OMMN-610 · OMM 1 Written Exam #1 · Mon 12 Oct 2026 · Weeks 1–8
OMM 1 Written · Practice Questions
Every practice question I could find for this exam, 655 questions after merging repeats: this year's in-class polls and practice docs, past clickers and Canvas quizzes (2021–2026), TA exam reviews (2020–2025), the textbook chapter questions and instructor review notes. asked N× means the same question showed up in N different decks or sets, so those are the ones to know cold. 2026 marks questions from this year's course material.
Each section now starts with a green Learn first box: the facts, tables and lecture slides you need to answer that section’s questions. Read it, then do the questions. Tap its title to fold it away.
How the Top 215 were chosen
Top 215 (under Show) is one question per high-yield fact, so nothing in it repeats. The questions are unchanged; only the selection is new.
Grouped by fact. Every one of the 655 questions was read and grouped with the others that test the same fact, meaning knowing one answers the other, even when the wording differs. That gives 350 distinct facts. Cases where the case changes the reasoning stay separate, like flexed vs extended Type II, inhalation vs exhalation ribs, or each organ's sympathetic level.
Rated for yield. Each fact was rated 1–5 for how likely it is to be on the exam, weighing faculty sources most: this year's clickers, Poll Everywhere, Canvas, the 2026 Written Review deck and instructor review notes. TA reviews and the textbook count less.
One best version per fact. Multiple choice over open ended, from a faculty or 2026 source where possible, and never a version whose key is disputed.
Highest yield first. Every fact rated 5 or 4 is in, plus the strongest of the 3s. What's left out is the least likely material: minor details of a point already covered, disputed keys, and trivia.
The 215 facts account for 496 of the 655 questions, because questions you skip often repeat a fact you've already practiced. 211 multiple choice, 4 open. Wk 1 16 · Wk 2 17 · Wk 3 28 · Wk 4 27 · Wk 5 44 · Wk 6 24 · Wk 7 30 · Wk 8 29. These questions carry a top 215 tag in every view.
About the answers
Answers follow each source's own key (answer slides, red or green text, highlighted choices, printed keys), checked against this year's lecture and review slides. Where an old key looks wrong or sources disagree, the question says so under Heads up and gives the answer this year's slides support. Each answer can open the lecture slide that teaches it. TA-written questions are not an official key, so defer to lecture and faculty.
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Learn firstWhat you need for 1.1
Andrew Taylor Still was born August 6, 1828 in Jonesville, Lee County, Virginia, and lived 1828–1917. He later moved west to Missouri and Kansas, but he was born in Virginia. His father, Abram Still, was a Methodist circuit-rider preacher and physician; A.T. Still trained the usual way for the time, by apprenticeship with his father. It was Abram (not A.T.) who was the missionary to the Shawnee in Kansas; A.T. helped him doctor at the Wakarusa Mission. During the Civil War (1861–1865) Still served as a surgeon and cavalry major in the Kansas militia.
The turning point: in February 1864, three of his children died of spinal meningitis despite the best orthodox (heroic) medicine of the day. This loss is what drove him to reject the medicine of his time and look for a better way; he then studied anatomy for about 10 years before announcing osteopathy. Older TA keys word this as the death of his daughters (the 2026 slides just say “3 of his children”), so pick the meningitis/children (or daughters) answer, not “sons”.
Influences on Still
What actually happened
Children's deaths (1864)
The main trigger: 3 children died of spinal meningitis
Headache at age 10
He relieved his own migraine by lying with the back of his neck resting on a rope (a lowered swing), “suspending the action of the great occipital nerve” (not magnetic healing): an early structure–function lesson
His father
Apprenticed and worked with Abram Still
Bonesetting
Exposed to European bonesetting as an adult (likely during the Civil War), not treated by one as a child
Heroic medicine
He rejected it (Benjamin Rush's bloodletting, purging, mercury); he never preferred it
Things that did not motivate him: Baker University refused to let him teach his methods; 1893 was the allopaths' first attack on DOs (not 1828). Still believed the physician does not “cure” disease: the physician removes structural impediments so the body can heal itself, and he saw the neuromusculoskeletal system as an access point to the body's physiology.
1top 215asked 4×Still's life & motivation
When and where was A.T. Still born?
Ans: Still's birth → August 6, 1828 → Lee County, Virginia
Why: A.T. Still was born on August 6, 1828 in Jonesville, Lee County, Virginia. He lived from 1828 to 1917.
Heads up: One 2025 TA version keyed 'Aug 6, 1826 – Lee County, Virginia'. The course lecture gives Still's dates as 1828–1917, born in Lee County, VA, so 1828 is correct.
Explanation & sources
Explanation
The other choices are other famous births: A is Elvis Presley (Tupelo), B is Abraham Lincoln (Kentucky), C is Michael Jackson (Gary, Indiana). Other versions of this question pair Virginia/1828 against Missouri or Kansas dates; Still moved to Missouri and Kansas later but was born in Virginia. His father Abram Still was a Methodist circuit-rider preacher and physician.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 3-4
2023 TA Review (Harlem) - Exam 1 · TA review · slides 4-5
2022 TA Review (Middletown) - Exam 1 · TA review · slides 3-4
2020 TA Review (Middletown) Exam 1 · TA review · slides 4-5
2Still's life & motivation
Which of the following significant events occurred in 1828?
Ans: 1828 → Still's birth year → born in Lee County, Virginia
Why:1828 is the year A.T. Still was born in Lee County, Virginia.
Explanation & sources
Explanation
B, the allopaths' first attack pushing DOs toward MD licensure, was 1893. C is wrong because the Civil War ran 1861–1865, when Still was a military surgeon and cavalry major for the Kansas militia. D happened in February 1864, when 3 of his children died of spinal meningitis.
Asked in
2020 TA Review Exam 1 · TA review · slides 5-6
3top 215asked 9×2026Still's life & motivation
A.T. Still had some significant experiences that were influential in the development of osteopathy. Which of the following represents one of these influential experiences?
Ans: What drove Still → 1864 spinal meningitis killed 3 of his children → sought better medicine
Why: In February 1864, three of his children died of spinal meningitis despite the best medicine of the day. This loss drove Still to look for an alternative to orthodox (heroic) medicine.
Explanation & sources
Explanation
A: his father Abram, not Still, was the missionary to the Shawnee in Kansas (Still helped him doctor at the Wakarusa Mission). B: Still was exposed to bonesetting ideas as an adult, not treated by a bonesetter as a child. C: at age 10 he relieved his own migraine by 'suspending the action of the great occipital nerve', not with magnetic healing. E: Baker University refused to let him teach his methods.
Why did A.T. Still develop the osteopathic approach?
Ans: Still's motivation → three children died of spinal meningitis → searched for a better way
Why: Still developed osteopathy after the tragic loss of 3 children to spinal meningitis, then spent about 10 years studying anatomy before announcing his approach.
Explanation & sources
Explanation
A is wrong because Still taught that the physician does not cure disease; the physician removes structural impediments so the body can heal itself. C reverses the history: people were fed up with toxic and addictive drugs. D is also reversed: Still saw the neuromusculoskeletal system as an access point to the underlying physiology.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 20-21
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 4
5asked 3×Still's life & motivation
What event pushed A.T. Still to reject the medical practice of his day?
Ans: Break from orthodox medicine → children lost to spinal meningitis (1864) → answer the meningitis deaths
Why: The deaths of his children in the 1864 spinal meningitis outbreak made Still reject the medicine of his time. The TA keys word this as the death of his daughters.
Heads up: The 2026 course slides only say '3 of his children' died of spinal meningitis in February 1864. The older TA keys say 'daughters', so D is kept here.
Explanation & sources
Explanation
Options A and C are made up. B (sons) is the distractor the TA writers set against 'daughters'. Other versions use joke distractors (Angel Gabriel, Shawnee spirit journey, Gettysburg). On the exam, choose the option about children dying of meningitis.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 7-8
2022 TA Review (Middletown) - Exam 1 · TA review · slides 5-6
2020 TA Review (Middletown) Exam 1 · TA review · slides 6-7
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 4
6Still's life & motivation
Which event led A.T. Still to question and ultimately sever all his ties to contemporary medical practice in the late 19th century?
Ans: Turning point → 1864 meningitis outbreak killed his children → rejected orthodox medicine
Why: The outcome of the 1864 meningitis outbreak, in which 3 of his children died, led Still to break from orthodox medicine.
Explanation & sources
Explanation
A: Still served as a Civil War surgeon, but he wrote that the war 'left my family unharmed'; meningitis was the turning point. C: his apprenticeship under his father Abram was simply how he trained. D: calomel (mercury) was part of the heroic medicine he later rejected, but it was not the triggering event.
Asked in
2020 TA Review Exam 1 · TA review · slides 7-8
7Still's life & motivation
All of the following were influential to A.T. Still in developing osteopathy EXCEPT:
Ans: EXCEPT → Still rejected heroic medicine → 'preference' for it is false
Why: Still rejected heroic medicine (Benjamin Rush's bloodletting, purging and mercury). He did not prefer it.
Explanation & sources
Explanation
A: the meningitis deaths of his children were the main trigger. C: at age 10 he relieved his own migraine by resting his neck, an early structure-function lesson. D: he trained by apprenticeship with his physician father. E: he was likely exposed to European bonesetting during the Civil War, and bonesetting is listed as an influence.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 4-5
Lecture slide (1)
Study note
1.2 · 3 questions · Questions 8–10
Medicine in the 1800s
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Learn firstWhat you need for 1.2
In the 1800s the mainstream (orthodox, MD) practice was heroic medicine, championed by Benjamin Rush. It tried to drive out disease by depleting the body and eliminating symptoms. Still saw these practices as ineffective and often harmful, and rejected them.
Heroic medicine practices: bloodletting and leeches, purging with mercury (calomel) and other inorganic substances, blistering, and high doses of opium, alcohol and arsenic.
System
Founder / key idea
Heroic medicine (mainstream)
Benjamin Rush; depletion: bloodletting, mercury purging, blistering, symptom elimination
Homeopathy
Samuel Hahnemann; “like cures like” (Law of Similars)
Thomsonian medicine → Eclecticism
Samuel Thomson, self-taught herbalist; also inspired naturopathy
Magnetic healing
Fringe practice; one of the influences on Still
What Still practiced instead: a holistic approach that treats the person as a unit of body, mind and spirit. Any answer naming bloodletting, blistering, purging or high-dose mercury/opium/alcohol is heroic medicine, which he rejected.
8top 215asked 6×2026Medicine in the 1800s
After the Civil War in 1864, Still concluded that the orthodox medical practices of his day were frequently ineffective and often harmful. Which of the following was the main form of medicine practiced by physicians at the time?
Ans: Orthodox 1800s medicine → bloodletting, mercury purging, blistering → heroic medicine
Why:Heroic medicine, championed by Benjamin Rush, was the main form of medicine practiced by MDs. It used bloodletting and leeches, purging with mercury (calomel), blistering, and high doses of opium, alcohol and arsenic.
Explanation & sources
Explanation
Homeopathy (A) was Hahnemann's 'like cures like' system, an alternative sect. Eclecticism (E) grew out of Samuel Thomson's herbal medicine, which also inspired naturopathy (B). Magnetic healing (C) was a fringe practice that influenced Still. None of these was the mainstream.
Which pairing of a type of medicine with its description is correct?
Ans: Benjamin Rush → depletion (purging, bloodletting, blistering) → heroic medicine
Why:Heroic medicine was advocated by Benjamin Rush: purging with mercury, bloodletting and leeches, blistering, and a focus on eliminating symptoms.
Explanation & sources
Explanation
A is wrong because Samuel Thomson, the self-taught herbalist, founded Thomsonian medicine (eclecticism), not homeopathy. C is wrong because Samuel Hahnemann and the Law of Similars belong to homeopathy, not heroic medicine.
Asked in
2022 TA Review - Exam 1 · TA review · slides 7-8
Lecture slide (1)
Study note
10Medicine in the 1800s
Which practice would Dr. Still practice?
Ans: Still rejected heroic depletion → favored whole-person care → holistic body-mind-spirit approach
Why: Still favored a holistic approach that treats the person as a unit of body, mind and spirit.
Explanation & sources
Explanation
Bloodletting (A), blistering (B), high doses of mercury, opium and alcohol (D), and purging with inorganic substances (E) are all heroic medicine practices, which Still rejected as harmful.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 7-8
Lecture slide (1)
Week 1 · Written Review deck · slide 8
1.3 · 3 questions · Questions 11–13
1874: birth of osteopathy
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Learn firstWhat you need for 1.3
On June 22, 1874, Still “flung to the breeze the banner of osteopathy”. The phrase means he divorced himself from (severed all ties to) the orthodox medicine of the time and publicly announced his new philosophy and practice. This date is the birth of osteopathy.
Watch for near-miss dates: July 22, 1874, June 22, 1873 and June 20, 1874 are all wrong. Know the timeline so you can reject distractors:
Year
Event
1828
Still born, Lee County, Virginia
Feb 1864
3 children die of spinal meningitis
June 22, 1874
Banner flung to the breeze: osteopathy is born
1892
American School of Osteopathy (ASO) opens, Kirksville, MO
1896
Vermont is the first state to license DOs
1897
Missouri guarantees DOs the right to practice; AOA founded
1916
AOA sets a standard 4-year curriculum
1918
Spanish flu pandemic
11asked 7×1874: birth of osteopathy
On what date was the banner of osteopathy “flung to the breeze”?
Ans: "Flung the banner" → birth of osteopathy → June 22, 1874
Why: On June 22, 1874, Still 'flung to the breeze the banner of osteopathy'. This date marks the birth of osteopathy.
Explanation & sources
Explanation
Watch for near-miss dates in other versions: July 22, 1874, June 22, 1873, and June 20, 1874 are all wrong. Other key dates used as distractors: February 1864 (his children's deaths), 1892 (ASO opens), 1918 (Spanish flu).
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 5-6
2024 TA Review (Harlem) Exam 1 · TA review · slides 3-4
2023 TA Review (Harlem) - Exam 1 · TA review · slides 9-10
2023 TA Review - Written Exam 1 · TA review · slides 6-7
2022 TA Review (Middletown) - Exam 1 · TA review · slides 9-10
2022 TA Review - Exam 1 · TA review · slides 3-4
2020 TA Review (Middletown) Exam 1 · TA review · slides 8-9
Lecture slides (2)
Week 1 · Written Review deck · slide 3Week 1 · Written Review deck · slide 2
12top 215asked 6×20261874: birth of osteopathy
What does “flung to the breeze the banner of osteopathy” refer to?
Ans: "Flung the banner" → Still divorced himself from orthodox medicine → announced osteopathy, 1874
Why: The phrase refers to Still divorcing himself from the orthodox medicine of the time and announcing his new philosophy and practice in 1874. It marks the birth of osteopathy.
Explanation & sources
Explanation
B: the first school (ASO) opened in 1892. C: the AOA mandated a 4-year curriculum in 1916. D: Missouri guaranteed DOs the right to practice in 1897, but Vermont (1896) was first. E: lesion osteopaths did try to keep surgery and pharmacology out of the curriculum, but that is not what the phrase means.
Week 1 · Written Review deck · slide 3Week 1 · Written Review deck · slide 2
13asked 2×1874: birth of osteopathy
June 22, 1874 is a significant date in the history of osteopathic medicine because it marks the date that…
Ans: June 22, 1874 → banner flung to the breeze → Still severs ties with traditional medicine
Why: On June 22, 1874, Still severed his ties to traditional medicine and 'flung to the breeze the banner' of osteopathy.
Explanation & sources
Explanation
A: the American School of Osteopathy was founded in 1892. B: Vermont became the first state to license DOs in 1896. C: Missouri guaranteed DOs the right to practice in 1897.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 6-7
2020 TA Review Exam 1 · TA review · slides 9-10
Lecture slide (1)
Week 1 · Written Review deck · slide 3
1.4 · 5 questions · Questions 14–18
Schools, licensure & the AOA
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Learn firstWhat you need for 1.4
American School of Osteopathy (ASO): opened 1892 in Kirksville, Missouri (today ATSU). The first class had 18 students (15 men, 3 women). Memory hook: about 400 years after Columbus (1492).
Licensure:Vermont was the first state to license DOs (1896). Missouri followed in 1897 with a law guaranteeing DOs the right to practice. By 1901, 14 states licensed osteopathy; Mississippi and Louisiana were the last to grant full practice rights (1973).
AOA: the American Osteopathic Association was founded in 1897 (it began as a student group in Kirksville) and is now headquartered in Chicago, Illinois.
Rod of Asclepius (AOA symbol)
Caduceus
Serpents
One serpent
Two serpents
Staff
Plain wooden staff, no wings
Winged staff
Belongs to
Asclepius, Greek god of healing and medicine
Hermes, messenger (herald) of the gods; often misused as a medical symbol
Other dates used as distractors: 1893 (allopaths' first attack), 1902 (Still publishes Philosophy and Mechanical Principles of Osteopathy), 1918 (Spanish flu), 1961 (California merger).
14top 215asked 3×Schools, licensure & the AOA
The American School of Osteopathy first opened its doors in what year and state?
Ans: ASO → Kirksville, Missouri → 1892
Why: The American School of Osteopathy opened in 1892 in Kirksville, Missouri (now ATSU).
Explanation & sources
Explanation
Each distractor is a real date: 1896 Vermont is the first state to license DOs; 1961 California is the California merger; 1828 Virginia is Still's birth; 1897 Illinois is the founding of the AOA, now headquartered in Chicago (it began as a student group in Kirksville). The first ASO class had 18 students (15 men, 3 women).
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 8-9
2023 TA Review - Written Exam 1 · TA review · slides 8-9
In what year did the American School of Osteopathy open?
Ans: ASO founded → Kirksville → 1892
Why: The ASO opened in 1892. A memory hook: about 400 years after Columbus sailed.
Explanation & sources
Explanation
1893 was the allopaths' first attack on osteopathy. 1902 is when Still published 'Philosophy and Mechanical Principles of Osteopathy'. 1918 was the Spanish flu pandemic. 1897 was Missouri's DO licensure law and the AOA's founding.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 15-16
2022 TA Review (Middletown) - Exam 1 · TA review · slides 11-12
2020 TA Review (Middletown) Exam 1 · TA review · slides 14-15
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 4
16top 215asked 12×2026Schools, licensure & the AOA
The first state to license DOs was:
Ans: First DO licensure → 1896 → Vermont
Why:Vermont was the first state to license osteopathic physicians, in 1896.
Explanation & sources
Explanation
Missouri (C) was second, in 1897, when it passed legislation guaranteeing DOs the right to practice. Alaska, Illinois and Iowa are distractors. Other versions use Virginia, California, Kansas, New York, Alabama or Pennsylvania. By 1901, 14 states licensed osteopathy, and Mississippi and Louisiana were the last to grant full practice rights, in 1973.
2020 TA Review (Middletown) Exam 1 · TA review · slides 256-257
2020 TA Review Exam 1 · TA review · slides 248-249
Lecture slide (1)
Study note
17asked 2×Schools, licensure & the AOA
What is the symbol of the American Osteopathic Association?
Ans: AOA symbol → single serpent on a staff → Rod of Asclepius
Why: The AOA uses the Rod of Asclepius: one serpent wound around a wooden staff. Asclepius is the Greek god of healing and medicine.
Explanation & sources
Explanation
The caduceus (two serpents on a winged staff) belongs to Hermes, messenger of the gods. It is often misused as a medical symbol.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 2-3
2020 TA Review (Middletown) Exam 1 · TA review · slides 2-3
18asked 2×Schools, licensure & the AOA
The AOA differs from the AMA in its use of the Rod of Asclepius as opposed to the Rod of Caduceus. Which of the following statements correctly describes the Rod of Asclepius?
Ans: Asclepius = god of healing → one serpent, plain wooden staff
Why: The Rod of Asclepius is a solitary serpent-entwined wooden staff belonging to Asclepius, the Greek deity of healing and medicine.
Explanation & sources
Explanation
A mixes one serpent with the messenger of the gods. B mixes the caduceus's wings and two serpents with the god of healing. D describes the caduceus (Hermes, herald of the gods), not the Rod of Asclepius.
Asked in
2022 TA Review - Exam 1 · TA review · slides 5-6
2020 TA Review Exam 1 · TA review · slides 2-3
1.5 · 6 questions · Questions 19–24
1918 flu & road to parity
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1918 Spanish flu: an H1N1 pandemic (not H3N2) that infected about 500 million people and killed about 50–100 million. Osteopathic patients did far better than those given standard care, which greatly boosted the profession's reputation. The OMT protocol aimed to increase lymphatic drainage via the thoracic pump and clear inflammatory exudate, decrease the work of breathing and improve thoracic compliance.
Mortality, 1918
Standard medical care
Osteopathic care
Influenza
5–6%
0.25% (about 95% lower, so an option saying “50% less” is keyed false: it understates the benefit)
Influenza + pneumonia
33%
10%
Road to parity:
1910 Flexner Report closed many schools; only 5 of 8 osteopathic schools survived.
1929: pharmacology added to the osteopathic curriculum (brought DO and MD curricula closer).
WWII: DOs could not serve as military physicians, so they gained patients at home.
1955 AMA committee on DO schools found: admission requirements the same, clinical study time the same, “pure medicine” = 90–95% of instruction, standard medical texts used, and instruction time 25% higher (extra teaching on MSK disease and manipulation). It concluded DO training was not “cult healing”.
1961 California merger: about 2,000 California DOs exchanged their DO for an MD degree ($65 and 12 Saturday classes); the separate DO licensing board was eliminated, and after a 1962 referendum no new DOs could be licensed in California. Existing DOs could keep practicing.
The AOA and remaining DOs fought back: licensure restored in 1971 and the 1962 law struck down by the California Supreme Court in 1974. The reversal led to broad acceptance of the DO as equal to the MD, a stronger AOA, and new COMs, beginning with MSUCOM in 1969 (the first new COM in 53 years).
1967: the AMA offered to let osteopathic students transfer to MD schools (a separate event).
Lecture slide for this section (1)
IA1 slide 32: the 1961 California merger
19top 215asked 6×20261918 flu & road to parity
The Spanish Flu Pandemic of 1918 is significant in osteopathic history. Which of the following is a true statement regarding this pandemic?
Why: The 1918 OMT influenza protocol aimed to increase lymphatic drainage via the thoracic pump. It also decreased the work of breathing and improved thoracic compliance.
Heads up: The 2026 IA1 poll shortened option E to 'Medical care had a 5% mortality for influenza cases', which by itself is close to the slide's 5–6%. The fuller wording used here (influenza cases that also developed pneumonia) is clearly false, and C matches the slide 'Increasing lymphatic drainage via thoracic pump', so C is the answer.
Explanation & sources
Explanation
A understates the benefit: influenza mortality was 0.25% with osteopathic care vs 5–6% with standard care, far more than 50% less. B: it was H1N1, not H3N2. D: about 50–100 million people died (about 500 million infected). E: standard care had 33% mortality when pneumonia developed (vs 10% with osteopathic care); 5–6% was the figure for influenza alone.
The treatment of patients during the Spanish Flu Pandemic in 1918 was influential for the development of osteopathy because:
Ans: 1918 flu → OMT patients had far lower mortality → boost for the profession
Why: Patients treated with OMT had much better outcomes: influenza mortality 0.25% and pneumonia mortality 10%, vs 5–6% and 33% with standard care.
Explanation & sources
Explanation
B is wrong because lymphatic techniques decrease, not increase, the work of breathing. C contradicts the data. D is wrong because pharmacology was not added to the osteopathic curriculum until 1929.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 12-13
211918 flu & road to parity
The findings of the AMA committee that investigated education at schools of osteopathy included:
Ans: 1950s AMA committee → found DO schools equivalent → same admission requirements
Why: The 1955 AMA committee found that admission requirements were the same as MD schools. It concluded that osteopathic instruction could not be called 'cult healing'.
Explanation & sources
Explanation
The real findings: clinical study time was the same (not less, B); 'pure medicine' was 90–95% of instruction (not 60–65%, C); standard medical texts were used (D); and instruction time was 25% higher (not lower, E), mostly from extra teaching on MSK disease and manipulation.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 16-17
22top 215asked 6×20261918 flu & road to parity
Which of the following events in osteopathic history was followed by a significant strengthening of the AOA and the opening of several new COMs?
Ans: After 1961 California merger → AOA fought back → new COMs from 1969 (MSUCOM)
Why: After the 1961 California merger, the remaining DOs and the AOA fought back and won (licensure restored in 1971; the 1962 law was struck down in 1974). New COMs then opened, starting with MSUCOM in 1969, the first new COM in 53 years.
Explanation & sources
Explanation
A: the 1910 Flexner Report closed schools; only 5 of 8 osteopathic schools survived. B: adding pharmacology (1929) brought the curricula closer to MD schools but was not followed by a wave of new COMs. C: WWII helped DOs gain patients at home, since DOs could not serve as military physicians. E: the 1918 flu boosted the profession's reputation.
Ans: 1961 California merger → DOs became MDs for $65, DO board eliminated → later reversed
Why: In 1961 about 2,000 California DOs exchanged their DO for an MD degree ($65 and 12 Saturday classes), the separate DO licensing board was eliminated, and the change was later reversed (1974 California Supreme Court).
Explanation & sources
Explanation
A is the opposite: no new DOs could be licensed in California after the 1962 referendum. B describes the AMA's 1967 offer to transfer osteopathic students to MD schools, a separate event. C overstates it: existing DOs could keep practicing, but new DO licensure stopped until 1974.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 9-10
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 32
241918 flu & road to parity
What was the importance of the California merger and what year did it happen?
Ans: California merger → 1961 → DOs became MDs, later overturned → DO proven equal
Why: The merger happened in 1961. DOs could easily convert to MDs, and when the law was overturned (1974) the episode led to broad acceptance of the DO degree as equal to the MD.
Explanation & sources
Explanation
A has the wrong year (1960). C uses 1910, the year of the Flexner Report. D is wrong on both counts: by 1973 the DO degree was recognized in all 50 states, and nothing ruled it unequal.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 5-6
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 32
1.6 · 14 questions · Questions 25–38
Tenets & philosophy
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There are exactly four tenets of osteopathic medicine. Most questions here are “which is NOT a tenet?”, so memorize the list and reject anything else, even if it is a true statement.
The body is a unit; the person is a (dynamic) unit of body, mind and spirit.
The body is capable of self-regulation, self-healing and health maintenance.
Structure and function are reciprocally interrelated (at all levels; neither ranks above the other).
Rational treatment is based on the above three principles.
Common fakes: “balance between homeostasis and allostasis”; “SD is only caused by trauma”; “treat or suppress symptoms” (that is the heroic approach); “body is many parts, function over structure”; “the nervous system is the sole determinant of disease”; “body and mind are indirectly related”; “mind, body, spirit are separate”. True-but-not-a-tenet traps: “the five models are...” and “SDs are diagnoses treatable with osteopathy”. Older expanded principle lists also say the body can defend and repair itself, and that disease can follow when adaptability is overwhelmed; these fit osteopathic thinking.
Health and disease. Still: “When all parts of the human body are in line we have perfect health. When they are not, the effect is disease.” and “To find health should be the object of the doctor. Anyone can find disease.” (A.T. Still, not Mitchell, Jones or Sutherland.)
Structure ↔ function works both ways. Example: an asymmetrically enlarged mastoid process from years of pull by a hypertonic SCM is abnormal function producing abnormal structure.
Host factors + Disease/Disturbance = Illness. Host factors are the patient's own terrain (age, genetics, health, nutrition, immune function, MSK and fascia) and are what OMT optimizes. Disturbances are outside insults: pathogens, toxins, environmental stressors, injury and trauma. Illness is the result, not an input.
Lecture slide for this section (1)
Written Review slide 8: the four tenets
25top 215asked 7×2026Tenets & philosophy
Which of the following is NOT one of the principles of osteopathic philosophy?
Ans: Four tenets: unit, self-regulation, structure-function, rational treatment → homeostasis/allostasis balance isn't one
Why: The four tenets are: the body is a dynamic unit of function; it has self-regulatory, self-healing mechanisms; structure and function are interrelated; and rational treatment is based on these. A 'balance between homeostasis and allostasis' is not a tenet.
Explanation & sources
Explanation
A, B, D and E are the four tenets almost word for word. C borrows physiology vocabulary to sound plausible. The tenet uses 'self-regulatory (homeostatic)', but there is no allostasis principle.
Which is NOT a principle of osteopathic philosophy?
Ans: Not among the four tenets → 'SD only from trauma' → false and not a tenet
Why: 'Somatic dysfunction is only caused by a traumatic event' is not a tenet, and it is false: SD also arises from posture, overuse and visceral reflexes.
Explanation & sources
Explanation
A, B, C and E are the four tenets: dynamic unit of function, self-regulation/self-healing, structure-function interrelation, and rational treatment based on these principles.
Asked in
2022 TA Review - Exam 1 · TA review · slides 11-12
Lecture slide (1)
Week 1 · Written Review deck · slide 8
27asked 3×Tenets & philosophy
What is NOT a principle of osteopathy?
Ans: Osteopathy treats the person, not just symptoms → suppressing symptoms isn't a tenet
Why:Treating or suppressing symptoms is the disease-focused (heroic) approach Still rejected. It is not one of the four tenets.
Explanation & sources
Explanation
A (self-regulation), B (unit of body, mind and spirit), D (rational treatment) and E (structure and function are reciprocally interrelated) are the four tenets.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 11-12
2020 TA Review (Middletown) Exam 1 · TA review · slides 10-11
2020 TA Review Exam 1 · TA review · slide 11
2020 TA Review Exam 1 · TA review · slide 12
Lecture slide (1)
Week 1 · Written Review deck · slide 8
28Tenets & philosophy
What is not a principle of osteopathic medicine?
Ans: Tenet: body is a unit; structure and function are equal partners → 'many parts, function over structure' is false
Why: Osteopathy holds that the body is a unit and that structure and function are reciprocally interrelated. Neither is ranked above the other, so E contradicts two tenets.
Explanation & sources
Explanation
A (mind, body, spirit), B (structure-function), C (rational treatment) and D (self-regulatory mechanisms) are the four tenets.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 11-12
Lecture slide (1)
Week 1 · Written Review deck · slide 8
29Tenets & philosophy
Which of the following are the Tenets of Osteopathic Medicine? (Select all that apply.)
Ans: Four tenets = self-regulation + unit + rational treatment + structure-function → C is symptom suppression
Why: The four tenets are self-regulation (A), unit of body, mind and spirit (B), rational treatment (D) and structure-function interrelation (E).
Explanation & sources
Explanation
C (treating or suppressing symptoms) is the disease-oriented approach of heroic medicine. Osteopathy focuses on finding health and supporting the body's own healing.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 13-14
Lecture slide (1)
Week 1 · Written Review deck · slide 8
30asked 2×Tenets & philosophy
Which is not a principle of the philosophy of osteopathic medicine?
Ans: True statement ≠ tenet → five models are a framework, not one of the four principles
Why: The five models are a true statement about osteopathic care, but they are a practice framework, not one of the four principles.
Explanation & sources
Explanation
A (structure-function), B (body is a unit), C (self-regulation and self-healing) and E (rational treatment) are the four principles. The trap is choosing between true statements: ask which one is on the tenet list.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 61-62
2022 TA Review (Middletown) - Exam 1 · TA review · slides 47-48
Lecture slides (2)
Week 1 · Written Review deck · slide 8Week 1 · IA1 History & Philosophy · slide 42
31Tenets & philosophy
Which of the following is NOT one of the four tenets of osteopathic medicine?
Ans: Body is a unit → no single system is the 'sole determinant' → C is not a tenet
Why: No tenet says the nervous system is the sole determinant of disease. That conflicts with the tenet that the body is a unit.
Explanation & sources
Explanation
A (self-regulation and self-healing), B (structure-function) and D (rational treatment based on the others) are tenets. The fourth tenet, not listed here, is that the body is a dynamic unit of function.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 15-16
Lecture slide (1)
Week 1 · Written Review deck · slide 8
32Tenets & philosophy
Which of the following is NOT one of the four tenets of osteopathy?
Ans: Tenets are philosophy, not diagnoses → 'SD treatable with osteopathy' isn't a tenet
Why: 'Somatic dysfunctions are diagnoses treatable with osteopathy' may be true, but it is not a tenet.
Explanation & sources
Explanation
A (dynamic unit), B (self-regulatory, self-healing mechanisms) and C (structure-function) are tenets. The fourth is that rational treatment is based on these principles.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 14-15
Lecture slide (1)
Week 1 · Written Review deck · slide 8
33Tenets & philosophy
Which one is NOT considered an osteopathic principle?
Ans: Body is a unit of body, mind and spirit → 'indirectly related' contradicts it
Why: Osteopathy holds that body, mind and spirit form one unit, so saying the body and mind are only indirectly related contradicts the first tenet.
Explanation & sources
Explanation
A, B and C are tenets. E and F come from older expanded lists of osteopathic principles: the body can defend and repair itself, and disease can follow when the body's adaptability is overwhelmed. Both fit osteopathic thinking.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 129-130
Lecture slide (1)
Week 1 · Written Review deck · slide 8
34Tenets & philosophy
Which one of the following is a correct statement regarding the four tenets of osteopathic philosophy?
Ans: Tenet 1 → human being is a dynamic unit of function
Why: The first tenet is that a human being is a dynamic unit of function (body, mind and spirit).
Explanation & sources
Explanation
B, C and D are negated versions of real tenets: the body does have self-regulatory, self-healing mechanisms; structure and function are interrelated; and mind, body and spirit are a unit.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 13-14
Lecture slide (1)
Week 1 · Written Review deck · slide 8
35Tenets & philosophy
Which of the following best describes the osteopathic view of health and disease?
Ans: Still: 'When all parts are in line we have perfect health' → disease from structural disruption
Why: Still taught: 'When all parts of the human body are in line we have perfect health. When they are not, the effect is disease.' Proper structure supports proper function.
Explanation & sources
Explanation
A ignores host factors and the body's self-healing. C is wrong because surgery is not always required (Still did surgery but used it selectively). D is wrong because osteopathy focuses on finding health, not just disease.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 13-14
36top 215Tenets & philosophy
The osteopathic principle which best describes the relationship of an asymmetrically enlarged left mastoid process is:
Ans: Enlarged mastoid → chronic muscle pull (SCM) remodels bone → abnormal function causes abnormal structure
Why: Long-term abnormal pull of muscles on the mastoid, such as a hypertonic SCM, remodels the bone. That is abnormal function producing abnormal structure.
Explanation & sources
Explanation
A and D describe structure acting on function, the reverse direction. C contradicts the tenet that structure and function are reciprocally interrelated.
Who said, “To find health should be the object of the doctor. Anyone can find disease.”
Ans: Health-focused quote → founder's philosophy → A.T. Still
Why:A.T. Still said it. It sums up the osteopathic focus on finding and supporting health rather than chasing disease.
Explanation & sources
Explanation
The others are key figures in OMT: Fred Mitchell Sr. developed muscle energy, Lawrence Jones developed counterstrain, and William G. Sutherland developed the cranial concept. Stephen C. Jones is a distractor.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 13-14
2022 TA Review (Middletown) - Exam 1 · TA review · slides 20-21
2020 TA Review (Middletown) Exam 1 · TA review · slides 12-13
38top 215asked 7×2026Tenets & philosophy
Within the equation, Host Factors + Disease/Disturbance = Illness, which component would trauma fit into?
Ans: Trauma = outside insult acting on the host → disease/disturbance factor
Why:Trauma is an outside insult, so it is a disease/disturbance factor, along with pathogens, toxins, environmental stressors and injury.
Explanation & sources
Explanation
A: host factors are the patient's own terrain (age, genetics, health state, nutrition, immune function, MSK and fascia). Host factors are what OMT optimizes. C: illness is the result of host plus disturbance, not an input. D and E are wrong because trauma fits one category.
Counterstrain (resets muscle spindle), palpitations from irritated SNS/PNS nerves to the heart
Metabolic-energy
Optimize energy expenditure/exchange; enhance immune and organ function; diet, exercise, nutrition, prevention
Weight loss
Behavioral
Psychological and social components: stress, anxiety, work/family, drug use, values, sleep habits
Changing sleep habits
Common traps: anything about the heart is not automatically respiratory-circulatory; if the problem is nerve tone, it is neurological. A lifestyle change aimed at posture (standing desk) is biomechanical, and weight loss is metabolic-energy, not behavioral. Rib raising also calms sympathetics, but it is filed under respiratory-circulatory for its breathing and fluid goals. For a purely physical trauma (whiplash with painful breathing) the behavioral model fits least.
Pneumonia OMT goals: lymphatic pumping to increase uptake of lymph from interstitial tissue, free rib motion and the diaphragm (decrease psoas tone so the diaphragm moves normally), create optimal intrathoracic negative pressure, and normalize (not increase) autonomic tone.
Lecture slide for this section (1)
IA1 slide 42: the five models
39top 215Five models
Which of the following best describes the Respiratory/Circulatory model?
Ans: Respiratory-circulatory → diaphragms, fluid flow, work of breathing, thoracic cage compliance
Why: The respiratory-circulatory model aims to reduce diaphragm restrictions, enhance circulation (arterial, venous, lymphatic), reduce the work of breathing and improve thoracic cage compliance.
Explanation & sources
Explanation
A describes the metabolic-energy model (energy expenditure, immune function). B describes the neurological model (autonomic balance, facilitated segments, proprioception). D describes the behavioral model (emotional balance, stress, coping).
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 12-13
Lecture slides (2)
Week 1 · IA1 History & Philosophy · slide 42Week 1 · Written Review deck · slide 7
40Five models
Match each model with its definition: Biomechanical, Behavioral, Respiratory-circulatory, Metabolic, Neurological. A. Optimize the body's energy expenditure and exchange; enhance immune system and organ function. B. Improve autonomic balance and facilitated segments (viscerosomatic reflexes), decrease nociceptive load, improve proprioception. C. Improve the psychological and social components of the health spectrum. D. Coordination and symmetry of musculoskeletal and fascial structures in posture and motion. E. Reduce diaphragm restrictions, enhance circulatory mechanisms, reduce work of breathing, improve thoracic cage compliance.
Ans: Key word per model: posture/symmetry → biomechanical; psyche → behavioral; diaphragms/fluids → resp-circ; energy → metabolic; autonomics → neuro
Why: Each model has a signature: biomechanical = posture and motion; behavioral = psychological and social; respiratory-circulatory = diaphragms and fluid flow; metabolic-energy = energy and immune/organ function; neurological = autonomic balance, reflexes, pain and proprioception.
Explanation & sources
Explanation
The usual mix-up is respiratory-circulatory vs neurological for thoracic problems. Fluid flow and breathing mechanics are respiratory-circulatory, while sympathetic and parasympathetic tone is neurological.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 25-26
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 42
41top 215asked 7×2026Five models
A patient comes to your office with complaints of neck pain and slight pain with breathing after being rear ended while driving over the weekend. Into which treatment model of OMM do these complaints least fit?
Ans: Physical trauma: neck MSK, breathing, pain/reflex, healing energy → no psychosocial complaint → behavioral
Why: The complaints are physical: neck strain, painful breathing, pain and reflex changes, and tissue healing. Nothing points to a psychological, social or lifestyle problem, so the behavioral model fits least.
Explanation & sources
Explanation
Biomechanical (A) covers the whiplash neck strain. Respiratory-circulatory (B) covers painful breathing and rib/diaphragm restriction. Neurologic (C) covers pain, facilitation and autonomic effects. Metabolic-energy (D) covers inflammation and the energy cost of healing.
A patient presents to your clinic with complaints of palpitations described as an occasional racing heartbeat. There is no pain but mild dizziness during these episodes. An electrocardiogram is normal. After your examination you decide that the heartbeat irregularity is the result of irritation to the sympathetic and parasympathetic nerves that go to the heart. Into which treatment model of OMM does this scenario most directly fit?
Ans: Irritated sympathetic/parasympathetic nerves → autonomic balance → neurological model
Why: The cause is autonomic nerve irritation, so treatment aims at autonomic balance. That is the neurological model.
Explanation & sources
Explanation
Respiratory-circulatory (B) is tempting because the heart is involved, but that model is about fluid flow and breathing mechanics, not nerve tone. Biomechanical (A) is posture and motion. Metabolic-energy (D) is energy and organ or immune function. Behavioral (E) is psychosocial.
Which model would describe getting a standing desk for studying?
Ans: Standing desk → changes posture and ergonomics → biomechanical model
Why: A standing desk changes posture and ergonomics, which falls under the biomechanical model (structure, posture, motion).
Explanation & sources
Explanation
Behavioral (E) is tempting because it is a lifestyle change, but its target is posture, not psyche or stress. The TA summary: biomechanical = structural/postural; resp-circ = fluids; neurological = nerves and reflexes; metabolic = energy; behavioral = mind, sleep, stress, lifestyle.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 10-11
Lecture slides (2)
Week 1 · IA1 History & Philosophy · slide 42Week 1 · Written Review deck · slide 6
44top 215asked 3×Five models
HVLA is an example of which osteopathic model?
Ans: HVLA thrust → restores joint motion → biomechanical model
Why:HVLA is a thrust technique that restores motion at a restricted joint, which makes it a biomechanical treatment.
Explanation & sources
Explanation
Rib raising goes with respiratory-circulatory, counterstrain with neurological (muscle spindle reset), weight loss with metabolic-energy, and sleep habits with behavioral.
Asked in
2022 TA Review - Exam 1 · TA review · slides 13-14
2020 TA Review (Middletown) Exam 1 · TA review · slides 22-26
2020 TA Review Exam 1 · TA review · slides 23-24
Lecture slide (1)
Week 1 · Written Review deck · slide 6
45Five models
Mr. Smith bends over forward and to the right to pick up a heavy box quickly and develops back pain. You diagnose a type 2 SD at T10 and treat with a Kirksville crunch. What model of osteopathy does this dysfunction and treatment most reflect?
Why: A lifting strain causing a vertebral somatic dysfunction, treated with a thrust (the Kirksville crunch is a thoracic HVLA), is classic biomechanical model care.
Explanation & sources
Explanation
The other models could add secondary goals, such as calming a facilitated segment (neurological), but the dysfunction and the chosen technique are structural.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 22-23
Why:Rib raising improves rib cage motion, reduces the work of breathing and helps fluid (lymph, venous) move. That is the respiratory/circulatory model.
Explanation & sources
Explanation
Rib raising also normalizes sympathetic tone (a neurological effect), but the TA key files it under respiratory-circulatory because of its breathing and fluid goals. Its typical uses are pneumonia and cardiac conditions.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 16-17
2020 TA Review Exam 1 · TA review · slides 17-18
Lecture slide (1)
Week 1 · Written Review deck · slide 7
47Five models
A 66-year-old male develops lobar pneumonia caused by Strep pneumo. You attempt to use rib and diaphragm based lymphatic techniques you learned in OMM to help move and clear inflammation. Which model of osteopathy would this treatment be a part of?
Why: Lymphatic pumps and rib/diaphragm work move fluid and improve breathing mechanics, which places them in the respiratory/circulatory model.
Explanation & sources
Explanation
Neurological (C) would be the choice if the goal were normalizing sympathetic or parasympathetic tone. Metabolic (D) would be the choice for immune or energy optimization through nutrition or medication. The question stresses moving fluid.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 16-17
Lecture slide (1)
Week 1 · Written Review deck · slide 7
48Five models
A patient with rheumatoid arthritis presents with persistent knee swelling. Which osteopathic model best addresses this condition by enhancing lymphatic drainage and improving thoracic cage compliance?
Why: Promoting venous and lymphatic return by freeing diaphragms and improving thoracic cage compliance is the respiratory-circulatory model. The RA knee swelling case is the lecture's own example.
Explanation & sources
Explanation
Biomechanical (A) would address joint alignment. Neurological (C) would address pain or autonomic tone. Behavioral (B) would address the psychosocial side. None of them targets fluid drainage.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 17-18
Lecture slide (1)
Week 1 · Written Review deck · slide 7
49Five models
What is the goal of OMT when treating pneumonia?
Ans: Pneumonia OMT → lymphatic pump techniques → uptake of lymph from interstitial tissue
Why: In pneumonia, OMT uses pumping techniques to assist lymphatic drainage, increasing uptake of lymph from the interstitial tissues. Other goals are freeing rib motion and the diaphragm and normalizing autonomic tone.
