymphatics, which exactly do soft tissue techniques encompass?

2. Re: diagnosing the cervical spine in a pt with neck pain. My understanding is to have the pt in a seated position, and evaluate for TART. But when I check for restriction, am I just evaluating the overall neck first, and then check the particular level where there is tenderness/asymmetry/tissue texture changes? Or do I check each of the 7 levels for restricted rotation, sidebending, etc?

3. When diagnosing the lumbar/thoracic spine, I check to see if one transverse process is more posterior. When I flex/extend to evaluate this further, is this done with the pt sitting or standing?

4. For HVLA of C6 FSrRr, the exam site as a sample says you will be checked on flexing down to C6, rotate left, SB right before applying the left rotational thrust; but I thought you want to engage the restrictive barrier (which would be SB left)? Also, do we as a general rule never extend the neck over concerns on vertebral artery injury?

5. In the above example, they also check to see that you cup the pt's chin with your left hand. Savarese however only describes the chin cupping for the AA joint.

6. Also re the above, isn't the thrust in the lower cervical spine preferrably sidebending rather than rotational? Or is this no longer the case?

7. If a pt has a sacral torsion, should I always say I would correct L5 first?

8. There are no HVLA techniques in Savarese for the pelvis. Are these not widely used?

Sorry if these questions seem overly technical - from what I remember there is variation. It's just that their grading seems to be based on specific checklists.

Thanks much [/QUOTE]