Explanation & sources
Explanation
A is reversed: you decrease psoas tone so the diaphragm can move normally. C is wrong because the goal is to normalize autonomic tone, not increase it. D is wrong because a free diaphragm generates optimal intrathoracic negative pressure, not positive pressure.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 23-24
Why:Counterstrain works by resetting the muscle spindle, an inappropriate proprioceptive reflex, so it belongs to the neurological model.
Explanation & sources
Explanation
Counterstrain does relieve musculoskeletal pain, which makes biomechanical (A) tempting, but its mechanism is neural: muscle spindles are sensory receptors. HVLA is the biomechanical example.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 19-20
2020 TA Review Exam 1 · TA review · slides 19-20
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 42
51asked 3×Five models
Which model would describe weight loss?
Ans: Weight loss → energy balance, diet and exercise → metabolic-energy
Why: Weight loss is about energy balance, diet and exercise, which fall under the metabolic-energy model.
Explanation & sources
Explanation
Behavioral (E) is tempting because habits change, but the metabolic-energy model explicitly includes diet and exercise education, nutritional deficiencies and preventive health measures.
Asked in
2022 TA Review - Exam 1 · TA review · slides 15-16
2020 TA Review (Middletown) Exam 1 · TA review · slides 25-26
2020 TA Review Exam 1 · TA review · slides 25-26
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 42
52asked 2×Five models
Which model would describe changing sleep habits?
Ans: Sleep habits → lifestyle and psyche → behavioral model
Why:Sleep habits are listed under the behavioral model, with stress, anxiety, work and family, drug use, and values and beliefs.
Explanation & sources
Explanation
The behavioral model covers the psychological and social side of health, including habits like sleep. The other models address structure, fluids, nerves and energy.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 21-22
2020 TA Review Exam 1 · TA review · slides 21-22
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 42
53Five models
A 48-year-old male truck driver presents with excessive daytime sleepiness; he gets at least 7 hours of sleep per night but frequently wakes unrested. In reference to his sleeping habits, which model of osteopathy may be of most interest?
Ans: Question asks about sleeping habits → lifestyle → behavioral model
Why: The question asks about his sleeping habits, which fall under the behavioral model.
Explanation & sources
Explanation
Other models might matter for the workup (for example, obstructive sleep apnea and respiratory mechanics), but the question asks specifically about habits.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 18-19
Lecture slide (1)
Week 1 · IA1 History & Philosophy · slide 42
1.8 · 10 questions · Questions 54–63
Touch & palpation
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Learn firstWhat you need for 1.8
Palpation is the art of feeling tissues with your hands so that changes in tension and position can be noticed, diagnosed and treated. Touch is a primary diagnostic tool and is essential to a trusting, respectful doctor-patient relationship. Palpatory skill can be developed to know the “feel” of conditions and can be used to monitor progress. Rules: don't rush or use rough maneuvers, and work with the tissues, not at them. Palpate from superficial to deep.
Physiology of touch: the stimulus is coded by primary afferent (sensory) neurons in the dermis and epidermis (Merkel discs, Meissner, Ruffini and Pacinian corpuscles) and processed in the postcentral gyrus (primary somatosensory cortex). Touch releases oxytocin, which downregulates the HPA axis, lowers cortisol, enhances parasympathetic tone and improves social and pair bonding (including during lactation).
Layer / test
Finding
Means
Skin temperature & texture
Change
Altered blood flow (SNS)
Skin drag
Moisture
Sudomotor (sweat) SNS activity
Erythema test (red reflex): stroke skin, watch redness
Redness lasts
Acute SNS activity / acute SD
Redness then early blanching (turns pale before the surrounding skin)
Chronic SD (chronic SNS → vasoconstriction). Normal skin: brief redness that fades
Skin roll
Fascial resistance
Acute or chronic dysfunction
Turgor
—
Hydration status
Subcutaneous tissue
Edema (most easily felt here)
Metabolic conditions or acute inflammation
Deep fascia, muscle
Tone, ropiness, bogginess
Felt deeper, after superficial layers
54Touch & palpation
Which one incorrectly describes touch/palpation in the OMM context?
Ans: Lecture: palpatory skills CAN develop and CAN monitor progress → C is incorrect
Why: The lecture states that palpatory skills can develop to know the 'feel' of conditions and can be used to monitor patient progress. C says the opposite.
Explanation & sources
Explanation
A is the Mitchell/Pruzzo definition of palpation. B and D are straight from the touch slide: touch is essential to a trusting doctor-patient relationship and is a primary diagnostic tool.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 15-16
Why: Touch is a primary diagnostic tool and is essential to a trusting, respectful doctor-patient relationship.
Explanation & sources
Explanation
A is wrong twice: oxytocin downregulates the HPA axis and enhances parasympathetic tone. B is wrong because the stimulus is coded in primary afferent (sensory), not efferent, neurons. C is wrong because oxytocin improves social and pair bonding, including during lactation.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 27-28
Why:Oxytocin is released in response to touch. It downregulates the HPA axis, lowers cortisol and enhances parasympathetic tone.
Explanation & sources
Explanation
A: touch strengthens the patient-physician relationship. B: touch is a primary, not secondary, diagnostic tool. D: touch downregulates, not upregulates, the HPA axis.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 16-17
57Touch & palpation
Which of the following is a physiological response to therapeutic touch in osteopathy?
Why: Touch triggers oxytocin release, which downregulates the HPA axis and activates the parasympathetic nervous system (lower stress, lower blood pressure).
Explanation & sources
Explanation
A is reversed: cortisol goes down. C is reversed: touch calms sympathetic activity. D is wrong because touch stimulates tactile receptors (Merkel, Meissner, Ruffini, Pacinian) rather than inhibiting them.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 21-22
58Touch & palpation
Which of the following is not true about touch?
Ans: Palpation rule: don't rush, work WITH the tissue → C is false
Why: The lecture rule is: don't rush palpation or use rough maneuvers, and work with the tissues, not at them.
Explanation & sources
Explanation
A and B: touch releases oxytocin and downregulates the HPA axis. D: Merkel discs and Pacinian corpuscles are touch receptors. E: tactile sensation is processed in the postcentral gyrus (primary somatosensory cortex).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 24-25
59Touch & palpation
Qualities and significance of altered palpation, fill in the blanks: ____: temperature and texture changes signify altered ____. Erythema test (____ reflex): prolonged redness signifies ____. Skin roll test: fascial resistance signifies ____ in that area. Subcutaneous tissue: edema signifies ____.
Ans: Each layer's finding → what it signifies (blood flow, acute SNS, dysfunction, fluid)
Why: Skin temperature/texture reflects blood flow controlled by the SNS. A prolonged red reflex means acute SNS activity. Skin roll resistance means acute or chronic dysfunction. Subcutaneous edema means metabolic conditions or acute inflammation.
Explanation & sources
Explanation
Other items on the same lecture list: skin drag reflects sudomotor (sweat) activity of the SNS, and turgor reflects hydration status.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 27-28
Lecture slide (1)
Week 3 · Written Review deck · slide 20
60Touch & palpation
Which palpatory test evaluates the sympathetic nervous system response by observing the duration of skin redness after stimulation?
Ans: Redness duration after stroking → erythema test (red reflex)
Why: The erythema test (red reflex) strokes the skin and watches how long the redness lasts. Prolonged redness suggests acute SNS activity or somatic dysfunction.
Explanation & sources
Explanation
Skin drag (A) checks for moisture from sudomotor SNS activity. Skin roll (B) checks superficial fascial resistance. Turgor (D) checks hydration.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 23-24
Why:Prolonged redness after stroking reflects acute SNS activity or acute injury. The irritated, facilitated tissue overreacts with hyperemia.
Explanation & sources
Explanation
B: in chronic dysfunction, chronic sympathetic tone causes vasoconstriction, so the redness fades and the area blanches early. C, D and E are not what the red reflex tests: hydration is checked by turgor, and ligament stretch or postural compensation are found by other exam steps.
The Erythema test or Red reflex is done by firmly stroking or rubbing the skin to elicit a response. What does a long-lasting reddening of the skin indicate?
Why: A long-lasting red reflex marks acute somatic dysfunction, with acute sympathetic activity and tissue irritation.
Explanation & sources
Explanation
B: in chronic SD the redness fades quickly and blanches. C (edema) is felt in the subcutaneous tissue, not tested by the red reflex. D and E do not cause a prolonged red reflex.
Ans: Fluid collects in the subcutaneous layer → edema felt in subQ
Why:Edema (excess tissue fluid) is palpated in the subcutaneous tissue. It points to metabolic conditions or acute inflammation.
Explanation & sources
Explanation
The epidermis (A) gives temperature and texture. Deep fascia (B) and muscle (D) are felt deeper, after the superficial layers, for tone, ropiness and bogginess. Palpation goes from superficial to deep.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 258-259
2020 TA Review Exam 1 · TA review · slides 250-251
No questions in this section match the current Show filter.
Learn firstWhat you need for 2.1
Every motion happens in a plane and around an axis that is perpendicular to that plane. Questions often ask for only one of the two, so read whether they want the plane or the axis.
Motion
Plane (moves IN)
Axis (moves AROUND)
Flexion / extension (forward–back)
Sagittal
Transverse = frontal = lateral (runs side to side)
Side bending
Frontal = coronal
Sagittal = A-P (runs front to back)
Rotation (turning)
Horizontal = transverse
Vertical = longitudinal (the “Y-axis”)
Naming trap: “frontal” and “transverse” each name both a plane and an axis. The frontal (lateral/transverse) axis is the axis for flexion, but the frontal plane is the plane for side bending. The transverse plane is the rotation plane. “Longitudinal” is an axis, never a plane. Tie-break: if both “Frontal” and “Transverse” are offered as the axis for forward/back motion, the key picks Frontal (it reads “Transverse” as the rotation plane). “Neutral” is a position (range of sagittal positioning), not a motion.
Quick cases: thrown forward and back in a car → sagittal plane (axis: frontal). Leaning forward then yanking head back → frontal/lateral axis. Turning to look right then left → horizontal plane.
Lecture slide for this section (1)
Written Review slide 11: planes and axes
64top 215asked 2×Planes & axes
Fill in the blanks: Flexion and extension occur in the ____ plane around the ____ axis. Side bending occurs in the ____ plane around the sagittal axis. Rotation occurs in the ____ plane around the ____ axis.
Ans: Motion happens IN a plane, AROUND the axis perpendicular to it
Why: Each motion happens in one plane around the axis perpendicular to that plane: flexion/extension = sagittal plane, transverse axis; side bending = frontal plane, A-P axis; rotation = horizontal plane, vertical axis.
Explanation & sources
Explanation
The naming trap: the frontal (lateral/transverse) axis runs side to side and is the axis for flexion. The frontal plane is the plane for side bending. Synonyms: frontal = coronal; horizontal = transverse plane; vertical = longitudinal axis; sagittal axis = A-P axis.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 21-22
2024 TA Review (Harlem) Exam 1 · TA review · slide 19
Lecture slide (1)
Week 2 · Written Review deck · slide 11
65asked 2×Planes & axes
Flexion/extension occurs in which plane and around which axis?
Why:Flexion/extension occurs in the sagittal plane around the frontal (transverse/lateral) axis.
Explanation & sources
Explanation
A pairs the sagittal plane with the rotation axis. B is side bending (frontal plane, sagittal axis). C is rotation (horizontal plane, longitudinal axis). Tip: the motion occurs on the plane; the axis is what you move about.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 23-24
2022 TA Review - Exam 1 · TA review · slides 26-27
Lecture slide (1)
Week 2 · Written Review deck · slide 11
66Planes & axes
Rotation occurs in the ____ plane around the ____ axis.
Why:Rotation occurs in the transverse (horizontal) plane around the longitudinal (vertical) axis.
Explanation & sources
Explanation
A mixes the flexion plane with the rotation axis. B is side bending. D is flexion/extension.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 31-32
Lecture slide (1)
Week 2 · Written Review deck · slide 11
67asked 2×2026Planes & axes
For each description, select the physiologic motion most closely associated with it (each heading may be used once, more than once, or not at all). Headings: A. flexion and extension; B. neutral; C. rotation; D. rotation and sidebending; E. sidebending. Description: Normal motion of the vertebral segments in a sagittal plane.
Ans: Sagittal plane → forward/backward bending → flexion and extension
Why: Motion in the sagittal plane (about a transverse axis) is flexion and extension.
Explanation & sources
Explanation
Neutral (B) is a range of sagittal positioning where Fryette's first principle applies, not a motion. Rotation (C) is about a vertical axis. Sidebending (E) is in the coronal plane about an A-P axis.
For each description, select the physiologic motion most closely associated with it (each heading may be used once, more than once, or not at all). Headings: A. flexion and extension; B. neutral; C. rotation; D. rotation and sidebending; E. sidebending. Description: Motion of vertebral segments around a vertical axis.
Why: Motion around the vertical (longitudinal) axis is rotation.
Explanation & sources
Explanation
Flexion/extension (A) is about a transverse axis. Sidebending (E) is about an A-P axis in the coronal plane. D combines two motions and does not describe a single axis.
A passenger's driver hits the brakes quickly, and the passenger is thrown forward and backward against the seat. In which plane of motion was the passenger moving forward and backward?
Ans: Forward/back = flexion/extension → asks for PLANE → sagittal
Why: Forward and backward motion is flexion/extension, which occurs in the sagittal plane. The question asks for the plane, not the axis.
Explanation & sources
Explanation
If the question asked for the axis, the answer would be frontal. Horizontal (B) is the rotation plane. Frontal (C) is the side bending plane. Longitudinal (D) is an axis, not a plane.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 35-36
Lecture slide (1)
Week 2 · Written Review deck · slide 11
70Planes & axes
A skier leans forward to stick her tongue to a ski-lift bar, then yanks her head backward. Along which axis of motion was she moving forward and back?
Why: Flexion/extension moves around the frontal (lateral/transverse) axis, while the motion itself occurs in the sagittal plane.
Explanation & sources
Explanation
Sagittal (A) is the plane, or the axis for side bending. Transverse (C) here would refer to the rotation plane. 'Y-axis' (D) is the vertical axis used for rotation.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 40-41
Lecture slide (1)
Week 2 · Written Review deck · slide 11
71Planes & axes
A man on a ski lift turned to his right to look at someone, then turned back to the left and felt back pain. In which plane of motion was he moving?
Reaching toward something in front and to the right = adds rotation right → horizontal plane, longitudinal (vertical) axis.
Leaning sideways = side bending → frontal plane, A-P (sagittal) axis. Only include it if the story describes it.
Apply it: picking up a child standing straight ahead = pure flexion (sagittal plane, transverse/lateral axis). Child in front and to the right = flexion and rotation right. If the question asks only about the rotational part, answer horizontal plane, longitudinal axis, and ignore the flexion.
72top 215asked 7×2026Describing spinal motion
A patient presents with pain in the low back. He says that it began with a sharp pain when he bent forward to pick up his child who was standing in front of him to the right. Which of the following describes his spinal motion?
Ans: Bent forward = flexion + reached toward the right = rotation right → flexion and rotation right
Why: Bending forward is flexion, and reaching for a child in front and to the right adds rotation right.
Explanation & sources
Explanation
A and E (both 'rotation right' on the source slide) leave out the forward bend. C adds side bending, which the story does not describe. D (flexion alone) fits only if the child were straight ahead, as in the next question.
A patient presents with pain in the low back. He says that it began with a sharp pain when he bent forward to pick up his child who was standing directly in front of him. Which of the following describes the plane and axis of the spinal motion?
Ans: Straight forward bend = pure flexion → sagittal plane, transverse/lateral axis
Why: A straight forward bend is pure flexion: sagittal plane around a transverse (frontal/lateral) axis.
Explanation & sources
Explanation
B is rotation (horizontal plane, vertical axis). C is side bending (frontal plane, A-P axis). D and E pair a plane with the wrong axis. Older versions word A as 'sagittal plane with a frontal/lateral axis', which means the same thing.
A patient presents with pain in the low back. He says that it began with a sharp pain when he bent forward and rotated to the right to pick up his child who was standing in front of him and to the side. Which of the following describes the plane and axis of the rotational spinal motion?
Ans: Asks only about rotation → horizontal plane, longitudinal axis
Why: The question asks only about the rotational part, which occurs in the horizontal plane around the longitudinal (vertical) axis.
Explanation & sources
Explanation
A describes the flexion part of the same movement, a trap for students who don't read 'rotational'. C is side bending. D and E pair a plane with the wrong axis.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 32-33
Lecture slide (1)
Week 2 · Written Review deck · slide 11
2.3 · 6 questions · Questions 75–80
Lateral gravity line
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The lateral gravity (plumb) line is viewed from the side. In ideal posture it passes, from top to bottom, through these points of lateral symmetry:
Vertex: just posterior to the apex of the coronal suture
External auditory meatus (not internal; not behind the ear canal)
Humeral head (not the greater tuberosity)
Middle of the L3 vertebral body (not L5)
Femoral head (not the lesser trochanter)
Just behind (posterior to) mid-knee
Just anterior to the lateral malleolus
The body's center of gravity is about 5 cm anterior to S2 (S2 is not itself a lateral-line landmark). A line falling in front of the knee or behind the lateral malleolus means postural misalignment. One question keys “anterior to the medial malleolus”; the slide says lateral, but that option is still the intended answer because the others are clearly wrong.
Reading a patient: a head and ear sitting well forward of the line means the external auditory meatus is the most deviated landmark (the 2026 key also accepts L3).
Whole-body deviations:anterior postural deviation = all points in front of the line, weight carried on the metatarsals. Posterior postural deviation = body leans back and balance is kept by an anterior thrust of the pelvis and hips, with marked lordosis from the mid-thoracic spine down.
Written Review slide 10: points of lateral symmetry
75asked 2×Lateral gravity line
Which of the following is a landmark the plumb line is drawn through?
Ans: Lateral line → EAM, humeral head, L3, femoral head, behind mid-knee, anterior to malleolus → B closest
Why: The lateral line passes just anterior to the lateral malleolus (the ankle). B is the only option near a true landmark.
Heads up: The keyed option says 'anterior to the MEDIAL malleolus'. The 2026 slides and the TA's own slide note say just anterior to the LATERAL malleolus. B is still the intended answer because the other three options are clearly wrong.
Explanation & sources
Explanation
A: the line passes through the external auditory meatus, not behind the ear canal. C: it passes just behind the mid-knee, not in front of the kneecap. D: it passes through the femoral head, not the lesser trochanter. The center of gravity is about 5 cm anterior to S2.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 19-20
2024 TA Review (Harlem) Exam 1 · TA review · slides 22-23
Lecture slide (1)
Week 2 · Written Review deck · slide 10
76top 215Lateral gravity line
Which of the following is NOT a point of lateral symmetry when comparing to the gravity line?
Ans: Gravity line at the ankle is just ANTERIOR to the lateral malleolus → 'posterior' is wrong
Why: At the ankle the gravity line falls just anterior to the lateral malleolus, not posterior to it.
Explanation & sources
Explanation
External auditory meatus (A), humeral head (B), femoral head (C) and the middle of L3 (E) are all true points of lateral symmetry.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 33-34
Lecture slide (1)
Week 2 · Written Review deck · slide 10
77top 215Lateral gravity line
A plumb line (gravity line) is dropped along the lateral side of a standing patient. Which physical landmark is a correct point of lateral symmetry?
Ans: Lateral line points → femoral head is on the list → D
Why: The femoral head is one of the points of lateral symmetry.
Explanation & sources
Explanation
Each other option is a near miss: A should be the external (not internal) auditory meatus; B should be the humeral head (not the greater tuberosity); C should be the middle of L3 (not L5); E should be just anterior (not posterior) to the lateral malleolus.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 46-47
Lecture slide (1)
Week 2 · Written Review deck · slide 10
78top 215Lateral gravity line
A patient comes to your OMM clinic concerned about their posture. You use a plumb line to look at their landmarks. Which of the following findings are a sign of postural misalignment?
Ans: Normal: just BEHIND mid-knee, just ANTERIOR to lateral malleolus → C and E deviate
Why: Normally the line passes just behind the mid-knee and just anterior to the lateral malleolus. A line anterior to the knee (C) or posterior to the lateral malleolus (E) both mean misalignment.
Heads up: The TA key marks only C. E (just posterior to the lateral malleolus) also contradicts the slide's landmark list (just ANTERIOR to the lateral malleolus), and the stem asks which findings 'are' signs, so C and E are both correct.
Explanation & sources
Explanation
A (middle of L3), B (external auditory meatus) and D (humeral head) are normal landmarks.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 28-29
Lecture slide (1)
Week 2 · Written Review deck · slide 10
79top 215asked 7×2026Lateral gravity line
In the assessment of this patient using the lateral gravity line, which landmark shows the most deviation?
Ans: Compare to ideal line: head/ear far forward of the line (and lumbar region off) → EAM most deviated
Why: The line should pass through the external auditory meatus, but this patient's head and ear sit well forward of it, which is the most obvious deviation. The 2026 answer slide also accepts the L3 vertebral body, where the lumbar curve falls off the line.
Heads up: The 2026 IA2 poll marks both B and D green. Earlier years (2021–2025 clickers) key B only. If an exam version allows only one answer, choose B (external auditory meatus).
Explanation & sources
Explanation
The ankle (A) is in its normal place, just in front of the line. The femoral head (C) is close to the line. S2 (E) is not a lateral line landmark; the body's center of gravity sits about 5 cm anterior to S2.
If all plumb line points are anterior to the gravity line, this means the patient has…
Ans: Whole body ahead of the line → anterior postural deviation → weight on the metatarsals
Why: When the whole body leans forward of the line, this is anterior postural deviation, and weight is supported by the metatarsals.
Explanation & sources
Explanation
A and D describe posterior deviation: the body leans back and balance is kept by an anterior thrust of the pelvis and hips, with marked lordosis from the mid-thoracic spine down. C (kyphosis-lordosis) is a curve pattern, not a whole-body forward lean.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 260-261
2020 TA Review Exam 1 · TA review · slides 252-253
Lecture slide (1)
Week 2 · Written Review deck · slide 9
2.4 · 6 questions · Questions 81–86
Static landmarks
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Static landmarks by view:
Anterior (from the front): head position, acromion process, iliac crest. (Ear position and knee flexion/extension are judged from the side.)
Posterior symmetry line: inion, midline of the vertebrae, midline of the sacrum, midline of the coccyx, and a point midway between the two ankles (left and right malleoli). The apex of the coronal suture is a lateral-line landmark, not posterior.
Landmark
Vertebral level
Suprasternal (sternal) notch
T2 vertebral body
Spine of the scapula
T3
Angle of Louis (sternal angle, rib 2 attaches)
Anterior to T4; aortic arch just superior, tracheal bifurcation just posterior
Inferior angle of the scapula
T7
Xiphoid process
Anterior to T9
12th rib
Follow it to T12
Umbilicus
About L3–L4 (L3 accepted)
Top of the iliac crests
L4–L5 interspace (L4 accepted)
Memory chain going down: notch T2 → scapular spine T3 → Louis T4 → inferior angle T7 → xiphoid T9 → iliac crest L4–5. A common trap is “Angle of Louis = T5”, which is wrong.
81Static landmarks
A patient asks for an osteopathic evaluation. The DO asks permission, then begins with observation from the front. Which anterior landmark is the doctor using?
Why: The lecture's anterior landmarks are head position, the acromion process and the iliac crest. Of these, only the acromion is offered.
Explanation & sources
Explanation
Ear position and knee flexion/extension (A, C) are assessed from the lateral view, against the lateral line. Navel deviation (D) is not on the course's anterior landmark list.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 52-53
82Static landmarks
The doctor then asks the patient to turn around and observes her posteriorly. What posterior landmarks are being used? (Select all that apply.)
Ans: Posterior line: inion, vertebral midline, sacral midline, coccyx midline, midway between both malleoli
Why: The posterior symmetry line runs through the inion, the midline of the vertebrae, the midline of the sacrum, the midline of the coccyx, and a point midway between both malleoli.
Explanation & sources
Explanation
A is wrong: the apex of the coronal suture is a lateral line landmark; posteriorly you use the inion. C is wrong as written: the point is midway between the two ankles (left and right malleoli), not between the lateral and medial malleolus of one ankle.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 54-55
83top 215asked 3×Static landmarks
What is the functional landmark of the iliac crest?
Ans: Iliac crests → L4-L5 interspace
Why: The top of the iliac crests marks the L4-L5 interspace.
Explanation & sources
Explanation
Distractors are other landmarks: T3 = spine of the scapula; T7 = inferior angle of the scapula; T2 vertebral body = suprasternal notch; anterior to T9 = xiphoid process.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 84-85
2020 TA Review (Middletown) Exam 1 · TA review · slides 95-96
2020 TA Review Exam 1 · TA review · slides 83-84
84top 215asked 2×Static landmarks
Which vertebra is at the level of the angle of Louis?
Ans: Angle of Louis (sternal angle, rib 2) → anterior to T4
Why: The angle of Louis (sternal angle, where rib 2 attaches) lies anterior to T4. The aortic arch lies just superior and the tracheal bifurcation just posterior.
Explanation & sources
Explanation
T2 (B) is the level of the suprasternal notch (T2 body). T3 is the spine of the scapula. T1 and T5 are distractors.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 197-198
2020 TA Review Exam 1 · TA review · slides 187-188
85Static landmarks
During an osteopathic exam you review the anatomical landmarks of the spine. Which of the following landmarks is incorrect?
Ans: Angle of Louis = T4, not T5 → C is incorrect
Why: The angle of Louis is at T4, not T5.
Explanation & sources
Explanation
Spine of the scapula = T3, sternal notch = T2 and inferior angle of the scapula = T7 are correct. The umbilicus lies at about L3-L4, and the iliac crest marks the L4-L5 interspace, so E and F are acceptable approximations.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 26-27
86Static landmarks
Match each landmark with its vertebral level: spine of scapula; suprasternal notch; xiphoid process; inferior angle of the scapula; angle of Louis. Choices: A. Anterior to T9; B. Anterior to T4; C. Aortic arch lies superior; D. T7; E. T3; F. Vertebral body of T2. (One landmark has two correct answers.)
AnswerSpine of scapula = E (T3); suprasternal notch = F (T2 body); xiphoid = A (anterior to T9); inferior angle of scapula = D (T7); angle of Louis = B and C.
Ans: Scapula spine T3 → notch T2 → Louis T4 → inferior angle T7 → xiphoid T9
Why: Functional landmarks: spine of scapula = T3, suprasternal notch = T2 body, angle of Louis = anterior to T4 (aortic arch just superior), inferior angle of scapula = T7, xiphoid = anterior to T9.
Explanation & sources
Explanation
Also know that the iliac crest marks the L4-L5 interspace and that the 12th rib can be followed to T12. Somatic dysfunction and group curves can shift these landmarks.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slide 72
Lecture slide (1)
Study note
2.5 · 7 questions · Questions 87–93
Spinal curves & development
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Convex = the side that bulges out. Lordosis = convex forward; kyphosis = convex backward (concave forward). The adult spine has four normal curves:
Region
Curve
Convexity
Cervical
Lordosis
Forward
Thoracic
Kyphosis
Backward
Lumbar
Lordosis
Forward
Sacrum (fused)
Kyphotic (not neutral)
Backward (per the 2026 review deck)
“Hyper” or increased lordosis/kyphosis refers to pathological states. There is no normal cervical kyphosis or thoracic lordosis.
Development: the spine starts as one kyphotic curve and the lordoses develop as the baby lifts its head and then stands.
Age
Spine
Birth
Whole spine kyphotic: one C-curve
13 months
Lumbar spine neutral
3 years
Lumbar lordosis begins to appear
8 years
Lumbar lordosis obvious
10 years
Clear adult stance (S-curve)
Causes of postural deviations:kyphosis: osteoporosis, compression fracture, depression, ankylosing spondylitis. Lordosis: pregnancy, obesity, high heels (weight in front or heels tip the pelvis forward → deeper lumbar curve). Scoliosis: unequal muscle use (e.g. carrying a bag), unequal growth, short leg, genetics. A pregnant woman in high heels → accentuated lumbar lordosis.
Lecture slide for this section (1)
Written Review slide 12: physiologic curves
87top 215Spinal curves & development
Which of the following curves is convex backward?
Ans: Convex backward = kyphosis → thoracic curve
Why: The thoracic kyphotic curve is convex backward (concave forward). The fused sacrum is also convex backward.
Explanation & sources
Explanation
Cervical (A) and lumbar (B) curves are lordotic, convex forward. There is no normal cervical kyphotic curve (D).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 31-32
Lecture slide (1)
Week 2 · Written Review deck · slide 12
88Spinal curves & development
At birth the spine is kyphotic; the curves change as we grow. Which of the following adult curvatures is incorrect?
Why: The adult sacrum is kyphotic (convex backward), not neutral.
Heads up: The original Lect 2 slide says 'Fused Sacrum is convex forward', but the 2026 review deck and IA2 slides say convex backward (kyphotic). Either way 'neutral' is the incorrect choice; follow the review deck (convex backward).
Explanation & sources
Explanation
Cervical lordosis (A), thoracic kyphosis (B) and lumbar lordosis (C) are the normal adult curves. Lordosis means convex forward; kyphosis means convex backward.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 37-38
Lecture slide (1)
Week 2 · Written Review deck · slide 12
89top 215asked 2×Spinal curves & development
At birth, what is the shape of the spine?
Ans: Newborn → whole spine kyphotic → C-curve
Why: At birth the whole spine is one kyphotic C-curve. The cervical and lumbar lordoses develop later, as the baby lifts its head and then stands.
Explanation & sources
Explanation
The S-curve (A) is the adult pattern of alternating curves. 'T curve' (B) is not a term.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 89-90
2020 TA Review Exam 1 · TA review · slides 77-78
90Spinal curves & development
Fill in the blank (development of spinal curves): Birth: whole spine is kyphotic/lordotic/neutral. 13 months: lumbar spine is kyphotic/lordotic/neutral. 3 years: lumbar kyphosis/lordosis begins to appear. 8 years: lumbar kyphosis/lordosis is obvious. 10 years: clear adult stance (cervical, thoracic, lumbar = ?).
Why: The spine starts as one kyphotic C-curve, the lumbar spine becomes neutral by 13 months, lordosis appears by 3 years, is obvious by 8, and the adult stance is clear by about 10 years.
2025 TA Review Exam 1 (Harlem) · TA review · slides 75-76
91Spinal curves & development
Match the development of the spinal curves with when they occur (Birth, 13 months, 3 years, 8 years, 10 years): A. Lordosis obvious; B. Lumbar spine neutral; C. Whole spine is a C-curve; D. Clear adult stance; E. Lordosis begins to appear.
AnswerBirth = C; 13 months = B; 3 years = E; 8 years = A; 10 years = D
Ans: C-curve at birth → neutral 13 mo → lordosis begins 3 y → obvious 8 y → adult 10 y
Why: Order: C-curve at birth, lumbar neutral at 13 months, lordosis begins at 3 years, lordosis obvious at 8 years, adult stance at 10 years.
Explanation & sources
Explanation
This matching set uses the same timeline as the fill-in-the-blank version, so learn it once as a sequence.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 68-69
92asked 3×Spinal curves & development
What could produce these disorders? Name some causes of each of these postural deviations: kyphosis, lordosis and scoliosis.
AnswerKyphosis: osteoporosis, compression fracture, depression, ankylosing spondylitis. Lordosis: pregnancy, obesity, high heels. Scoliosis: unequal muscle use (e.g., carrying a bag), unequal growth, short leg, genetics.
Why:Kyphosis: osteoporosis, compression fracture, depression, rheumatologic disease such as ankylosing spondylitis. Lordosis: pregnancy, obesity, high heels. Scoliosis: unequal muscle use, unequal growth, short leg, genetics.
Explanation & sources
Explanation
Lordosis causes share one idea: weight carried in front (or heels tipping the pelvis) pulls the lumbar curve deeper. Short leg as a cause of functional scoliosis returns in Week 5.
A woman comes in pregnant, wearing high heels, with back pain. What would you expect to find on observation of her posture?
Ans: Pregnancy + high heels → anterior load and pelvic tilt → increased lumbar lordosis
Why: Both pregnancy and high heels shift weight forward and tilt the pelvis anteriorly, producing an accentuated lumbar lordosis.
Explanation & sources
Explanation
A (flat back) is the opposite, a flattened lumbar curve. C and D swap the normal curve names: the cervical spine is lordotic and the thoracic spine is kyphotic.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 40-41
Lecture slide (1)
Week 2 · Written Review deck · slide 12
2.6 · 10 questions · Questions 94–103
Postural types
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The figure “Four Types of Postural Alignment” (Kendall) is used for picture questions. Its order is fixed: A = ideal, B = kyphosis-lordosis, C = flat back, D = sway back.
Posture
Key features
Ideal / normal
Line through ear, shoulder, hip, just behind knee, just in front of ankle; normal curves
Head forward, slight ↑ cervical lordosis, slight upper thoracic kyphosis flattening below, flattened lumbar lordosis, hips and knees extended
Sway back
Pelvis shifted forward with posterior tilt, upper trunk sways back, ↑ cervical/thoracic curves, decreased lumbar lordosis, hyperextended hips and knees
Military bearing (“chest out, stomach in”)
Head tilted posteriorly, chest elevated (anterior cervical, posterior thoracic deviation), cervical/thoracic spine otherwise normal (no ↑ kyphosis), increased lumbar lordosis, anterior pelvic tilt, knees extended, ankles plantar flexed
Anterior postural deviation
Whole body ahead of the line; weight on the metatarsals
Posterior postural deviation
Body leans back; balance by anterior thrust of pelvis and hips; increased lordosis from the mid-thoracic spine down
Sway back vs posterior deviation: both push the pelvis forward, but sway back has a decreased lumbar curve while posterior deviation has a marked lordosis.
IA2 slide 15: four types of postural alignment (A ideal, B kyphosis-lordosis, C flat back, D sway back)
94asked 2×Postural types
What posture is shown?
Ans: Plumb line through ear, shoulder, hip, behind knee, in front of ankle → normal (ideal)
Why: The plumb line falls through the ear, shoulder, mid-trunk and hip, just behind the knee, and just in front of the ankle, with normal curves. This is normal (ideal) alignment.
Explanation & sources
Explanation
Sway-back (A) shows the pelvis pushed forward with the upper trunk back. Flat-back (C) shows a flattened lumbar curve. Kyphosis-lordosis (D) shows exaggerated thoracic and lumbar curves.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 17-18
2020 TA Review (Middletown) Exam 1 · TA review · slides 27-28
Lecture slide (1)
Week 2 · IA2 Gross Motion · slide 15
95top 215asked 7×2026Postural types
Which of the following postures is described as “swayback”?
Ans: Pelvis pushed forward of the line, trunk swayed back, hips/knees hyperextended → D
Why: In sway-back (D) the pelvis is shifted forward with a posterior tilt, the upper trunk sways back, the lumbar lordosis is decreased, and the hips and knees are hyperextended.
Explanation & sources
Explanation
A is ideal alignment. B is kyphosis-lordosis (exaggerated thoracic and lumbar curves). C is flat back (flattened lumbar curve, hips and knees extended).
In the 'Four Types of Postural Alignment' figure (A-D), which posture is C?
AnswerFlat-back posture
Ans: C: lumbar curve flattened, head forward, hips and knees extended → flat back
Why: Posture C is flat back: head forward, slight increase in cervical lordosis, slight upper thoracic kyphosis that flattens below, flattened lumbar lordosis, and hips and knees extended.
Explanation & sources
Explanation
Figure order (Kendall): A ideal, B kyphosis-lordosis, C flat back, D sway back.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 26-27
2022 TA Review - Exam 1 · TA review · slides 21-22
Lecture slide (1)
Week 2 · IA2 Gross Motion · slide 15
97Postural types
Identify the posture shown in the image.
Ans: Hips pushed forward, upper back leaning behind → sway-back
Why: The pelvis is pushed forward past the line while the upper trunk leans back, which is sway-back.
Explanation & sources
Explanation
Normal (B) stacks the head, trunk and pelvis over the ankle. Flat-back (C) lacks the forward pelvic shift. Kyphosis-lordosis (D) shows a rounded upper back plus a deep lumbar curve and protruding abdomen.
Asked in
2020 TA Review Exam 1 · TA review · slides 28-29
Lecture slide (1)
Week 2 · IA2 Gross Motion · slide 15
98Postural types
Identify the posture shown in the image.
Ans: Forward head, rounded upper back, deep low-back curve with belly forward → kyphosis-lordosis
Why: Forward head, a rounded thoracic spine and an increased lumbar lordosis with a forward abdomen make this kyphosis-lordosis posture.
Explanation & sources
Explanation
Sway-back (A) has a decreased lumbar curve with the pelvis pushed forward. Flat-back (C) has a flattened lumbar curve. Normal (B) has neither exaggeration.
Asked in
2020 TA Review Exam 1 · TA review · slides 30-31
Lecture slide (1)
Week 2 · IA2 Gross Motion · slide 15
99top 215Postural types
While observing a patient standing next to a plumb line, you note that the head is slightly posterior, the neck is anterior, the shoulders are back, the abdomen is flat and there is an increased lumbar lordosis. The pelvis has an anterior tilt, the knees are extended and the ankles are plantar flexed. What would you name this posture type?
Ans: Chest out, stomach in, head back + increased lordosis, anterior pelvic tilt → military
Swayback (A) has decreased lumbar lordosis and a posterior pelvic tilt. Kypholordotic (B) has a forward head and rounded upper back. Flatback (C) has a flattened lumbar curve.
Why: Military-bearing posture has an increased lumbar lordosis with an anterior pelvic tilt.
Explanation & sources
Explanation
A: the thoracic spine is normal, not decreased. C: the head is tilted posteriorly, not anteriorly. D: the posture is upright ('chest out'), not leaning forward.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 25-26
Lecture slide (1)
Week 2 · Written Review deck · slide 9
101asked 2×Postural types
Which of the following does NOT describe military-bearing posture?
Ans: Military: head back, ↑ lumbar lordosis, knees extended; C/T spine normal → no ↑ kyphosis
Why: In military-bearing posture the cervical and thoracic spine are described as normal, so increased thoracic kyphosis does not fit.
Explanation & sources
Explanation
Head tilted posteriorly (A), increased lumbar lordosis (B) and knees extended (C) are all features of military-bearing posture.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 30-31
2022 TA Review - Exam 1 · TA review · slides 24-25
Lecture slide (1)
Week 2 · Written Review deck · slide 9
102Postural types
What are characteristics of the military-bearing posture? (Select all that apply.)
Why: Military bearing: head tilted posteriorly, chest elevated with anterior cervical and posterior thoracic deviation, increased lumbar lordosis, anterior pelvic tilt, knees extended, ankles plantar flexed.
Explanation & sources
Explanation
C, D and F are each reversed: the lumbar lordosis is increased, the pelvis tilts anteriorly, and the ankles are plantar flexed (not dorsiflexed).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 49-50
Lecture slide (1)
Week 2 · Written Review deck · slide 9
103Postural types
Match each description to the correct posture (flat back, military-bearing, anterior postural deviation, swayback, posterior postural deviation): (1) body deviates anteriorly, weight supported by the metatarsals; (2) increased cervical lordosis, slight upper thoracic kyphosis, flattening in the lower thoracic and lumbar spine; (3) anterior cervical and posterior thoracic deviation, increased lumbar lordosis, anterior pelvic tilt, ankles plantar flexed; (4) body deviates posteriorly, balance kept by anterior thrust of the pelvis, increased lordosis from the mid-thoracic spine down; (5) increased cervical and thoracic curves, decreased lumbar lordosis, posterior pelvic tilt, hyperextended hips and knees.
Why: Key features: anterior deviation = weight on the metatarsals; flat back = flattened lumbar curve; military = chest up, increased lordosis, ankles plantar flexed; posterior deviation = anterior pelvic thrust; swayback = decreased lordosis, hyperextended hips and knees.
Explanation & sources
Explanation
Swayback and posterior deviation both push the pelvis forward. Swayback has a decreased lumbar curve, while posterior deviation has marked lordosis from the mid-thoracic spine down.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 35-36
Lecture slide (1)
Week 2 · Written Review deck · slide 9
2.7 · 9 questions · Questions 104–112
Muscles in posture
No questions in this section match the current Show filter.
Learn firstWhat you need for 2.7
Postures are held by a pattern of tight/overactive (hypertonic, shortened) muscles that need stretching and inhibited/weakened muscles that need strengthening. Learn the two course slides below, which take priority over the textbook table when they differ.
Back extensors, multifidus, iliacus, and psoas (2026 Canvas correction: psoas is long and weak, not tight)
The rectus abdominis is tight in both; the glutei are the key difference (tight in flat back, weak in sway back). Tight hamstrings pull the pelvis into posterior tilt → sway back. Muscles like the pectoralis major are not on either list (they shorten in kyphotic and forward-head postures).
Why: In sway-back the tight/overactive muscles are the rectus abdominis, hamstrings and TFL/ITB. Tight hamstrings hold the pelvis in posterior tilt.
Explanation & sources
Explanation
The thoracic extensors (B), iliopsoas (C) and glutei (E) are the inhibited/weakened muscles in sway-back, along with the obliques and multifidus. The cervical extensors (A) are not on the sway-back list.
Memory aid: in sway-back the pelvis tucks (posterior tilt) and the hips hyperextend, so the muscles pulling the pelvis down in back (hamstrings) and up in front (rectus abdominis) are short.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 20-21
While walking to the market, a student notices a man at the bus stop with a flat-back posture. Which muscles would be inhibited/weakened by this posture?
Ans: Flat back weak: back extensors, multifidus, iliacus + psoas (long & weak per Canvas correction)
Why: In flat back the back extensors are inhibited/weakened. Per the course's Canvas correction, the psoas is also long and weak (the postural table lists hip flexors as weakened).
Heads up: The 2023 TA key marks only C (back extensors) and treats the psoas as tight, following the original slide. The 2026 Canvas correction says the flat-back psoas is LONG and WEAK, so B and C are both correct.
Explanation & sources
Explanation
Rectus abdominis (A) is normal or tight in flat back, together with the glutei.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 37-38
Which of the following is a correct description of what you would expect to find in flat-back or sway-back posture?
Ans: Flat back → weak back extensors (lumbar curve lost) → A
Why: In flat back the back extensors are weak, along with the multifidus and iliacus, so the lumbar curve flattens.
Explanation & sources
Explanation
B: the glutei are tight, not weak, in flat back. C: the glutei are weak, not tight, in sway-back. D: the hamstrings are tight, not weak, in sway-back. E: the rectus abdominis is normal or tight in flat back.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 262-263
2020 TA Review Exam 1 · TA review · slides 254-255
Hypertonic muscles can cause asymmetry. What muscles would be hypertonic in a flat back compared with a sway back postural alignment?
AnswerFlat back: rectus abdominis and glutei (psoas is long and weak). Sway back: rectus abdominis, hamstrings, TFL/ITB.
Ans: Flat back tight: RA + glutei; sway back tight: RA + hamstrings + TFL
Why:Flat back hypertonic: rectus abdominis and glutei; weak: back extensors, multifidus, iliacus and psoas. Sway back hypertonic: rectus abdominis, hamstrings, TFL/ITB; weak: obliques, iliopsoas, multifidus, thoracic extensors, glutei.
Heads up: The TA key lists the psoas as hypertonic in flat back, following the original slide. The 2026 Canvas correction says the flat-back psoas is long and weak, so it is left out here.
Explanation & sources
Explanation
The rectus abdominis is tight in both. The glutei are the key difference: tight in flat back, weak in sway back.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 34-35
Bonus: Which posture would present with tight hamstrings? Which with weak abdominal muscles?
AnswerTight hamstrings: sway-back (posterior pelvic tilt; also rectus abdominis and TFL tight). Weak abdominals: lordotic (kyphosis-lordosis) posture with anterior pelvic tilt and tight hip flexors and lumbar extensors.
Ans: Hamstrings pull pelvis into posterior tilt → sway-back; weak abs let pelvis tip forward → lordotic
Why:Tight hamstrings pull the pelvis into posterior tilt, as in sway-back. Weak abdominals let tight hip flexors tip the pelvis into anterior tilt, the lordotic (kyphosis-lordosis) pattern.
Explanation & sources
Explanation
From the postural table: lordotic posture has shortened lumbar extensors and hip flexors with weakened abdominals; sway-back has weakened lower abdominals and shortened hip extensors.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 31-32
No questions in this section match the current Show filter.
Learn firstWhat you need for 3.1
Somatic dysfunction (SD) is an impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial (joint) and myofascial structures, plus their related vascular, lymphatic and neural elements. It is not the red reflex, not a vasodilation response, and not “the direction of freer motion” (that is how an SD is named).
SD is diagnosed with the TART criteria (letter order varies by source; the four findings never change):
Inflammation or arthritis (diagnoses, not palpatory criteria)
A
Asymmetry
Atrophy
R
Restriction of motion
Redness / red reflex (a separate special test)
T
Tenderness
—
Because restriction is a criterion, full range of motion is not a finding of SD (in acute SD range may not be clearly reduced, but motion feels sluggish).
Two true facts: a region can have more than one SD at a time (e.g. a Type II at the apex or end of a Type I group curve; treat the Type II first). And the body compensates for SDs over time: chronic SD shows asymmetry with compensation in other areas, while acute SD is segmental without much compensation yet.
Lecture slide for this section (1)
Written Review slide 15: TART
113top 215asked 5×Definition & TART
Which of the following best defines somatic dysfunction?
Ans: Somatic dysfunction → impaired/altered function of somatic framework → D
Why: Somatic dysfunction is an impaired or altered function of related components of the somatic framework: skeletal, arthrodial and myofascial structures plus their related vascular, lymphatic and neural elements.
Explanation & sources
Explanation
B is the definition of the red reflex (erythema test), not of somatic dysfunction. A is wrong because the sympathetic response in SD causes vasoconstriction, not vasodilation. C describes the freedom of motion, which is how an SD is named, not what an SD is. The term 'somatic dysfunction' replaced 'osteopathic lesion' in 1968.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 41-42
2023 TA Review (Harlem) - Exam 1 · TA review · slides 34-35
2022 TA Review - Exam 1 · TA review · slides 29-30
2020 TA Review (Middletown) Exam 1 · TA review · slides 39-40
2020 TA Review Exam 1 · TA review · slides 42-43
Lecture slide (1)
Week 3 · Written Review deck · slide 15
114asked 3×Definition & TART
What does TART stand for?
AnswerTissue texture change, Asymmetry, Restriction of motion, Tenderness.
Ans: TART → the four objective findings used to diagnose somatic dysfunction
Why: TART lists the objective findings that diagnose somatic dysfunction: Tissue texture change, Asymmetry, Restriction of motion, Tenderness.
Explanation & sources
Explanation
The letter order varies between sources (some start with Tenderness), but the four findings are always the same. Common wrong substitutions are 'Atrophy' for Asymmetry and 'Redness' for Restriction. The red reflex is a special test, not a TART criterion.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 36-37
2024 TA Review (Harlem) Exam 1 · TA review · slides 32-33
2022 TA Review - Exam 1 · TA review · slides 19-20
Lecture slide (1)
Week 3 · Written Review deck · slide 15
115Definition & TART
What is the correct form of the TART acronym?
Ans: TART → Tenderness, Asymmetry, Restriction, Tissue texture → E
Why: The A is Asymmetry and the R is Restricted motion, so only E is correct.
Explanation & sources
Explanation
Any option with 'Atrophy' or 'Redness' is wrong. Redness belongs to the red reflex test, and atrophy is not one of the four criteria. B and D are identical distractors that both swap in Redness.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 63-64
Lecture slide (1)
Week 3 · Written Review deck · slide 15
116Definition & TART
What is not found in the acronym TART?
Ans: TART = tissue texture, asymmetry, restriction, tenderness → atrophy absent → A
Why: The A in TART is Asymmetry, not atrophy.
Explanation & sources
Explanation
Asymmetry, restricted motion, tenderness and tissue texture changes are the four TART findings. Atrophy is a common trap because it also starts with A.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 49-50
Lecture slide (1)
Week 3 · Written Review deck · slide 15
117Definition & TART
Which of these is not correctly categorized as a TART sign?
Ans: TART's R = Restriction of motion, not Red reflex → C
Why: The R in TART is Restriction of motion. The red reflex is a separate special test used to judge acute vs chronic SD.
Explanation & sources
Explanation
Tenderness, asymmetry and tissue texture change are all TART criteria. Normal skin gets initial redness that fades quickly; lingering redness suggests acute SD and early blanching suggests chronic SD.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 43-44
Lecture slides (2)
Week 3 · Written Review deck · slide 15Week 3 · Written Review deck · slide 20
118asked 3×Definition & TART
Which of the following findings is a diagnostic characteristic of somatic dysfunction?
Ans: Diagnostic characteristics = TART → tissue texture changes → B
Why:Tissue texture change is the first T of TART.
Explanation & sources
Explanation
Full range of motion is the opposite of the R (restriction). Inflammation and arthritis are diagnoses, not palpatory TART criteria. Warmth, edema and bogginess are examples of tissue texture change.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 31-32
2020 TA Review (Middletown) Exam 1 · TA review · slides 36-37
2020 TA Review Exam 1 · TA review · slides 38-39
Lecture slide (1)
Week 3 · Written Review deck · slide 15
119top 215asked 8×2026Definition & TART
Which of the following findings is not a diagnostic characteristic of somatic dysfunction?
Ans: TART includes Restriction → full ROM is not SD → D
Why: Somatic dysfunction requires restriction of motion (the R in TART), so full range of motion is not a finding of SD.
Explanation & sources
Explanation
Edema and temperature change are both tissue texture changes (the first T). Tenderness and asymmetry are the other two TART criteria. Note that in acute SD range may not be clearly restricted but feels sluggish.
True or false when referring to a somatic dysfunction? Patients can only have one SD per body part.
Ans: Type II can sit inside a Type I curve → multiple SDs possible → False
Why: A region can have more than one SD at once. A classic example is a Type II dysfunction at the apex or end of a Type I group curve.
Explanation & sources
Explanation
Because Type II and Type I can coexist, you must decide which to treat first. The course rule is to treat the Type II dysfunction before the Type I curve.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 38-39
Lecture slide (1)
Week 3 · Written Review deck · slide 18
121Definition & TART
True or false when referring to a somatic dysfunction? The body can compensate for them after a while.
Contracture but decreased tone: mushy, flaccid, fibrotic, ropy, atrophic
Tissue
Boggy, edematous, congested
Doughy: chronic congestion from a poor lymphatic pump; little or no edema
Motion
Range not always restricted but sluggish; painful restriction
Limited ROM from contracture/fibrosis; restriction with little or no pain
Visceral
Somatovisceral effects minimal
Somatovisceral effects common
Compensation
Segmental, little compensation
Compensation in other areas
Traps: boggy (acute edema) vs doughy (chronic congestion). Chronic SD does not usually involve swelling. Chronic muscle is not hypertrophied. Mixed options like “cold and boggy” are wrong. Paresthesia and itching-only answers are not acute tissue findings.
Lecture slide for this section (1)
Written Review slide 16: acute vs chronic findings
122Acute vs chronic
You palpate a patient's paraspinal muscles and notice bogginess, edema, tenderness, and warmth. Which best describes this dysfunction?
Why:Boggy, edematous, warm and more tender tissue is the acute pattern.
Explanation & sources
Explanation
Chronic SD feels cool, dry, ropy/fibrotic and less tender. Type I and Type II describe spinal mechanics, not tissue quality. A viscerosomatic reflex can produce acute-looking changes, but the question asks what describes the palpatory finding itself.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 47-48
Lecture slide (1)
Week 3 · Written Review deck · slide 16
123top 215asked 3×Acute vs chronic
What changes take place in an acute somatic dysfunction?
Why: Acute SD tissues are boggy, edematous and congested from the vascular and chemical changes of injury.
Explanation & sources
Explanation
Cool dry skin (A), mushy/flaccid/ropy muscle (B) and common somatovisceral effects (D) are all chronic findings. In acute SD somatovisceral effects are minimal.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 27-28
2020 TA Review (Middletown) Exam 1 · TA review · slides 31-32
2020 TA Review Exam 1 · TA review · slides 33-35
Lecture slide (1)
Week 3 · Written Review deck · slide 16
124top 215asked 2×2026Acute vs chronic
A 50-year-old male with no history of low back pain presents with acute low back pain after gardening for several hours yesterday. Structural examination reveals tissue texture changes to the right lumbar paraspinal region. Which of the following would most likely be appreciated at this time?
Your gym friend is complaining about muscle pain and asks you for help. You begin with palpation and decide that it is an acute change. How would you describe an acute change in musculature?
Ans: Acute → warm (inflamed) + boggy (edema) → C
Why: Acute tissue is warm and boggy.
Explanation & sources
Explanation
Cold, firm, mushy and dry are chronic descriptors. E mixes a chronic temperature (cold) with an acute texture (boggy). Remember: acute = warm, moist, boggy, red; chronic = cool, dry, ropy, fibrotic.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 138-139
Lecture slide (1)
Week 3 · Written Review deck · slide 16
126Acute vs chronic
Which of the following correctly describes an acute change to musculature?
Ans: Acute → inflammation → redness (rubor) → D
Why:Rubor (redness) reflects the inflammatory, vasodilated state of acute SD.
Explanation & sources
Explanation
Ropiness, dryness, coolness and firmness all describe chronic tissue. Acute skin is warm, moist and shows a prolonged red reflex.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 164-165
Lecture slide (1)
Week 3 · Written Review deck · slide 16
127top 215asked 7×2026Acute vs chronic
What changes take place in chronic somatic dysfunctions?
Ans: Chronic → fibrosis replaces muscle → contracture with decreased tone → E
Why: In chronic SD, fibrotic tissue replaces contractile muscle, producing contracture (fixed shortening) with decreased tone that feels mushy, ropy and fibrotic.
Explanation & sources
Explanation
Warmth, sharp pain and boggy edema are acute findings. Chronic muscle is not hypertrophied; tone is decreased. Chronic ROM is limited because of the contracture or fibrosis.
Why: Chronic tissues feel doughy from chronic congestion and a poor lymphatic pump.
Explanation & sources
Explanation
Sharp pain, warm moist skin and hypertonic muscle are acute findings. Chronic muscle has decreased tone. Do not confuse doughy (chronic congestion) with boggy (acute edema).
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 29-30
2020 TA Review (Middletown) Exam 1 · TA review · slides 33-34
2020 TA Review Exam 1 · TA review · slides 34-36
Lecture slide (1)
Week 3 · Written Review deck · slide 16
129top 215asked 2×2026Acute vs chronic
A 60-year-old female presents for a general wellness examination. She denies any complaints and has no noticeable limitations to range of motion by routine musculoskeletal examination. However, focused osteopathic structural examination reveals somatic dysfunction of T1-T2 on the left, and fibrotic muscles with decreased tension. Which of the following is most associated with this type of somatic dysfunction?
Ans: Fibrotic, decreased tone → chronic SD → cool, dry skin → A
Why: Fibrosis with decreased tone means chronic SD, which goes with cool, dry skin.
Explanation & sources
Explanation
Sharp pain, erythema and moist boggy tissue are acute findings. Segmental asymmetry without compensation also suggests acute SD; chronic SD shows compensation elsewhere.
A 22-year-old male presents with a 7-month history of right-sided back pain that worsens after prolonged standing. On exam, you find tissue texture changes including cool temperature, ropy and fibrotic consistency, and decreased tenderness over the right paraspinal muscles. Which of the following best describes the pain associated with this type of somatic dysfunction?
Ans: 7 months + cool, ropy, less tender → chronic → dull ache → A
Why: Chronic SD pain is a dull ache (sometimes burning), less intense than acute pain.
Explanation & sources
Explanation
Sharp, severe pain is acute. Throbbing and radiating pain are not the textbook SD descriptors. Burning appears in some chronic lists but 'radiating' suggests nerve root pain.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 45-46
Lecture slide (1)
Week 3 · Written Review deck · slide 16
131asked 2×Acute vs chronic
Which of the following is NOT an example of a chronic somatic dysfunction of the shoulder?
Ans: Moist, edematous, erythematous, boggy → acute, not chronic → C
Why:Moist, edematous, erythematous, boggy tissue is the acute picture.
Explanation & sources
Explanation
Little or no temperature rise, compensation in other areas, and restriction with little or no pain all fit chronic SD. TAs flagged acute vs chronic as a favorite exam topic.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 64-65
2022 TA Review - Exam 1 · TA review · slides 31-32
Lecture slide (1)
Week 3 · Written Review deck · slide 16
132Acute vs chronic
True or false when referring to a somatic dysfunction? Chronic SDs usually involve swelling.
Ans: Swelling/edema → acute; chronic → decreased or no edema → False
Why:Edema is an acute finding. Chronic SD has decreased or no edema; its tissues feel doughy from chronic congestion instead.
Explanation & sources
Explanation
Acute tissues are boggy and edematous. Chronic tissues are cool, dry, ropy and fibrotic.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 38-39
Lecture slide (1)
Week 3 · Written Review deck · slide 16
133Acute vs chronic
Which of the following are correctly matched between acute/chronic somatic dysfunctions and their findings? (There may be more than one correct.)
Ans: Sharp pain + hypertonia = acute; mushy, ropy, low tone = chronic → A and F
Why: Acute SD has sharp, severe pain with hypertonic muscle. Chronic SD has decreased tone that feels mushy, fibrotic and ropy.
Explanation & sources
Explanation
B (dull ache) and C (doughy, poor lymphatic pump) are chronic findings mislabeled as acute. D (warm, moist, red reflex) and E (boggy, edematous) are acute findings mislabeled as chronic.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 51-52
Lecture slide (1)
Week 3 · Written Review deck · slide 16
134Acute vs chronic
Compare and contrast acute vs chronic somatic dysfunction findings: tenderness, tissue texture changes, moist or dry, temperature, red reflex/erythema test.
AnswerAcute: more tender; hypertonic, boggy, edematous; moist; warm; redness lingers. Chronic: less tender; atrophic, fibrotic, ropy; dry; cool; early blanching.
Why: Acute findings come from inflammation (vasoactive mediators, edema). Chronic findings come from long-standing sympathetic vasoconstriction and fibrosis.
Explanation & sources
Explanation
Learn the table as two pictures rather than isolated facts. Acute pain is sharp and severe; chronic pain is a dull ache. Somatovisceral effects are minimal in acute SD and common in chronic SD.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 40-41
Match each finding to acute or chronic somatic dysfunction: A. Boggy on palpation; B. Doughy on palpation; C. Dull ache, burning pain; D. Sharp, severe pain; E. Skin is scaly and dry; F. Skin has an acute red reflex; G. Fibrotic; H. Congested soft tissue.
The tricky pair is boggy vs doughy: boggy is acute edema, doughy is chronic congestion from a poor lymphatic pump. 'Congested soft tissue' is listed with boggy and edematous on the acute side of the course table.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 36-37
Lecture slide (1)
Week 3 · Written Review deck · slide 16
136Acute vs chronic
Match each finding with acute or chronic somatic dysfunction: edematous/erythematous/boggy tissues; increased tissue moisture, warmth; hypertonic muscles; painful restriction with movement; severe and sharp tenderness; cool, dry skin with slight tension; decreased or no edema; decreased muscle tone, flaccid, fibrotic, ropy; restriction with decreased or no pain; dull, achy, or burning tenderness.
AnswerAcute: edematous/erythematous/boggy; moist, warm; hypertonic; painful restriction; sharp severe tenderness. Chronic: cool dry skin; little or no edema; decreased tone, flaccid, fibrotic, ropy; painless restriction; dull, achy, burning tenderness.
Ans: First five findings → acute; last five findings → chronic
Why: The list splits cleanly: the first five are acute (inflamed, painful) and the last five are chronic (cool, fibrotic, less painful).
Explanation & sources
Explanation
Restriction occurs in both, but acute restriction is painful while chronic restriction has little or no pain. Muscle tone is increased (hypertonic) in acute and decreased in chronic SD.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slide 110
Lecture slide (1)
Week 3 · Written Review deck · slide 16
137Acute vs chronic
Label the following somatic dysfunction findings as acute or chronic: sharp severe pain with hypertonic musculature; dull ache, burning pain; tissue congestion, doughy tissues, poor lymphatic pump; skin warm, moist, acute red reflex; boggy, edematous, congested soft tissue; common to have somatovisceral effects; sluggish mobility; limited ROM due to contracture or fibrosis; skin cool, dry, scaly, pale, itchy, pigmentation change; decreased muscle tone, mushy/flaccid, ropy, fibrotic.
AnswerAcute: sharp pain with hypertonia; warm moist skin with red reflex; boggy edematous tissue; sluggish mobility. Chronic: dull/burning ache; doughy congestion; common somatovisceral effects; contracture-limited ROM; cool dry scaly skin; decreased tone, ropy.
Why:Sluggish mobility (range not always restricted) is acute, while ROM limited by contracture or fibrosis is chronic. Somatovisceral effects are common in chronic and minimal in acute SD.
Explanation & sources
Explanation
Acute red reflex: local bradykinin and histamine override sympathetic vasoconstriction, so redness lingers. Chronic red reflex: initial redness then blanching before the surrounding skin.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 65-66
No questions in this section match the current Show filter.
Learn firstWhat you need for 3.3
The red reflex (erythema test): stroke the paraspinal skin firmly with two finger pads and watch how the redness behaves compared with the surrounding skin. Normal skin reddens briefly and fades.
Acute SD
Chronic SD
What you see
Redness that remains longer than the rest of the area
Initial redness, then blanching before the rest of the area blanches
Mechanism
Irritated skin releases bradykinin, histamine and other vasoactive mediators → hyperemia. Sympathetic outflow is increased, but the region is facilitated (lowered threshold) and over-responds, so the local mediators win
Long-standing hypersympathetic tone → vasoconstriction (the chemical mediation is long gone) → ↓ blood flow; fibrosis, ↓ circulation, ↓ local response, trophic changes
Decide acute vs chronic from the history: scoliosis diagnosed 12 years ago or 30 years of smoking/COPD = chronic (expect blanching and chronic tissue such as fibrotic, ropy muscle). A box-lifting injury yesterday = acute (lingering redness). An acute red reflex can also come from an acute visceral problem at that segment (viscerosomatic reflex).
Lecture slides for this section (2)
IA3 slide 26: acute red reflexIA3 slide 27: chronic red reflex
138top 215asked 3×Red reflex
A new 22-year-old patient presents for a comprehensive history and physical. If the patient has a history of scoliosis, diagnosed at age 10, what would their red reflex look like?
Ans: 12-year history → chronic → early blanching → D
Why: A 12-year-old problem is chronic, and the chronic red reflex is initial redness followed by blanching before the surrounding skin.
Explanation & sources
Explanation
Lingering redness indicates acute SD, so B pairs the wrong response with chronic. A and C pair the responses with acute. Chronic blanching comes from long-standing hypersympathetic vasoconstriction and fibrosis.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 38-39
2020 TA Review (Middletown) Exam 1 · TA review · slides 43-44
2020 TA Review Exam 1 · TA review · slides 46-47
Lecture slide (1)
Week 3 · IA3 Somatic Dysfunction · slide 27
139Red reflex
A patient presents with shortness of breath due to COPD. He has been smoking 1 pack a day for the last 30 years. You perform a red reflex test on his back as part of your osteopathic examination. What do you expect to find?
Ans: 30-year COPD → chronic viscerosomatic changes → only chronic option = fibrotic, ropy → C
Why: Long-standing COPD produces chronic segmental changes, and flaccid, fibrotic, ropy musculature is the only chronic finding offered.
Heads up: None of the options describes the chronic red reflex itself (redness, then early blanching). The key picks C because it is the only chronic finding listed.
Explanation & sources
Explanation
Prolonged redness (B) is the acute red reflex. Sharp pain, boggy tissue and minimal somatovisceral effects are all acute findings. The true chronic red reflex result would be early blanching.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 44-45
A 34-year-old patient presents with acute thoracic back pain after lifting a heavy box. During physical examination, the physician runs a firm stroke with two finger pads along the paravertebral area (Red Reflex / Erythema Test). The test results in sustained, exaggerated redness in the T4–T6 region that lasts significantly longer than surrounding tissues. Which underlying mechanism best accounts for this palpatory finding?
Ans: Acute SD + lingering redness → local bradykinin/histamine override vasoconstriction → C
Why: In acute SD, bradykinin, histamine and other vasoactive mediators cause local hyperemia. The region is facilitated, so it overreacts to slight irritation and redness lasts longer.
Explanation & sources
Explanation
A, B, D and E describe chronic mechanisms: long-standing sympathetic vasoconstriction, fibrosis, poor lymphatic pump and blanching. Sympathetic outflow is increased in acute SD too, but the local mediators override it.
Asked in
2026 Textbook Q&A Compilation - Somatic Dysfunction Practice Questions · Practice questions · slide 141 (answer slide 142)
Lecture slide (1)
Week 3 · IA3 Somatic Dysfunction · slide 26
3.4 · 4 questions · Questions 141–144
Barriers
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Motion barriers, from neutral outward:
Barrier
Definition
Physiologic
Limit of active motion (the patient moves on their own); springy end-feel; can be stretched past with a warm-up. Example: a healthy person sidebending the neck to 45°
Elastic
Safe zone of passive stretch between the physiologic and anatomic barriers
Anatomic
Absolute limit of passive motion, set by bones and ligaments; hard end-feel (e.g. olecranon in elbow extension); forcing past it tears tissue
Restrictive
Early, abnormal stop caused by somatic dysfunction, before the physiologic barrier. This is what OMT treats
Pathologic
Permanent, hard stop from tissue disease, bone spurs or joint damage; does not change easily with OMT
Disrupted vs created: when SD reduces active range (e.g. neck rotation limited by pain after a car accident), the normal physiologic barrier is the one disrupted; a restrictive barrier is what gets created. With SD present, motion stops early at the restrictive barrier. A firm stop that appears before the expected end of active motion is restrictive, even if the stem says going further would damage tissue.
Lecture slide for this section (1)
Written Review slide 21: motion barriers
141top 215asked 2×2026Barriers
A 20-year-old female presents for a general maintenance examination without complaints. Structural examination is negative for somatic dysfunction. The patient without a cervical somatic dysfunction actively sidebends her cervical spine to an endpoint of 45 degrees. This limit is most appropriately described as the
Ans: Active motion limit, no SD → physiologic barrier → C
Why: The physiologic barrier is the limit of active (patient-generated) motion.
Explanation & sources
Explanation
The anatomic barrier is the limit of passive motion set by bone and ligament. The elastic barrier is the zone of passive stretch between the physiologic and anatomic barriers. A restrictive barrier requires somatic dysfunction, which this patient lacks. 'Rotational barrier' is not a term.
A physician performs passive motion testing on a patient's lumbar spine. Movement toward left sidebending meets a firm end-feel prior to reaching the expected limit of active movement, significantly shortening the patient's available range of motion. Passive movement beyond this newly encountered barrier is impossible without causing tissue damage. How should this new limit to motion be classified?
Ans: Early abnormal stop inside the active range → restrictive barrier → C
Why: A restrictive barrier is an early, abnormal stop caused by somatic dysfunction that lies before the physiologic barrier. It is what OMT treats.
Explanation & sources
Explanation
The anatomic barrier lies beyond the physiologic barrier, not before it, even though the stem's tissue-damage wording sounds anatomic. The physiologic barrier is the normal end of active motion. Neutral point shifting and hypermobility are not barrier types. A pathologic barrier (permanent stop from tissue disease, spurs or joint damage) is not offered.
Asked in
2026 Textbook Q&A Compilation - Somatic Dysfunction Practice Questions · Practice questions · slide 147 (answer slide 148)
Lecture slide (1)
Week 3 · Written Review deck · slide 21
143top 2152026Barriers
A 22-year-old female presents to the office with the complaint of sharp, non-radiating pain at the base of her neck. She reports that she was a seatbelt-restrained driver in a motor vehicle accident 2 weeks ago and that she hit her head against the steering wheel. She denies any numbness, weakness, or paresthesias. Physical examination reveals that the patient can actively rotate her head 65° to the left and 75° to the right, limited by pain. The type of barrier that is most likely disrupted in this patient is
Ans: Active ROM reduced → normal physiologic barrier disrupted → restrictive barrier created → D
Why: Active motion ends at the physiologic barrier. When somatic dysfunction occurs, that normal barrier is disrupted and a restrictive (or pathologic) barrier is created in its place.
Explanation & sources
Explanation
Restrictive and pathologic barriers are what is created, not what is disrupted. An anatomic barrier disruption would mean torn ligament or fracture, and she has no neurologic signs. The elastic barrier is a passive zone that is not tested by active rotation.
Match each to A. Anatomical barrier, B. Physiological barrier, C. Restrictive barrier: (1) How far you can forward bend (or bend your knee) without an SD; (2) Limited by ligaments and bones; (3) How far you can sidebend your neck to the right after tweaking it.
Answer1-B (physiologic, springy end-feel); 2-A (anatomic, hard end-feel, e.g. olecranon in elbow extension); 3-C (restrictive).
Ans: Normal active limit = physiologic; bone/ligament limit = anatomic; SD limit = restrictive
Why:Physiologic = normal limit of active motion. Anatomic = absolute passive limit set by bones and ligaments. Restrictive = early stop caused by somatic dysfunction.
Explanation & sources
Explanation
Order from neutral outward in a healthy joint: physiologic barrier, then the elastic zone, then the anatomic barrier. An SD adds a restrictive barrier inside the physiologic range.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 43-44
Lecture slide (1)
Week 3 · Written Review deck · slide 21
3.5 · 8 questions · Questions 145–152
Fryette's principles
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Fryette's principles describe how the thoracic and lumbar spine couple sidebending and rotation. Rotation is named for where the anterior vertebral body turns (so the spinous process moves the opposite way).
Principle 1 = Type I
Principle 2 = Type II
Spine position
Neutral
Non-neutral: sufficiently flexed or extended
Which comes first
Sidebending precedes rotation
Rotation (of one segment) precedes sidebending
Coupling
Rotation to the opposite side (toward the convexity)
Rotation and sidebending to the same side (rotation into the concavity)
Segments
Group: two or more
Single segment
Principle 3 (motion restriction) applies to the entire spine: moving a segment in one plane reduces its motion in the other two planes. Example: a flexed segment has less sidebending and rotation available.
Type II dysfunctions are found at the apex (mid-point) or extremes (ends) of Type I curves, at transitional areas, or by themselves. Clinical clues: sitting at a desk / neutral spine → Law I (one TA question describes the spinous processes in a way that technically gives same-side coupling, but it says neutral and is keyed Law I: let the stated position decide); acute lifting injury with the spine flexed and same-side coupling → Law II. Watch the wording: “opposite” coupling paired with flexion, or “same side” paired with neutral, mixes up the two laws.
Lecture slides for this section (2)
Written Review slide 17: Type I mechanicsWritten Review slide 18: Type II mechanics and Law 3
145top 215asked 3×Fryette's principles
Fryette's principles define Type 1 Mechanics as:
Ans: Type 1 → neutral, sidebending first, rotation opposite → A
Why: Type I: from neutral, sidebending precedes rotation and rotation goes to the opposite side, involving two or more segments.
Explanation & sources
Explanation
B and C describe Type II dysfunction (traumatic, non-neutral). D is Fryette's third principle. In Type I, disc compression on the sidebent side pushes disc material to the other side, which rotates the bodies opposite.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 44-45
2020 TA Review (Middletown) Exam 1 · TA review · slides 45-46
2020 TA Review Exam 1 · TA review · slides 48-49
Lecture slide (1)
Week 3 · Written Review deck · slide 17
146asked 2×Fryette's principles
Which of the following statements concerning Fryette's law I is true?
Ans: Law I = neutral → sidebending and rotation opposite → C
Why: Fryette's first law: in neutral, sidebending and rotation occur to opposite sides.
Explanation & sources
Explanation
A is Law II (non-neutral, same side), not Law I. B wrongly pairs opposite-side coupling with flexion. D pairs neutral with same-side coupling, which mixes up the two laws.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 50-51
2022 TA Review - Exam 1 · TA review · slides 35-36
Lecture slide (1)
Week 3 · Written Review deck · slide 17
147Fryette's principles
A 25-year-old man presents with low back stiffness after sitting at his desk for long hours. On exam, when his lumbar spine is in a neutral position, you notice that as you side bend him to the right, the spinous processes rotate toward the left. Which of Fryette's principles does this describe?
Ans: Neutral + sidebending with opposite rotation (intended) → Law I → A
Why: The question intends neutral coupling with rotation opposite the sidebending, which is Fryette's Law I.
Heads up: Wording flaw: if the spinous processes go left, the bodies rotate right, the same side as the sidebending. The TA key still marks Law I because the stem says neutral and means opposite-side coupling.
Explanation & sources
Explanation
Law II requires a flexed or extended (non-neutral) spine, as in an acute lifting injury. Law III says motion in one plane reduces motion in the other planes. Rotation is named for the anterior vertebral body, so spinous processes move opposite to the named rotation.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 54-55
Lecture slide (1)
Week 3 · Written Review deck · slide 17
148Fryette's principles
A 40-year-old woman presents with acute back pain after lifting a heavy box. Exam shows that when her lumbar spine is flexed, sidebending her to the right is accompanied by rotation to the right as well. Which Fryette's law best explains this coupled motion?
Ans: Flexed (non-neutral) + same-side coupling → Law II → B
Why: Fryette's Law II: in a non-neutral (flexed or extended) spine, rotation and sidebending occur to the same side.
Explanation & sources
Explanation
Law I is neutral with opposite-side coupling. Law III states that motion in one plane reduces motion in the other planes. Acute lifting injuries typically produce Type II dysfunctions.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 52-53
Lecture slide (1)
Week 3 · Written Review deck · slide 18
149top 215asked 2×2026Fryette's principles
A 20-year-old female presents for a general maintenance examination without complaints. Structural examination is negative for somatic dysfunction. The examiner evaluates the physiologic motion of T3 on T4. Which of the following most accurately describes this segment's Fryette Type 2 mechanics?
Ans: Type 2 → sufficiently flexed/extended → same-direction coupling → E
Why: Type II mechanics: with sufficient flexion or extension, a single segment sidebends and rotates to the same side (rotation into the concavity).
Explanation & sources
Explanation
A is Fryette's third principle. B correctly describes Type I, not Type II. C and D mismatch the position and the coupling direction.
Which of these Fryette's Principles are correctly matched?
Ans: Second principle = non-neutral, rotation first, same side → B
Why: The second principle (Type II) is non-neutral, rotation precedes sidebending, and both go to the same side.
Explanation & sources
Explanation
A gives the third principle's text with the label 'first'. C gives the first principle's text with the label 'third'. Order: 1 = neutral/opposite, 2 = non-neutral/same, 3 = motion in one plane affects the others.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 67-68
2022 TA Review (Middletown) - Exam 1 · TA review · slides 55-56
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 18
151top 215Fryette's principles
What does Fryette's third principle of spinal mechanics state?
Ans: Third principle → motion in one plane limits the other planes → A
Why: Fryette's third principle: moving a segment in one plane reduces its motion in the other two planes. Example: a flexed segment has less sidebending and rotation.
Explanation & sources
Explanation
C is the second principle (Type II) and D is the first (Type I). B is a vague statement, not a Fryette principle. The third principle applies to the entire spine.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 47-48
Lecture slide (1)
Week 3 · Written Review deck · slide 18
152Fryette's principles
Fill in the blanks for Fryette's Principles: (1) Principle 1/Type 1 SD: sidebending/rotation precedes sidebending/rotation, and they are in the same/opposite directions. (2) Principle 2/Type 2 SD: found at the ____ and/or ____ of type 1 curves. (3) Principle 3: if a vertebral unit was flexed, its range of sidebending and rotation would/would not be reduced.
Answer(1) Sidebending precedes rotation; opposite directions. (2) Apex and/or extremes (ends) of Type 1 curves. (3) Would be reduced.
Ans: Type 1 = S before R, opposite; Type 2 at apex/ends; Law 3 = reduced
Why: Type I: sidebending first, opposite rotation. Type II: found at the apex or extremes of Type I curves. Third principle: flexion reduces sidebending and rotation.
Explanation & sources
Explanation
This is why Type I is written N SxRy and Type II is written F/E RxSx. Type II can also occur by itself or at transitional areas.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 45-46
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 18
3.6 · 9 questions · Questions 153–161
Type I vs Type II
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Type I
Type II
Segments
Group (2 or more)
Single
Position
Neutral: flexion/extension do not change it
Flexed or extended: asymmetry changes with F/E
Coupling
Sidebending first; S and R opposite
Rotation first; R and S same side
Typical onset
Gradual, compensatory, usually chronic
Acute: trauma / abrupt twisting
Where
Group curves
Apex (mid-point) or ends of a Type I curve, transitional areas, or alone
Muscles maintaining it
Long restrictors: erector spinae (iliocostalis, longissimus, spinalis)
Short deep restrictors: rotatores (brevis and longus), intertransversarii, multifidus (interspinalis are also short segmental)
Treatment order
Second
Treat first; fixing an apex Type II often lets the curve improve
The deep intrinsic muscles and the facets determine Type II behavior; the rotatores are dense in muscle spindles, which is why twisting injuries provoke Type II dysfunction. A Type II is not “less severe” than a Type I. Trapezius and serratus posterior inferior are not Fryette restrictors.
153Type I vs Type II
Which is true of a Type 1 somatic dysfunction?
Ans: Type 1 → neutral group, SB and R opposite → C
Why: In Type I mechanics sidebending and rotation occur in opposite directions (e.g. T6-T8 N Sr Rl).
Explanation & sources
Explanation
Type I involves two or more segments, not one. It is neutral, so flexion and extension do not change it. Sidebending precedes rotation in Type I; rotation first is Type II.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 40-41
Lecture slide (1)
Week 3 · Written Review deck · slide 17
154top 215Type I vs Type II
True or false when referring to a somatic dysfunction? A type 1 SD of the spine is acute.
Ans: Type 1 → gradual, compensatory group curve → usually chronic → False
Why: Type I group curves form gradually, usually as compensation, so they are typically chronic. Type II is the one linked to acute trauma or abrupt twisting.
Explanation & sources
Explanation
Type I is maintained by the long erector spinae muscles. Type II is maintained by short deep muscles such as the rotatores and intertransversarii.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 38-39
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 18
155top 215asked 7×2026Type I vs Type II
Which of the following is a characteristic of a type II somatic dysfunction?
Ans: Type II found at apex (mid-point) or extremes of Type I curves → A
Why: Type II dysfunctions are found at the apex or extremes of Type I curves, and the apex is the mid-point of the curve.
Explanation & sources
Explanation
Type II is usually acute and traumatic (B wrong). Opposite-side coupling (C) and sidebending first (D) are Type I features. Type II should be treated before Type I, so it is not 'less severe' (E).
It is possible for a Type II somatic dysfunction to be located within a Type I curve. Which letter in the image corresponds to the vertebra at which the Type II SD would likely be located?
Ans: Type II sits at the apex (mid-point) of a Type I curve → C
Why: Type II dysfunctions classically sit at the apex of a Type I curve, which is the mid-point of the curve (C).
Explanation & sources
Explanation
B and D are mid-curve segments that are neither apex nor end. The course also says Type II can appear at the extremes (ends) of the curve or at transitional areas, but the apex is the answer they want.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 56-57
Lecture slide (1)
Week 3 · Written Review deck · slide 18
157top 2152026Type I vs Type II
During a structural examination, a physician identifies a multi-segment group curve spanning T4–T8 that is neutral, sidebent right, and rotated left (T4–T8 N SR RL). At the apex of this curve (T6), palpation reveals an acute single-segment dysfunction that worsens in flexion and improves in extension (T6 E RR SR). Which dysfunction should be treated first, and why?
Ans: Type II at apex of Type I curve → treat Type II first → B
Why: The course rule: Type II dysfunctions should be treated before Type I. Fixing the apex Type II often lets the group curve improve.
Explanation & sources
Explanation
C is wrong because Type I couples sidebending and rotation to opposite sides. D is wrong because Type I is maintained by the long erector spinae, Type II by short deep muscles. Waiting for skin changes (E) has no basis.
Asked in
2026 Textbook Q&A Compilation - Somatic Dysfunction Practice Questions · Practice questions · slide 145 (answer slide 146)
Lecture slide (1)
Week 3 · Written Review deck · slide 18
158Type I vs Type II
Which muscles are commonly involved in Type 2 SD?
Ans: Type 2 → single segment → short deep restrictors (rotatores) → C
Why: Type II SD is maintained by short deep restrictors: rotatores (brevis), intertransversarii and multifidus.
Explanation & sources
Explanation
Erector spinae, including longissimus, maintain Type I group curves. Trapezius is a superficial muscle not used to explain Fryette mechanics. Deep intrinsic muscles and the facets determine Type II behavior.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 42-43
A patient presents with "I went to pick up a box and now my back hurts." According to Fryette's principles, which muscles are affected in this type of somatic dysfunction?
Ans: Lifting injury → acute Type II → short restrictors → rotatores brevis → C
Why: A sudden lifting/twisting injury gives an acute Type II SD, maintained by short restrictors such as the rotatores brevis and intertransversarii.
Explanation & sources
Explanation
Iliocostalis and spinalis are parts of the erector spinae, which maintain Type I curves. Serratus posterior inferior is an intermediate-layer extrinsic back muscle and not a Fryette restrictor.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 116-117
2020 TA Review Exam 1 · TA review · slides 105-106
The muscular TA Gregory is attempting to break the deadlifting world record. While bending over, he seems to have twisted his back and injured himself. In regards to this type of somatic dysfunction, which of Gregory's muscles is least likely to be directly involved in his injury?
Ans: Bent + twisted → Type II → short deep muscles; erector spinae = Type I → C
Why: A twisting injury while bent gives a Type II SD maintained by short deep muscles. The erector spinae maintain Type I group curves, so they are least likely involved.
Explanation & sources
Explanation
Rotatores (brevis and longus), intertransversarii and interspinalis are short segmental muscles that span one or two levels. The rotatores are dense in muscle spindles, which is why twisting motions provoke Type II dysfunction.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 62-63
Which muscles maintain a type I and a type II somatic dysfunction, respectively?
AnswerType I: erector spinae (long restrictors). Type II: short restrictors, i.e. rotatores, multifidus and intertransversarii.
Ans: Group curve → long muscles (erector spinae); single segment → short deep muscles
Why: Long multi-segment muscles (erector spinae) hold multi-segment Type I curves. Short one-segment muscles (rotatores, intertransversarii, multifidus) hold single-segment Type II dysfunctions.
Explanation & sources
Explanation
The erector spinae are iliocostalis, longissimus and spinalis. Because Type II lives in small deep muscles, muscle energy is usually preferred over a broad myofascial technique.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 60-61
Lecture slide (1)
Week 3 · Written Review deck · slide 18
3.7 · 7 questions · Questions 162–168
Type I/II notation
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This course writes the two types in a fixed format. Check a diagnosis against all four rules:
Type I
Type II
Levels
A range (T2-T6)
One vertebra (T3)
Position letter
N
F or E
Written first
Sidebending, then rotation
Rotation, then sidebending
Sides
Opposite
Same
Example
T2-T6 N Sl Rr, T10-L2 N Sr Rl
T3 F Rl Sl, T3 F Rr Sr, T6 FRSl
How distractors fail: a group that is F or E (not neutral); a neutral group with same-side letters; a single segment labelled N; a flexed single segment with opposite sides (fits neither type); a range labelled F/E with same sides (Type II must be one segment).
Letter order: when the choices include both forms, pick the course form: S-then-R for Type I (N Sr Rl, not N Rl Sr) and R-then-S for Type II (F Rr Sr, not F Sr Rr). Textbook/board-style questions sometimes write Type I as “N RL SR”; if that is the only neutral, opposite-side group offered, it still describes Type I.
Clinical clue: involvement of the erector spinae with ropy (chronic) tissue points to a Type I group curve (e.g. T4-T7 N Sr Rl).
Lecture slide for this section (1)
Written Review slide 19: naming SDs
162top 215asked 7×2026Type I/II notation
Which of the following most closely follows a dysfunction with a classic Type I mechanics pattern?
Ans: Type I = group + neutral + S first + opposite sides → T10-L2 NSrRl → C
Why: Classic Type I is a group, neutral, sidebending written first, rotation opposite: T10-L2 N Sr Rl.
Heads up: Older deck speaker notes said 'D', but D (T2-9 NRlSl) has rotation and sidebending to the same side. The red answer slide in every year, including 2026, marks C.
Explanation & sources
Explanation
A and D are neutral groups but rotate and sidebend to the same side. B is flexed, so not neutral. E is a single cervical segment in extension, and Fryette mechanics are taught for the thoracic and lumbar spine.
Which of the following most closely follows a dysfunction with a classic Type 1 mechanics pattern?
Ans: Group + N + S first + opposite → T3-T5 N SLRR → C
Why:T3-T5 N SL RR is a neutral group with sidebending written first and rotation to the opposite side.
Explanation & sources
Explanation
A is neutral but rotation comes first and both are to the same side. B is a single flexed segment (Type II). D is flexed, so not neutral. E is extended with same-side coupling. For this course, Type I is written S then R; boards may switch the order.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 48-49
2020 TA Review (Middletown) Exam 1 · TA review · slides 51-52
2020 TA Review Exam 1 · TA review · slides 54-55
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 19
164Type I/II notation
Which is a correct Type I diagnosis?
Ans: Type I = N + Sx then opposite Ry → T2-T6 N Sl Rr → E
Why:T2-T6 N Sl Rr: group, neutral, sidebending listed first, rotation to the opposite side.
Explanation & sources
Explanation
A is flexed and B is extended, so neither is neutral. C is neutral but both components go right. D lists rotation first and both go right, which is Type II style.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 73-74
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 19
165Type I/II notation
Which of the following is a correct Type I diagnosis?
Ans: Group + neutral + opposite sides → T2-T4 N Sr Rl → C
Why:T2-T4 N Sr Rl is a neutral group curve with sidebending and rotation to opposite sides.
Explanation & sources
Explanation
A is neutral but same side. B is flexed. D is a single segment. E has opposite sides in a flexed single segment, which fits neither type. F (T3 F Rr Sr) is a correct Type II diagnosis, not Type I.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 57-60
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 19
166top 215Type I/II notation
Which of the following is a correct Type II diagnosis?
Ans: Type II = single segment, F or E, R first, same side → T3 F Rl Sl → D
Why: Type II: single segment, flexed or extended, rotation written first, rotation and sidebending to the same side: T3 F Rl Sl.
Explanation & sources
Explanation
A lists sidebending first with opposite sides. B and C are neutral. E is flexed but the sides are opposite. F is a group (T2-5), and Type II is a single segment.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 71-72
Lecture slides (2)
Week 3 · Written Review deck · slide 18Week 3 · Written Review deck · slide 19
167Type I/II notation
Which of the following is a correct Type II diagnosis?
Ans: Single segment + non-neutral + same side → T3 F Rr Sr → F
Why:T3 F Rr Sr: one segment, non-neutral, rotation first, rotation and sidebending to the same side.
Explanation & sources
Explanation
C (T2-T4 N Sr Rl) is the correct Type I diagnosis from the same option set. D is a single segment but neutral. E is flexed with opposite sides. A and B are groups.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 58-60
Lecture slides (2)
Week 3 · Written Review deck · slide 18Week 3 · Written Review deck · slide 19
168asked 2×Type I/II notation
In one of your patients, the erector spinae muscles are limited in their range of motion and feel ropy to palpation. What type of somatic dysfunction could this be diagnosed as?
Ans: Erector spinae + ropy (chronic) → Type I group → N, S first, opposite → D
Why: Erector spinae involvement and ropy (chronic) tissue point to a Type I curve: group, neutral, sidebending first, opposite rotation (T4-T7 N SR RL).
Explanation & sources
Explanation
A is a group but flexed. B is a single extended segment (Type II). C is neutral with opposite sides but lists rotation first, which is wrong for Type I in this course. E is a flexed single segment with sidebending first and opposite sides.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 121-122
2020 TA Review Exam 1 · TA review · slides 110-111
Lecture slides (2)
Week 3 · Written Review deck · slide 17Week 3 · Written Review deck · slide 19
3.8 · 4 questions · Questions 169–172
Naming for freedom
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A somatic dysfunction is named for its freedom: the direction(s) it moves easily, also called its preference or position of ease. It is never named for the restriction.
To find the restriction, flip every component of the name:
Diagnosis (freedom)
Restricted in
F
E
E
F
R left
R right
S left
S right
T6 E Rl Sl
Flexion, right rotation, right sidebending
T10 F Rr Sr
Extension, left rotation, left sidebending
Segmental motion is always described as the vertebra relative to the one below: T6 moves on T7, not on T5. Half-flipped answers (flipping F/E but not the sides, or vice versa) are the usual traps. A restriction is a barrier with a firm end-feel; in muscle energy the patient is placed into the restrictive barrier and pushes toward the freedom.
169top 215asked 2×Naming for freedom
When naming a somatic dysfunction, name the:
Ans: SD named for preference/position of ease → freedom → A
Why: An SD is named for its freedom, which is the same as its preference or position of ease.
Explanation & sources
Explanation
The restriction is the opposite of the name in every plane. A restriction is a barrier with a firm end-feel. In muscle energy the patient is placed into the restrictive barrier and pushes toward the freedom.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 69-70
2022 TA Review (Middletown) - Exam 1 · TA review · slides 53-54
Lecture slides (2)
Week 3 · Written Review deck · slide 14Week 3 · Written Review deck · slide 19
170Naming for freedom
True or false when referring to a somatic dysfunction? It is named for the patient's restriction.
Ans: SD named for freedom (ease), not restriction → False
Why: SDs are named for the freedom (position of ease), not the restriction.
Explanation & sources
Explanation
To get the restriction, flip every component of the name: F↔E, Rr↔Rl, Sr↔Sl. Example: T6 ERlSl is restricted in flexion, right rotation and right sidebending.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 38-39
Lecture slide (1)
Week 3 · Written Review deck · slide 14
171top 215asked 11×2026Naming for freedom
In evaluation of a patient with thoracic pain, your diagnosis on palpation is T6 ERlSl. This means that T6 is restricted in?
Ans: Name = freedom; flip every letter (E→F, Rl→Rr, Sl→Sr); motion is T6 on T7 → B
Why: T6 ERlSl is free in extension, left rotation and left sidebending, so it is restricted in flexion, right rotation and right sidebending. Segmental motion is always described relative to the vertebra below (T6 on T7).
Heads up: On the 2026 IA3 poll everyone received credit for this question (announced at IA5). B is still the correct answer on the answer slide in every year and in the textbook version.
Explanation & sources
Explanation
A flips flexion but keeps the left side, so it is half right. C has the right motions but the wrong reference vertebra (T5). D and E keep extension, which is the freedom, and also use T5.
Mr. Smith bent over forward and to the right to pick up a heavy box, and you diagnose T10 F RrSr. In what motions may Mr. Smith have restriction?
Ans: Freedom F Rr Sr → flip every letter → restricted E, Rl, Sl → D
Why: The restriction is the exact opposite of the freedom: extension, left rotation and left sidebending.
Explanation & sources
Explanation
A is the freedom. B flips the rotation but keeps flexion, and C flips flexion but keeps right rotation. Both are half-flips.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 263-264
Lecture slide (1)
Week 3 · Written Review deck · slide 14
3.9 · 13 questions · Questions 173–185
Palpation to diagnosis
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Turn palpation findings into a diagnosis in four steps:
Rotation = side of the posterior transverse process. Rotating left turns the body left and pushes the left TP posterior. If your left thumb is more anterior (deeper), the right TP is posterior → rotated right.
Group or single? Several segments (or a whole region with one curve) → think Type I. One segment with other levels moving normally → Type II.
Does the asymmetry change with flexion/extension? No change → Neutral, Type I: sidebending opposite the rotation → write N Sx Ry. Changes → Type II: name it for the position where the asymmetry improves or disappears (better in flexion → F; better in extension → E); sidebending to the same side → write F/E Rx Sx.
Name the freedom, never the position that makes it worse.
Finding
Diagnosis
3 segments, left TPs posterior, no change with F/E
N Sr Rl
Chronic, ropy L2–L4, L3 left TP posterior, no change with F/E
L2–L4 N Sr Rl
T3 left TP posterior, worse in flexion, level in extension
T3 E Rl Sl
T4 right TP posterior, better in flexion, worse in extension
T4 F Rr Sr
T2 restricted in left rotation, worse in flexion, normal in extension
T2 E Rr Sr
T6 at end of T3–T6 N Sr Rl, worse in flexion, symmetric in extension
T6 E Rl Sl
Group curves by shape: sidebending is named toward the concavity; Type I rotation goes toward the convexity. A lumbar spine convex right = sidebent left, rotated right (Type I).
Why Type II changes with F/E (facets): an extended dysfunction (ERS) “disappears” in extension and is accentuated in flexion: in flexion both posterior facets should open, but one stays closed, so the vertebra rotates and sidebends toward that side (facet closed on the side of rotation). A flexed dysfunction (FRS) disappears in flexion and worsens in extension: in extension both facets should close, but one stays open, so it rotates and sidebends to the opposite side. So “restricted in flexion, posterior on the left” = left facet stuck closed = E Rl Sl. And since an ERS is restricted in flexion and the opposite rotation, flexing T3 E Rl Sl limits its right rotation.
Lecture slide for this section (1)
IA5 slide 67: ERS vs FRS and the facets
173asked 7×2026Palpation to diagnosis
On palpation of your patient you notice posterior transverse processes of three vertebrae on the left. Flexion and extension yield no change in the transverse process asymmetry. Which of the following is correct regarding this patient's somatic dysfunction?
Ans: Posterior TP left → rotated left; group + no F/E change → neutral Type I → sidebent right → D
Why: Posterior TP on the left means rotated left. A group that does not change with flexion or extension is neutral (Type I), so sidebending is opposite: N Sr Rl.
Explanation & sources
Explanation
A, B and C are non-neutral Type II patterns, which change with flexion or extension. E has the right type but the wrong sides (rotation would then be right, with posterior TPs on the right).
A 27-year-old female presents to the office for evaluation of acute-on-chronic back pain. Osteopathic examination reveals reproducible lumbar paraspinal muscle tenderness. When palpating this region, the physician's left thumb is more anterior than the right thumb. This finding does not improve or worsen when the patient bends forward or backward. The most likely somatic dysfunction is
Ans: Left thumb anterior → right TP posterior → rotated right; no F/E change → neutral → sidebent left → E
Why: If the left thumb is anterior, the right TP is posterior, so the segment is rotated right. No change with flexion or extension means neutral (Type I), so it is sidebent left.
Explanation & sources
Explanation
F is the trap: it reads the anterior left thumb as left rotation. A to D are non-neutral and would change with forward or backward bending.
A 55-year-old man presents to the office with chronic low back pain. The pain began shortly after he started work as an accountant several years ago. His job requires prolonged sitting at a desk. Osteopathic examination reveals: ropy tissue texture changes in the L2–L4 region; L3 left transverse process is posteriorly displaced; L3 left transverse process does not change with lumbar flexion or extension. The most likely diagnosis is
Ans: Chronic group L2-L4 + no F/E change → neutral; posterior left TP → rotated left → sidebent right → B
Why: Chronic, ropy, multi-segment and unchanged by flexion or extension means a neutral Type I group (L2–L4). Left posterior TP means rotated left, so sidebending is right.
Explanation & sources
Explanation
A is a group but flexed. C has neutral mechanics but the wrong sides. D and E name a single segment, but the findings span L2–L4; E is also a Type II pattern. In course notation this is L2-L4 N Sr Rl.
A patient presents to your office with chronic low back pain. While lying prone, the patient's entire lumbar spine appears to have a lateral convexity to the right. State a possible diagnosis.
Ans: Group curve → Type I; convex right = concave left → sidebent left → rotated right (toward convexity) → D
Why: A whole-region curve is Type I. Sidebending is named toward the concavity (left), and Type I rotation goes to the opposite side, toward the convexity (right).
Explanation & sources
Explanation
C is the classic trap: it names sidebending toward the convexity. A and B are Type II, which is a single segment, and A also has opposite sides. The information given is enough, so E is wrong.
While evaluating a patient's upper back, you notice that T3's transverse process is posterior on the left. Flexing T3 worsens the prominence of the posterior transverse process on the left. Extension allows the left transverse process to move anteriorly with ease. What can be said regarding this somatic dysfunction at T3?
Ans: Posterior left, worse in flexion → T3 ERlSl → restricted F, Rr, Sr → flexion limits right rotation → E
Why: The findings give T3 E Rl Sl. Its restrictions are flexion, right rotation and right sidebending, so flexing T3 engages the barrier and limits right rotation.
Explanation & sources
Explanation
A names Type II correctly but gives opposite-side coupling, which is Type I. B is wrong because head extension extends T2 on T3. C is backward: left rotation is the freedom. D is wrong because extension makes the Type II asymmetry disappear; it does not convert it to Type I.
While evaluating a patient seated on the examination table, you place your thumbs over the transverse processes of T3. In the neutral position, your left thumb is noticeably more posterior than your right thumb. You instruct the patient to bend forward (flexion), and the left transverse process becomes significantly more prominent. When the patient slumps backward into extension, your thumbs become level. What is the correct diagnosis for T3?
Ans: Posterior left → RL; level in extension → E; Type II same side → SL → B
Why: Posterior left TP = rotated left. Asymmetry disappears in extension = extended. Type II couples to the same side: T3 E RL SL.
Explanation & sources
Explanation
A gets the rotation right but picks flexion, the position that worsens it. C and E put the rotation on the wrong side. D is a neutral Type I pattern, but this finding changes with flexion and extension.
Asked in
2026 Textbook Q&A Compilation - Somatic Dysfunction Practice Questions · Practice questions · slide 149 (answer slide 150)
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
179Palpation to diagnosis
On palpation, you notice a posterior TP on the right side at T4. Flexing T4 worsens the prominence on the right; extension allows more freedom of motion of T4 on the right anteriorly. What is the somatic dysfunction?
Ans: Posterior right → Rr; worse in flexion, better in extension → E; Type II → Sr → A
Why: Rotated right with asymmetry that improves in extension gives T4 E Rr Sr.
Explanation & sources
Explanation
B is a neutral Type I pattern, which would not change with flexion or extension. C names the position that worsens the asymmetry; an SD is named for the position that eases it.
Asked in
2022 TA Review - Exam 1 · TA review · slides 49-50
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
1802026Palpation to diagnosis
A 17-year-old male presents to the office with acute back pain. Osteopathic examination reveals that the left transverse process of T2 is more posterior than the right. This finding is exaggerated with forward bending of the spine. All other spinal segments demonstrate preserved motion. According to Fryette principles, with this patient's somatic dysfunction
Ans: Single segment, worse in flexion → T2 E Rl Sl (Type II) → improves with extension → B
Why: This is a Type II T2 E Rl Sl. An extended dysfunction improves (the asymmetry disappears) in extension.
Explanation & sources
Explanation
A describes Type I (neutral). C and E imply a group curve, but all other segments move normally. D describes Type I coupling; Type II rotates and sidebends to the same side.
A 25-year-old male complains of upper back pain. Structural examination reveals T2 is restricted with left rotation. Flexing the body down to T2 causes the segment to further rotate to the right, while extending the area causes T2 to return to the neutral position. The most appropriate nomenclature for this dysfunction is?
Ans: Restricted left rotation → rotated right; worse in flexion, neutral in extension → E; Type II → SR → B
Why: Restricted in left rotation means the freedom is right rotation. It worsens in flexion and normalizes in extension, so it is extended. A single non-neutral segment follows Type II, so it sidebends right: ERRSR.
Explanation & sources
Explanation
A and C have the rotation on the wrong side. D picks flexion, the position that worsens it. E is a neutral pattern, but this segment changes with flexion and extension.
2023 TA Review (Harlem) - Exam 1 · TA review · slides 54-55
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
182asked 3×Palpation to diagnosis
While evaluating a patient's upper back, you notice that T4's transverse process is more posterior on the right. When the patient bends chin to chest, T4's posterior TP becomes better and the right TP moves anteriorly with ease. When the patient arches back and looks at the ceiling, T4's posterior TP becomes worse. Name the somatic dysfunction.
Ans: Posterior right → RR; better in flexion → F; Type II → SR, rotation written first → E
Why: Rotated right, better in flexion and worse in extension gives T4 F RR SR. Name for the freedom.
Explanation & sources
Explanation
C has the right motions but lists sidebending first; in this course, Type II is written with rotation first. B is extended with opposite sides. A and D are group diagnoses, and D is also flexed with opposite sides.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 56-57
2020 TA Review (Middletown) Exam 1 · TA review · slides 56-57
2020 TA Review Exam 1 · TA review · slides 59-60
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
183Palpation to diagnosis
On palpation of L3, the transverse process is more posterior on the left. The dysfunction worsens in extension and improves in flexion. What is the correct diagnosis?
Ans: Posterior left → Rl; better in flexion → F; Type II same side → Sl → A
Why: Posterior left TP = rotated left; it improves in flexion; Type II couples the same side: L3 F Rl Sl.
Explanation & sources
Explanation
B picks extension, the position that worsens it. C and D put rotation on the wrong side. E is a neutral pattern, which would not change with flexion or extension.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 60-61
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
184Palpation to diagnosis
A patient has a group dysfunction T3-T6 N Sr Rl. Upon further evaluation, at the level of T6 the asymmetry in the TPs gets worse in flexion and becomes more symmetrical in extension. What is the patient's diagnosis at T6?
Ans: Group rotated left → T6 rotated left; symmetrical in extension → E; Type II same side → D
Why: T6 shares the left rotation, and its asymmetry clears in extension, so it is a Type II T6 E Rl Sl at the end of the group curve.
Explanation & sources
Explanation
A and B are neutral, but this segment changes with flexion and extension. C picks flexion, which worsens the asymmetry. Type II dysfunctions are typically found at the top, bottom or apex of a Type I curve.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 63-64
A patient comes in with lower back pain. After performing an osteopathic structural exam, the physician states the patient is restricted in forward flexion and the vertebra is shallow (posterior) on the left compared to the right. What is the motion of the facet joint causing this dysfunction?
Ans: Restricted flexion → ERS; posterior left → RL SL; left facet can't open → stuck closed → A
Why: Restricted flexion with left posterior = E RL SL. In flexion both facets should open; the left facet stays closed, so the segment pivots and rotates/sidebends left.
Explanation & sources
Explanation
B and D are flexion dysfunctions, but this patient is restricted in flexion. C names an ERS left but blames the wrong facet; the closed facet is on the side of rotation. Flexed dysfunctions (FRS) come from a facet stuck open, on the side opposite the rotation.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 109-110
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An SD usually matches the position of its mechanism of injury. The position the patient was in when they got hurt becomes the freedom, and the opposite becomes the restriction (which is why these patients cannot straighten up).
Acute trauma (sudden onset, redness, warmth, sharp pain) → Type II single segment (F or E, rotation written first, same side). Neutral group curves are chronic and compensatory, so they do not fit an acute injury.
“Can't straighten up / stand up straight” = restricted extension → freedom is flexion (F).
Bending forward and to the right → F Rr Sr (e.g. L2 F Rr Sr, T10 F Rr Sr).
Bending forward toward the left → F Rl Sl (e.g. L4 F Rl Sl).
Reaching back and to the left (pen dropped behind) → extension with left rotation/sidebending.
Eliminate options that are extended when the patient was bent forward, that are on the wrong side, that list sidebending first, or that have opposite-side coupling in a single flexed segment.
186Mechanism of injury
True or false when referring to a somatic dysfunction? SDs usually match the positions of their mechanisms of injury (e.g., if you tweak your back bending forward to pick something, or someone, up, it will be a flexion SD).
Ans: Injured position becomes the freedom → SD matches mechanism → True
Why: The review deck states that SD usually matches the position of the mechanism of injury. The position the patient was in when hurt becomes the freedom.
Explanation & sources
Explanation
Bending forward and to the right when injured gives F Rr Sr. The restriction is the opposite (E, Rl, Sl), which is why these patients cannot straighten up.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 38-39
Lecture slide (1)
Week 3 · Written Review deck · slide 14
187top 215asked 9×2026Mechanism of injury
A man presents to your office with acute pain on the lower lumbar spine, unable to straighten his back. He was trying to pick up a box while bent forward and leaning over to the right. What is the most likely somatic dysfunction that you will palpate in this traumatic presentation?
Ans: Acute trauma → Type II; can't extend → F; leaning right → RR SR, rotation first → E
Why: Acute trauma gives a Type II single segment. He cannot straighten (extend), so the freedom is flexion. Injured while leaning right gives rotated and sidebent right, written rotation first: FRRSR.
Explanation & sources
Explanation
A and B are neutral group (Type I) curves, which are chronic and compensatory. C is extended and leans left. D is flexed but lists sidebending first with opposite sides, which is not Type II.
A patient presents with acute pain in his lower lumbar spine and is unable to straighten his back. He bent forward to pick up his son on the left, which is how the pain started. What is the most likely somatic dysfunction that you will palpate?
Ans: Acute → Type II; can't straighten → F; bent toward left → RL SL → D
Why: Unable to straighten (extend) means the freedom is flexion. An acute single segment is Type II, and bending toward the left gives rotated and sidebent left: L4 F RL SL.
Explanation & sources
Explanation
A and C are neutral group curves (C is a correct Type I format but does not fit an acute injury). B and E are extended, which is the motion he cannot do. The position at the time of injury is the freedom.
Asked in
2022 TA Review - Exam 1 · TA review · slides 37-38
2020 TA Review (Middletown) Exam 1 · TA review · slides 47-48
A woman presents to your office with acute back pain, unable to stand up straight. She was bending forward leaning to the right to pick up her child. What is the most likely somatic dysfunction that you will palpate?
Ans: Can't extend → F; leaning right → Rr Sr; Type II, rotation first → E
Why: She cannot stand straight, so the freedom is flexion. She was leaning right, so Rr Sr, written rotation first: T4 F Rr Sr.
Explanation & sources
Explanation
A lists sidebending first with opposite sides. B lists sidebending first. C and D are extended. F has the correct format but the wrong side.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 76-77
Lecture slides (2)
Week 3 · Written Review deck · slide 14Week 3 · Written Review deck · slide 18
190Mechanism of injury
Mr. Smith bends over forward and to the right to pick up a heavy box quickly. The next day he has back pain with marked redness and warmth around T10. What may be the potential dysfunction?
Ans: Forward → F; to the right → Rr; acute (red, warm) → Type II → Sr → C
Why: Bending forward and right gives flexed, rotated right. Redness and warmth mean acute, so Type II with same-side sidebending: T10 F Rr Sr.
Explanation & sources
Explanation
A is a neutral group curve. B and E have opposite-side coupling. D has the correct sides but is extended rather than flexed.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 261-266
Lecture slides (2)
Week 3 · Written Review deck · slide 14Week 3 · Written Review deck · slide 18
191Mechanism of injury
A patient presents with low back pain. He says that it began after reaching back to pick up a pen that dropped behind and to the left of him. Which of the following describes his spinal motion?
Ans: Reaching back → extension; behind and left → rotation/sidebending left → D
Why: Reaching back and to the left is extension with left rotation and sidebending. That position is the freedom; the restriction is flexion and right rotation/sidebending.
Explanation & sources
Explanation
A and B describe forward bending, which does not match reaching behind. C and E leave out one of the two motions involved.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 57-58
Lecture slide (1)
Week 3 · Written Review deck · slide 14
3.11 · 1 question · Question 192
Direct vs indirect
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Direct techniques move the dysfunctional segment into the restrictive barrier; indirect techniques move it away from the barrier, into the freedom (position of ease).
Direct
Indirect
Goes toward
Restrictive barrier (opposite of the name)
Freedom / ease (same as the name)
Examples
Muscle energy, HVLA
Counterstrain
Positioning for T6 E Rl Sl
Flexion, right rotation, right sidebending
Extension, left rotation, left sidebending
For a direct setup, flip every letter of the diagnosis (F↔E, left↔right for both rotation and sidebending).
192top 2152026Direct vs indirect
An osteopathic physician evaluates a patient with mid-back pain and diagnoses a T6 E RL SL somatic dysfunction. The physician chooses to perform a Direct technique (such as Muscle Energy Technique) to treat the dysfunction. Into which positioning combination must T6 be placed to properly engage the restrictive barrier?
Ans: Name = freedom; direct → into barrier → flip every letter → F RR SR → B
Why: T6 E RL SL is free in extension, left rotation and left sidebending. A direct technique goes into the barrier: flexion, right rotation, right sidebending.
Explanation & sources
Explanation
A is the freedom, which is where an indirect technique (e.g. counterstrain) would position the segment. C and D flip only some components. E is a neutral Type I setup.
Asked in
2026 Textbook Q&A Compilation - Somatic Dysfunction Practice Questions · Practice questions · slide 143 (answer slide 144)
Lecture slide (1)
Week 3 · IA3 Somatic Dysfunction · slide 51
3.12 · 2 questions · Questions 193–194
Related topics
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The atlantoaxial joint (C1 on C2) is mainly a rotation joint. Rotation occurs in the transverse (horizontal) plane about a vertical axis. Don't confuse transverse plane (rotation) with transverse axis (flexion/extension).
Autonomics and the gut: the sacral region carries parasympathetic outflow (S2–S4, pelvic splanchnic nerves). Increased parasympathetic drive speeds gut motility → diarrhea. Sacral SD → ↑ parasympathetic drive to the gut → diarrhea. By contrast, hypersympathetic drive (thoracolumbar SD) slows the bowel → constipation.
1932026Related topics
A 14-year-old female is brought to the office for a sports physical examination. Vital signs and cardiopulmonary examination are normal. Musculoskeletal examination reveals a somatic dysfunction of the atlantoaxial joint. This somatic dysfunction is assessed in the
Ans: Atlantoaxial = rotation joint → rotation occurs in transverse (horizontal) plane → E
Why: The atlantoaxial joint is mainly a rotation joint, and rotation occurs in the transverse (horizontal) plane about a vertical axis.
Explanation & sources
Explanation
The A-P axis and coronal plane go with sidebending. The sagittal plane and transverse axis go with flexion and extension. Note the trap between 'transverse axis' (flexion/extension) and 'transverse plane' (rotation).
If you have somatic dysfunction of the sacrum, what are the effects on your health?
Ans: Sacrum → S2-S4 pelvic splanchnics (parasympathetic) → more gut motility → diarrhea → C
Why: The sacral region carries parasympathetic outflow (S2-S4, pelvic splanchnics). Sacral SD can increase parasympathetic drive to the gut, which increases motility and causes diarrhea.
Explanation & sources
Explanation
Parasympathetic tone speeds the gut, so A pairs it with the wrong effect. Hypersympathetic drive slows the bowel and causes constipation (D), which is the effect of a thoracolumbar SD. B pairs sympathetic drive with the wrong effect.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 36-37
2020 TA Review (Middletown) Exam 1 · TA review · slides 41-42
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Learn firstWhat you need for 4.1
Fascia envelops muscles (muscles grow within it) and guides their contraction and motion, which is why muscle and fascia are called myofascia. FOM3 defines fascia as loose or dense irregular connective tissue organized as concentric tubes (not sheets). Dense regular tissue is tendon and ligament, not fascia.
FOM3 fascial layer (outside → in)
Where / what
1. Pannicular
Superficial (subcutaneous) fascia; contains muscles such as the platysma
2. Axial and appendicular
Deep investing fascia of the trunk and limbs, just under the pannicular layer
3. Meningeal
Surrounds the CNS
4. Visceral
Surrounds the organs of the body cavities
So removing the platysma removes the pannicular layer and reveals the axial/appendicular layer beneath it.
Cells of fascia: fibroblasts, myofibroblasts, macrophages and mast cells. (Reticulocytes are immature red blood cells, not fascia.) Extracellular matrix: collagen, elastic fibers, laminin, fibronectin.
195Fascia
Which of the following houses muscle and guides its contraction and motions?
Ans: Envelops muscle + guides its motion → fascia
Why: Muscles grow within and are enveloped by fascia, and fascia guides their contraction and motion. That is why the lecture calls it myofascia.
Explanation & sources
Explanation
Ligaments connect bone to bone and do not house muscle. Cartilage covers joint surfaces. 'Fibrous connective tissue' is too general; fascia is the specific structure. Tendons insert into bone through Sharpey's fibers.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 82-83
196asked 2×Fascia
According to FOM3, fascia is what type of connective tissue?
Ans: FOM3: fascia = irregular connective tissue arranged as concentric tubes → dense irregular, tubes
Why: FOM3 defines fascia as loose or dense irregular connective tissue, organized as concentric tubes (pannicular, axial/appendicular, meningeal, visceral).
Explanation & sources
Explanation
Dense regular tissue is tendon and ligament, not fascia. 'Loose regular' is not a fascia type. 'Loose irregular, sheets' gets the tissue partly right but the layers are described as tubes, not sheets.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 135-136
2020 TA Review (Middletown) Exam 1 · TA review · slides 74-75
197Fascia
You remove the platysma from your cadaver. What layer of fascia did you remove?
Ans: Platysma lies in superficial fascia → pannicular layer
Why: The platysma is a muscle embedded in the superficial (subcutaneous) fascia, which FOM3 calls the pannicular layer.
Explanation & sources
Explanation
Axial and appendicular fascia is the deep investing layer under the pannicular layer. Meningeal fascia surrounds the CNS. Visceral fascia surrounds the body-cavity organs.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 77-80
198Fascia
You remove the platysma from your cadaver. What layer of fascia is being revealed?
Ans: Remove pannicular (platysma) layer → next deeper = axial/appendicular
Why: Removing the platysma takes away the pannicular layer and exposes the next deeper tube, the axial and appendicular (deep investing) fascia.
Explanation & sources
Explanation
Pannicular is the layer you removed, not the one revealed. Meningeal and visceral layers lie much deeper, around the CNS and the organs. Order from outside in: pannicular, axial/appendicular, then meningeal and visceral.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 78-80
199Fascia
Which cells are NOT a component of fascia?
Ans: Fascia cells = fibroblasts, myofibroblasts, macrophages, mast cells → reticulocytes are not
Why: The cells of fascia are fibroblasts, myofibroblasts, macrophages and mast cells. Reticulocytes are immature red blood cells found in blood.
Explanation & sources
Explanation
The other four are all resident cells of fascia. Its extracellular matrix holds collagen, elastic fibers, laminin and fibronectin.
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2020 TA Review (Middletown) Exam 1 · TA review · slides 81-82
4.2 · 14 questions · Questions 200–213
Muscle receptors
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Two receptors are specific to muscle: the muscle spindle and the Golgi tendon organ (GTO). Together they provide continuous feedback and adjustment of muscular tone. (Nociceptors, Ruffini, Meissner and Pacinian receptors are found in skin, joints and other tissues.)
Muscle spindle
Golgi tendon organ
Location
Belly of the muscle
Myotendinous junction (periphery/ends of the muscle); encapsulated, 10–15 muscle fibers pass through it
Senses
Stretch: change in length and rate of change of length
Tension (from contracting or stretching)
Afferent (sensory) fibers
Ia (primary) and II (secondary)
Ib: large, rapidly conducting
Motor supply
Gamma motor neurons to its intrafusal fibers
None
Reflex effect
Stretch → the same muscle contracts
High tension → the same muscle relaxes
Memory hooks: GTO = Tension, and “b” for tendon: Ib = GTO. The Ia fiber is the primary sensory neuron in muscle (main afferent of the stretch reflex). Alpha and gamma are motor (efferent) neurons, never sensory. Neither receptor is a pain receptor.
Spindle anatomy: a 3–10 mm capsule holding 3–12 intrafusal fibers, surrounded by the large extrafusal fibers that make up the muscle. Gamma motor neurons supply the intrafusal fibers; alpha motor neurons supply the extrafusal fibers; Ia and II carry its sensory signal.
Lecture slide for this section (1)
Written Review slide 26: alpha and gamma motor innervation
200Muscle receptors
What are the two receptors specific to muscle?
Ans: Receptors specific to muscle → muscle spindle + Golgi tendon organ
Why: The two receptors specific to muscle are the muscle spindle (in the belly) and the Golgi tendon organ (at the myotendinous junction). Together they give continuous feedback and adjust muscle tone.
Explanation & sources
Explanation
Nociceptors, Ruffini endings, Meissner and Pacinian corpuscles are found in skin, joints and other tissues, not only in muscle. Each wrong option pairs one muscle receptor with a general receptor.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 83-84
Lecture slide (1)
Week 4 · Written Review deck · slide 23
201top 215Muscle receptors
What is the function of each muscle receptor?
Ans: GTO senses tension; spindle senses stretch (length) → B
Why: The Golgi tendon organ detects tension and the muscle spindle detects stretch (length and rate of change of length).
Explanation & sources
Explanation
A swaps the two. Neither receptor is a pain receptor, which rules out C, D and E. Memory hook: GTO = Tension, both have a T.
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2023 TA Review - Written Exam 1 · TA review · slides 85-86
What is the role of the muscle spindle and golgi tendon?
Ans: Lecture: spindle + GTO 'provide continuous feedback and adjustment of muscular tone' → C and D
Why: The lecture states these two receptors provide continuous feedback and adjustment of muscular tone, so the answer combines C and D.
Explanation & sources
Explanation
Regulation of movement and proprioception are loosely true but are not the lecture's wording. When a 'both' option matches a lecture line word for word, pick it.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 88-89
203Muscle receptors
Which of the following is located in the belly of the muscle?
Ans: Belly of muscle → muscle spindle (GTO is at the tendon)
Why: The muscle spindle is the receptor located in the belly of the muscle, where it senses stretch.
Explanation & sources
Explanation
The GTO is at the myotendinous junction. Intrafusal fibers sit inside the spindle, but the question asks for the receptor. Extrafusal fibers make up the whole muscle, not a receptor.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 84-85
204Muscle receptors
Which of the following is located at the periphery of the muscle?
Ans: Periphery (end) of muscle = myotendinous junction → GTO
Why: The Golgi tendon organ sits at the myotendinous junction, at the ends of the muscle, where it senses tension.
Explanation & sources
Explanation
The muscle spindle and its intrafusal fibers are in the belly. Extrafusal fibers make up the bulk of the muscle and are not a receptor.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 86-87
205top 215Muscle receptors
Describe the anatomical location of the muscle spindle and golgi tendon organ.
Ans: Spindle = belly; GTO = myotendinous junction
Why: The muscle spindle lies in the belly of the muscle and the GTO lies at the myotendinous junction.
Explanation & sources
Explanation
C swaps the locations. D and E are invented. The GTO is an encapsulated receptor that 10-15 muscle fibers pass through.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 142-143
206Muscle receptors
After your legs give out during a workout, you tell your friend your golgi tendon reflex saved you. How would you describe the anatomical location of the golgi tendon organ?
Ans: GTO location → myotendinous junction
Why: The Golgi tendon organ is located at the myotendinous junction.
Explanation & sources
Explanation
The belly holds the muscle spindle. C and D describe the spindle (Ia fibers, change in length), and neither is a location anyway. The GTO uses Ib fibers and senses tension.
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2023 TA Review - Written Exam 1 · TA review · slides 136-137
207asked 3×Muscle receptors
What is the primary sensory neuron in the muscle?
Ans: Primary spindle afferent → type Ia
Why: The Ia fiber is the primary afferent of the muscle spindle. It is the main sensory neuron of the stretch reflex and fires strongly with rapid stretch.
Explanation & sources
Explanation
Ib carries GTO signals. II is the secondary spindle afferent. Alpha and gamma are motor (efferent) neurons, not sensory.
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2023 TA Review (Harlem) - Exam 1 · TA review · slides 62-63
2020 TA Review (Middletown) Exam 1 · TA review · slides 58-59
2020 TA Review Exam 1 · TA review · slides 61-62
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 4
208top 215Muscle receptors
What are the afferent neural components for each receptor?
Ans: Spindle afferents Ia + II; GTO afferent Ib → E
Why: Muscle spindle afferents are Ia and II. The Golgi tendon organ afferent is Ib.
Explanation & sources
Explanation
A puts Ib on the spindle. B invents a 'Type Ic' fiber. C gives Ia to the GTO. D lists fibers that are not used by either receptor.
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2023 TA Review - Written Exam 1 · TA review · slides 87-88
209Muscle receptors
Just as the golgi tendon organ afferents run on type Ib fibers, muscle spindle afferents run on:
Ans: Spindle afferents → Ia + II
Why: Muscle spindle afferents are type Ia and II fibers.
Explanation & sources
Explanation
Ib belongs to the GTO, which rules out C and E. Type III fibers carry pain and pressure. IIa and IIb are not afferent labels used in the lecture.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 148-149
210top 215asked 3×Muscle receptors
What type of nerve fiber is associated with transmission of the golgi tendon signal?
Ans: GTO signal → type Ib
Why: Golgi tendon organ signals travel on type Ib fibers.
Explanation & sources
Explanation
Ia is the primary spindle afferent. 'Id' does not exist. IIa and IIb are not afferent labels in this lecture; spindle secondary afferents are just 'II'.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 54-55
2022 TA Review (Middletown) - Exam 1 · TA review · slides 136-137
2022 TA Review - Exam 1 · TA review · slides 77-78
211Muscle receptors
Which describes the fibers that transmit GTO signals?
Ans: GTO signals → large, rapidly conducting type Ib
Why: Lecture: GTO signals are transmitted through a large, rapidly conducting type Ib nerve fiber.
Explanation & sources
Explanation
Large fibers conduct fast, so 'large, slowly conducting' and 'small, rapidly conducting' are mismatched. Ia belongs to the spindle and is also large and fast.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 108-109
212Muscle receptors
Match the sensory fibers with either the muscle spindle or the golgi tendon organ: Ia fibers, Ib fibers, II fibers.
Why: The muscle spindle has two afferents, Ia and II. The GTO has one, Ib.
Explanation & sources
Explanation
A common trap is pairing Ia with Ib on the same receptor. Remember 'b' for tendon: Ib = GTO.
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2022 TA Review (Middletown) - Exam 1 · TA review · slide 100
213Muscle receptors
What are the primary components of the muscle spindle?
Answer3-12 intrafusal fibers in a 3-10 mm spindle, surrounded by large extrafusal fibers; motor supply by gamma motor neurons (alpha supplies extrafusal fibers); sensory supply by Ia and II afferents.
Why: A spindle holds 3-12 intrafusal fibers surrounded by extrafusal fibers. Gamma motor neurons supply the intrafusal fibers, and Ia and II fibers carry its sensory signals.
Explanation & sources
Explanation
Its central region has the sensory receptors and does not contract. The ends contract when gamma motor neurons fire.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 90-91
Lecture slide (1)
Week 4 · Written Review deck · slide 26
4.3 · 11 questions · Questions 214–224
Muscle spindle
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The muscle spindle reports length and the rate of change of length, for both lengthening and shortening. It does not sense tension (that is the GTO).
Event
Spindle response
Result
Slow stretch
Static response: afferents fire in proportion to the degree of stretch
No strong contraction; this is why OMT stretches slowly
Sudden / too-fast stretch
Dynamic response: Ia (and II) afferents fire powerfully (rate-sensitive)
Muscle contracts powerfully: the stretch reflex
Muscle shortened
Opposite signal: afferent firing drops
Muscle relaxes (basis of counterstrain)
The stretch (muscle spindle) reflex: a quick stretch fires spindle afferents (Ia, II), which excite alpha motor neurons, so the same muscle contracts. It protects against overstretch and regulates length automatically (e.g. the knee jerk; a sudden split tightening the hamstring). The antagonist relaxes at the same time (reciprocal inhibition).
Clinical application: if a muscle suddenly tightens during a stretch or myofascial technique, you went too fast and triggered the dynamic response of the muscle spindle via afferent Ia and II fibers. Static and dynamic responses belong to the spindle, not the GTO. One myofascial goal is to stimulate the stretch reflex in hypotonic muscles.
214asked 2×Muscle spindle
What does the muscle spindle respond to and what are its afferents?
Ans: Spindle senses length + rate of change; afferents Ia + II
Why: The muscle spindle responds to change in length and rate of change of length, and its afferents are Ia and II.
Explanation & sources
Explanation
B has the right stimulus but adds Ib, the GTO fiber. C describes the GTO (tension) and names a motor neuron as an afferent. A is incomplete and includes Ib.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 60-61
2024 TA Review (Harlem) Exam 1 · TA review · slides 61-62
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 3
215top 215asked 2×Muscle spindle
Which is true of the muscle spindle?
Ans: Spindle = length + rate of change of length
Why: The muscle spindle responds to change in length and the rate of change of length.
Explanation & sources
Explanation
The spindle reflex contracts the muscle in response to stretch; relaxing is a GTO effect. Afferents fire especially powerfully when length increases suddenly (dynamic response), not slowly.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 68-69
2022 TA Review - Exam 1 · TA review · slides 51-52
Which of the following is true about muscle spindles?
Ans: Spindle reports lengthening (→ contraction) and shortening (→ inhibition) → both
Why: When a muscle lengthens or shortens, the spindle conveys it: lengthening leads to contraction (stretch reflex) and shortening leads to inhibition.
Explanation & sources
Explanation
A and B each give only half of the lecture statement. D and E are unrelated to spindle function.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 145-146
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 4
217Muscle spindle
The muscle spindles are directly associated with length of the muscle. However, their response is also linked to:
Ans: Spindle = length + RATE of change (lengthening or shortening); tension = GTO
Why: Besides length, the spindle responds to the rate of change in length, whether the muscle is being lengthened or shortened.
Explanation & sources
Explanation
Tension is sensed by the Golgi tendon organ, which removes A and therefore D.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 151-152
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 3
218Muscle spindle
The muscle spindle also detects shortening of the muscle. Which of the following most accurately describes the effects of rapidly shortening the muscle in regards to the muscle spindle reflex?
Why: When the spindle shortens, the opposite sensory signals occur and the muscle relaxes. The spindle responds to length, not tension.
Explanation & sources
Explanation
A is the response to rapid lengthening (stretch reflex). B describes the GTO, which senses tension, so E is also wrong. D describes the crossed extensor reflex.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 155-156
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 4
219Muscle spindle
Which response is elicited when the muscle spindle is stretched slowly?
Why: When the spindle is stretched slowly, afferent signals are sent in proportion to the degree of stretch. This steady signal is the static response.
Explanation & sources
Explanation
The dynamic response is the burst of firing with a sudden stretch. OMT stretches slowly to stay in the static response and avoid reflex contraction.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 102-105
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 2
220Muscle spindle
Which response is elicited when the muscle spindle is stretched suddenly?
Why: A sudden increase in spindle length stimulates the afferents powerfully. This excess stimulus is the dynamic response, which is sensitive to the rate of change.
Explanation & sources
Explanation
The static response is the steady, proportional signal during a slow stretch. The dynamic response makes the muscle contract powerfully.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 103-105
While practicing OMM in preparation for the exam, you perform a lateral stretching technique. However, in your enthusiasm, you engage the stretch too quickly. The muscle contracts in response. Which type of neurological response has been engaged and which receptors have been activated?
Why: A quick stretch triggers the dynamic response of the muscle spindle: Ia afferents fire powerfully and the muscle contracts (stretch reflex) to protect itself.
Explanation & sources
Explanation
Static and dynamic responses belong to the spindle, not the GTO, and the GTO inhibits rather than contracts. The static response happens with a slow stretch and does not cause a strong contraction. 'Golgi spindle' is not a real structure.
You are performing a myofascial technique on your patient when you suddenly feel their muscles tighten up. Why did this occur and what is the physiological explanation?
Ans: Sudden tightening → stretch too fast → spindle afferents Ia + II → strong contraction
Why: Stretching too quickly fires the spindle afferents (Ia and II) at a high rate, producing a strong reflex contraction. Go slow to keep the muscle relaxed.
Explanation & sources
Explanation
Ia and II are afferent (sensory), not efferent, which removes A and B. D includes Ib, the GTO afferent, which causes relaxation, not contraction.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 56-57
2024 TA Review (Harlem) Exam 1 · TA review · slides 57-58
Your patient is a 38-year-old female complaining of right hamstring pain after trying to do the splits for the first time since high school. What nerve fibers are involved in the reflex causing the contraction of her hamstring?
Ans: Sudden overstretch → stretch reflex (spindle) → Ia + II afferents
Why: The sudden stretch triggered the stretch reflex of the muscle spindle, whose afferents are type Ia and II. The muscle contracts to prevent over-stretching.
Explanation & sources
Explanation
Ib is the GTO fiber, which would cause relaxation, so A and B are wrong. 'Type I' is too vague; the spindle primary afferent is specifically Ia.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 67-68
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 26
224Muscle spindle
What is the stretch reflex?
AnswerMuscle spindle reflex: a quick stretch fires spindle afferents (Ia, II), which excite alpha motor neurons so the stretched muscle contracts powerfully. It is protective (e.g., knee-jerk). The spindle senses length and rate of change of length.
Ans: Fast stretch → spindle Ia burst → alpha motor neuron → same muscle contracts
Why: The stretch reflex is contraction of a muscle in response to passive stretch. It protects against injury and regulates muscle length automatically, as in the knee-jerk reflex.
Explanation & sources
Explanation
A goal of myofascial treatment is a stimulatory effect on the stretch reflex in hypotonic muscles. The reflex also relaxes the antagonist through reciprocal inhibition.
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2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'What is the stretch reflex?'
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 26
4.4 · 8 questions · Questions 225–232
Alpha & gamma motor neurons
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Alpha motor neuron (Type A-alpha)
Gamma motor neuron
Supplies
Extrafusal fibers (the bulk of the muscle); alpha + its fibers = the motor unit
Intrafusal fibers inside the muscle spindle
Effect
Tells the muscle to contract
Tells the intrafusal fibers to contract (at the ends of the spindle)
The spindle contains intrafusal fibers and is surrounded by extrafusal fibers. Its central region lacks myofibrils, holds the sensory receptors and does not contract; only the ends contract when gamma fires. Gamma firing pulls on the center, stretching the receptors: this sets the spindle's sensitivity (the “gain” of the stretch reflex) and the baseline activity of the motor neuron.
Alpha–gamma co-activation: alpha and gamma fire together. Whenever a muscle contracts/shortens (e.g. a biceps curl), gamma neurons also fire so the spindle shortens with the muscle and stays taut, still able to sense stretch. A shortened spindle is the result gamma firing corrects, not its trigger, so “during muscle contraction” beats “when the spindle length is shortened”. Gamma does not fire because alpha is inhibited, because of GTO stimulation, or because of a too-fast stretch (that is the Ia stretch reflex).
The GTO has no motor supply (only Ib afferents).
225top 215Alpha & gamma motor neurons
The muscle spindle contains ____ and is surrounded by ____
Why: The spindle contains 3-12 intrafusal fibers and is surrounded by large extrafusal fibers.
Explanation & sources
Explanation
Alpha motor neurons innervate extrafusal fibers and gamma motor neurons innervate intrafusal fibers, but neurons are not what the spindle 'contains'. Alpha and gamma fire together (co-activation) so the spindle keeps reporting accurately.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 71-72
Lecture slide (1)
Week 4 · Written Review deck · slide 26
226Alpha & gamma motor neurons
What is the function of the alpha motor neurons?
Ans: Alpha motor neuron → extrafusal fibers → muscle contracts
Why: The alpha motor neuron (Type A alpha) instructs the extrafusal fibers to contract. It and its fibers form the motor unit.
Explanation & sources
Explanation
Relaxation and response to tension describe the GTO pathway, which acts through an inhibitory interneuron. Alpha neurons carry the contraction signal; they do not inhibit.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 92-93
Lecture slide (1)
Week 4 · Written Review deck · slide 26
227top 215Alpha & gamma motor neurons
Where are the gamma motor neurons located? And what is their function?
The ____ region of the muscle spindle lacks myofibrils and therefore does not contract.
AnswerCentral region
Ans: No myofibrils → central region; ends contract via gamma
Why: The central region of the spindle lacks myofibrils and does not contract. It holds the sensory receptors. The ends contract when gamma motor neurons fire.
Explanation & sources
Explanation
Gamma firing contracts the ends, which stretches the central region and makes the receptors fire. That is the second way to stretch the spindle besides lengthening the whole muscle.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 96-97
229Alpha & gamma motor neurons
Where do the gamma motor neurons induce contraction of the muscle spindle?
Ans: Center has no myofibrils → gamma contracts the ends
Why: Gamma motor neurons cause contraction at the ends of the spindle. The central region lacks myofibrils and cannot contract.
Explanation & sources
Explanation
The middle is the sensory region, stretched when the ends contract. 'Lateral aspects' is not how the lecture describes it.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 98-99
230asked 5×2026Alpha & gamma motor neurons
When would the gamma motor neurons be stimulated?
Ans: Alpha-gamma co-activation → gamma fires whenever the muscle contracts/shortens
Why: With alpha-gamma co-activation, gamma motor neurons fire whenever alpha motor neurons tell the muscle to contract and shorten (e.g., a biceps curl). This keeps the spindle taut so it still senses stretch.
Explanation & sources
Explanation
Gamma fires with alpha, not when alpha is inhibited. A too-fast stretch triggers the spindle's Ia afferents and the stretch reflex, not gamma firing. A neutral, resting muscle has no change to adjust for.
Ans: Co-activation: alpha + gamma fire together → during muscle contraction
Why:Alpha and gamma motor neurons fire together, so gamma neurons are stimulated during muscle contraction. The spindle shortens along with the muscle and keeps working as a stretch sensor.
Explanation & sources
Explanation
GTO stimulation inhibits the muscle; it does not drive gamma. Gamma fires with alpha, not when alpha is inhibited. Slow lengthening gives the spindle's static response. 'Spindle shortened' is the result of gamma firing, not the trigger.
Stimulation of the gamma motor neurons results in which of the following?
AnswerContraction of the intrafusal fibers (the ends of the spindle).
Ans: Gamma → intrafusal fibers → ends of spindle contract
Why: Gamma motor neurons make the intrafusal fibers contract at the ends of the spindle. This sets spindle tension, the 'gain' of the stretch reflex.
Explanation & sources
Explanation
Alpha motor neurons contract the extrafusal fibers. Gamma activity sets the baseline activity of the motor neuron and helps regulate muscle length and tone.
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The Golgi tendon organ senses tension created by contracting or stretching the muscle (not “only stretching”). It is a negative feedback mechanism that prevents too much tension from developing.
Pathway (Golgi tendon reflex): GTO fires (Ib) → excites an inhibitory interneuron in the cord → the alpha motor neuron is inhibited → the same muscle relaxes. When tension, and therefore inhibition, becomes extreme, the entire muscle relaxes and the load is dropped: the lengthening reaction. This protects the muscle from excessively heavy loads.
Recognize it: arms or legs suddenly “give out” under a heavy load (grocery bags, a stack of books, a 100 lb weight, the millionth squat) = GTO / Golgi tendon reflex. The spindle reflex does the opposite (makes the muscle contract) and the biceps/triceps hammer reflexes are spindle reflexes.
Using it in OMT: having a tight (hypertonic) muscle contract against resistance builds tension that the GTO senses, which inhibits that muscle so it can be stretched further. If asked for the receptor, answer the GTO; if asked for the named principle/technique, answer post-isometric relaxation: right after an isometric contraction of the tight muscle it is in a refractory state, so slack can be taken up without stretch-reflex opposition. (Contracting the antagonist instead would be reciprocal inhibition.)
Lecture slides for this section (2)
Written Review slide 24: the Golgi tendon reflexIA6 slide 8: post-isometric relaxation
233top 215asked 2×Golgi tendon organ
Which does NOT describe the Golgi Tendon Organ?
Ans: GTO fires with tension from contracting OR stretching → 'only stretching' is false
Why: The GTO is stimulated by tension created by contracting OR stretching the muscle. The word only makes C false.
Explanation & sources
Explanation
A is the lecture's definition of the GTO: a negative feedback mechanism. B is the lengthening reaction, where extreme tension relaxes the whole muscle and you drop the load.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 70-71
2022 TA Review - Exam 1 · TA review · slides 53-54
After a trip to the grocery store, you decide that you can carry all of your shopping bags inside in one trip. After loading 7 bags on each arm, you begin walking to the door and suddenly drop everything unwillingly. What was activated in your muscles and how did this process occur?
Ans: Heavy load → high tension → GTO → excites inhibitory interneuron → alpha output drops
Why: Extreme tension activates the Golgi tendon organ. Its signal excites a single inhibitory interneuron, which cuts alpha motor output to that muscle so it relaxes and drops the load.
Explanation & sources
Explanation
The spindle senses length, not load. In C, inhibiting an inhibitory interneuron would increase muscle activity, the opposite of what happens. An 'excitatory interneuron to relax' makes no sense.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 58-59
2024 TA Review (Harlem) Exam 1 · TA review · slides 59-60
Lecture slide (1)
Week 4 · Written Review deck · slide 24
235Golgi tendon organ
A 35-year-old man tries carrying all the heavy grocery bags up his 4-story walk-up in one trip, but drops them after his arms suddenly 'give out'. Which of the following was activated?
Ans: Arms give out under heavy load → tension → GTO
Why: Heavy load creates high tension, which activates the Golgi tendon organ. Its inhibitory reflex relaxes the muscle (lengthening reaction).
Explanation & sources
Explanation
The spindle responds to stretch and makes the muscle contract, not give out. The biceps and triceps reflexes are spindle stretch reflexes tested with a hammer.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 106-107
Lecture slide (1)
Week 4 · IA4 Neuromuscular · slide 8
236Golgi tendon organ
A 26-year-old school teacher is changing classrooms. She was carrying a heavy stack of books to her new room, but before she was able to make it to her destination they became too heavy and she drops them all. What reflex is responsible for causing her to drop all her books?
Ans: Too heavy → excess tension → GTO reflex → muscle relaxes
Why: Excess tension fires the Golgi tendon organ reflex, which inhibits the muscle so it relaxes and the load drops.
Explanation & sources
Explanation
The stretch reflex and muscle spindle reflex are the same reflex, and they cause contraction. The biceps reflex is a spindle reflex tested with a hammer.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 65-66
Lecture slide (1)
Week 4 · Written Review deck · slide 24
237Golgi tendon organ
Tiger is holding a 100 lb weight in his arms because he thinks he is stronger than Brandon. However, his arms give out and the weight drops to the floor. What is the name of this reflex and which muscle receptor is involved?
Ans: Arms give out under load → tension → Golgi tendon reflex via GTO
Why: The heavy weight creates extreme tension, so the Golgi tendon reflex through the Golgi tendon organ relaxes the muscle.
Explanation & sources
Explanation
A and C mismatch the reflex and its receptor. B, the spindle reflex, contracts the muscle and would not make the arms give out.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 91-92
You are working out with your friend at the gym and they are putting you through an intense workout. As you are doing what feels like your millionth squat, you feel your legs give out. What reflex is most likely elicited to protect your legs?
Ans: Legs give out under high tension → protective GTO inhibition
Why: High muscle tension activates the Golgi tendon reflex, which inhibits the muscle to prevent damage. That is why the legs give out.
Explanation & sources
Explanation
The spindle reflex responds to stretch and causes contraction. Reciprocal inhibition relaxes the antagonist when the agonist contracts. The crossed extensor reflex involves the opposite limb (step on a nail, the other leg extends).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 133-134
2022 TA Review (Middletown) - Exam 1 · TA review · slides 139-140
Lecture slide (1)
Week 4 · Written Review deck · slide 24
239Golgi tendon organ
Which of the following scenarios describes the "Lengthening Reaction"?
Why: Tension is sensed by the Golgi tendon organ, and extreme inhibition that relaxes the whole muscle is the lengthening reaction.
Explanation & sources
Explanation
The muscle spindle senses length, not tension. There is no 'shortening reaction' in the lecture. (AT Still was born in 1828.)
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 157-158
241top 215asked 7×2026Golgi tendon organ
A patient comes in after going to an 'advanced' yoga class, for which she was not prepared. She complains of tight hamstring muscles. After passively and slowly stretching her hamstring muscles you reassess to find minimal change in the hypertonicity. You then remember that adding an active component to the stretch by having her contract the hypertonic muscles against resistance can enhance the effectiveness. Which muscle receptor is being engaged more strongly and through which process?
Ans: Contract the tight muscle against resistance → tension → GTO → inhibition
Why: Contracting the hypertonic muscle against resistance builds tension, which the Golgi tendon organ senses. The GTO then inhibits that muscle so it relaxes.
Explanation & sources
Explanation
A attaches the right mechanism (tension) to the wrong receptor. B and C describe length changes, which the spindle senses, but the active contraction works through tension. E gives the GTO intrafusal fibers, which belong only to the spindle.
A 46-year-old female presents to Urgent Care with complaints of leg pain and tight hamstrings. The pain began after going to an 'advanced' yoga class, for which she was not prepared. After passively and slowly stretching her hamstring muscles you reassess to find minimal change in the hypertonicity. You then recall that adding an active component to the stretch by having her contract the hypertonic muscles against resistance can enhance the effectiveness. Which physiologic principle is being employed?
Ans: Tight muscle contracts isometrically against resistance → then stretch → post-isometric relaxation
Why:Post-isometric relaxation: right after an isometric contraction of the tight muscle, it is in a refractory state, so you can take up the slack without stretch-reflex opposition. GTO tension provides the inhibition.
Explanation & sources
Explanation
GTO physiology is the receptor mechanism, but the named principle (technique) is post-isometric relaxation. A different question asks for the receptor and the answer there is the GTO. Crossed extensor uses the opposite limb, and contracting the antagonist would be reciprocal inhibition.
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Three reflexes relax a target muscle. The difference is which muscle contracts:
Reflex
Contract
What relaxes
Example
Post-isometric relaxation (GTO)
The tight muscle itself
The same muscle
Tight R biceps contracts against resistance
Reciprocal inhibition
The antagonist, same limb
The agonist
Contract R triceps → R biceps relaxes; contract quads → hamstrings relax
Crossed extensor
The same muscle in the opposite limb
That muscle on the other side
Contract L biceps → R biceps relaxes; contract L hamstring → R hamstring relaxes
Reciprocal inhibition occurs in the stretch reflex and in any contraction: when an agonist contracts, its antagonist must relax. It uses a very gentle force (ounces, not pounds), which suits sore, acutely tight muscles. Knee jerk: tapping the patellar tendon stretches the quadriceps spindle → quadriceps (extensor) contracts and hamstrings (flexor) relax in the same (ipsilateral) leg.
Crossed extensor in OMT: used when the injured limb cannot be treated directly (burns, fractures, severe strain or pain). Lecture example: stretch reflex to the R biceps causes relaxation of the L biceps (same muscle, opposite side). Options that pair same-side agonist/antagonist are reciprocal inhibition, not crossed extensor.
Lecture slide for this section (1)
Written Review slide 25: reciprocal inhibition and the knee jerk
A patient comes in after going to an 'advanced' yoga class, for which she was not prepared. She complains of very sore and tight hamstring muscles. You decide to have her contract the antagonist muscles as a way to ease into the treatment. Which physiologic principle are you employing?
Why: Contracting the antagonist (quadriceps) reflexively relaxes the tight hamstrings. This is reciprocal inhibition, and it occurs with any contraction.
Explanation & sources
Explanation
GTO physiology would mean contracting the tight hamstring itself. The crossed extensor reflex uses the opposite limb. Reciprocal inhibition uses a very gentle force (think ounces, not pounds), which suits sore, acutely tight muscles.
Why: Contracting the ipsilateral antagonist (right triceps) reflexively relaxes the right biceps. That is reciprocal inhibition.
Explanation & sources
Explanation
The Golgi tendon reflex would mean contracting the biceps itself. The cross-extensor reflex would use the left arm. The spindle reflex contracts a stretched muscle.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 131-132
2020 TA Review (Middletown) Exam 1 · TA review · slides 70-71
2020 TA Review Exam 1 · TA review · slides 73-74
Lecture slide (1)
Week 4 · Written Review deck · slide 25
245Reciprocal inhibition & crossed extensor
Which of the following reflexes occurs during any contraction?
Ans: Every agonist contraction → antagonist must relax → reciprocal inhibition
Why:Reciprocal inhibition occurs in the stretch reflex and in any contraction: when an agonist contracts, its antagonist must relax.
Explanation & sources
Explanation
The Golgi tendon reflex needs significant tension. The spindle reflex needs a stretch. The crossed extensor reflex involves the opposite limb.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 160-161
You visit your PCP and have your reflexes tested. The doctor taps your patellar tendon with the reflex hammer. What actions will your muscles elicit?
Ans: Tap stretches quads spindle → quads contract + hamstrings relax (reciprocal inhibition), same leg
Why: The tap stretches the quadriceps spindle, so the quadriceps (extensor) contracts through the stretch reflex. Through reciprocal inhibition the hamstrings (flexor) relax in the same leg.
Explanation & sources
Explanation
The knee jerk is a single-leg reflex, so the contralateral options are wrong. Both muscles cannot relax, because the extensor must contract to kick.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 97-98
2022 TA Review - Exam 1 · TA review · slides 79-80
Which of the following describes the cross-extensor reflex?
Ans: Crossed extensor = opposite side, SAME muscle relaxes → R biceps → L biceps
Why: The lecture's example of the crossed extensor reflex: a stretch reflex to the R biceps causes relaxation of the L biceps, the same muscle on the opposite side.
Explanation & sources
Explanation
C and D are same-side antagonist pairs, which is reciprocal inhibition. A and B cross sides but change muscle groups. In muscle energy, contracting a flexor in one limb relaxes the flexor in the opposite limb.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 128-129
2020 TA Review (Middletown) Exam 1 · TA review · slides 67-68
After hitting the gym a little too hard and doing too many bicep curls, you feel extreme pain and can't move your biceps on the right. Your friend asks you to tuck your left elbow to your side and have your palm face up, then push upwards while they provide isometric resistance. What technique did your friend use and what is the goal?
Ans: Injured R biceps + contract L biceps → same muscle, other limb → crossed extensor
Why: Contracting the left biceps to relax the injured right biceps uses the crossed extensor reflex: contracting a muscle group in one limb relaxes the same group in the opposite limb.
Explanation & sources
Explanation
Reciprocal inhibition would contract the right triceps. Isolytic lengthening uses an operator force greater than the patient's to stretch fibrotic tissue; D pairs that name with the crossed extensor definition. Crossed extensor is used when the injured limb cannot be treated directly (burns, fractures, severe strain).
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 95-96
2024 TA Review (Harlem) Exam 1 · TA review · slides 85-86
249Reciprocal inhibition & crossed extensor
A 14-year-old boy presents with right hamstring tightness following a soccer game. The physician decides to use a form of muscle energy that takes advantage of the crossed extensor reflex. The patient is instructed to contract his left hamstring while the physician monitors the restricted right hamstring. Which of the following best explains the physiologic basis of this technique?
Ans: Contract L hamstring → crossed spinal pathway → R hamstring relaxes
Why: Through crossed extensor pathways, voluntary contraction of the left hamstring reflexively relaxes the right hamstring.
Explanation & sources
Explanation
The GTO acts only on its own muscle, so it cannot explain relaxation on the other side. The reflex relaxes, not contracts, the opposite flexor. E is a true mechanism (reciprocal inhibition) but not the technique described.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 123-124
4.7 · 9 questions · Questions 250–258
Types of muscle contraction
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Contraction
Length
Forces (Dr vs Pt)
Example
Concentric
Shortens; origin and insertion approximate
Pt > load
Lifting a weight in a curl (tension varies through the arc)
Isotonic
Shortens with constant tension; course: “fix only one end of the attachment”
Dr < Pt
Curling up when the stem says tension does not change; used for hypotonic, reflexively inhibited muscles
Isometric
No change; tension rises without approximation; origin and insertion stationary
Dr = Pt
Holding a weight steady at 90°; the most common contraction in muscle energy
Eccentric
Lengthens while contracting
Load > Pt
Lowering a weight under control
Isolytic
Lengthened by a greater outside force while the patient contracts
Dr > Pt
Too-heavy weight pulls the arm down; used to break adhesions in fibrotic, shortened tissue
Decision tips: “lifting” → concentric, unless the stem says tension is constant → isotonic. “Holding still” → isometric. “Lowering” → eccentric, unless an outside force is overpowering the muscle or the goal is to break adhesions → isolytic. “Iso-metric” = same length; “iso-tonic” = same tension.
250top 215asked 2×2026Types of muscle contraction
Select the type of muscle contraction most closely associated with the description: the activity of the biceps muscle during the elevation of a weight while performing a curling maneuver.
Ans: Lifting = attachments approximate while contracting → concentric
Why: Lifting a weight is a concentric contraction: the muscle shortens and its origin and insertion approximate.
Explanation & sources
Explanation
It is not isotonic in the textbook's view because tension changes as the weight swings through its arc. Eccentric is lowering. Isometric is holding still. Isolytic is a lengthening contraction overpowered by an outside force.
Select the type of muscle contraction most closely associated with the description: the activity of the biceps muscle while holding a weight steady with arms flexed at 90 degrees.
Ans: Holding steady = no length change → isometric
Why: Holding a weight still is isometric: muscle force equals the load, so length does not change and origin and insertion stay put.
Explanation & sources
Explanation
Concentric shortens and eccentric lengthens. Isolytic needs an outside force that lengthens the muscle. Isometric is the most common contraction used in muscle energy.
Select the type of muscle contraction most closely associated with the description: the activity of the biceps muscle while lowering a weight during a curling exercise.
Ans: Lowering under control = contracting while lengthening → eccentric
Why: Lowering a weight is eccentric: the biceps contracts while it lengthens under an external force.
Explanation & sources
Explanation
Concentric is the lifting phase. Isolytic is a special eccentric contraction in OMT where the operator's force exceeds the patient's to break adhesions. Isometric involves no movement.
Select the type of muscle contraction most closely associated with the description: muscle contraction against resistance while an external force causes the muscle to lengthen with the purpose of breaking adhesions.
Ans: Lengthened by greater outside force + breaks adhesions → isolytic
Why:Isolytic contraction: the counterforce is greater than the patient's force, so the muscle lengthens while contracting. It is used to break adhesions in fibrotic, shortened tissue.
Explanation & sources
Explanation
Eccentric also lengthens, but 'breaking adhesions' with an operator force is the defining feature of isolytic. Concentric shortens and isometric does not move.
You hold a dumbbell with your arm flexed at 90 degrees without letting it drop. What is the activity of the biceps when you are holding the weight steady?
Ans: Steady = same length (iso-metric) → isometric
Why:Isometric means same length: the arm opposes the weight with equal force, so the muscle length does not change.
Explanation & sources
Explanation
Isolytic means the muscle is lengthened. Concentric and isotonic both involve shortening.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 102-103
255Types of muscle contraction
You hold a dumbbell with your arm flexed at 90 degrees, but this time it's too heavy and it's bringing your arm down. What is the activity of the biceps when your arm is being lowered?
Ans: External force > muscle force → muscle lengthens while contracting → isolytic
Why: The external force is greater than the muscle's force, so the contracting biceps is lengthened. That is isolytic (Dr > Pt).
Explanation & sources
Explanation
Isometric would hold still (Dr = Pt). Concentric and isotonic shorten the muscle (Dr < Pt). Eccentric is the general term for lengthening contractions, but it is not an option here.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 104-105
256Types of muscle contraction
You hold a dumbbell with your arm flexed at 90 degrees, but this time you got stronger and were able to bring it up for a bicep curl. What is the activity of the biceps when the weight is brought up? (considering there is no change in tension for the sake of simplicity)
Ans: Shortens + tension held constant (iso-tonic) → isotonic
Why: With tension stated as constant, lifting the weight is isotonic (same tension): the muscle force exceeds the load and the muscle shortens.
Explanation & sources
Explanation
Concentric also shortens, but the stem's 'no change in tension' points to isotonic. When tension varies through the arc, the textbook calls a curl concentric. Isometric holds still and isolytic lengthens.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 106-107
257Types of muscle contraction
Which of the following statements concerning muscle contraction is correct?
Ans: Isometric = tension rises, length fixed (no approximation)
Why: In an isometric contraction, tension increases while origin and insertion do not approximate.
Explanation & sources
Explanation
Isotonic contraction approximates origin and insertion with constant tension, so A and E change the tension. B gives isometric approximation, which it lacks. C describes isometric but calls it isotonic.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 65-66
258top 215Types of muscle contraction
Match each contraction type (isotonic, isometric, isolytic) to its description: A. Lengthening the muscle as the patient actively contracts it; B. Contracting a muscle while fixing only one end of the muscular attachment; C. Origin and insertion points are maintained in a stationary position while the muscle is contracted against resistance.
AnswerIsotonic: B; Isometric: C; Isolytic: A.
Ans: Stationary attachments = isometric; one end fixed = isotonic; lengthened while contracting = isolytic
Why: Per the course: isometric keeps origin and insertion stationary against resistance, isotonic fixes only one end of the attachment, and isolyticlengthens the muscle while the patient contracts it.
Heads up: The 2023 TA answer slide matched Isotonic to C and Isometric to B. The 2026 Lect 6 slide 31 defines isometric as origin and insertion kept stationary (C) and isotonic as fixing only one end (B), so those two are swapped on that slide. Isolytic to A is correct.
Explanation & sources
Explanation
Isometric is the most common contraction in muscle energy. Isotonic is often used for hypotonic, reflexively inhibited muscles. Isolytic treats fibrotic, chronically shortened tissue.
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2023 TA Review - Written Exam 1 · TA review · slides 145-146
4.8 · 5 questions · Questions 259–263
Technique physiology
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Each soft tissue / OMT technique relies on a piece of neuromuscular physiology:
Technique
Mechanism
Kneading (intermittent force on paraspinals)
Muscle spindle principles: go slowly so the rate-sensitive spindle does not fire a reactive contraction
Cross-arm technique (bilateral stretch, steady force increased slowly)
Done slowly to prevent muscle spindle activation (also linked to the GTO when that option is offered)
Counterstrain
Passive shortening of the hypertonic muscle reduces spindle afferent input, resetting the overactive spindle so the muscle relaxes
Contract the antagonist
Reciprocal inhibition
Direct vs indirect:shortening a hypertonic muscle moves it away from the barrier toward ease → indirect (e.g. counterstrain). Stretching it engages the barrier → direct; perpendicular and parallel stretches are both direct.
259top 215asked 7×2026Technique physiology
Shortening a hypertonic muscle with OMT would be an example of which kind of technique?
Ans: Shortening = moving away from the barrier toward ease → indirect
Why: Shortening a hypertonic muscle moves it away from the restrictive barrier toward ease, so it is an indirect technique.
Explanation & sources
Explanation
Stretching a hypertonic muscle engages the barrier, which is direct. Perpendicular and parallel stretches are both direct stretching techniques, and shortening is not stretching. Counterstrain is the classic indirect technique that shortens a muscle.
Ans: Kneading = intermittent force, go slow so spindle doesn't fire → muscle spindle principle
Why: The lecture pairs kneading of the paraspinals with muscle spindle principles: the spindle responds to length and rate of change of length, so you go slow to avoid a reactive contraction.
Explanation & sources
Explanation
The lecture's GTO example is the steady bilateral stretch (cross-arm technique). The accommodation, rooting and Hering-Breuer reflexes are not muscle reflexes used in OMT.
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2023 TA Review (Harlem) - Exam 1 · TA review · slides 122-123
2020 TA Review (Middletown) Exam 1 · TA review · slides 61-62
2020 TA Review Exam 1 · TA review · slides 64-65
261asked 3×Technique physiology
Cross arm technique uses which physiological mechanism?
Ans: Cross-arm = bilateral stretch with steady, slowly increased force → GTO reflex
Why: The cross-arm (bilateral linear) stretch applies a steady force increased slowly, which builds tension and uses the Golgi tendon reflex to relax the muscle (lengthening reaction).
Explanation & sources
Explanation
The lecture pairs kneading with spindle principles and bilateral stretching with the GTO. The other reflexes are unrelated to soft tissue technique.
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2023 TA Review (Harlem) - Exam 1 · TA review · slides 125-126
2020 TA Review (Middletown) Exam 1 · TA review · slides 64-65
2020 TA Review Exam 1 · TA review · slides 67-68
262Technique physiology
What is the physiological principle at play for the bilateral linear cervical stretch?
Ans: Slow linear stretch → avoids rate-sensitive spindle firing → no reflex contraction
Why: The stretch is done slowly so the spindle, which senses rate of change of length, does not trigger a stretch reflex. That is preventing muscle spindle activation.
Explanation & sources
Explanation
No antagonist or opposite-side contraction is used, so reciprocal inhibition and crossed extensor do not apply. The lecture also links this steady bilateral stretch with the GTO, but the GTO is not an option here.
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2023 TA Review - Written Exam 1 · TA review · slides 99-100
263top 215Technique physiology
You are performing counterstrain to treat a patient's anterior T8 tenderpoint. How is the muscle spindle involved in this technique?
Why: Counterstrain places the hypertonic muscle in a shortened position. This reduces spindle afferent input, resets the overactive spindle, and lets the muscle relax.
Explanation & sources
Explanation
A slow stretch gives a static response but does not 'inhibit' afferents. B describes reciprocal inhibition. A quick stretch causes the dynamic response and a strong contraction.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 69-70
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 17
4.9 · 8 questions · Questions 264–271
Hypertonia & goals of treatment
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Causes of muscle hypertonia: pain, postural strain, spinal facilitation, supraspinal influence and psychological stress (so “all of the above”). Hypertonia limits movement across a joint and decreases function.
The four goals of myofascial (soft tissue) treatment, learned word for word:
Goal
Effect
1. Relaxation of contracted (hypertonic) muscles
↓ pain, normalized range of motion across a joint, ↓ oxygen demand of the muscle
2. Increase circulation to an area of ischemia
Supplies blood carrying oxygen and nutrients to the tissues
3. Increase venous and lymphatic drainage
↓ local swelling, removes metabolic waste
4. Stimulatory effect on the stretch reflex in hypotonic muscles
Tones up weak, hypotonic muscles
Twisted (false) versions to reject: increase hypertonicity, decrease drainage, decrease circulation, inhibit the stretch reflex, shorten tight muscles, increase ischemia, decrease tissue elasticity, “increase contraction of hypotonic muscles” (the goal is to stimulate the stretch reflex).
264Hypertonia & goals of treatment
Which of the following is a cause of muscle hypertonia?
Why: The lecture lists causes of hypertonia as pain, postural strain, spinal facilitation, supraspinal influence and psychological stress, so all of the above.
Explanation & sources
Explanation
The lecture slide says 'psychological stress'; the stress option here means the same thing. Hypertonia limits movement across a joint and decreases function.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 112-113
265Hypertonia & goals of treatment
What are the 4 goals of myofascial treatments?
Answer1) Relax contracted muscles. 2) Increase circulation to an area of ischemia. 3) Increase venous and lymphatic drainage. 4) Stimulate the stretch reflex in hypotonic muscles.
Ans: Relax, circulate, drain, stimulate
Why: Four goals: relax contracted muscles, increase circulation to ischemic areas, increase venous and lymphatic drainage, and a stimulatory effect on the stretch reflex in hypotonic muscles.
Explanation & sources
Explanation
Relaxation decreases pain, normalizes range of motion and lowers the muscle's oxygen demand. Drainage decreases swelling and removes metabolic waste.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 127-128
266Hypertonia & goals of treatment
Which of the following is one of the four goals of OMT?
Ans: A-D are exactly the 4 lecture goals → all
Why: A through D are the four goals of myofascial treatment listed word for word in the lecture.
Explanation & sources
Explanation
Watch for twisted versions on the exam, such as 'decrease drainage' or 'increase hypertonicity', which are false.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 168-169
267Hypertonia & goals of treatment
What is the effect of the relaxation of contracted muscles?
Ans: Relaxation goal → less pain, normal ROM, less O2 demand (D belongs to circulation goal)
Why: The lecture lists three effects of relaxing contracted muscles: decreases pain, normalizes range of motion, and decreases oxygen demand.
Explanation & sources
Explanation
Supplying oxygen and nutrients falls under a different goal, increasing circulation to an area of ischemia, so 'all of the above' is wrong.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 125-126
268asked 2×Hypertonia & goals of treatment
Which of the following is not a goal of myofascial treatments?
Ans: Goals relax muscles → decrease, not increase, hypertonicity
Why: Myofascial treatment aims to decrease hypertonicity by relaxing contracted muscles. Increasing it is not a goal.
Explanation & sources
Explanation
A, B and C come from the lecture's goals list. The only 'stimulatory' goal targets the stretch reflex in hypotonic muscles, not hypertonic ones.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 62-63
2024 TA Review (Harlem) Exam 1 · TA review · slides 63-64
269Hypertonia & goals of treatment
Which is not a goal of OMT?
Ans: Goal is INCREASED drainage → 'decreasing' is false
Why: The goal is to increase venous and lymphatic drainage, which reduces swelling and clears metabolic waste. Decreasing it is not a goal.
Explanation & sources
Explanation
B, C and D are three of the four goals stated in the lecture.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 78-79
270Hypertonia & goals of treatment
Which is a goal of myofascial treatment?
Ans: Goal list → increase venous + lymphatic drainage
Why:Increased venous and lymphatic drainage is one of the four goals. It decreases local swelling and removes metabolic waste.
Explanation & sources
Explanation
Circulation is increased, not decreased. The goal is to stimulate, not inhibit, the stretch reflex in hypotonic muscles. D distorts that goal into directly increasing contraction.
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2023 TA Review - Written Exam 1 · TA review · slides 97-98
271top 215Hypertonia & goals of treatment
Which of the following is a goal of passive myofascial techniques?
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Soft tissue (myofascial) technique treats muscle and fascia. It can be the primary treatment or preparation for other techniques such as HVLA. Unlike muscle energy, it does not require a specific joint diagnosis.
Passive: the physician does the work. Active: the patient makes an isometric contraction of the tight muscle against resistance, then the muscle is stretched.
Perpendicular stretch: pushes the muscle at right angles to its fibers (medial to lateral), e.g. prone thoracic paraspinals or unilateral cervical perpendicular stretch for hypertonic scalenes.
Parallel (linear, longitudinal) stretch: hands spread apart along the long axis of the muscle.
Bidirectional: e.g. thoracolumbar stretch in lateral recumbent.
Performed slowly and rhythmically (rapid springing would trigger the stretch reflex) and repeated until the tissue relaxes.
After any OMT, reassess the somatic dysfunction.
Indications: hypertonic muscles, low back pain, muscle strain (gentle work). Contraindications:patient refusal or an uncooperative patient (applies to all OMT); an acute muscle tear (don't stretch the injured tissue); infection such as abscess or fever. The 90-second hold belongs to counterstrain, not soft tissue.
272Soft tissue techniques
Which of the following statements is false regarding active myofascial techniques?
Ans: Soft tissue targets muscle/fascia, not a specific joint → joint diagnosis not required
Why: Active myofascial technique treats muscle and fascia. It does not require a specific joint diagnosis. Muscle energy is the technique that treats a specific mechanical (joint) diagnosis.
Explanation & sources
Explanation
A, C and D are true. The patient actively makes an isometric contraction of the tight muscle against resistance, then the muscle is stretched.
Why:Patient refusal (or an uncooperative patient) is a contraindication to any OMT, listed under the psychosocial model.
Explanation & sources
Explanation
Low back pain and hypertonic muscles are reasons to treat. A muscle strain is not a contraindication to gentle myofascial work, though an acute severe strain is a relative contraindication for more forceful technique.
Why: Soft tissue stretching is aimed at hypertonic muscles. Here, cervical muscles such as the scalenes.
Explanation & sources
Explanation
An acute muscle tear is a contraindication to stretching the injured tissue. Abscess and fever point to infection, a contraindication rather than an indication.
When performing the thoracic myofascial technique shown in the image, which statement best describes the technique?
Ans: Perpendicular stretch of thoracic paraspinals → paraspinals are stretched
Why: The figure shows a prone perpendicular stretch of the thoracic paraspinals. The paraspinal muscles are being stretched at right angles to their long axis.
Explanation & sources
Explanation
The technique is slow and rhythmic, not rapid springing, which would trigger the stretch reflex. It is repeated until the tissue relaxes. Its goal is muscle relaxation, not autonomic excitation.
You would like to perform the parallel myofascial treatment. Which of the following statements is true?
Ans: Soft tissue = primary tx OR preparation for other methods (e.g., HVLA)
Why: Soft tissue technique can be the primary treatment or preparation for other methods such as HVLA.
Explanation & sources
Explanation
A describes a perpendicular stretch, not parallel. B adds an active contraction, which a passive parallel stretch does not use. The 90-second hold belongs to counterstrain.
In the image below, which direction is the myofascial stretch being performed?
Ans: Force along the long axis of the paraspinals → parallel (linear) stretch
Why: The hands spread apart along the long axis of the paraspinals, so this is a parallel (linear/longitudinal) stretch.
Explanation & sources
Explanation
Perpendicular stretch pushes the muscle at right angles to its fibers (medial to lateral). Bidirectional is a different setup (the thoracolumbar stretch in lateral recumbent). HVLA uses a quick thrust, not a sustained stretch.
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Myofascial release (MFR): the tissue is loaded with a constant force until it releases, guided by palpatory feedback. Holding cephalad traction on the suboccipital tissues until they relax is MFR.
Direct MFR
Indirect MFR
Direction
Into the restrictive barrier (direction of limited motion), gentle constant load, wait for release, take up new slack
Away from the restrictive barrier, toward ease; the textbook says this is toward the anatomic barrier (the course key)
Indications: goals include relieving edema and improving lymph flow, so peripheral edema is an indication. Relative contraindications: fracture, trauma, malignancy and infection (lymphatic contraindications also apply).
Fragile patients: for a debilitated ICU patient with heart failure and vertebral metastases, the gentlest choice offered is direct MFR (not over the metastasis itself). Muscle energy needs patient effort; HVLA is contraindicated with bone metastases; lymphatic techniques (pumps, thoraco-abdominal diaphragm release) are relatively contraindicated in advanced cancer and unlikely to help musculoskeletal pain. (The 2026 review deck also lists unstable/infirm patients and metastases in the treatment area as contraindications for direct MFR, which is why it is used gently and not over the metastasis.)
Look-alikes: articulatory = moving a joint repeatedly through its range; counterstrain and FPR = positions of ease (indirect); BLT/LAS = balancing ligamentous tension; Galbreath = mandibular drainage for the ear.
Zink fascial patterns (rotational preference at the 4 junctions: OA / cervicothoracic / thoracolumbar / lumbosacral):
Pattern
OA / CT / TL / LS
Frequency
Common compensatory
L / R / L / R
About 80% of healthy people
Uncommon compensatory
R / L / R / L
About 20%
Uncompensated
Does not alternate
Unhealthy, stressed or recently traumatized
279asked 4×2026Myofascial release
When performing indirect myofascial release, which barrier is engaged?
Ans: Indirect = move away from restrictive barrier → toward the anatomic barrier side
Why: Indirect MFR moves tissue away from the restrictive barrier, toward ease. The textbook says this direction moves toward the anatomic barrier (the limit of passive motion), which is more comfortable for the patient.
Heads up: All keys mark anatomic (the 2026 course MFR text, and 'C. Anatomic' on the 2023 TA slide, which used a different letter order). A note on the TA copy questioned this, but the course textbook explanation supports anatomic, so A stands.
Explanation & sources
Explanation
The restrictive (pathologic) barrier is what direct MFR engages. The physiologic barrier is the limit of active, patient-made motion. The elastic barrier is the range between physiologic and anatomic where passive ligament stretch occurs.
Why: Goals of MFR include relieving edema and improving lymph flow, so peripheral edema is an indication.
Explanation & sources
Explanation
Fracture, trauma, malignancy and infection are relative contraindications to MFR. Because MFR improves lymph flow, lymphatic contraindications such as advanced cancer and serious infection apply too.
A young adult with chronic headaches undergoes osteopathic manipulative treatment. With the patient supine the physician holds cephalad traction to the suboccipital tissues until the regional musculature relaxes. This technique is a type of
Ans: Constant load held until tissue releases → myofascial release
Why: Loading the tissue with a constant force until it releases, guided by palpatory feedback, defines myofascial release.
Explanation & sources
Explanation
BLT and LAS balance ligamentous tension at a joint. FPR uses a shortened position plus a facilitating force such as compression. The Galbreath maneuver is a mandibular drainage technique for the ear.
You are consulted to see a severely debilitated 87-year-old male with complaints of mid thoracic pain. He was in the intensive care unit for 3 weeks and was transferred to a medical/surgical bed yesterday. He has a history of coronary artery disease, congestive heart failure and prostate cancer with vertebral metastasis. His back pain is localized to the mid thoracic region and seems to be musculoskeletal in nature. Which osteopathic manipulative techniques would be best suited to relieve this patient's symptoms?
Ans: Fragile patient + bone mets → gentle soft tissue → direct MFR
Why: Fragile, hospitalized patients do best with gentle techniques. Direct myofascial release can treat musculoskeletal pain without stressing him.
Heads up: Textbook key E. Note: the 2026 review deck (slide 39) lists unstable/infirm patients and metastases in the area of treatment as contraindications for ME, HVLA and dMFR. Choose E here as the gentlest of these options, but do not use dMFR directly over a metastasis.
Explanation & sources
Explanation
Muscle energy needs patient effort and is contraindicated in ICU or low-vitality patients. HVLA is contraindicated with bone metastases (risk of pathologic fracture). Diaphragm release and pedal pump are lymphatic techniques, relatively contraindicated in advanced cancer and unlikely to help musculoskeletal pain.
A patient complains of neck pain that is worse at the end of the work day. Structural examination reveals somatic dysfunction in the upper cervical segments. The physician slowly turns the patient's neck in the direction of limited movement, loads the soft tissues with a gentle constant force, then waits a few seconds until the tissues release and more motion is possible. This technique is an example of
Ans: Toward restriction (barrier) + constant load until release → direct MFR
Why: Moving into the restrictive barrier and loading the tissue with a constant force until release is direct myofascial release.
Explanation & sources
Explanation
Indirect MFR moves away from the barrier. Articulatory technique moves a joint repeatedly through its range. Counterstrain and FPR both use positions of ease (shortening), which are indirect.
A young male presents for a routine physical. Structural examination reveals he has the most common fascial pattern noted in the population. The most likely compensatory pattern is
Ans: Zink common compensatory pattern (80%) → OA L, CT R, TL L, LS R
Why: Zink's common compensatory pattern (about 80% of healthy people) alternates at the four junctions: OA left, cervicothoracic right, thoracolumbar left, lumbosacral right (L/R/L/R).
Explanation & sources
Explanation
R/L/R/L is the uncommon compensatory pattern (about 20%). Patterns that do not alternate (A, B, E) are uncompensated, seen in unhealthy, stressed or recently traumatized patients.
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Learn firstWhat you need for 5.1
Rotation is the main (greatest) motion of the thoracic spine; it is limited mainly by ligament tension. The other motions are limited by specific structures:
Motion
Limited mainly by
Extension
Long, overlapping (“shingled”) spinous processes; also the ALL
Sidebending (lateral flexion) and unilateral joint motion
The ribs (costovertebral/costotransverse joints); the rib cage makes the thoracic spine stiffer than the cervical or lumbar spine
Functional regions: C7–T1 cervicothoracic junction; T1–T3 transitional; T4–T9 = the true thoracic kyphosis (apex at T5–T6; vertebral bodies a bit taller posteriorly); T12–L1 thoracolumbar junction.
Superior facet orientation (mnemonic BUM–BUL–BUM, top to bottom):
Region
Superior facets face
Cervical
Back, Up, Medial
Thoracic
Back, Up, Lateral
Lumbar
Back, Up, Medial (backward and medial)
Inferior facets face the opposite way (forward, down, medial in the thoracics) to mate with the superior facets below.
Dermatomes: T10 = umbilicus; T11 just below; T12 just above the inguinal ligament (suprapubic); L1 anterior thigh just below the inguinal ligament; L2 middle/anterior thigh. The epigastrium is above T10.
285asked 2×Thoracic anatomy & motion
The main motion of the thoracic vertebrae is:
Ans: Ribs limit sidebending, SPs limit extension → rotation is the largest thoracic motion
Why:Rotation is the greatest motion allowed in the thoracic spine. It is limited mainly by ligament tension.
Explanation & sources
Explanation
Flexion and extension are limited: extension by the shingled spinous processes (and the ALL), flexion by the interspinous ligaments, ligamentum flavum and PLL. Sidebending is limited by the ribs. "Sidebending and rotation" describes coupled motion, not the main single motion.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 94-95
2022 TA Review - Exam 1 · TA review · slides 55-56
286asked 3×Thoracic anatomy & motion
What is the true thoracic kyphosis of the T-spine?
Why: The lecture divides the thoracic spine into functional regions. T4-T9 is the true thoracic kyphosis, with its apex at T5-T6.
Explanation & sources
Explanation
C7-T1 is the cervicothoracic junction. T1-T3 is a transitional (lordotic) region, and T12-L1 is the lordotic thoracolumbar junction. T5-T6 is only the apex, not the whole kyphotic region. The kyphosis comes mainly from vertebral bodies that are a bit taller posteriorly than anteriorly.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 81-82
2020 TA Review (Middletown) Exam 1 · TA review · slides 92-93
2020 TA Review Exam 1 · TA review · slides 80-81
287top 215asked 7×2026Thoracic anatomy & motion
Extension of the thoracic spine is most affected by which of the following?
Why: Thoracic spinous processes are long and overlap like shingles, so they block extension. The ALL also limits extension, but less.
Explanation & sources
Explanation
The PLL (with the interspinous ligaments and ligamentum flavum) limits flexion, the opposite motion. The ribs limit sidebending. The transverse processes are not the main block to extension. The Canvas version of this question words it "most limit extension" with the same answer.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q5 (answer list at end of doc)
Why: Thoracic flexion is limited by tension in the posterior longitudinal ligament, the interspinous ligaments and the ligamentum flavum.
Explanation & sources
Explanation
Spinous processes and the ALL limit extension. The ribs limit sidebending. Keep the pair straight: flexion is stopped by the PLL group, extension by the shingled SPs.
Asked in
2022 TA Review - Exam 1 · TA review · slides 63-64
Lateral flexion and unilateral joint motion is restricted by which of the following?
Ans: Rib attachments at costovertebral/costotransverse joints → restrict lateral flexion
Why: The ribs articulate with the thoracic vertebrae and restrict lateral flexion (sidebending) and unilateral joint motion.
Explanation & sources
Explanation
Spinous processes and the ALL limit extension. The PLL limits flexion. Transverse processes are attachment points, not the main restrictor. The rib cage is the main reason the thoracic spine is stiffer than the cervical or lumbar spine.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 74-75
2020 TA Review (Middletown) Exam 1 · TA review · slides 104-105
2020 TA Review Exam 1 · TA review · slides 92-93
290top 215asked 8×2026Thoracic anatomy & motion
The superior articular facets of the thoracic vertebrae face which directions?
Ans: Thoracic superior facets → BUL → posteriorly, superiorly, laterally
Why: Thoracic superior facets face back, up and lateral (BUL). Cervical and lumbar superior facets face back, up and medial (BUM).
Explanation & sources
Explanation
The options with anteriorly, inferiorly and medially describe the inferior facets, which face the opposite way to mate with the superior facets below. Mnemonic: BUM-BUL-BUM for cervical, thoracic, lumbar.
2022 TA Review (Middletown) - Exam 1 · TA review · slides 78-79
2020 TA Review (Middletown) Exam 1 · TA review · slides 107-108
2020 TA Review Exam 1 · TA review · slides 96-97
Lecture slide (1)
Week 5 · Written Review deck · slide 27
291Thoracic anatomy & motion
Fill in the blank: The superior articular facets of the thoracic vertebrae face back, up and ____. The superior articular facets of the cervical vertebrae face back, up and ____.
Why: Superior facets face back and up at every level. Only the third direction changes: thoracic = lateral (BUL), cervical = medial (BUM).
Explanation & sources
Explanation
Lumbar superior facets are also back, up and medial (BUM), so the full mnemonic is BUM-BUL-BUM from top to bottom. A common trap is giving the thoracic answer (lateral) for a lumbar or cervical question.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 74-75
Lecture slide (1)
Week 5 · Written Review deck · slide 27
292Thoracic anatomy & motion
In the lumbar spinal segments, what position will you normally find the facet joints facing?
Why: Lumbar superior facets face backward and medial (BUM). Back, up and lateral is the thoracic pattern.
Heads up: The 2023 TA answer slide highlights C (back, up, lateral), which is the thoracic orientation. The same slide's mnemonic and the 2026 lecture (BUM-BUL-BUM: lumbar = back, up, medial) make D correct.
Explanation & sources
Explanation
C (back, up, lateral) is the thoracic orientation, the classic trap. A and B combine directions that do not go together. Mnemonic BUM-BUL-BUM: cervical, thoracic, lumbar.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 107-108
293asked 2×2026Thoracic anatomy & motion
A 20-year-old female presents for a general maintenance examination without complaints. Structural examination reveals T10 is flexed, rotated and sidebent right. The associated dermatome at the level of T10 is at the
Ans: T10 dermatome → umbilicus
Why: The T10 dermatome is at the level of the umbilicus.
Explanation & sources
Explanation
T11 is just below the umbilicus and T12 is just above the inguinal ligament (suprapubic). L1 covers the anterior thigh just below the inguinal ligament and L2 the middle and anterior thigh. The epigastrium sits above T10.
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Learn firstWhat you need for 5.2
The rule of 3s tells you where each thoracic spinous process (SP) sits relative to its own transverse processes (TPs). TPs always sit at their own vertebra's level; the SPs angle downward.
Group
Tip of the SP lies
So the SP of Tn is beside the TPs of
T1–T3
At the same level as its own TPs
Tn (same vertebra)
T4–T6
½ segment below: halfway between its own TPs and the TPs below
Between Tn and Tn+1
T7–T9
1 full segment below: level with the TPs of the vertebra below
Tn+1
T10
Like T7–T9 (1 full below)
T11
T11
Like T4–T6 (½ below)
Between T11 and T12
T12
Like T1–T3 (same level)
T12
Working backward (from a TP to the SP beside it): T5 TPs lie halfway between the T4 and T5 SPs; T8 TPs are at the T8 level, beside the T7 SP; T10 TPs are at the level of the T9 SP. No thoracic SP ever sits above its own TPs.
Two-trap question: thumbs beside the T8 SP are on the T9 TPs. An anterior (deep) TP on the right means the left TP is posterior → T9 rotated left. Always ask: was I given the SP or the TP, and which side is posterior?
Landmarks: spine of scapula = T3; inferior angle of scapula = T7; follow rib 12 to T12; iliac crests = L4–L5. Anterior: suprasternal notch T2, angle of Louis T4, xiphoid T9.
Written Review slide 36: rule of 3s
294asked 3×Rule of 3s & landmarks
According to the rule of threes, which group of vertebrae have spinous processes that project one half segment below?
Ans: Rule of 3s: T1-3 same, T4-6 half below, T7-9 one below → T4-T6
Why: Rule of 3s: T1-T3 SPs are level with their own TPs, T4-T6 SPs sit one half segment below, and T7-T9 SPs sit one full segment below.
Explanation & sources
Explanation
T1-T3: same level. T7-T9: one full level below. T10-T12 reverse the pattern (T10 full, T11 half, T12 same), so the group as a whole is not "half below," although T11 alone is.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 70-71
2020 TA Review (Middletown) Exam 1 · TA review · slides 100-101
2020 TA Review Exam 1 · TA review · slides 88-89
Lecture slide (1)
Week 5 · Written Review deck · slide 36
295Rule of 3s & landmarks
According to the "Rule of 3's" of the thoracic spine, the spinous processes of T1-T3 would be located on what plane level in relation to its own transverse process?
Ans: T1-T3 → SP level with its own TP → same level
Why: For T1-T3 the spinous process is at the same level as its own transverse processes.
Explanation & sources
Explanation
Halfway below describes T4-T6 (and T11). A full level below describes T7-T9 (and T10). No thoracic SP sits above its own TPs.
Which of the following statements is true regarding the Rule of Three's for thoracic spinal diagnosis?
Ans: T4-6 SP half below → between own TP and TP below
Why: For T4-T6 the SP lies halfway between its own TPs and the TPs of the vertebra below.
Explanation & sources
Explanation
A: T1-T3 SPs are level with their own TPs. C: T7-T9 SPs lie at the TPs of the vertebra below, not above. D: T10-T12 run the pattern in reverse (T10 full, T11 half, T12 same), not the T1-T3 rule in reverse.
Based on the Rule of 3's for the thoracic spinous processes, which of the following statements is correct?
Ans: T2 in T1-T3 group → SP level with own TPs
Why:T2 is in the T1-T3 group, where the SP and TPs are at the same level.
Explanation & sources
Explanation
B: the T7 SP is one full level below, at the T8 TPs, not up at T6. C: the T5 SP is half a level below, between T5 and T6, not T4 and T5. D: the T11 TPs are above the T11 SP (half a level), while the T12 SP is level with the T12 TPs, so the T11 TPs are not in line with the T12 SP.
Asked in
2026 Practice Questions for OMM 1 - Lect 5 Thoracic Spine/Fryette's Principles (Canvas) · Practice questions · Q1
Lecture slide (1)
Week 5 · Written Review deck · slide 36
298Rule of 3s & landmarks
During a thoracic spine OMM lab, a medical student palpates the spinous process of T5 on her OMM partner. Which group of thoracic vertebrae has the same anatomical relationship between their spinous and transverse processes as T5?
Ans: T5 in T4-T6 → SP half segment below → between own TP and TP below
Why:T5 belongs to the T4-T6 group: each SP sits halfway between its own TPs and the TPs of the vertebra below.
Explanation & sources
Explanation
A describes T1-T3 (and T12). C describes T7-T9 (and T10). D is false; the rule of 3s exists precisely because the pattern is predictable.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 81-82
Lecture slide (1)
Week 5 · Written Review deck · slide 36
299asked 2×Rule of 3s & landmarks
Using the "rule of threes," the transverse process of T5 can be located:
Ans: T5 SP sits half below its TPs → T5 TPs between T4 and T5 SPs
Why: T4-T6 SPs project half a segment below their own TPs. So the T5 TPs sit halfway between the T4 and T5 spinous processes.
Explanation & sources
Explanation
C (halfway between the T5 and T6 SPs) is where the T6 TPs are. B would be true only for T1-T3. D and E point to spinous processes well below T5.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 92-93
2022 TA Review - Exam 1 · TA review · slides 57-58
Lecture slide (1)
Week 5 · Written Review deck · slide 36
300Rule of 3s & landmarks
You are completing the palpation part of your thoracic rubric during your mock practical. Placing your fingers on your partner's back, you locate T7, which is associated with the inferior angle of the scapula. According to the rule of threes, where is the spinous process of the T7 vertebra located?
Ans: T7 in T7-T9 → SP one full segment below → at T8 level
Why: T7-T9 spinous processes project one full segment below, so the T7 SP lies at the level of the T8 TPs.
Explanation & sources
Explanation
A is wrong twice: the T7 SP is not at its own level, and the spine of the scapula is T3, not T7. C is wrong because thoracic SPs never project above their own level. Landmarks: spine of scapula = T3, inferior angle = T7.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 104-105
Lecture slide (1)
Week 5 · Written Review deck · slide 36
301top 215Rule of 3s & landmarks
If you are at the spinous process of T8, what level TPs are just lateral to it?
Ans: SP of T8 (T7-T9 group) projects one level down → T9 TPs beside it
Why: The T8 SP projects one full segment down, so the TPs just lateral to it belong to T9.
Explanation & sources
Explanation
C (T8) is the trap: it assumes SP and TP are level, which is true only for T1-T3 and T12. T7 and T6 go the wrong direction. Read carefully whether a question gives the level of the SP or the TP.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 70-71
Lecture slide (1)
Week 5 · Written Review deck · slide 36
302Rule of 3s & landmarks
During a structural exam, a medical student palpates the transverse processes of T8. These transverse processes are located:
Ans: T8 SP projects down to T9 → T8 TPs stay at T8 level (T7 SP level)
Why: TPs belong to their own vertebra, so the T8 TPs are at the level of T8. Because T7-T9 SPs project one level down, the SP found beside them is the T7 SP.
Heads up: The 2025 TA key marks C ("At the level of T9"). By the rule of 3s, the T8 SP lies at the T9 TPs, but the T8 TPs themselves lie at the T8 level, beside the T7 SP. The key appears to confuse SP with TP, so A is given here.
Explanation & sources
Explanation
C reverses the rule: it is the T8 spinous process that sits at the T9 level. B and D use the half-segment (T4-T6) pattern, which does not apply to T8.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 83-84
Lecture slide (1)
Week 5 · Written Review deck · slide 36
303Rule of 3s & landmarks
The spinous process of T10 can be found over which spinal vertebra?
Ans: T10 follows T7-T9 → SP one full level down → over T11
Why:T10 follows the T7-T9 rule: its SP lies one full segment below, over T11.
Explanation & sources
Explanation
B assumes SP and body are level (true for T1-T3 and T12). C and D go upward, which never happens. E skips two levels.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 74-75
Lecture slide (1)
Week 5 · Written Review deck · slide 36
304asked 2×2026Rule of 3s & landmarks
A 20-year-old female presents for a general maintenance examination without complaints. Structural examination reveals T10 is flexed, rotated and sidebent right. The transverse process of this segment can be found
Ans: T10 SP = one level down (T7-9 rule) → T9 SP lies at T10 TPs
Why: Work the rule in reverse: which SP sits at T10? T9 is in the T7-T9 group, so the T9 SP lies at the T10 TPs.
Explanation & sources
Explanation
B: the T10 SP is one level lower, at the T11 TPs. C: the T11 SP is about half a level below T11. D and E use the half-segment rule, which does not apply to T9-T10. The FRS detail in the stem is a distractor.
You palpate the spinous process of T8 and put a thumb on either side of it, finding an anterior TP on the right. Which is correct?
Ans: TPs beside T8 SP belong to T9 → anterior right = posterior left → T9 rotated left
Why: The TPs beside the T8 SP belong to T9 (T7-T9 SPs project one level down). An anterior TP on the right means the left TP is posterior, so T9 is rotated left.
Explanation & sources
Explanation
C and D name the wrong level (the SP is T8, the TPs are T9). F gets the level right but reads the anterior TP as posterior. A and B go up a level instead of down. Two traps in one: SP vs TP level, and anterior vs posterior.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 77-78
Lecture slide (1)
Week 5 · Written Review deck · slide 36
306top 215Rule of 3s & landmarks
Which landmarks are helpful in determining thoracic levels during a physical exam?
Ans: Spine of scapula = T3; inferior angle = T7
Why: Surface landmarks: spine of the scapula = T3, inferior angle of the scapula = T7, 12th rib followed to T12, iliac crests = L4-L5 interspace.
Explanation & sources
Explanation
A: the inferior angle is T7, not T9. D: the 12th rib leads to T12, not T9. B is not a landmark. Anterior landmarks from lecture: suprasternal notch = T2, angle of Louis = T4, xiphoid = T9.
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Learn firstWhat you need for 5.3
Several adjacent segments rotated the same way (or a visible curve / rib hump over many levels) = a Type I group curve: neutral, does not change with flexion or extension, sidebending and rotation to opposite sides.
Rotation = side of the posterior TPs = side of the rib hump / paraspinal prominence = the convexity.
Sidebending = the opposite side = toward the concavity. (Translating the vertebrae to the right = sidebending them left.)
Rotation is greatest at the apex, not the base. The posterior component is on the convex side.
The region moves freely into its dysfunction: a curve convex left (Sr Rl) freely rotates left.
Type I curves are usually chronic (dull, achy; cool, doughy tissue).
Finding
Diagnosis
Posterior TPs right T3–T5
T3–T5 N Sl Rr
Rib hump left T1–T10
T1–T10 N Sr Rl
Whole lumbar spine convex left
Sidebent right, rotated left
Posterior TPs right from spine of scapula down 4 segments
T3–T6 N Sl Rr
Hump right from spine of scapula to inferior angle
T3–T7 N Sl Rr
Hump right from SP of T8 to SP of T12
Convert with the rule of 3s: T8 SP sits at T9; T12 SP at T12 → T9–T12 N Sl Rr
Use landmarks to get the levels (spine of scapula T3, inferior angle T7) and the rule of 3s when the stem gives spinous processes. Write Type I with sidebending first (N Sx Ry). When both orders are offered, pick the sidebending-first form; accept the textbook rotation-first form (“NRLSR”) only when it is the only correct pattern offered. If your left thumb goes deeper, the left TP is anterior, so the right is posterior (rotated right).
Where's the Type II? At the first, apex, and last segments of the group curve. The apex of T1–T10 is about T5. Treat the Type II first.
307top 215asked 10×2026Type I group curves
You find 3 posterior transverse processes on the right side at T3-5. Which of the following is a true statement?
Ans: 3 adjacent segments posterior right → group curve = Type I → rotated right, sidebent left
Why: Several adjacent segments rotated the same way is a group curve, which follows Type I (neutral) mechanics: rotation toward the posterior TPs (right) and sidebending the opposite way (left).
Explanation & sources
Explanation
A says Type I but flips the directions; posterior TPs on the right mean rotation right. B couples rotation and sidebending to the same side, which is Type II. D is false because Type I curves do not change with flexion or extension; a change would point to Type II. Older versions used "the facets are controlling vertebral mechanics," which also describes Type II.
An elderly patient presents for a general wellness visit without complaints. Structural examination reveals a group curve in the thoracic region. Which of the following is most associated with this segment's spinal mechanics?
Ans: Group curve → Type I → sidebend into concavity, rotate into convexity
Why: A group curve follows Type I mechanics: it sidebends into the concavity and the bodies rotate toward the convexity.
Explanation & sources
Explanation
A: rotation is greatest at the apex, not the base. B and C describe Type II (same-side coupling, rotation into the concavity). E: the posterior TP is on the convex side, where the bodies rotate.
A scoliotic patient presents with right upper back pain. Structural examination reveals a type I dysfunction from T3-T8 and a prominent kyphosis. The right scapula is posterior. Upon forward flexion there is paraspinal muscle prominence on the right upper thoracic area. What spinal motion pattern would you suspect in this scenario?
Ans: Type I T3-T8 + right paraspinal prominence → rotated right → sidebent left
Why: A Type I curve with paraspinal prominence on the right is rotated right and sidebent left (dextroscoliosis, T3-8 NRRSL). Motion is free in those directions.
Explanation & sources
Explanation
D flips both directions. A, B and E use same-side coupling or flexion/extension terms that belong to Type II, and Type I rotation is not limited to the apex segment. The posterior right scapula rides on the posteriorly displaced right ribs.
2022 TA Review (Middletown) - Exam 1 · TA review · slides 176-177
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 53
310asked 3×2026Type I group curves
A patient has a type I curvature from T6-T12, convex left. The apex of the segment is T9. You would expect the thoracic spine to
Ans: Type I convex left → sidebent right, rotated left → free left rotation
Why: Convex left = sidebent right, rotated left (T6-T12 NSrRl). The region moves freely into its dysfunction, so it freely rotates left.
Explanation & sources
Explanation
B: translating right equals sidebending left, which is restricted. C: the apex rotates maximally to the left, not right. D: the curve is sidebent right. E is Type II coupling.
A 40-year-old male presents with a thoracic curve. History reveals it has had a dull, achy quality. Structural examination reveals a large paraspinal hump on the left side. Which of the following is the most likely diagnosis?
Ans: Curve + dull achy (chronic) → Type I; left hump → rotated left, sidebent right
Why: A curve with a dull, achy (chronic) quality is a Type I group curve. A left paraspinal hump means rotation left, so sidebending is right: T7-9 NRLSR.
Explanation & sources
Explanation
A and E are single-segment Type II diagnoses, and E rotates right. B couples rotation and sidebending to the same side, which Type I never does. C is a single segment with the same error. NRLSR is textbook notation for neutral, rotated left, sidebent right (NSrRl).
A patient with chronic low back pain lies prone and you notice that her entire lumbar spine appears to have a lateral convexity to the left. What is a possible diagnosis?
Ans: Whole region curved = Type I; convex left → sidebent right, rotated left
Why: A whole region in a curve is Type I. Convex left means the spine is sidebent right, and Type I rotates opposite: rotated left.
Explanation & sources
Explanation
A uses Type II for a group curve. C is the pattern for a curve convex right. D couples the same side, which is not Type I.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 53-54
You perform the standing flexion test and see a thoracic rib hump on the left from T1-T10. What is your diagnosis?
Ans: Rib hump left over many segments → Type I rotated left → sidebent right
Why: A rib hump marks the side of rotation (the convexity) of a Type I group curve. Hump on the left → rotated left, sidebent right: T1-T10NSrRl.
Explanation & sources
Explanation
C flips the directions. B and D add E or F, but group curves are neutral and do not change with flexion or extension. Type I always couples rotation and sidebending to opposite sides.
A patient with scoliosis has restriction from T2–T5. When bending forward, a rib hump is noticed on the left. Which of the following is the correct diagnosis?
Ans: Multiple segments = Type I; hump left → rotated left → sidebent right
Why: A group dysfunction (T2-T5) follows Type I. Rib hump on the left = rotated left, so sidebent right: T2-T5 NSrRl.
Explanation & sources
Explanation
B flips the directions. C, D and E are Type II (F/E with same-side coupling), which describe single segments.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 58-59
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 53
315Type I group curves
A patient comes in with upper-mid back pain. You find posterior TPs on the left starting from the level of the spine of the scapula down for 4 segments. What is the patient's diagnosis?
Ans: Spine of scapula = T3, 4 segments → T3-T6; posterior left → NSrRl
Why: The spine of the scapula = T3, so four segments down is T3-T6. Posterior TPs on the left = rotated left; Type I sidebends opposite: T3-T6 NSrRl.
Explanation & sources
Explanation
A and B start at T4, one level too low. D flips the directions. Rule of 3s is not needed here because T1-T3 SPs and TPs are level.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 61-62
An elderly man, Mike, presents to your office complaining of dull back pain that has been persistent for the past 10 years. On palpation, the patient's skin is cool, dry, and the tissues feel doughy. While performing a forward flexion test, you take note of posterior TPs on the right side starting from the spine of the scapula down for 4 segments. What is the most likely somatic dysfunction that you will palpate?
Ans: Chronic + spine of scapula (T3) ×4 segments, posterior right → T3-T6 NSlRr
Why: Chronic pain with cool, doughy tissue fits a chronic Type I curve. Spine of scapula = T3, four segments = T3-T6; posterior TPs right = rotated right, sidebent left.
Explanation & sources
Explanation
B flips the directions. C and D start one level too low at T4, and C also flips the directions. Acute findings (warm, moist, boggy) would fit a more recent dysfunction.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 78-79
A patient comes in with upper back pain. On forward flexion test you see a rib hump on the right from the level of the spine of the scapula to the inferior border of the scapula. On palpation, the TPs do not get better in flexion or extension. On gross examination, the patient's right shoulder is higher. What is your somatic dysfunction diagnosis?
Ans: Spine of scapula T3 → inferior angle T7; no F/E change; hump right → T3-T7 NSlRr
Why: Landmarks give T3 (spine of scapula) to T7 (inferior angle). TPs that don't change in flexion or extension = neutral Type I. Hump right = rotated right, so sidebent left.
Explanation & sources
Explanation
A and C use F or E, but the TPs do not change with flexion or extension. D has the wrong levels and flips the directions. The higher right shoulder is a postural clue, not part of the naming.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 76-77
A 1st year medical student presents with upper back pain. On observation there is hypertonicity starting at the level of the spine of the scapula to the inferior angle. When you palpate the transverse processes, your left thumb goes deeper. When you ask the patient to bend forward and back, neither makes the transverse processes even. The vertebrae are easier to translate to the right. What is the diagnosis of their somatic dysfunction?
Ans: T3-T7 landmarks; left thumb deeper = right TP posterior; translate right = sidebent left
Why: Spine of scapula to inferior angle = T3-T7. The left thumb goes deeper, so the right TP is posterior (rotated right). No change with flexion or extension = neutral. Easier to translate right = sidebent left. Answer: T3-T7 NSlRr.
Explanation & sources
Explanation
A and B are single Type II segments. C uses E for a curve that does not change with extension. D has the right pattern at the wrong levels. Translation trap: translating right = sidebending left.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 115-116
A 40 year old male presents after 'throwing' out his back while lifting a heavy box. The transverse processes from T4 to T9 are all rotated right, with no change in flexion or extension. How would you write this dysfunction?
Ans: T4-T9 all rotated right, no F/E change → Type I → sidebent left
Why: Six segments rotated right with no change in flexion or extension = Type I group curve: sidebent left, rotated right (NSlRr).
Explanation & sources
Explanation
A and B are Type II notations. C lists rotation before sidebending; Type I notation writes sidebending first (NSxRy) because sidebending precedes rotation. D couples the same side. "Threw out his back" hints at trauma, but the palpatory findings define the diagnosis.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 71-72
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 53
320top 215asked 8×2026Type I group curves
Patient presents with back pain. On forward bending you find a rib hump on the right that begins at the spinous process of T8 and ends at spinous process of T12. The TPs in that area are all rotated to the right and do not change in flexion or extension. What is your diagnosis written in "shorthand"?
Ans: SP T8 sits at T9 TPs; SP T12 at T12 → T9-T12; right, no F/E change → NSlRr
Why: Convert the SP landmarks with the rule of 3s: the T8 SP lies at the T9 TPs (T7-T9 project one full level down) and the T12 SP is level with T12. TPs right with no change in flexion/extension = Type I, rotated right, sidebent left: T9-T12NSlRr.
Explanation & sources
Explanation
A and C are Type II diagnoses, which change with flexion or extension. B couples sidebending and rotation to the same side. D shifts the top down a level but also stops at T11; the T12 SP is level with its own TPs (T12 follows T1-T3). Lecture version: SP T7 to SP T10 = T8-T11NSlRr. Other versions of this question use different distractors, same answer.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q2 (answer list at end of doc)
After assessing Mike by observation, AROM, PROM, forward flexion test, red reflex and TART, your Type I diagnosis is consistent with the rib hump (T3-T6 N Sl Rr). You assess each segment within that group curve to find a Type II SD. Where will the Type II SD likely be located?
Ans: Type II found at apex or extremes of Type I curve → first, apex, last
Why: Type II dysfunctions sit at the transition points of a Type I curve: the first, apex and last segments.
Explanation & sources
Explanation
A is too broad. C misses the apex. D misses the ends. The course wording is "found at apex or extremes of Type I curves."
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 80-81
Lecture slide (1)
Week 3 · Written Review deck · slide 18
5.4 · 10 questions · Questions 323–332
Type II diagnosis
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A Type II dysfunction is a single segment whose coupled motion is controlled by the rotatores (short restrictors) and the facet joints. Discs and the long erector spinae maintain Type I curves instead.
Diagnose it in three steps:
Level: use landmarks (spine of scapula = T3, inferior angle = T7) or the stated level.
Rotation = side of the posterior TP. (“Restricted in left rotation” means rotated right.)
F or E = the position where the asymmetry disappears (becomes symmetric). It worsens in the opposite position. Head to chest / bending forward = flexion; sticking the chest out / looking at the ceiling = extension.
Sidebending goes to the same side as rotation; write rotation first: T3 F Rr Sr.
Diagnosis
Expect on exam
Freedom
Restriction (barrier)
T3 F Rr Sr
Right TP posterior at the spine of scapula; symmetric in flexion, worse in extension
F, Rr, Sr
E, Rl, Sl
T7 E Rr Sr
Right TP posterior at the inferior angle; symmetric in extension, worse in flexion
E, Rr, Sr
F, Rl, Sl
T2 F Rl Sl
Left TP posterior; worse with chest out/looking up; symmetric with head to chest
F, Rl, Sl
E, Rr, Sr
Mechanism clue: a sudden “tweak” bending forward and right holds that position → T10 F Rr Sr, so flexion is the freedom (extension is restricted). Read the verbs: “prefers / likes / freedom” vs “restricted / barrier”. A Type II at the apex of a curve that improves in flexion (e.g. apex of T3–T7 N Sr Rl) = T5 F Rl Sl.
Direct techniques (ME, HVLA) go toward the restriction; indirect (counterstrain) toward the freedom.
323top 215asked 8×2026Type II diagnosis
In a type II somatic dysfunction of the thoracic or lumbar spine coupled motion is most influenced by which of the following?
Ans: Type II → short restrictors (rotatores) + facets control coupling
Why:Type II dysfunctions are maintained by the short restrictors (rotatores, intertransversarii), and the facets control which way the segment couples.
Explanation & sources
Explanation
Discs and long superficial muscles (erector spinae) maintain Type I group curves. Costovertebral joints mainly limit sidebending. The longitudinal and interspinous ligaments limit flexion and extension rather than steering coupled motion. Type II is a single segment, often traumatic, and is treated before Type I.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q4 (answer list at end of doc)
You are reviewing a patient's last visit. The diagnosis documented in the chart includes somatic dysfunctions of the thoracic spine including a notation of T3FRrSr. If this diagnosis is still present on this follow-up visit, which of the following findings would you expect on palpatory exam.
Ans: T3 = spine of scapula; FRrSr → right TP posterior (shows in extension)
Why:T3 is at the spine of the scapula. FRrSr means the segment is rotated right, so the right TP is posterior.
Explanation & sources
Explanation
A and C describe a Type I group curve, not a single Type II segment; C also puts the rotation on the wrong side. B is backward: a flexed dysfunction becomes symmetric in flexion and worsens in extension. E: the inferior angle of the scapula marks T7, not T3.
You diagnose your lab partner with a somatic dysfunction of thoracic spine as T7ERrSr. Which of the following findings would you also expect on exam?
Ans: T7 = inferior angle of scapula; ERrSr → right TP posterior
Why:T7 is at the inferior angle of the scapula. ERrSr means the segment is rotated right, so the right TP is posterior.
Explanation & sources
Explanation
B is backward: an extended dysfunction becomes symmetric in extension and worsens in flexion. A and E describe a Type I group curve. D: the spine of the scapula marks T3, not T7.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q1 (answer list at end of doc)
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
326Type II diagnosis
On examination of your patient, you find a posterior transverse process on the right at the level of the spine of the scapula. The right transverse process becomes less posterior with flexion and becomes more prominent in extension. How would you name this somatic dysfunction?
Ans: Spine of scapula = T3; posterior right, better in flexion → FRrSr
Why:Spine of scapula = T3. The right TP is posterior (rotated right), and it improves with flexion and worsens in extension, so the SD is flexed: T3FRrSr.
Explanation & sources
Explanation
B describes rotation left with extension as the freedom. C and D use T7, which is the inferior angle. A Type II SD is named for the position where its asymmetry disappears.
Your patient has a posterior TP on the right at the spine of the scapula. When he bends forward the TP disappears under your finger on the right. What is his freedom and what is his restriction?
Ans: Spine of scapula = T3 → posterior right TP disappears in flexion → FRrSr; barrier is the opposite
Why: The SD is named for its freedom (position of ease): flexed, rotated right, sidebent right. The restriction is the opposite: extension, rotation left, sidebending left.
Explanation & sources
Explanation
Do not confuse the diagnosis with the barrier. Direct techniques such as muscle energy and HVLA take the segment toward the restriction (ERlSl); indirect techniques such as counterstrain go toward the freedom.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 80-81
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
328top 215asked 3×2026Type II diagnosis
You palpate a posterior transverse process at T2 on the left. It significantly worsens with the patient sticking out their chest and looking up at the ceiling, and becomes symmetrical with the patient dropping their head to their chest. Which of the following is the correct somatic dysfunction diagnosis?
Ans: Posterior left; worse in extension, symmetric in flexion → flexed → T2FRlSl
Why: A posterior left TP means rotation (and Type II sidebending) left. It becomes symmetric with flexion (head to chest) and worse with extension, so the SD is flexed: T2FRlSl.
Explanation & sources
Explanation
A and B rotate right, but the posterior TP is on the left. C is an extended SD, which would become symmetric in extension and worsen in flexion, the opposite of this exam.
Asked in
2026 Textbook Q&A Compilation - Fryette's Practice Questions · Practice questions · slide 155 (answer slide 156)
Fryette's Practice Questions with answers · Practice questions · Q2
2025 Fryette's Practice Questions with answers · Practice questions · Q2
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
329Type II diagnosis
You palpate a posterior T6 vertebral transverse process on the left side. When the patient flexes forward the posterior transverse process becomes less prominent and becomes more prominent in extension. What is your thoracic diagnosis?
Ans: Posterior left TP; better in flexion, worse in extension → T6FRlSl
Why: Posterior left TP = rotated left. It improves in flexion and worsens in extension, so the SD is flexed: T6FRlSl.
Explanation & sources
Explanation
A and B rotate right. C has the right side but names extension, which would be the position of ease only if the TP became symmetric in extension.
You examine your lab partner and find the following: a posterior transverse process at T4 on the right; no transverse process asymmetry at T3 or T5; symmetry of the T4 transverse processes with your partner sticking out their chest. Which of the following is the correct diagnosis for this dysfunction?
Ans: Single segment → Type II; symmetric with chest out (extension); posterior right → T4ERrSr
Why: Only T4 is asymmetric, so it is a single-segment Type II. The TPs become symmetric with extension (sticking out the chest), so it is extended; posterior right = rotated right: T4ERrSr.
Explanation & sources
Explanation
A names flexion, but the asymmetry disappears in extension. B and E name the wrong level and rotation. C is a group curve, yet T3 and T5 are normal.
Asked in
2026 Practice Questions for OMM 1 - Lect 5 Thoracic Spine/Fryette's Principles (Canvas) · Practice questions · Q3
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 67
331Type II diagnosis
A dad tweaks his back bending over and to the right to pick up his toddler. He develops a somatic dysfunction at T10. Which would you expect to be correct?
Ans: Sudden tweak bent forward + right → Type II FRrSr → freedom = flexion
Why: A sudden "tweak" while bent forward and to the right creates a Type II dysfunction that holds that position: T10 FRrSr. An SD is named for its freedom, so flexion is free.
Explanation & sources
Explanation
A is a Type I pattern (opposite sides). B: flexion is the freedom; extension is the restriction. D and E: the segment prefers rotation and sidebending right, so left is the barrier. Read the verbs: "prefers/likes/freedom" vs "restricted/barrier."
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 83-84
On diagnosis, you find that the transverse processes of T3 to T7 are rotated to the left and do not change with flexion or extension. You also find that the transverse processes of the apex of the curve improve with flexion. What would be your shorthand diagnosis of the Type II dysfunction?
Ans: T3-T7 curve apex = T5; apex better in flexion; rotated left → T5FRlSl
Why: The group curve is T3-T7 NSrRl. Type II sits at the apex or ends, and the apex is T5. Its TPs improve with flexion, so it is flexed, rotated and sidebent left: T5FRlSl.
Explanation & sources
Explanation
A is the Type I curve, not the Type II. B: an extended SD improves with extension, not flexion. C is an end segment, but the stem points to the apex. D is not a valid Type II (F with opposite-side coupling).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 117-118
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Why does a Type II segment change with flexion and extension? Because one facet is stuck. In flexion both posterior facets should open; in extension both should close.
Extended SD (ERS)
Flexed SD (FRS)
Stuck facet
Locked closed
Locked open
Which side
Same side as the rotation
Opposite side to the rotation (“flexion is the weird one”)
Asymmetry disappears in
Extension (both facets can close)
Flexion (both facets can open)
Asymmetry worsens in
Flexion: one facet stays closed, the vertebra pivots on it and rotates/sidebends toward that side
Extension: one facet stays open, the vertebra rotates/sidebends to the opposite side
Diagnosis
Stuck facet
E Rr Sr
Right facet closed
E Rl Sl
Left facet closed
F Rr Sr
Left facet open
F Rl Sl
Right facet open
Check yourself: right facet locked open + extension → right can't close → segment turns left → F Rl Sl. Right facet locked closed + flexion → right can't open → pivots and turns right → E Rr Sr. Testing an FRS in flexion (or an ERS in extension) gives no asymmetry, and that is the patient's most comfortable position.
Lecture slide for this section (1)
IA5 slide 67: ERS vs FRS and the facets
333top 215asked 10×2026Facets open/closed
You examine your partner and note the following diagnosis: T5 F Rr Sr. Which of the following is correct?
Ans: Flexed SD → facet stuck open, opposite side to rotation → FRrSr → left open
Why: In a flexed dysfunction a facet is stuck open, on the side opposite the rotation and sidebending. FRrSr → left facet locked open.
Explanation & sources
Explanation
A (right closed) is ERrSr. B (right open) is FRlSl. C (left closed) is ERlSl. Lecture summary: ERrSr = closed right, ERlSl = closed left, FRrSr = open left, FRlSl = open right. "Flexion is the weird one."
You examine your partner and note the following diagnosis: T3 E Rl Sl. Which of the following is correct?
Ans: Extended SD → facet stuck closed, same side as rotation → ERlSl → left closed
Why: In an extended dysfunction a facet is stuck closed on the same side as rotation and sidebending. ERlSl → left facet locked closed.
Explanation & sources
Explanation
A (right closed) is ERrSr. B (right open) is FRlSl. D (left open) is FRrSr. When flexion is attempted, the left facet cannot open, so the vertebra pivots around it and turns left.
Asked in
2026 Textbook Q&A Compilation - Fryette's Practice Questions · Practice questions · slide 159 (answer slide 160)
Fryette's Practice Questions with answers · Practice questions · Q4
2025 Fryette's Practice Questions with answers · Practice questions · Q4
Based on the diagnosis of T7 F RlSl, which of the following is a true statement?
Ans: Flexed SD → stuck open on side opposite rotation → FRlSl → right open
Why: A flexed SD has a facet stuck open on the side opposite the rotation. FRlSl → right facet stuck open.
Explanation & sources
Explanation
A (right closed) is ERrSr. B (left open) is FRrSr. D (left closed) is ERlSl. Check: in extension the right facet cannot close, so the segment turns left, matching Rl Sl.
Asked in
2026 Practice Questions for OMM 1 - Lect 5 Thoracic Spine/Fryette's Principles (Canvas) · Practice questions · Q4
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
336Facets open/closed
A new patient is examined in the OMM clinic. The physician diagnoses a flexion somatic dysfunction with sidebending and rotation to the right. What is the orientation of the facet joint causing the rotation and sidebending to the right?
Ans: Flexion SD rotated right → open facet on opposite side → left locked open
Why: In a flexion SD the culprit facet is stuck open on the side opposite the rotation and sidebending. Rotated and sidebent right → left facet locked open.
Explanation & sources
Explanation
A (right closed) is the extended version, ERrSr. C (right open) would turn the segment left. D (left closed) is ERlSl. In extension the left facet should close but cannot, so the segment turns right.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 111-112
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
337asked 2×Facets open/closed
You diagnose a somatic dysfunction of T3 ERlSl on your patient. Describe the positions of the posterior facets:
Ans: Extended SD → left facet stuck closed → in flexion it stays closed → turns left
Why: An extended SD has a facet stuck closed. In extreme flexion both facets should open, but the left stays closed, so the vertebra pivots and rotates and sidebends toward the closed side (left).
Explanation & sources
Explanation
A describes a flexed SD: in extension one facet stays open and the vertebra turns the opposite way. B: if both facets open there is no asymmetry. D: a segment turns away from a facet stuck open, not toward it.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 80-81
2022 TA Review - Exam 1 · TA review · slides 65-66
You diagnose a somatic dysfunction of T3 FRlSl on your patient. Describe the positions of the posterior facets:
Ans: Flexed SD → right facet stuck open → in extension it stays open → turns left
Why: A flexed SD has a facet stuck open. In extreme extension both facets should close, but the right stays open, so the vertebra rotates and sidebends to the opposite side (left).
Explanation & sources
Explanation
C describes an extended SD. B is the normal flexed state with no asymmetry. D has the direction backward: the segment turns away from the open facet.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 125-126
2020 TA Review Exam 1 · TA review · slides 114-115
A thoracic segment has a flexion somatic dysfunction: the right facet is locked open and the segment is rotated left. You test it in flexion. What happens?
AnswerNo asymmetry: both facets can open easily, so there is no rotation or sidebending asymmetry. Flexion is the most comfortable position for the patient.
Ans: Flexed SD (facet stuck open) + flexion → both facets open → asymmetry disappears
Why: A flexed SD has a facet stuck open. Flexion asks both facets to open, which they can, so the TPs become symmetric. FRS "disappears" in flexion.
Explanation & sources
Explanation
The asymmetry shows in the opposite motion: in extension the right facet cannot close, so the segment turns left. The same logic runs in reverse for an extended SD: it disappears in extension and worsens in flexion.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slide 130
2020 TA Review Exam 1 · TA review · slide 119
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
340asked 2×Facets open/closed
A thoracic segment has a flexion somatic dysfunction with the right facet locked open. You test it in extension. What happens?
AnswerThe asymmetry is exaggerated: the left facet closes normally, but the right facet is locked open and cannot close, so the segment sidebends and rotates left. Diagnosis (position of ease) = flexed, rotated left, sidebent left (FRlSl).
Ans: Right facet stuck open + extension → right cannot close → segment turns left → FRlSl
Why: Extension asks both facets to close. The right facet is stuck open, so the segment pivots and turns to the opposite side (left). The asymmetry is worse in extension.
Explanation & sources
Explanation
Contrast with flexion, where both facets open and the asymmetry disappears. A flexed SD always has its open facet on the side opposite the rotation (FRlSl = right open).
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slide 131
2020 TA Review Exam 1 · TA review · slide 120
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 73
341asked 2×Facets open/closed
A thoracic segment has an extension somatic dysfunction with the right facet locked closed. You test it in extension. What happens?
AnswerNo asymmetry: both facets can close easily, so there is no rotation or sidebending asymmetry. Extension is the most comfortable position for the patient.
Ans: Extended SD (facet stuck closed) + extension → both facets close → asymmetry disappears
Why: An extended SD has a facet stuck closed. Extension asks both facets to close, which they can, so the TPs become symmetric. ERS "disappears" in extension.
Explanation & sources
Explanation
The asymmetry appears in flexion, when the right facet cannot open and the segment turns right. Mirror image of the flexed SD, which disappears in flexion.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slide 133
2020 TA Review Exam 1 · TA review · slide 122
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 70
342asked 2×Facets open/closed
A thoracic segment has an extension somatic dysfunction with the right facet locked closed. You test it in flexion. What happens?
AnswerAsymmetry worsens: the left facet opens, but the right facet is locked closed, so the segment pivots on it and rotates and sidebends right. Diagnosis = ERrSr (extended, rotated right, sidebent right).
Ans: Right facet stuck closed + flexion → right cannot open → pivots → turns right → ERrSr
Why: Flexion asks both facets to open. The right facet is stuck closed, so the segment pivots around it and rotates and sidebends toward it (right). The asymmetry is worse in flexion.
Explanation & sources
Explanation
In an extended SD the closed facet is on the same side as the rotation (ERrSr = right closed). In extension both facets close and the asymmetry disappears.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slide 134
2020 TA Review Exam 1 · TA review · slide 123
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 70
5.6 · 3 questions · Questions 343–345
Viscerosomatic levels
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A spinal dysfunction that keeps coming back right after OMT (improves briefly, returns the next day) or has acute findings in a hospitalized patient suggests a viscerosomatic reflex: an irritated organ facilitating the spinal segments that share its sympathetic innervation. Match the segments to the organ:
Levels
Viscera (sympathetic innervation)
T1–T4
Head and neck
T1–T6
Heart and lungs (heart tends to give left-sided findings)
T5–T9 (celiac)
Upper abdominal viscera. Right: liver, gallbladder, duodenum, head of pancreas. Left: stomach, spleen, tail of pancreas
T10–T11 (superior mesenteric)
Rest of small intestine, kidney, upper ureter (often given as T9–T12, so T11–T12 findings still mean kidney/upper ureter), gonads; right: appendix, cecum, ascending colon
Worked examples: rib hump from the SP of T10 to the SP of T12 → by the rule of 3s the segments are T11–T12 → kidney / upper ureter (UTI in the upper ureters). Acute T6–7 F Rr Sr with bogginess → right T5–T9 → liver (hepatitis). Acute T7–8 with a left red reflex → left T5–T9 → stomach (gastritis). Pneumonia would be T1–T6; sinusitis T1–T4.
Lecture slide for this section (1)
Written Review slide 34: sympathetic innervation by level
343top 215asked 7×2026Viscerosomatic levels
Patient presents with back pain that improves with manipulation only briefly then returns the next day. On forward bending you find a rib hump on the right that begins at the spinous process of T10 and ends at spinous process of T12. The TPs in that area are all rotated to the right and do not change in flexion or extension. You suspect a visceral origin of this somatic dysfunction. What is highest on your differential?
Why: Rule of 3s: the T10 SP lies at the T11 TPs and the T12 SP at T12, so the segments are T11-T12. A curve that keeps coming back after OMT suggests a viscerosomatic reflex, and T10-T11 (T9-T12) supplies the kidney and upper ureter.
Explanation & sources
Explanation
Hepatitis, gastritis and gallbladder disease map to T5-T9 (upper GI). Pneumonia maps to T1-T6. An older version offered "kidney infection (pyelonephritis)," same level and same answer.
Examination of a hospitalized patient reveals the following somatic dysfunction: T6-7 F RrSr. There are associated acute changes of bogginess and marked tenderness consistent with an acute reflex at these levels. Which of the following diagnoses could cause this somatic dysfunction based on visceral segmental innervation?
Why:T6-7 falls in T5-T9 (upper abdominal viscera). Right-sided T5-T9 findings fit the liver, gallbladder and duodenum.
Explanation & sources
Explanation
Pneumonia maps to T1-T6, which only touches T6. Kidney maps to T10-T11. Appendicitis maps to T10-T11 on the right. Acute viscerosomatic changes are boggy, warm and tender.
Asked in
2026 Practice Questions for OMM 1 - Lect 5 Thoracic Spine/Fryette's Principles (Canvas) · Practice questions · Q2
Lecture slide (1)
Week 8 · Written Review deck · slide 34
345top 2152026Viscerosomatic levels
A patient is evaluated in the emergency department and found to have an acute somatic dysfunction of T7-8 with a marked red reflex on the left side with edema. You suspect a visceral cause for the somatic dysfunction. Which of the following clinical diagnoses is consistent with these TART findings based on shared segmental innervation patterns?
Why:T7-8 is in T5-T9 (upper GI). Left-sided findings fit the stomach (left: stomach, spleen, tail of pancreas).
Explanation & sources
Explanation
Hepatitis is also T5-T9 but right-sided. Colitis maps lower (T10-T11 for the right colon, T12-L2 for descending and sigmoid). UTI maps to T10-T11 (kidney, upper ureter) or T12-L2 (bladder). Sinusitis maps to T1-T4 (head and neck).
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q3 (answer list at end of doc)
Lecture slide (1)
Week 8 · Written Review deck · slide 34
5.7 · 20 questions · Questions 346–365
Scoliosis types & naming
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Scoliosis is a lateral (coronal-plane) curve of a group of vertebrae: sidebending with coupled rotation toward the convexity (Type I mechanics). It is more common in females, and most children with it have no symptoms.
Naming: name the curve for its convexity. The spine is sidebent toward the concavity.
Dextroscoliosis
Levoscoliosis
Convex
Right
Left
Sidebent / concave
Left
Right
Vertebral bodies rotate (Type I)
Right
Left
Rib hump
Right
Left
Diagnosis example
T3–T12 N Sl Rr
N Sr Rl
Convex vs concave side: on the convex side the vertebral bodies turn toward it and push the ribs posteriorly (the rib hump is caused by spinal rotation, not muscle), the ribs are spread apart (easier expansion/breathing on that side), and the muscles are stretched and weak. On the concave side the ribs crowd together, the muscles (e.g. erector spinae) are short and tight, and the spinous processes point toward the concavity.
Types of structural scoliosis:
Type
Key facts
Idiopathic
Most common: 70–90% of curves; adolescent idiopathic most common; female predominance; often a family history / genetic predisposition (so structural scoliosis “can be classified as genetic”)
Congenital
Present from birth (e.g. hemivertebra); about 75% progressive (“often progress”)
Acquired
Osteomalacia, inflammation, sciatic irritability, psoas syndrome, healed leg fracture, hip prosthesis, short leg syndrome, degenerative
Neuromuscular
Muscular dystrophy, cerebral palsy
The apex is the most rotated vertebra (highest point of the curve). The most tilted vertebrae at the top and bottom are the end vertebrae used for the Cobb angle. Structural curves can be C- or S-shaped, and they are not reversed by OMT. Functional vs structural is decided by reversibility (a functional hump levels out when sidebending toward the hump/convexity; functional can become structural, never the reverse), not by a 15° cutoff (see 5.8).
Lecture slides for this section (2)
Written Review slide 28: types of structural scoliosisWritten Review slide 29: naming scoliosis
346top 215asked 8×2026Scoliosis types & naming
A mother brings her 11-year-old daughter in for a scoliosis evaluation. She does not complain of back pain, and her past medical history is unremarkable. There is a family history of scoliosis; her mother was diagnosed with scoliosis as a child. Your physical exam shows no leg length discrepancy but does reveal asymmetry of the posterior chest wall on bending forward of the trunk. Which of the following statements is correct regarding this patient's diagnosis?
Why:Congenital curves are about 75% progressive, so "congenital curves often progress" is true.
Explanation & sources
Explanation
A: idiopathic causes 70-90% of curves, not short leg. B: a functional hump levels out when the patient sidebends toward the convexity (the hump), not the concavity. C: scoliosis is named for the convexity, and the short, tight erector spinae are on the concave side, so short muscles on the left means convex right (dextroscoliosis). D: functional curves can become structural, not the reverse.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q6 (answer list at end of doc)
An elderly patient presents for a general wellness visit without complaints. Structural examination reveals a group curve in the thoracic region. The most likely cause in this patient is
Ans: Most common cause of scoliosis → idiopathic (70-90%)
Why:Idiopathic scoliosis accounts for 70-90% of scoliotic curves, so it is the most likely cause. Osteopathic thinking holds that some are compensation for an unlevel sacral or cranial base.
Explanation & sources
Explanation
Cerebral palsy is neuromuscular. Congenital malformation is congenital (about 75% progressive). Psoas syndrome and inflammation are acquired causes. Short leg syndrome, listed in another version, is also acquired or functional.
2023 TA Review (Harlem) - Exam 1 · TA review · slides 113-114
Lecture slide (1)
Week 5 · Written Review deck · slide 28
348asked 2×Scoliosis types & naming
A 16-year-old male's school screening indicated scoliosis. He has no back pain; his father had scoliosis as a child, untreated. There is no leg length discrepancy, but there is asymmetry of the back on forward bending. You suspect:
Ans: Adolescent + family history + no short leg + forward-bend asymmetry → idiopathic
Why: An adolescent with a family history, no leg length discrepancy and asymmetry on forward bending most likely has idiopathic (structural) scoliosis, the most common type.
Explanation & sources
Explanation
Functional scoliosis needs a cause such as a short leg, muscle hypertonicity or compensation, and none is given. Neuromuscular scoliosis comes with conditions such as CP or muscular dystrophy. A heel lift is for a short leg, which he does not have.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 162-163
2020 TA Review Exam 1 · TA review · slides 152-153
Lecture slide (1)
Week 5 · Written Review deck · slide 28
349Scoliosis types & naming
Structural scoliosis:
Ans: Structural = idiopathic, genetic predisposition, fixed → can be called genetic
Why: Structural scoliosis is also called idiopathic, and it often has a genetic predisposition.
Explanation & sources
Explanation
A: OMT can ease symptoms and may slow progression, but it does not reverse a structural curve. B: structural curves do not reduce with forward bending, sidebending or rotation. C: they can be C- or S-shaped; neither is "usually" the rule.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 215-216
In the wonderful land of Wakanda, you were peacefully walking in the palace until you see Bridget, Jasmine, and Janet fighting Killmonger as he tries to attack. As they defeat Killmonger, Bridget's love, you notice an unequal leg length and very curved spine as they tie him up. What vertebral disorder does Killmonger have?
Ans: Unequal leg length + curved spine → scoliosis
Why: A lateral spinal curve with an unequal leg length describes scoliosis. Short leg syndrome is a recognized cause.
Explanation & sources
Explanation
Sway back, military posture and flat back are sagittal-plane postural types, not a lateral curve. A short leg tilts the sacral base, and the spine curves to keep the eyes level.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 43-44
Lecture slides (2)
Week 5 · Written Review deck · slide 28Week 5 · Written Review deck · slide 31
351Scoliosis types & naming
Which of the following is true regarding scoliosis?
Ans: Named for convexity → sidebent left = convex right = dextroscoliosis
Why: Scoliosis is named for the convexity. A curve sidebent left is convex right, which is dextroscoliosis.
Explanation & sources
Explanation
B: scoliosis is more common in females. A: most children with scoliosis have no symptoms, as in the pain-free screening vignettes. D: structural vs functional depends on whether the curve reverses, not on a 15-degree cutoff.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 109-110
Lecture slides (2)
Week 5 · Written Review deck · slide 29Week 5 · Written Review deck · slide 28
352asked 2×Scoliosis types & naming
Your patient with scoliosis has a curve which is convex on the left and the spine sidebends to the right. What do you name this?
Ans: Convex left (sidebent right) → named for convexity → levoscoliosis
Why: Scoliosis is named for the side of the convexity. Convex left (sidebent right) = levoscoliosis.
Explanation & sources
Explanation
Dextroscoliosis is convex right, with the spine sidebent left. Trap: naming the curve for the sidebending direction instead of the convexity.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 182-183
2020 TA Review Exam 1 · TA review · slides 172-173
Lecture slide (1)
Week 5 · Written Review deck · slide 29
353top 215Scoliosis types & naming
A 12-year-old adolescent undergoes a scoliosis screening at school. On forward bend test, the examiner notes a thoracic curvature that is convex to the left. Which of the following best describes this spinal curvature?
Ans: Convex left → levoscoliosis → spine sidebent right (toward concavity)
Why: Named for the convexity: convex left = levoscoliosis. The spine is sidebent right, toward the concavity.
Explanation & sources
Explanation
B pairs levoscoliosis with sidebending toward the convexity, which is backward. C and D are dextroscoliosis (convex right). Concave side = sidebending side.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 96-97
Lecture slide (1)
Week 5 · Written Review deck · slide 29
354Scoliosis types & naming
A patient is side bent to the right. Which side of the curve is convex and which is concave?
AnswerConvex on the left, concave on the right.
Ans: Sidebending side = concave side → SB right → concave right, convex left
Why: The spine bends toward the concavity, so sidebent right = concave right, convex left (a levoscoliosis pattern).
Explanation & sources
Explanation
Always name the curve for the convexity: convex left = levoscoliosis. In a Type I curve the bodies rotate toward the convexity, so rotation would be left.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 38-39
Lecture slide (1)
Week 5 · Written Review deck · slide 29
355Scoliosis types & naming
Concept check: is the side of lumbar sidebending the concave or the convex side?
AnswerConcave side.
Ans: Bending toward a side shortens it → sidebending side = concavity
Why: The side the spine sidebends toward is shortened and becomes the concavity. The opposite side is the convexity.
Explanation & sources
Explanation
Example: dextroscoliosis is convex right, so the spine is sidebent left and the left side is concave. The concave side has the shortened, tight muscles; ribs crowd together there.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 42-43
Lecture slide (1)
Week 5 · Written Review deck · slide 29
356Scoliosis types & naming
Name the scoliosis in the image:
Ans: Image: curve bulges right (ribs spread right) → convex right → dextroscoliosis
Why: In the drawing (posterior view) the thoracic curve bulges to the right, with the ribs spread on the right. Convex right = dextroscoliosis.
Explanation & sources
Explanation
Levoscoliosis is convex left. The label in the image gives a second clue: ribs crowd on the concave side and spread on the convex side.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 221-222
Lecture slide (1)
Week 5 · Written Review deck · slide 29
357Scoliosis types & naming
On the following image, the ribs are further apart on the:
Ans: Ribs spread on convex side (right) → more room → easier expansion
Why: Ribs spread apart on the convex side (here the right) and crowd together on the concave side. More space means easier expansion on the convex side.
Explanation & sources
Explanation
B and D call the right side concave, but it is convex. C reverses the breathing effect; compression is on the concave side. Large curves still compromise breathing overall (more than 50 degrees).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 219-220
Lecture slide (1)
Week 5 · Written Review deck · slide 29
358top 215Scoliosis types & naming
You are examining a patient with a structural scoliosis in the mid thoracic area. The concavity of the curve is on the left side. Which of the following correlate with your findings?
Ans: Concave left → convex right → right ribs spread apart
Why: Concavity on the left means convexity on the right. Ribs are spread on the convex side and crowded on the concave side.
Explanation & sources
Explanation
A: the vertebral body deviates toward the convexity (right). B: the spinous process deviates toward the concavity (left). D reverses the rib spacing.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 212-213
Lecture slide (1)
Week 5 · Written Review deck · slide 29
359top 215Scoliosis types & naming
When the ribs are pushed posteriorly on the Left with a Scoliotic curve:
Ans: Ribs posterior on left = convex left → SP swings to concave right
Why: Ribs are pushed posteriorly on the convex side, so the convexity is left. The vertebral body turns toward the convexity and the spinous process swings to the concave (right) side.
Explanation & sources
Explanation
A and D put the concavity or convexity on the wrong side. B has the SP going toward the convexity; the body goes there, the SP goes the other way.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 217-218
Lecture slide (1)
Week 5 · Written Review deck · slide 29
360Scoliosis types & naming
When vertebrae rotate in a scoliotic curve (rib hump), which direction does the vertebral body point and which direction does the spinous process point?
AnswerThe vertebral body rotates toward the convexity; the spinous process points toward the concavity.
Ans: Rotation toward convexity → body to convex side → SP (behind) swings to concave side
Why: In scoliosis the vertebral body turns toward the convexity and pushes the ribs back there (the rib hump). The spinous process, behind the body, points toward the concavity.
Explanation & sources
Explanation
Example: right thoracic (dextro) curve = sidebent left, rotated right; the bodies face right and the SPs swing left. Ribs on the concave side crowd together.
Asked in
2022 Instructor Exam Review (Dr. Banihashem) - Exam 1 · Instructor review · p.2, scoliosis photo + 'Directions of vertebra when they rotate'
Lecture slide (1)
Week 5 · Written Review deck · slide 29
361top 215asked 3×2026Scoliosis types & naming
A 15-year-old female presents for routine follow-up for idiopathic scoliosis. History is significant for exertional dyspnea with an associated decreased respiratory excursion. Structural examination is significant for obvious paravertebral humping on the right. A comprehensive evaluation for cardiovascular disease is unremarkable; however pulmonary function testing is abnormal. The paravertebral hump seen during structural examination is the result of
A 15-year-old female presents for routine follow-up for idiopathic scoliosis. History is significant for exertional dyspnea with an associated decreased respiratory excursion. Structural examination is significant for obvious paravertebral humping on the right. A comprehensive evaluation for cardiovascular disease is unremarkable; however pulmonary function testing is abnormal. The most likely diagnosis is
Ans: Right hump → rotated right → Type I sidebent left → convex right → dextro
Why: A right paravertebral hump = rotated right. Type I sidebends the opposite way (left), so the convexity is right: dextroscoliosis, rotated right, sidebent left.
Explanation & sources
Explanation
A is dextro but flips the rotation. C, D and E are levoscoliosis (convex left). E also couples the same side, which group curves do not do.
A 13 year old boy presents to your office after the school nurse noticed a rib hump from T3 to T12. After obtaining x-rays you calculate a cobb angle of 24 degrees and diagnose a moderate, dextroscoliosis. Which somatic dysfunction are you most likely to find?
Ans: Dextroscoliosis = convex right → sidebent left, rotated right → T3-12 NSlRr
Why:Dextroscoliosis = convex right = sidebent left, rotated right. A scoliotic curve is a neutral Type I curve: T3-12NSlRr.
Explanation & sources
Explanation
A and D use F or E, which belong to single Type II segments. B and C describe a levoscoliosis (sidebent right, rotated left). Cobb 24 degrees is moderate (20-45).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 210-211
Ans: Apex = vertebra at the peak of the hump → most rotated
Why: The apex is the vertebra at the highest point of the curve. It is the most rotated vertebra, and it defines the curve's location.
Explanation & sources
Explanation
A and B are the end vertebrae, which are the most tilted and are used to draw the Cobb angle. D describes the junction between two curves in an S-curve, not the apex.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 225-226
Why: Scoliosis is a lateral curvature (sidebending) of a group of vertebrae with coupled rotation toward the convexity, which makes the rib hump.
Heads up: The 2020 TA key (speaker notes) marks B, sidebending and flexion. The original options C and E were duplicates (sidebending and rotation). The 2026 lecture defines scoliosis as a lateral (coronal-plane) deviation with rotation toward the convexity, so C is given and the duplicate E is dropped.
Explanation & sources
Explanation
Flexion and extension describe sagittal-plane curves (kyphosis, lordosis). These can accompany scoliosis but do not define it. A describes anteroposterior curves.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 254-255
2020 TA Review Exam 1 · TA review · slides 246-247
Lecture slides (2)
Week 5 · Written Review deck · slide 29Week 5 · Written Review deck · slide 28
5.8 · 11 questions · Questions 366–376
Scoliosis screening & reversibility
No questions in this section match the current Show filter.
Learn firstWhat you need for 5.8
Screening: the AAP recommends screening at ages 10, 12, 14 and 16. Use the Adam's forward bend test (look for a rib hump) plus checking the horizontal planes for levelness (occiput, shoulders, scapulae, iliac crests, PSIS, greater trochanters). X-rays confirm and measure (Cobb angle) after a positive screen; bracing is treatment, not screening.
Classifying a curve (RSLE, “wrestle”):Reversibility (functional vs structural), Severity (Cobb angle), Location (apex: thoracic, lumbar, double major), Etiology (idiopathic, congenital, acquired, neuromuscular). Having the patient sidebend during the Adam's test checks reversibility.
Functional
Structural
Reverses with sidebending, rotation or forward bending?
Yes; the hump levels out when the patient sidebends toward it (toward the convexity)
No: fixed
Causes
Postural factors, compensation, muscle hypertonicity (Type I “bowstring” effect, not Type II) or weakness, short leg, some neurological conditions, trauma
Idiopathic (genetic), congenital, etc.
Notes
Treat while flexible, or it can progress to structural (functional → structural, never the reverse)
First sign: early loss of spinal flexibility
The course key treats any change in the hump with sidebending (Adam's reversibility test) as a flexible, functional curve. Example: a curve that began after a car accident, improves with sidebending, and whose apparent short leg levels out after OMT = functional scoliosis secondary to trauma (an anatomic short leg would not level out).
Lecture slide for this section (1)
IA5 slide 14: functional vs structural (reversibility)
The American Academy of Pediatrics recommends scoliosis screening at routine health visits at ages 10, 12, 14, and 16. Which of the following are used in screening for scoliosis?
Ans: Screening → look for rib hump → Adam's forward bend test
Why: Screening uses the Adam's forward bend test: the patient bends forward and you look for a rib hump.
Explanation & sources
Explanation
X-rays confirm the curve and measure the Cobb angle after a positive screen. Bracing is treatment. Passive sidebending tests reversibility once a curve is found. Scoliosis is a coronal-plane curve, so sagittal-plane asymmetry is the wrong plane. Universal school screening is no longer routine in the US.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q7 (answer list at end of doc)
Ans: Screen → Adam's test + level of horizontal planes
Why: Screen with Adam's forward bend test plus checking the horizontal planes (occiput, shoulders, scapulae, iliac crests, PSIS, greater trochanters) for levelness.
Explanation & sources
Explanation
Thomas test checks hip flexor tightness. Straight leg raise checks lumbar radicular pain or hamstrings. Spurling's checks cervical radiculopathy, and x-rays confirm rather than screen.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 171-172
2020 TA Review Exam 1 · TA review · slides 161-162
Lecture slide (1)
Week 5 · Written Review deck · slide 30
368asked 2×Scoliosis screening & reversibility
You notice a rib hump on the right with Adam's forward flexion test; it gets better with sidebending right and left. What classification of scoliosis is this testing?
Why: Sidebending to see if the hump levels out tests reversibility (functional vs structural).
Explanation & sources
Explanation
Severity is the Cobb angle. Location is the apex vertebra (thoracic, lumbar, double major). Etiology is the cause (idiopathic, congenital, acquired, neuromuscular). Mnemonic RSLE ("wrestle").
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 174-175
2020 TA Review Exam 1 · TA review · slides 164-165
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 14
369top 215Scoliosis screening & reversibility
You are performing a musculoskeletal exam on your partner's thoracic spine and find a mid-thoracic left sided rib hump on Adam's forward bend test which minimizes with sidebending to the left. What is the significance of this finding?
Ans: Hump left lessens with sidebending left (toward hump) → reversible → functional
Why: The hump lessens when the patient sidebends toward it, so the curve is reversible, which means a functional curve.
Explanation & sources
Explanation
A: a structural curve would not change. B: the hump is on the convex side, not the concave side. D: rib humps come from Type I group curves.
You notice a rib hump on your patient in the right thoracic region with the Adam's Forward Flexion test. When the patient sidebends, the rib hump improves. Which of the following describes this patient's Dx?
Ans: Hump improves with sidebending → reversible → functional
Why: A rib hump that improves with sidebending is reversible, which is functional scoliosis.
Explanation & sources
Explanation
Structural curves do not reduce with sidebending, rotation or forward bending. B: a right hump means convex right; the short, hypertonic muscles are on the concave (left) side.
Asked in
2022 TA Review - Exam 1 · TA review · slides 74-75
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 14
371top 215Scoliosis screening & reversibility
While performing the Adam's Forward Bend Test, you notice a rib hump on your patient's thoracic region. When the patient sidebends, the rib hump does not improve. Which of the following describes the patient's diagnosis, and what is the first sign of this condition?
Ans: Hump does not improve with sidebending → structural; first sign = early loss of flexibility
Why: A hump that does not improve with sidebending is structural. The lecture lists early loss of spinal flexibility as its first sign.
Explanation & sources
Explanation
A and B call it functional, but functional curves reverse. D has the right diagnosis but the wrong first sign; asymmetry that resolves with forward bending would point to a functional curve.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 92-93
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 14
372Scoliosis screening & reversibility
Which of the following is not true about functional scoliosis:
Ans: Functional = reversible → it DOES improve with sidebending → D is false
Why:Functional scoliosis is reversible, so it does improve with sidebending. "It will not improve" is the false statement.
Explanation & sources
Explanation
A, B and C are true: functional curves come from postural factors, compensation, muscle hypertonicity or weakness, or a short leg, and they reverse.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 227-228
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 14
373Scoliosis screening & reversibility
A 16-year-old boy presents for evaluation of uneven shoulders noticed by his parents. During the Adam's forward bending test, his spinal curve corrects with sidebending and he is diagnosed with functional scoliosis. All of the following are characteristics of functional scoliosis except:
Ans: Functional scoliosis hypertonicity = Type I (bowstring), not Type II → C false
Why: The muscle hypertonicity behind functional scoliosis comes from Type I group dysfunction (a bowstring effect of long muscles), not Type II.
Explanation & sources
Explanation
A, B and D are true: functional curves are postural or biomechanical, must be treated while flexible or they can become structural, and come from causes such as short leg syndrome or some neurological conditions.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 94-95
Your patient has thoracic back pain; the leg length test shows one leg shorter. You also see a Type 1 SD with hypertonic muscle on one side creating a bowstring effect on the spine. What do you suspect?
Ans: Short leg + Type I hypertonic bowstring → secondary curve → functional
Why: A short leg and hypertonic muscle pulling like a bowstring are causes of a functional curve.
Explanation & sources
Explanation
Structural and idiopathic curves have no such correctable cause. Neuromuscular scoliosis comes with conditions such as CP or muscular dystrophy. Functional causes: hypertonicity, weakness, compensation, short leg.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 166-167
2020 TA Review Exam 1 · TA review · slides 156-157
You have a patient with a rib hump in the lower right thorax. When you stabilize their hips as you look at the hump and they side-bend to the left, the rib hump gets worse/more pronounced. Name that test and type of curve in their spine.
Ans: Hump changes with sidebending → flexible curve → functional; test is Adam's
Why: The test is Adam's forward bend with sidebending to check reversibility. The hump changes with sidebending, so the curve is still flexible, which the key reads as functional.
Heads up: Keyed A by the 2025 TA review. The stem only describes sidebending away from the hump (which exaggerates any curve), so it does not truly prove reversibility. The key treats any change with sidebending as a flexible (functional) curve.
Explanation & sources
Explanation
"Aaron's" test does not exist. A structural curve is fixed and should not change with sidebending. The cleaner check is sidebending toward the hump: a functional hump levels out.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 88-89
A 35-year-old woman seen in clinic with a symptom of mid-thoracic pain, low back and right hip pain for the last 8 months. It started shortly after an MVA (motor vehicle accident), where she was rear ended. She was stopped at a red light, when a Yukon traveling 40 mph hit her car. She was wearing her seatbelt and the airbags did not deploy. PMHx: GERD PSHx: none Meds: Zantac 75 mg qd prn. Denies etoh, tobacco, ivdu. PE: BP 128/60, Neurological examination was within normal limits, ROM testing of the extremities was full both actively and passively; abdominal exam was normal; Osteopathic structural exam: T1FRrSr, T4FSrSr, Hypertonicity at left side T1-7, PSIS higher on left. Adams' test + rib hump on the right - improves with sidebending right and rotating left. Left medial malleolus superior but levels out after OMT. What is the most likely diagnosis in this patient?
Ans: Post-MVA onset + hump improves with sidebending + short leg levels after OMT → functional
Why: The curve started after trauma, the hump improves with sidebending and rotation (reversible = functional), and the apparent short leg levels out after OMT (not anatomic).
Explanation & sources
Explanation
An anatomic short leg would not level out after OMT. Congenital scoliosis is present from birth and is structural. A compression fracture would leave a fixed deformity that does not reverse with sidebending.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q10 (answer list at end of doc)
No questions in this section match the current Show filter.
Learn firstWhat you need for 5.9
Cobb angle = severity. On a standing postural (AP) x-ray, draw tangent lines along the end plates of the most tilted vertebra above the apex and the most tilted vertebra below the apex, in the coronal plane; the angle between them (or their perpendiculars) is the Cobb angle.
Cobb angle
Severity / significance
5–15°
Mild
20–45°
Moderate; >30° should be treated; >5° progression is an indication to treat
>50°
Severe; compromises respiratory function
>70° (75° in some sources)
Also compromises cardiovascular function
So abnormal PFTs with a normal cardiac workup fits about 52° (lungs only), not 77°. A worsening curve: compare x-rays within about 5 months; >5° increase or a height change.
Treatment: COMLEX rule <25° monitor, 25–45° brace, >45° surgery. Surgery is most favorable for severe, progressive curves, e.g. one that progressed despite bracing and causes respiratory compromise. Other options: functional orthotics, bracing, exercise, physical therapy, and patient/family education. A mild, flexible curve → OMT, PT and education (not monthly x-rays, heel lift without a short leg, or surgery).
OMT is safe to perform before orthopedic evaluation. Its benefits: relaxes and stretches contracted muscles, corrects SD, increases mobility, normalizes tissues, and mobilizes/may slow progression of the curve. Muscle energy (direct) positions toward the barrier: for dextroscoliosis (Sl Rr) that is sidebend right, rotate left. A Beighton score of 2/5 is not hypermobility.
Lecture slide for this section (1)
IA5 slide 22: Cobb angle and severity
377top 215asked 2×Cobb angle & treatment
To test the severity of scoliosis on postural X-ray, you measure the angles of the most tilted vertebra above the apex and the most tilted vertebra below the apex. What is this called?
Ans: Angle between most-tilted vertebrae above and below apex → Cobb angle
Why: The Cobb angle measures severity on a postural x-ray using the most tilted end vertebrae above and below the apex.
Explanation & sources
Explanation
The other options are not standard measures. The apex vertebra defines location, not severity.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 177-178
2020 TA Review Exam 1 · TA review · slides 167-168
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
378asked 4×2026Cobb angle & treatment
A 12-year-old female presents for routine follow-up for her chronic thoracic scoliosis. She has minimal symptoms but is cosmetically not pleased with her appearance. Structural examination reveals a small paravertebral hump on the right that improves with right sidebending. A plain film radiograph is obtained and the Cobb angle of 12 degrees is measured which is stable from prior imaging. This angle represents the intersection of
Ans: Cobb = lines along end plates of end vertebrae in coronal plane
Why: The Cobb angle is formed by tangent lines along the end plates of the top and bottom vertebrae of the curve, measured in the coronal plane (an AP film).
Explanation & sources
Explanation
A and B use lines parallel to flexed or extended positions, which is not the method. D and E use the sagittal plane, but scoliosis is a coronal-plane curve.
2022 TA Review (Middletown) - Exam 1 · TA review · slides 178-179
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
379top 215Cobb angle & treatment
While reviewing your patient's x-ray you calculate a cobb angle of 13 degrees and classify the severity of the scoliosis as…
Ans: 13 degrees → 5-15 = mild
Why:Mild scoliosis is 5-15 degrees, so 13 degrees is mild.
Explanation & sources
Explanation
Moderate is 20-45 degrees; severe is more than 50 degrees. "Extreme" is not a category.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 208-209
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
380top 215asked 2×Cobb angle & treatment
A 14-year-old adolescent undergoes a school scoliosis screening. The physician orders a standing postural x-ray which shows a Cobb angle of 35°, the severity of this scoliosis is classified as
Ans: 35 degrees → 20-45 = moderate
Why:Moderate scoliosis is 20-45 degrees, so 35 degrees is moderate. Curves over 30 degrees should be treated.
Explanation & sources
Explanation
Mild is 5-15 degrees. Severe is more than 50 degrees, which compromises respiration. Another version used 30 degrees, also moderate.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 88-89
2023 TA Review - Written Exam 1 · TA review · slides 223-224
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
381asked 2×Cobb angle & treatment
You measure a Cobb angle of 40 degrees. What classification of severity of scoliosis is this?
Ans: 40 degrees → 20-45 = moderate
Why:40 degrees falls in the moderate range (20-45 degrees).
Explanation & sources
Explanation
Mild is 5-15 degrees. Severe is more than 50 degrees. Do not call it severe just because it is large; the cutoff is 50.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 179-180
2020 TA Review Exam 1 · TA review · slides 169-170
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
382Cobb angle & treatment
You have a young patient that you have found to have a Cobb angle of 30º. The C curve is concave right. Classify this case of scoliosis.
Ans: 30 degrees = moderate; concave right → convex left → levoscoliosis
Why: 30 degrees is moderate (20-45). Concave right means convex left, and scoliosis is named for the convexity: levoscoliosis.
Explanation & sources
Explanation
A misgrades the curve and names it for the concavity. C names it for the concavity. D and E misgrade it as severe (more than 50).
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 85-86
A 15-year-old female presents for routine follow-up for idiopathic scoliosis. History is significant for exertional dyspnea with an associated decreased respiratory excursion. Structural examination is significant for obvious paravertebral humping on the right. A comprehensive evaluation for cardiovascular disease is unremarkable; however pulmonary function testing is abnormal. Which of the following is most associated with this patient's condition?
Ans: Respiratory but not cardiac compromise → >50 but <70-75 → 52 degrees
Why: Curves over 50 degrees compromise respiratory function. Cardiovascular compromise starts around 70 degrees (75 in some sources), so 52 degrees fits lungs only.
Explanation & sources
Explanation
B (77 degrees) would also compromise cardiovascular function, but her cardiac workup is normal. C, D and E are causes (neuromuscular, acquired, congenital), not markers of respiratory-only compromise.
2023 TA Review (Harlem) - Exam 1 · TA review · slides 111-112
2022 TA Review (Middletown) - Exam 1 · TA review · slide 180
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
384top 215asked 8×2026Cobb angle & treatment
A 17 year old girl came to the urgent care clinic complaining of upper back pain for the past month. She has a continuous pain in her upper back, especially while studying. Stress worsens the pain. PMHX (Past Medical History): none, PSHX (Past Surgical History): none, Meds: None Denies alcohol use, tobacco, IV Drug use. With forward bending, rib hump was seen on the right. Palpation of spine revealed dextroscoliosis from T4-T10. There was hypertonicity of the erector spinae muscles on the left side. Thoracic spine x rays revealed a Cobb angle of 20 degrees. The Beighton non-dominant limb hypermobility screening test score was positive for 2 out of 5 parameters. Which of the following is a true statement regarding this patient?
Ans: IA5: safe to perform OMT before orthopedic evaluation
Why: The IA5 slide says it is safe to perform OMT before orthopedic evaluation. OMT aims to improve function, posture and mobility and may slow progression.
Explanation & sources
Explanation
A: a Beighton score of 2/5 does not indicate hypermobility, so HVLA is not contraindicated on that basis. B: muscle energy is direct; dextroscoliosis is sidebent left, rotated right, so ME positions toward the barrier (sidebend right, rotate left). C: OMT does not need to wait for an x-ray.
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q8 (answer list at end of doc)
Which of the following is false regarding the treatment of scoliosis?
Ans: OMT is safe before orthopedic evaluation → "cannot" is false
Why: OMT can be performed before orthopedic evaluation, so C is the false statement.
Explanation & sources
Explanation
A, B and D are true: surgery is considered for severe curves (especially over 45 degrees); orthotics, bracing, exercise and PT are options; and patient and family education is part of care.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 90-91
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 45
386asked 2×Cobb angle & treatment
What is NOT an advantage of using OMT to treat scoliosis?
Ans: OMT for scoliosis increases mobility → "decreases mobility" is not a benefit
Why: OMT for scoliosis increases mobility. "Decreases mobility" is the one that is not an advantage.
Explanation & sources
Explanation
The listed benefits are from lecture: mobilizing and slowing progression, relaxing and stretching contracted muscles, correcting SD, increasing mobility and normalizing tissues.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 185-186
2020 TA Review Exam 1 · TA review · slides 175-176
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 30
387asked 4×2026Cobb angle & treatment
A 12-year-old female presents for routine follow-up for her chronic thoracic scoliosis. She has minimal symptoms but is cosmetically not pleased with her appearance. Structural examination reveals a small paravertebral hump on the right that improves with right sidebending. Prognosis and management options are discussed. Surgery for scoliosis is most likely to have favorable results in which of the following cases?
Ans: Surgery → severe progressive curves with organ compromise → progressed despite bracing + respiratory compromise
Why: Surgery is for severe, progressive curves, especially those compromising respiration. A curve that progressed despite bracing and affects breathing fits best.
Explanation & sources
Explanation
A: progression alone is first managed with closer monitoring and bracing. C and D: 30-35 degrees is moderate and usually braced. E: 40 degrees in a skeletally mature patient is below the usual surgical range (over 45-50 degrees). Course COMLEX rule: under 25 monitor, 25-45 brace, over 45 surgery.
2022 TA Review (Middletown) - Exam 1 · TA review · slides 188-189
Lecture slide (1)
Week 5 · IA5 Thoracic & Scoliosis · slide 22
388asked 3×2026Cobb angle & treatment
A 12-year-old female presents for routine follow-up for her chronic thoracic scoliosis. She has minimal symptoms but is cosmetically not pleased with her appearance. Structural examination reveals a small paravertebral hump on the right that improves with right sidebending. Which of the following is the most appropriate management in this patient?
Ans: Small hump that improves with sidebending (mild, functional) → OMT, PT, education
Why: A small hump that improves with sidebending is mild and flexible. The right care is OMT, physical therapy and patient/family education.
Explanation & sources
Explanation
A: a heel lift is for a short leg, which is not described. C: monthly x-rays add radiation without changing care; mild curves are rechecked about every 6-12 months. D: surgery is for severe, progressive curves. E: orthotics or bracing are for moderate curves (about 25-45 degrees).
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Learn firstWhat you need for 5.10
Measuring: at the bedside, tape from the ASIS to the medial malleolus of each leg. The most accurate test is a standing postural x-ray of the iliac crests, sacral base and femoral heads. Pant-leg complaints, knee flexion and IT band tightness are clues, not measurements; the standing flexion test checks iliosacral motion and is not a leg-length test.
What a short leg does (example: right short leg):
Sacral base (anterior/deep), iliac crest, PSIS and greater trochanter are low on the short (right) side; the innominate on the short side rotates anterior.
The lumbar spine sidebends away from the short leg (left) and rotates toward it (right) → compensatory lumbar curve convex toward the short leg (convex right).
The pelvis side shifts toward the long leg (left). (Textbook: a right short leg pairs with a left-on-left forward sacral torsion, not right-on-right.)
The iliolumbar ligament on the side of lumbar convexity (short side) is the first structure to react and the point of maximal tenderness (refers to the groin); sacroiliac ligaments on the convex side may be tender (refer down the lateral leg).
Mirror it for a left short leg: left malleolus higher (supine) = left leg short → lumbar N Sr Rl (convex left), pelvic side shift right.
Most common cause of a short leg: hip replacement (textbook: anatomic; 2026 slide: functional).
Heel lift therapy: the goal is to level the sacral base (not the iliac crests or the measured leg length). Start small: 1/16 inch for a fragile, elderly or acutely painful patient, rechecked in about 2 weeks (1/8 inch for a sturdier patient). The full difference is rarely given at once unless the leg suddenly lost length (e.g. fracture). Balance the sacrum with OMT plus lift, then re-evaluate.
Lecture slides for this section (2)
Written Review slide 31: short leg syndromeWritten Review slide 32: clinical presentation of a short leg
389top 215asked 2×Short leg
How do you measure leg length discrepancy?
Ans: Clinical leg length → tape from ASIS to medial malleolus
Why: At the bedside, measure leg length from the ASIS to the medial malleolus of each leg.
Explanation & sources
Explanation
PSIS, lateral malleolus and greater trochanter are not the standard points. A standing postural x-ray is the most accurate test.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 168-169
2020 TA Review Exam 1 · TA review · slides 158-159
Lecture slide (1)
Week 5 · Written Review deck · slide 31
390top 215asked 8×2026Short leg
What is the most accurate way to determine a leg length discrepancy?
Ans: Most accurate → standing postural x-ray (iliac crests, sacral base, femoral heads)
Why: The standing postural x-ray of the iliac crests, sacral base and femoral heads is the most accurate way to determine a leg length discrepancy.
Explanation & sources
Explanation
ASIS to medial malleolus is the bedside measurement but less accurate. Pant-leg complaints, knee flexion deformity and IT band tightness are clues, not measurements. The film is taken barefoot with L5 centered and both acetabula visible (about 2 mm error).
Asked in
2026 Canvas Qs Week 5 Thoracic/Scoliosis · Canvas quiz · Q9 (answer list at end of doc)
A 30-year-old man presents with functional scoliosis. On physical exam, you note a pelvic tilt and a possible leg length discrepancy. Which of the following is the most accurate method to confirm a diagnosis of short leg syndrome?
Ans: Most accurate confirmation → standing postural x-ray
Why: The standing postural x-ray of the iliac crests, sacral base and femoral heads is the most accurate confirmation.
Explanation & sources
Explanation
Tape measurement (ASIS to medial malleolus) and palpating iliac crest heights are less accurate screening tools. The standing flexion test checks iliosacral motion, not leg length.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 99-100
Lecture slide (1)
Week 5 · Written Review deck · slide 31
392top 215asked 3×2026Short leg
A young adult presents with low back pain and measurements reveal an anatomic short leg on the right side. This is most associated with
Ans: Right short leg → sacral base low right → lumbar sidebends left, convex right
Why: With a right short leg the sacral base drops on the right, and the lumbar spine sidebends away (left) and rotates toward the short leg, giving a curve convex right.
Explanation & sources
Explanation
A: landmarks are low on the short (right) side. D: the pelvis shifts toward the long leg (left). E: the tender iliolumbar ligament is on the short-leg side, which is the side of lumbar convexity (right). C: the textbook pairs a right short leg with a left-on-left forward torsion, not right-on-right.
Week 5 · Written Review deck · slide 31Week 5 · Written Review deck · slide 32
393Short leg
While performing an osteopathic structural exam on your patient, you notice a lateral curve in the lumbar region. You examine further and discover the left medial malleolus is slightly higher than the right. What else would you expect to find on your physical examination?
Ans: Left malleolus higher → left leg short → lumbar sidebends right, rotates left
Why: The left medial malleolus is higher, so the left leg is short. The lumbar spine sidebends away from the short leg (right) and rotates toward it (left): L2-4NSrRl.
Explanation & sources
Explanation
A: the curve is convex left (levoscoliosis), not dextro. B is the pattern for a right short leg. C: the left leg is the short one.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 205-206
Lecture slides (2)
Week 5 · Written Review deck · slide 31Week 5 · Written Review deck · slide 32
394top 215asked 4×2026Short leg
A 75-year-old male complains of persistent buttock pain despite right total hip arthroplasty. Standing palpatory examination reveals the iliac crest and greater trochanter to be inferior on the left. Postural radiographic studies reveal an unlevel sacral base that is inferior on the left. The most likely cause of this patient's leg length discrepancy is
Ans: Hip arthroplasty + new leg length difference → most common cause = hip replacement
Why:Hip replacement is the most common cause of a short leg, and this patient just had a total hip arthroplasty.
Heads up: The textbook calls hip replacement the most common cause of an anatomic short leg. The 2026 review slide lists it as the "most common cause of functional short leg." Either way the answer is E.
Explanation & sources
Explanation
A: dislocation would present acutely. B and C would make the left leg short only through a left hip process, and protrusio acetabuli (femoral head displaced medially) is uncommon. D: scoliosis is the result, not the cause. Treatment: balance the sacrum with OMT and heel lift, then re-evaluate.
2022 TA Review (Middletown) - Exam 1 · TA review · slides 185-186
Lecture slide (1)
Week 5 · Written Review deck · slide 32
395top 215asked 3×2026Short leg
A 75-year-old male complains of persistent buttock pain despite right total hip arthroplasty. Standing palpatory examination reveals the iliac crest and greater trochanter to be inferior on the left. Postural radiographic studies reveal an unlevel sacral base that is inferior on the left. The structural exam finding most associated with this presentation is
Ans: Left short leg → pelvis shifts toward long leg → side shift right
Why: The left leg is short, so the pelvis side shifts toward the long leg (right).
Explanation & sources
Explanation
A: the lumbar curve is convex toward the short leg (left). D: the innominate on the short side rotates anterior, not posterior. E: the anterior (deep) sacral base is on the short (left) side. B: pelvic rotation is not the defining finding.
A 65-year-old female presents with acute low back pain. Observation reveals she has a frail body habitus with a wide-based, antalgic gait. Physical examination reveals a leg length discrepancy of 5/8th inches. A postural radiographic series is obtained and reveals the right femoral head is 1/2 inch cephalad when compared to the left. The most valid objective for heel lift therapy is to
Ans: Heel lift goal → level the sacral base (functional balance)
Why: The goal of lift therapy is to level the sacral base. A level base lets the spine above it rebalance.
Explanation & sources
Explanation
Iliac crest and leg length numbers can differ from the sacral base and are not the target. Lumbar and thoracic curves improve secondarily once the base is level.
A 65-year-old female presents with acute low back pain. Observation reveals she has a frail body habitus with a wide-based, antalgic gait. Physical examination reveals a leg length discrepancy of 5/8th inches. A postural radiographic series is obtained and reveals the right femoral head is 1/2 inch cephalad when compared to the left. The most appropriate initial management is
Ans: Frail, elderly, acute pain → start small → 1/16 inch heel lift, recheck 2 weeks
Why: In a frail, elderly patient with acute pain, start with a small 1/16-inch heel lift and recheck in 2 weeks.
Explanation & sources
Explanation
The full measured difference is rarely given at once unless the leg suddenly lost length (for example, after a fracture). A 1/8-inch start suits a patient who is not fragile. Increasing without rechecking (D) or waiting 8 weeks (B) is too aggressive or too slow.
No questions in this section match the current Show filter.
Learn firstWhat you need for 6.1
Every technique is classified by where you position the patient at the start:
Direct
Indirect
Start position
Toward / into the restrictive barrier
Position of ease, away from the barrier
Relation to the diagnosis
Opposite the diagnosis (flip every letter)
Equal to the diagnosis (the SD itself)
Effect on a hypertonic muscle
Stretches (lengthens) it
Shortens it
Examples
Muscle energy, HVLA
Counterstrain
Quick rule: a position that reads the same as the diagnosis is indirect; the exact opposite is direct. For T4 F Rr Sr: positioning into E Rl Sl = direct; positioning into F Rr Sr = indirect.
Direct/indirect is a separate axis from active/passive. “The patient stays still” (passive) or “the patient moves” (active) does not tell you direct vs indirect. Myofascial release can be done either way.
Lecture slide for this section (1)
IA6 slide 23: indirect vs direct
398Direct vs indirect
A direct technique is best described as:
Ans: Direct → engage the restrictive barrier → patient placed toward the barrier
Why: A direct technique starts by positioning the patient toward the restrictive barrier, which is opposite the somatic dysfunction.
Explanation & sources
Explanation
A describes a passive technique and D an active one; active/passive is a separate axis from direct/indirect. C is the definition of an indirect technique. Muscle energy and HVLA are the course's direct techniques.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 170-171
2022 TA Review (Middletown) - Exam 1 · TA review · slides 116-117
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
399top 215asked 7×2026Direct vs indirect
When considering osteopathic manipulative treatment, which of the following statements accurately describes an indirect technique?
Ans: Indirect → position of ease → ease = the diagnosis → position equals the SD
Why: An indirect technique places the patient in the position of ease, which equals the diagnosis (the somatic dysfunction), at the start of the modality.
Explanation & sources
Explanation
A, B and C all describe a direct technique: into the barrier, opposite the diagnosis, stretching the hypertonic muscle. D describes an active technique, which is a separate axis. Counterstrain is the course's example of an indirect, passive technique.
What is the difference between a direct technique and an indirect technique?
Ans: Indirect → away from barrier → into ease → hypertonic muscle shortened
Why: An indirect technique moves away from the barrier into the position of ease, which shortens the hypertonic muscle. A direct technique goes toward the barrier and stretches it.
Explanation & sources
Explanation
A and D swap the direction for each technique. C pairs the right direction for direct with the wrong muscle effect: moving into the barrier lengthens (stretches) a hypertonic muscle. Counterstrain is the classic shortening (indirect) technique.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 91-92
2024 TA Review (Harlem) Exam 1 · TA review · slides 65-66
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
401top 215Direct vs indirect
A first-year medical student presents with upper back pain after long hours of slouching. Exam reveals T4 FRrSr. For the first treatment, you position the patient into extension, left rotation, left sidebending. For the second treatment, you position the patient into flexion, right rotation, right sidebending. Which of the following best describes the techniques used?
Ans: FRrSr = freedom → ERlSl is the barrier (direct) → FRrSr is the ease (indirect)
Why: The diagnosis names the freedom. Positioning into the opposite (ERlSl) engages the barrier, so the first is direct. Positioning into FRrSr matches the diagnosis, so the second is indirect.
Explanation & sources
Explanation
A and B ignore that the two positions are mirror images. C reverses them. Quick rule: a position that reads the same as the diagnosis is indirect; the exact opposite is direct.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 109-110
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
402Direct vs indirect
What are direct vs indirect techniques?
AnswerIndirect: patient placed in the position of ease (equal to the diagnosis) at the start, e.g., counterstrain. Direct: patient positioned toward the restrictive barrier (opposite the diagnosis) at the start, e.g., muscle energy and HVLA.
Ans: Ease = diagnosis → indirect; barrier = opposite of diagnosis → direct
Why:Indirect means starting in the position of ease, which equals the somatic dysfunction. Direct means starting at the restrictive barrier, opposite the diagnosis.
Explanation & sources
Explanation
Counterstrain is indirect; muscle energy and HVLA are direct. Myofascial release can be done either way. Direct/indirect describes where you position; active/passive describes whether the patient contracts.
Asked in
2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'What are direct vs indirect techniques'
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
6.2 · 6 questions · Questions 403–408
Technique types
No questions in this section match the current Show filter.
Learn firstWhat you need for 6.2
Classify each technique on two independent axes: direct vs indirect (toward the barrier vs into ease) and active vs passive (does the patient contract or not).
Technique
Direct / indirect
Active / passive
Muscle energy
Direct
Active (patient contracts against the physician)
HVLA
Direct
Passive (physician thrusts)
Counterstrain
Indirect
Passive (“fold and hold”)
Facilitated positional release
Indirect
Passive
Myofascial release
Either
Either
Of the three Week 6 techniques, only muscle energy is active. None of them is active and indirect. Watch for “only” in options: “myofascial release = direct with passive forces only” is wrong because MFR can be done several ways.
Lecture slide for this section (1)
Study note: ME vs CS vs HVLA at a glance
403asked 3×Technique types
Match each item to one description: Indirect technique; Counterstrain; Muscle energy; HVLA; Direct technique. Descriptions: A. Active and direct. B. Passive and direct. C. Passive and indirect. D. Positioned toward the barrier. E. Patient is placed in a position of ease (which equals the diagnosis, the somatic dysfunction).
AnswerIndirect technique–E; Counterstrain–C; Muscle energy–A; HVLA–B; Direct technique–D.
Ans: ME = active + direct; HVLA = passive + direct; CS = passive + indirect
Why:Muscle energy is active and direct, HVLA is passive and direct, counterstrain is passive and indirect. Direct means toward the barrier; indirect means the position of ease, equal to the diagnosis.
Explanation & sources
Explanation
The 2023 version used only three items (HVLA, muscle energy, counterstrain) matched to direct-active, direct-passive and indirect. The only active technique of the three is muscle energy, because the patient contracts against the physician.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 93-94
2024 TA Review (Harlem) Exam 1 · TA review · slides 83-84
2023 TA Review - Written Exam 1 · TA review · slides 147-148
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
404top 215asked 4×Technique types
Counterstrain is what type of technique?
Ans: CS → shorten muscle into ease (indirect) → physician does all the moving (passive)
Why: Counterstrain places the patient into a position of ease that shortens the hypertonic muscle (indirect), and the physician moves the patient without any patient effort (passive). Think "fold and hold."
Explanation & sources
Explanation
Active, direct is muscle energy. Passive, direct is HVLA. No technique in this lecture is active and indirect. The patient must stay passive, even while being returned to neutral, or the reflex can restart.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 131-132
2023 TA Review - Written Exam 1 · TA review · slides 113-114
2022 TA Review - Exam 1 · TA review · slides 47-48
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
405top 215Technique types
What type of technique is HVLA?
Ans: HVLA → thrust through the barrier (direct) → no patient effort (passive)
Why: HVLA engages the restrictive barrier and the physician delivers the thrust, so it is direct and passive.
Explanation & sources
Explanation
Active, direct is muscle energy. Passive, indirect is counterstrain. Active, indirect fits none of the three Week 6 techniques. The Kirksville Crunch (supine) and Texas Twist (prone) are thoracic HVLA examples.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 136-137
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
406Technique types
Which of the following treatments is correctly matched?
Ans: CS = indirect + passive → only B matches
Why:Counterstrain is an indirect, passive technique: the physician positions the patient into ease with no patient effort.
Explanation & sources
Explanation
A fails because of "only": myofascial release can be direct or indirect and active or passive. C is wrong because muscle energy is direct and active. E is wrong because HVLA is direct. Facilitated positional release is indirect but passive, not active.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 119-120
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
407top 215Technique types
A patient has T4 FRrSr. You treat with a muscle energy technique, followed by a counterstrain technique. Which of the following best describes the patient's participation in these techniques, respectively?
Why: In muscle energy the patient contracts against the physician's counterforce (active). In counterstrain the physician positions a relaxed patient (passive).
Explanation & sources
Explanation
A reverses the two. C and D treat them as the same. Summary: ME direct/active, CS indirect/passive, HVLA direct/passive, myofascial release can be either.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 111-112
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
408Technique types
What are active vs passive techniques?
AnswerActive: the patient contracts or moves on request (muscle energy, active myofascial release). Passive: the patient stays relaxed while the physician does the work (counterstrain, indirect; HVLA, direct).
Ans: Patient effort → active (ME); no patient effort → passive (CS, HVLA)
Why:Active techniques use the patient's own muscle effort, as in muscle energy. Passive techniques keep the patient relaxed, as in counterstrain and HVLA.
Explanation & sources
Explanation
Active/passive is independent of direct/indirect: HVLA is passive but direct, counterstrain is passive and indirect. Myofascial release can be done actively or passively.
Asked in
2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'What are Active vs. Passive Techniques'
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
6.3 · 8 questions · Questions 409–416
ME basics
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Learn firstWhat you need for 6.3
Muscle energy (ME) was developed by Fred Mitchell Sr., DO (first published 1958). It uses physician-guided, voluntary muscle contraction to treat a specific mechanical diagnosis, restoring normal muscle tone and/or joint mechanics. It is direct and active, engages the restrictive barrier (never the anatomic barrier), and its main mechanism is the Golgi tendon organ (post-isometric relaxation). The muscle spindle with an alpha/gamma mismatch is the counterstrain story (counterstrain = Lawrence Jones, indirect, passive), not ME.
The patient's effort is required in every version of ME (90-second holds = counterstrain; thrust = HVLA). After each effort you take up the slack to the new barrier, not the freedom.
The 9 physiologic principles of ME: post-isometric relaxation, reciprocal inhibition, joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, crossed extensor reflex, isokinetic strengthening, isolytic lengthening, and using muscle force to move one region to move another. (“It is an indirect technique” is never a principle.)
Indications: clinically relevant somatic dysfunction; mobilizing joints (“misaligned bones”); strengthening weak muscles; stretching tight muscles and fascia; improving circulation (contraction pumps lymph and venous blood); relaxing hypertonic muscles; preparing a joint for HVLA. ME does have contraindications (e.g. no consent, a patient who cannot follow commands).
Lecture slide for this section (1)
IA6 slide 7: muscle energy mechanism
409top 215asked 6×2026ME basics
Which of the following statements is correct when describing muscle energy?
Ans: ME → Fred Mitchell → direct, active → Golgi tendon organ
Why: Muscle energy was developed by Fred Mitchell Sr., DO. It is a direct, active technique that works through the Golgi tendon organ (post-isometric relaxation).
Explanation & sources
Explanation
Lawrence Jones developed counterstrain, which is indirect, passive and acts on the muscle spindle (option C describes counterstrain). E has the right person but the counterstrain mechanism. Mitchell first published ME in 1958; his son published the ME manual in 1979.
Fill in the blanks: "____ is a direct and active osteopathic treatment modality developed by ____ which requires the physician to engage a restrictive barrier, while having the patient move into their freedom. It uses gentle isometric contractions to cause muscle relaxation through autogenic or reciprocal inhibition and lengthening of a hypertonic muscle (or group of muscles)."
Ans: Direct + active + isometric contraction into freedom → muscle energy → Fred Mitchell
Why: Only muscle energy is direct and active with isometric contractions, and it was developed by Fred Mitchell, DO.
Explanation & sources
Explanation
Counterstrain (Jones) is indirect and passive. Still's technique and cranial osteopathy (Sutherland) do not use patient isometric contraction against a barrier. Autogenic inhibition is the Golgi tendon organ effect behind post-isometric relaxation.
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2020 TA Review Exam 1 · TA review · slides 13-14
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 7
411asked 3×2026ME basics
Which of the following is a true statement regarding muscle energy technique?
Ans: ME → patient contracts against barrier → active, direct
Why: Muscle energy is the prototypical active, direct technique.
Explanation & sources
Explanation
A is wrong because ME relies on the Golgi tendon organ (post-isometric relaxation); the spindle is the counterstrain mechanism. C is wrong because after each effort you take up the slack to the new barrier, not the freedom. D is wrong: ME has absolute contraindications (e.g., no consent, patient unable to follow commands) and relative ones.
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2026 Textbook Q&A Compilation - Physiology of Treatment Modalities: ME/CS/HVLA · Practice questions · slide 161 (answer slide 162)
OMM1 Practice Questions - Physiology of Treatment Modalities: ME/CS/HVLA (doc header 'OMM 1 Fall 2020') · Practice questions · Q1
2024 Practice questions Physiology of Treatment Modalities - ME/CS/HVLA (Lect 6) · Practice questions · Q1 (doc header 'OMM 1 Fall 2020')
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 7
412ME basics
Muscle energy is an example of a(n) ____ technique; it engages the ____ barrier.
Ans: ME → direct → engages the SD's restrictive barrier (never the anatomic)
Why: Muscle energy is direct and engages the restrictive barrier, the early abnormal stop caused by the somatic dysfunction.
Explanation & sources
Explanation
The anatomic barrier is the limit of passive motion; forcing past it tears tissue, so no technique targets it. Indirect techniques move away from the restrictive barrier. ME starts at the "feather edge," the first point where tension is palpable.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 73-74
All of the following are principles of muscle energy EXCEPT:
Ans: ME is direct → 'indirect' is the exception
Why: Muscle energy is a direct technique, so "indirect" is the false statement.
Explanation & sources
Explanation
Isokinetic strengthening, reciprocal inhibition and post-isometric relaxation are all among the 9 physiologic principles of ME. The others: joint mobilization using muscle force, respiratory assistance, oculocephalic reflex, crossed extensor reflex, isolytic lengthening, and using muscle force to move another region.
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2023 TA Review - Written Exam 1 · TA review · slides 127-128
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 7
414asked 2×ME basics
Which of the following is UNTRUE of muscle energy technique?
Ans: Spindle + alpha/gamma mismatch → counterstrain theory, not ME
Why: The muscle spindle with an alpha/gamma mismatch is the proposed mechanism of counterstrain. Muscle energy works through the Golgi tendon organ.
Explanation & sources
Explanation
A, B and C are all true of ME: Mitchell, active and direct, and post-isometric relaxation via the GTO. Counterstrain shortens the hypertonic muscle so the spindle stops over-reporting and gamma gain resets.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 107-108
2022 TA Review - Exam 1 · TA review · slides 70-71
Which of the following is a necessary component for a successful muscle energy treatment?
Ans: ME = active → patient must contract → patient assistance is required
Why: Muscle energy is active: every version needs the patient to contract on request against the physician's counterforce, so patient assistance is required.
Explanation & sources
Explanation
A is indirect positioning; ME positions into the barrier. C (90 s hold) is counterstrain. D is HVLA. Reciprocal inhibition and post-isometric relaxation are each only one of several ME principles, so neither is required in every treatment.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 113-114
2023 TA Review (Harlem) - Exam 1 · TA review · slides 120-121
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 7
416asked 2×ME basics
What is an indication for muscle energy?
Ans: ME mobilizes joints, stretches tight tissue, improves circulation, relaxes muscles → all
Why: Lecture 6 lists ME indications as clinically relevant somatic dysfunction, mobilizing joints, strengthening weak muscles, stretching tight muscles and fascia, and improving circulation; muscle relaxation is its main goal.
Explanation & sources
Explanation
Each option on its own is a valid use, so "all of the above" is best. Muscle contraction also pumps lymph and venous blood, which is why ME helps edema and congestion. ME can also prepare a joint for HVLA.
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2020 TA Review (Middletown) Exam 1 · TA review · slides 147-148
2020 TA Review Exam 1 · TA review · slides 137-138
6.4 · 7 questions · Questions 417–423
ME physiology
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ME principle
What the patient does
Mechanism / use
Post-isometric relaxation
The tight muscle contracts isometrically toward its freedom, 3–5 s
Tendon tension → GTO inhibits alpha motor neurons of the same muscle (negative feedback); a refractory window follows, so slack is taken up without stretch-reflex opposition. Gentle 10–20 lb; e.g. hamstring spasm
Reciprocal inhibition
Gentle contraction of the muscle opposite the tight one. Textbook wording: “contraction of the agonist relaxes the antagonist”
Relaxes the tight muscle (e.g. contract hamstrings to relax a left quadriceps in acute spasm); force in ounces
Oculocephalic reflex
Looks toward the freedom
Cervical/trunk muscles contract reflexly to follow the eyes; exceptionally gentle (e.g. hypertonic SCM). Avoid after recent eye surgery/trauma
Respiratory assistance
Voluntary, exaggerated breathing
Breath is the corrective force against a physician fulcrum; used for rib dysfunctions
Crossed extensor reflex
Contracts the flexor of the opposite limb
Contralateral flexor relaxes and extensor contracts; for a limb too injured to treat (fracture, burn, severe strain); force in ounces
Push direction: the patient is placed into the barrier but pushes toward the freedom. That raises tendon tension and fires the GTO. Patients cannot selectively contract single intercostals; ribs are treated with respiratory assistance.
Lecture slide for this section (1)
IA6 slide 8: post-isometric relaxation
417ME physiology
You are performing muscle energy and wonder about the physiology behind the technique. You conclude that you are:
Why: In muscle energy the patient pushes toward their freedom against your counterforce. That raises tendon tension, which fires the Golgi tendon organ and relaxes the muscle.
Explanation & sources
Explanation
C has the right reflex but the wrong push direction: the patient is placed into the barrier but pushes toward the freedom. A and D describe the spindle, which is the counterstrain story. E is a joke option.
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2022 TA Review (Middletown) - Exam 1 · TA review · slide 135
After positioning the patient into the restrictive barrier, you instruct them to gently push against your resistance for 3-5 seconds, then relax. You then reposition them further into the barrier. What is the relaxation called and what is the physiologic basis for why the muscles lengthen after contraction?
Why: This is post-isometric relaxation. The contraction raises tendon tension, and the Golgi tendon organs inhibit the alpha motor neurons of the same muscle (negative feedback), so you can take up the slack.
Explanation & sources
Explanation
B names reciprocal inhibition, which relaxes a muscle by contracting its antagonist, and pairs it with a wrong mechanism. C is used for injured limbs. D, the stretch reflex, causes contraction and is what ME avoids. E has the right name but the wrong mechanism; raising gamma gain increases tone.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 121-122
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 8
419asked 2×ME physiology
Which of the following uses the Golgi tendon proprioceptors?
Ans: GTO inhibits the contracting muscle → basis of post-isometric relaxation
Why: In post-isometric relaxation, the Golgi tendon proprioceptors inhibit the active contraction after an isometric effort, leaving a refractory window for passive stretch.
Explanation & sources
Explanation
The crossed extensor reflex uses learned crossed locomotion patterns. Isokinetic strengthening uses a slow concentric contraction to strengthen a weak muscle. Isolytic lengthening stretches a fibrotic muscle while it contracts (physician force > patient force). PIR uses gentle 10-20 lb pressure; the lecture example is hamstring spasm.
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2020 TA Review (Middletown) Exam 1 · TA review · slides 140-141
2020 TA Review Exam 1 · TA review · slides 129-130
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 8
420top 215ME physiology
Samantha has an acute left quadriceps spasm after a weight training session. To relax the left quadriceps, Dr. Mitchell tells her to apply a gentle contraction with her left hamstrings. Which muscle energy principle is used here?
Why:Reciprocal inhibition: a gentle contraction of the agonist (hamstrings) reflexly relaxes its antagonist (quadriceps). It is used to lengthen a muscle in cramp or acute spasm.
Explanation & sources
Explanation
Post-isometric relaxation would have the spasming quadriceps itself contract. The oculocephalic reflex uses eye movements. Isolytic lengthening uses a strong contraction overpowered by the physician for chronic fibrosis, not acute spasm. Reciprocal inhibition force is very gentle (ounces, not pounds).
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2023 TA Review - Written Exam 1 · TA review · slides 141-142
Lecture slide (1)
Week 4 · Written Review deck · slide 25
421asked 2×ME physiology
A 30-year-old male has a hypertonic sternocleidomastoid. You set him up at his barrier and tell him to look toward his freedom. Which physiologic principle of muscle energy is involved?
Why: The oculocephalic reflex uses voluntary eye motion: the cervical and trunk muscles contract reflexly to follow the eyes. The force is exceptionally gentle.
Explanation & sources
Explanation
Reciprocal inhibition would mean contracting the opposing muscle directly; the lecture example is torticollis from acute SCM spasm, which is why D tempts. Here the cue is the eyes. This technique is contraindicated after recent eye surgery or eye trauma.
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2020 TA Review (Middletown) Exam 1 · TA review · slides 138-139
2020 TA Review Exam 1 · TA review · slides 127-128
422top 215asked 5×ME physiology
Which of the following mechanisms can be utilized when treating a patient with rib somatic dysfunctions?
Ans: Ribs move with breathing → use the patient's breath → respiratory assistance
Why:Respiratory assistance uses the patient's voluntary, exaggerated breathing as the corrective force, with the physician holding a fulcrum. It is the ME principle for rib dysfunctions such as an inhalation rib.
Explanation & sources
Explanation
Eye motion (oculocephalic reflex) targets cervical and trunk muscles. Patients cannot selectively contract single intercostals. The crossed extensor reflex is for injured extremities. Isolytic contraction is for fibrotic, shortened muscle. The 2020 version asked about a rib 4 inhalation dysfunction, with the same answer.
2020 TA Review (Middletown) Exam 1 · TA review · slides 145-146
2020 TA Review Exam 1 · TA review · slides 135-136
423top 215ME physiology
A patient with a broken right femur is being treated with muscle energy using the crossed extensor reflex. Which of the following correctly describes the crossed extensor reflex?
Ans: Injured limb can't be treated → work the opposite limb → crossed locomotion reflex
Why: The crossed extensor reflex uses learned locomotion patterns: voluntary flexor contraction on one side relaxes the contralateral flexor and contracts the contralateral extensor. It lets you treat a limb that is too injured or inaccessible (fracture, burn).
Explanation & sources
Explanation
A is reciprocal inhibition. B is isokinetic strengthening. D is the oculocephalic reflex. Crossed extensor force is very gentle (ounces, not pounds); the lecture example is a severe acute hamstring strain.
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2023 TA Review - Written Exam 1 · TA review · slides 143-144
6.5 · 9 questions · Questions 424–432
ME setup
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Muscle energy sequence:
Diagnose the specific SD first (ME treats a specific mechanical diagnosis).
Position into the restrictive barrier at the “feather edge”, in all three planes = the exact opposite of the diagnosis.
Patient pushes toward the freedom (= the diagnosis) for 3–5 s; physician gives an equal and opposite counterforce (isometric; greater force = isolytic, lesser = isotonic).
Both relax; pause a few seconds; then take up the slack to the new barrier.
Repeat 3–5 times, then a final passive stretch.
Reassess at the end (forgetting to re-evaluate and not letting the patient rest between efforts are common errors).
Diagnosis
Position (barrier)
Patient pushes toward
T3–T7 N Sl Rr
Neutral, Sr Rl
Sidebend left, rotate right
T4–T10 N Sl Rr
Monitor the apex (T7); N Sr Rl
Sl Rr
T10 F Rr Sr
Seated, monitor T10 TP; extend, rotate left, sidebend left
Rr Sr (e.g. rotate right)
A Type I (neutral) group needs no flexion or extension in the setup; a Type II needs F or E to lock the segment. The trunk and shoulders (not the neck alone) localize force to the segment.
Hypertonic biceps treated by contracting the triceps against resistance = direct (moves toward extension, the barrier) and active = muscle energy using reciprocal inhibition.
424top 215ME setup
When performing muscle energy, you place the patient in what direction in relation to their somatic dysfunction?
Ans: ME is direct → position into barrier → patient pushes back toward freedom
Why: Muscle energy is direct, so you position at the barrier, then the patient pushes toward the freedom against your equal counterforce (isometric).
Explanation & sources
Explanation
Pushing toward the barrier would move the patient through it actively, which is not ME. Starting in the freedom is indirect positioning. After 3-5 s the patient relaxes, you take up the slack to the new barrier, and repeat 3-5 times.
Which is true regarding the localization of forces used in muscle energy technique?
Ans: Contract 3-5 s → both relax → pause → take up slack to the new barrier
Why: After each contraction both relax, the physician pauses for neuromuscular adaptation, then takes up the slack and re-engages the new restrictive barrier.
Explanation & sources
Explanation
A is wrong: the barrier is engaged at the feather edge in all three planes. B describes isolytic lengthening and C an isotonic (concentric) contraction; standard ME uses an equal and opposite counterforce (isometric). A common error is not letting the patient rest between contractions.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 109-110
2022 TA Review - Exam 1 · TA review · slides 72-73
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 8
426ME setup
Which of the following is true regarding the seated thoracic muscle energy treatment shown?
Ans: ME treats a specific mechanical diagnosis → diagnose first
Why: Muscle energy treats a specific mechanical diagnosis, so an accurate diagnosis must come first. It is step 1 of the ME sequence.
Explanation & sources
Explanation
B is wrong: ME engages barriers in three planes, not freedoms. C is wrong because the contraction is isometric, not isokinetic. D is wrong: always recheck the original somatic dysfunction; forgetting to re-evaluate is a listed common error.
Why: In ME the patient pushes toward the freedom while the physician gives an equal counterforce, so the contraction is isometric.
Explanation & sources
Explanation
A is wrong: the trunk and shoulders are used to localize to the segment, not the neck alone. B reverses the push direction. C is wrong because reassessment comes after the final passive stretch, at the end.
A 30-year-old male has a hypertonic right biceps. You treat him by having him engage his right triceps against your resistance. How can this technique be described?
Why: A hypertonic biceps holds the elbow toward flexion, so extension is the barrier. Working with the triceps engages that barrier (direct), and the patient does the contracting (active). This is muscle energy.
Explanation & sources
Explanation
Indirect would mean positioning into flexion (the ease). Passive would mean the patient does no work. Contracting the opposing muscle to relax the hypertonic one is the reciprocal inhibition principle.
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2023 TA Review (Harlem) - Exam 1 · TA review · slides 133-134
2020 TA Review (Middletown) Exam 1 · TA review · slides 72-73
2020 TA Review Exam 1 · TA review · slides 75-76
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
429ME setup
You diagnose T3-T7 NSlRr and decide to treat with muscle energy. How do you position the patient initially?
Ans: ME = direct → reverse the diagnosis → NSlRr becomes NSrRl
Why: Muscle energy is direct, so you position into the barrier, the exact opposite of the diagnosis: neutral, sidebent right, rotated left.
Explanation & sources
Explanation
E repeats the diagnosis (that is indirect positioning). C keeps Type II coupling, which does not match a Type I group. A and B add flexion or extension, which a neutral (Type I) dysfunction does not need.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 117-118
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
430ME setup
Continuing the same case (SD is T3-T7 NSlRr), you have positioned the patient into the barrier (NSrRl). In which direction should the patient push against your resistance?
Why: In ME the patient is placed into the barrier but pushes toward the freedom, which is the diagnosis: rotate right, sidebend left.
Explanation & sources
Explanation
D is the barrier direction, where the patient is already positioned. B and C mix freedom and barrier. The contraction is isometric: you match the patient's force so nothing moves.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 119-120
431asked 2×ME setup
You diagnose T4-T10 NSlRr. How do you set up the patient for muscle energy?
Ans: Type I group → localize to apex T7 → reverse the diagnosis → NSrRl
Why: For a Type I group curve, monitor at the apex (T7) and position into the barrier, which reverses the diagnosis: neutral, sidebent right, rotated left.
Explanation & sources
Explanation
A and E monitor at the ends of the curve and add extension. B and C use Type II-style flexion or extension with same-side coupling. Type I (neutral) dysfunctions are maintained by long restrictor (polyarticular) muscles.
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2020 TA Review (Middletown) Exam 1 · TA review · slides 136-137
2020 TA Review Exam 1 · TA review · slides 125-126
432ME setup
A patient has T10 FRrSr. What are the steps for his muscle energy treatment setup?
Why: Muscle energy goes into the barrier, the opposite of FRrSr: extension, left rotation, left sidebending, while monitoring T10. The patient then pushes toward the freedom (e.g., rotating right).
Explanation & sources
Explanation
A is a Kirksville Crunch, which is HVLA. B positions into the freedom (indirect). D mixes the planes and leaves out extension, so it does not lock the Type II segment.
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2022 TA Review (Middletown) - Exam 1 · TA review · slides 265-266
6.6 · 6 questions · Questions 433–438
Counterstrain basics
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Counterstrain (CS) was developed by Lawrence H. Jones, DO, after a chance discovery in 1955 treating a patient with psoasitis (not Stephen Jones). It is indirect and passive: the patient is placed in a position of ease that shortens the hypertonic muscle (“fold and hold”). The position of comfort usually matches the position of the original injury.
Mechanism: after a strain, the spindles of a hypertonic muscle “report strain where there is none” (gamma gain set too high). Shortening the muscle reduces spindle afferent input, so the spindle is reset and gamma motor neuron activity (gamma gain) drops; the tender point softens. CS does not stretch the spindle, does not engage the barrier, and does not use reciprocal inhibition (that needs a contraction).
Counterstrain tender point
Trigger point
Pain
Localized; does not radiate
Radiates away from the point
Feel
Small, discrete, tense, edematous, often fibrotic; about the size of a dime
—
Where
Muscle, fascia, tendons, ligaments; consistent locations from patient to patient
—
Tenderness
Tender to pressure that would not normally hurt (enough to blanch your fingernail)
—
Lecture slide for this section (1)
IA6 slide 17: counterstrain mechanism
433top 215asked 4×Counterstrain basics
Who developed counterstrain?
Ans: Counterstrain → Lawrence H. Jones, DO (1955 discovery)
Why:Lawrence H. Jones, DO developed counterstrain after a chance discovery in 1955 while treating a patient with psoasitis.
Explanation & sources
Explanation
Fred Mitchell developed muscle energy. William Sutherland founded cranial osteopathy. A.T. Still founded osteopathy. Stephen Jones is a distractor that plays on the surname. Jones first mapped posterior tender points, then added anterior points.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 127-128
2023 TA Review (Harlem) - Exam 1 · TA review · slides 137-138
2020 TA Review (Middletown) Exam 1 · TA review · slides 151-152
2020 TA Review Exam 1 · TA review · slides 141-142
Lecture slide (1)
Study note
434Counterstrain basics
Counterstrain is an example of a(n) ____ technique; it places the patient ____.
Ans: CS → position of ease (away from barrier) → indirect
Why: Counterstrain is indirect: it places the patient in a position of ease, away from the restrictive barrier, which shortens the hypertonic tissue.
Explanation & sources
Explanation
A and B are internally contradictory pairs. D describes direct techniques like muscle energy and HVLA. The position of comfort usually matches the position of the original injury.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 75-76
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
435top 215asked 3×2026Counterstrain basics
Counterstrain positioning:
Ans: CS = fold and hold → shortens hypertonic muscle → spindle quiets
Why: Counterstrain positions the patient so the hypertonic muscle is shortened. That quiets its over-reporting spindle and lets gamma gain reset.
Explanation & sources
Explanation
A is direct technique (ME, HVLA). B is the opposite: CS shortens the spindle. D is a muscle energy principle that needs patient contraction, while CS is passive.
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2026 Textbook Q&A Compilation - Physiology of Treatment Modalities: ME/CS/HVLA · Practice questions · slide 163 (answer slide 164)
OMM1 Practice Questions - Physiology of Treatment Modalities: ME/CS/HVLA (doc header 'OMM 1 Fall 2020') · Practice questions · Q2
2024 Practice questions Physiology of Treatment Modalities - ME/CS/HVLA (Lect 6) · Practice questions · Q2 (doc header 'OMM 1 Fall 2020')
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 17
436top 215Counterstrain basics
A 23-year-old medical student presents with acute right-sided upper back pain after a back day at the gym. A tender point on the right transverse process of T5 is treated with counterstrain: the patient is passively positioned into comfort for 90 seconds, then slowly returned to neutral. Which of the following best explains the physiologic mechanism behind this treatment?
Ans: Shorten muscle → spindle firing drops → gamma gain resets → tender point softens
Why: Counterstrain shortens the hypertonic muscle, so the spindle stops firing inappropriately and gamma motor neuron activity (gamma gain) is reduced. The tender point softens.
Explanation & sources
Explanation
A is the muscle energy (post-isometric relaxation) mechanism. C and D are other ME principles that require patient contraction. E is a distractor. High-yield: counterstrain resets gamma gain.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 133-134
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 17
437top 215Counterstrain basics
Which statement is true regarding counterstrain technique?
Ans: Dime-sized + in muscle/fascia/tendon/ligament + consistent locations → all true
Why: A tender point is a small, discrete, tense, edematous area about the size of a dime, found in muscle, fascia, tendons or ligaments, at consistent locations from patient to patient.
Explanation & sources
Explanation
Each of A, B and C restates part of the lecture definition. The pressure used to find one is the amount that blanches your fingernail bed; it does not hurt healthy tissue and does not radiate.
Which of the following does NOT describe a tender point?
Ans: Radiating pain → trigger point, not tender point → A
Why: Tender point pain stays localized. Pain that radiates away from the point describes a trigger point, not a counterstrain tender point.
Explanation & sources
Explanation
B through E are all from the lecture definition of a tender point. In the 2020 version the radiating option was listed as E; the answer is the same.
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2025 TA Review Exam 1 (Middletown) · TA review · slides 129-130
2020 TA Review (Middletown) Exam 1 · TA review · slides 153-154
2020 TA Review Exam 1 · TA review · slides 143-144
6.7 · 5 questions · Questions 439–443
Counterstrain treatment
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Counterstrain steps:
Find the tender point and call its tenderness a 10.
Position into ease: anterior points → flexion, posterior points → extension; fine-tune with small arcs of sidebending/rotation.
Fine-tune until tenderness is 3 or less = at least a 70% reduction (goal 100%).
Hold 90 seconds (proprioceptive firing falls; you may feel a therapeutic pulse).
Return slowly and passively to neutral (if the patient helps, the reflex can restart).
Recheck: the point should stay at 3 or less.
Which point first? Treat the most tender (most significant) points first, and in a row of points treat the middle one first. Example: posterior T2–T4 and much more tender sternal points → start with AT3, in flexion.
Anterior thoracic points
Location
AT1–AT6
On the sternum at the matching costosternal levels (AT3 = 3rd costosternal joint)
AT7–AT11
Anterior abdominal wall, between the xiphoid and the lower abdomen
AT12
Inner surface of the iliac crest at the midaxillary line
Lecture slide for this section (1)
IA6 slide 19: the AT3 point; treat the middle point first
439top 215asked 3×Counterstrain treatment
When fine-tuning position for counterstrain, what is the minimum acceptable reduction of pain?
Ans: Tender point starts at 10 → must drop to ≤3 → at least 70% reduction
Why: The tender point is called a 10; the position of ease must bring it to 3 or less, a reduction of at least 70% (goal 100%).
Explanation & sources
Explanation
30% and 60% leave the point too tender. 95% is a good result, not the minimum. After positioning, hold 90 s, return slowly and passively to neutral, then recheck for 3 or less.
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2025 TA Review Exam 1 (Harlem) · TA review · slides 105-106
2023 TA Review (Harlem) - Exam 1 · TA review · slides 118-119
2022 TA Review - Exam 1 · TA review · slides 68-69
Lecture slide (1)
Study note
440top 215Counterstrain treatment
In performing counterstrain, approximately how long would one hold the patient in a position of comfort to achieve a decrease in proprioceptive firing and to reduce stimulation of muscle contraction?
Ans: Counterstrain hold → 90 seconds
Why: Hold the position of comfort for 90 seconds. That lets proprioceptive firing fall in frequency and amplitude so the mechanoreceptors stop driving contraction.
Explanation & sources
Explanation
30, 45 and 120 seconds are distractors. During the hold you may feel a therapeutic pulse at the tender point, which signals good relaxation. Then return the patient slowly and passively to neutral.
A 45-year-old male presents with upper back pain. Physical exam identifies tender points at the spinous processes of T2-4 with associated tender points along the sternum. The T2-4 sternum points are much more tender. In applying a counterstrain treatment, which of the following best describes the best initial tender point to treat and its treatment positioning?
Ans: Most tender = anterior → middle of a row = T3 → anterior point → flexion
Why: Treat the most significant points first (the sternal, anterior ones), and in a row treat the middle one first (T3). Anterior points are treated in flexion.
Explanation & sources
Explanation
C and E pick the less tender posterior points. D has the right point but the posterior-point motion. A pairs a posterior point with flexion. AT3 sits on the sternum at the level of the 3rd costosternal joint.
On physical examination, you locate an anterior thoracic counterstrain tender point on the right lateral iliac crest. What is the most likely thoracic vertebral level associated with this tender point?
Ans: Anterior thoracic point on the iliac crest (midaxillary line) → AT12
Why: The anterior T12 tender point lies on the inner surface of the iliac crest at the midaxillary line.
Explanation & sources
Explanation
AT7-AT11 lie higher, on the anterior abdominal wall between the xiphoid and the lower abdomen, so T8, T9 and T10 are too high. AT1-AT6 are on the sternum at the matching costal levels.
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HVLA (high-velocity, low-amplitude) is direct and passive: the segment is locked against the restrictive barrier and the physician delivers a short, quick thrust through it, usually during exhalation. A pop (cavitation, a gas bubble from joint distraction) may occur but is not a sign of success; A.T. Still: “popping is no criterion to go by.”
Indication: a distinct somatic dysfunction confirmed by TART, with a firm (hard, solid) restrictive articular end-feel at the barrier, and a conclusion that freeing the joint will help. Pain alone is NOT an indication. A rubbery, spongy or indistinct end-feel, or hypermobility, means choose another technique.
Mechanism: the sudden stretch of the tight muscle and tendon strongly stimulates the Golgi tendon organs → reflex relaxation of the hypertonic muscle (plus a barrage of spindle afferents that turns down gamma activity). ME loads the GTO slowly; HVLA does it suddenly.
Always: consent, explanation, soft tissue preparation first (“don't put the cart before the horse”), and reassessment. Success = barrier resolved and motion improved on recheck.
Thoracic HVLA:
Kirksville Crunch
Texas Twist
Position
Supine
Prone
Setup
Thenar eminence fulcrum under the posterior TP (side of rotation); upper thoracics (T1–T4) hands clasped behind the neck, mid-thoracics arms crossed over the chest; sidebend to the barrier; thrust through the arms toward the table after exhalation
Hands on the paraspinal/TP region; in the course photo both hands induce left sidebending (the key marks the “hand contacts the vertebra above/below” options incorrect)
Reading a setup: fulcrum under the right TP → rotated right; “improves with flexion” → F; sidebending left is the barrier → freedom Sr. So the case is T5 F Rr Sr.
Lecture slide for this section (1)
IA6 slide 28: HVLA indications
444HVLA
Which of the following is FALSE regarding HVLA?
Ans: HVLA thrusts through the barrier → direct, not indirect
Why: HVLA is direct: the segment is locked into the barrier and the thrust goes through it. Calling it indirect is false.
Explanation & sources
Explanation
A, C, D and E are true: HVLA is passive, uses a short quick thrust, is often delivered on exhalation, and may produce a pop (cavitation), though a pop is not proof of success.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 104-105
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 23
445top 215asked 9×2026HVLA
Which of the following is an indication for HVLA?
Ans: HVLA needs distinct SD with TART + firm restrictive end-feel → all listed
Why: HVLA is indicated for a distinct somatic dysfunction confirmed by TART (tissue texture change, asymmetry, restriction, tenderness) with a firm restrictive articular end-feel at the barrier.
Explanation & sources
Explanation
Each option is one required piece, so "all of the above" is right. Pain alone is NOT an indication for HVLA. A rubbery, indistinct or hypermobile barrier means choose another technique.
Ans: HVLA indication = SD shown by TART; pain alone is not
Why: The indication for HVLA is a distinct somatic dysfunction shown by TART changes, with a firm end-feel.
Explanation & sources
Explanation
Pain alone is NOT an indication for HVLA. A rubbery end-feel makes the thrust ineffective. Hypermobility is a relative contraindication.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 157-158
2020 TA Review Exam 1 · TA review · slides 147-148
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 28
447HVLA
You are evaluating a 22-year-old female for back pain and find a somatic dysfunction of T5 that improves with flexion. You decide to treat it with HVLA. Which of the following is considered an indication for HVLA?
Ans: HVLA needs a firm articular end-feel at the barrier → D
Why: A firm restrictive articular end-feel at the barrier (with TART findings) is the indication for HVLA.
Explanation & sources
Explanation
Hypermobility is a relative contraindication. Pain alone is not an indication. A rubbery end-feel means the thrust will fail and another technique should be used.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 140-141
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 28
448asked 3×HVLA
What end-feel is required for treatment with HVLA?
Ans: HVLA barrier must feel solid; rubbery/indistinct → choose another technique
Why: The barrier must have a firm, solid end-feel for HVLA to work.
Explanation & sources
Explanation
If the barrier feels rubbery, indistinct or hypermobile, the thrust will be ineffective and another modality should be chosen. Boggy describes acute tissue texture, not a joint end-feel.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 103-104
2024 TA Review (Harlem) Exam 1 · TA review · slides 90-91
2022 TA Review (Middletown) - Exam 1 · TA review · slides 122-123
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 28
449HVLA
A patient presents with back pain after a prolonged period of studying, and you decide to treat using HVLA after myofascial release. Which of the following describes the physiologic mechanism underlying HVLA?
Why: The thrust suddenly stretches the tight muscle and tendon, strongly stimulating the Golgi tendon organs, which reflexly relax the hypertonic muscle. The lecture also credits a barrage of spindle afferents that turns down gamma activity.
Explanation & sources
Explanation
B describes counterstrain, which works by passive positioning, not a thrust. C is a muscle energy principle. D and E are distractors; increasing agonist contraction would defeat the treatment. ME loads the GTO slowly by isometric contraction; HVLA does it with a sudden thrust.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 138-139
450asked 3×HVLA
After a Kirksville Crunch HVLA for a T5 somatic dysfunction, which of the following indicates the treatment was successful?
Ans: Reassess → barrier gone, motion improved = success; a pop proves nothing
Why: Success is judged by reassessment: the restrictive barrier is resolved and motion is improved.
Explanation & sources
Explanation
A pop is a nitrogen bubble from joint distraction and may come from an unrelated joint; A.T. Still said "popping is no criterion to go by." Soreness and dizziness are side effects, not success. A felt release still has to be confirmed by rechecking.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 146-147
2020 TA Review (Middletown) Exam 1 · TA review · slides 159-160
2020 TA Review Exam 1 · TA review · slides 149-150
451HVLA
Which factor is the most important when performing HVLA?
Why: Every option is part of safe, effective HVLA: consent, explanation, soft tissue preparation and reassessment.
Explanation & sources
Explanation
Patient refusal is an absolute contraindication, so consent is mandatory. A.T. Still warned that restoring the joint before the muscles and ligaments is "putting the cart before the horse." Reassessment confirms whether the barrier resolved.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 123-124
452HVLA
A 22-year-old has a somatic dysfunction of T5 that improves with flexion. With the patient supine and arms crossed, you place your left thenar eminence on the right transverse process of T5. You then sidebend the neck and torso to the left. After the patient exhales deeply, you apply a quick, short thrust through the patient's crossed arms toward the table. What technique is being used?
Why: A supine thoracic thrust over a thenar-eminence fulcrum through the crossed arms is the Kirksville Crunch, an HVLA technique.
Explanation & sources
Explanation
The Texas Twist is the prone thoracic HVLA. Muscle energy uses patient contraction, not a thrust. Counterstrain is a passive hold in the position of ease with no thrust.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 144-145
453HVLA
A 22-year-old has a somatic dysfunction of T5 that improves with flexion. With the patient supine and arms crossed, you place your left thenar eminence on the right transverse process of T5, sidebend the neck and torso to the left, and after deep exhalation thrust through the crossed arms toward the table. What is the somatic dysfunction being treated?
Ans: Improves in flexion → F; fulcrum under right TP → Rr; sidebend left = barrier → Sr → FRrSr
Why: Improving with flexion makes it flexed (F). The fulcrum sits under the posterior right TP, so it is rotated right. Sidebending left is the barrier, so the freedom is sidebent right: T5 FRrSr.
Explanation & sources
Explanation
Both E options contradict "improves with flexion." FRlSl puts the rotation on the wrong side. Type II dysfunctions rotate and sidebend to the same side.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 148-149
454HVLA
During your practical, you diagnose your partner with an upper thoracic somatic dysfunction, T3 FRrSr. Your proctor instructs you to treat it with a Kirksville Crunch HVLA. How would you set the patient up?
Ans: Rotated right → fulcrum under right TP; upper thoracic (T1-T4) → hands behind neck
Why: Place the thenar fulcrum under the right (posterior) TP of T3, the side of the rotation. For upper thoracic segments (T1-T4) the patient clasps the hands behind the neck.
Explanation & sources
Explanation
A and B put the fulcrum on the wrong side. D uses the crossed-arm hold, which the TA notes reserve for mid-thoracic segments (T5-T8), with the arm on the side of the dysfunction on top.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 119-120
455HVLA
In the prone HVLA technique shown, which option describes the action of the physician's hands?
Ans: Follow the curved arrows → both hands drive the same direction → left sidebending
Why: The 2023 Canvas quiz key marks A: the curved arrows in the photo show both hands working together to induce left sidebending.
Explanation & sources
Explanation
C names the opposite direction. B and D describe hand contacts the key marks as incorrect. This is a prone thoracic thrust of the Texas Twist type; the Kirksville Crunch is the supine version.
No questions in this section match the current Show filter.
Learn firstWhat you need for 6.9
Absolute = never do it. Relative = use caution or choose another technique. Patient refusal is an absolute contraindication to all OMT.
Technique
Absolute
Relative
HVLA (Lecture 6)
Patient refusal; fracture/dislocation; bony malignancy; ankylosis/fusion; upper cervical: Down syndrome, RA, Chiari malformation, achondroplastic dwarfism (risk to the transverse ligament of the dens)
Unstabilized fracture or torn ligament in the area; patient refusal
Stressed patients who can't relax, uncooperative children, severe osteoporosis, C-spine with vertebral artery disease, severely ill patients (metastatic CA, cervicals in RA)
Muscle energy
No consent; patient unable to follow commands. (Excessive patient contraction is a technique error, not a contraindication, though one 2020 TA key used it as the answer.)
Rheumatologic joint (cervical) instability, e.g. Down syndrome; ICU/low-vitality patients (ME needs the patient's energy)
2026 review slide (ME, HVLA and direct MFR): fracture/dislocation; rheumatologic joint instability (RA, scleroderma, Down syndrome); osteoporosis; acute injury where damaged tissue could be further damaged (sprains/strains/tears); undiagnosed joint swelling; open wounds; hematoma; cervical OMT with vertebral or carotid artery disease; unstable/infirm patient; infection or metastases/neoplasia in the area; neurologic entrapment syndromes (HVLA).
Counterstrain indications (not contraindications): acute or chronic SD, as primary treatment or with other modalities, and frail patients.
Puzzle: a patient with Chiari malformation who wants a “passive and direct” technique → the only passive-direct technique is HVLA, which is absolutely contraindicated → none of the above.
You are evaluating a 22-year-old for back pain and find a somatic dysfunction of T5 that improves with flexion. You plan HVLA. Which of the following is an absolute contraindication?
Ans: No consent → no treatment → patient refusal is absolute
Why:Patient refusal is an absolute contraindication to HVLA and to all OMT.
Explanation & sources
Explanation
Acute radiculopathy, acute sprain/strain and hypermobility are relative HVLA contraindications in Lecture 6. Pain is not a contraindication, but pain alone is not an indication either. The 2025 Harlem version offered osteoporosis and acute whiplash as distractors; Lecture 6 lists both as relative.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 101-102
2025 TA Review Exam 1 (Middletown) · TA review · slides 142-143
2024 TA Review (Harlem) Exam 1 · TA review · slides 88-89
Lecture slide (1)
Week 6 · Written Review deck · slide 39
457Contraindications
Which of the following is an example of a relative contraindication for HVLA?
Ans: Spasm → treat with caution (relative); fracture and bony malignancy → never (absolute)
Why:Severe muscle spasm (with acute whiplash and strain/sprain) is a relative HVLA contraindication in Lecture 6.
Explanation & sources
Explanation
Fracture and bony malignancy are absolute contraindications. D is the indication for HVLA. Other relative ones: acute herniated disc, acute radiculopathy, osteopenia/osteoporosis, spondylolisthesis, hypermobility syndromes.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 129-130
458Contraindications
What is the difference between a relative contraindication and an absolute contraindication to HVLA? Give examples.
AnswerAbsolute: never thrust (patient refusal, fracture/dislocation, Down syndrome, RA, Chiari malformation, achondroplasia, ankylosis/fusion, bony malignancy). Relative: use caution or another technique (hypermobility, acute herniated disc, acute radiculopathy, acute whiplash, osteoporosis, spondylolisthesis).
Ans: Absolute → do not perform; relative → caution, weigh risk, often choose another technique
Why: An absolute contraindication means HVLA must not be done. A relative contraindication means it may be done with caution, or another technique is safer.
Explanation & sources
Explanation
Lecture 6 lists the upper cervical group (Down syndrome, RA, achondroplastic dwarfism, Chiari malformation) as absolute; cervical thrusts in RA and Down syndrome risk disrupting the transverse ligament of the dens. Hypermobility is relative because you cannot get a solid lock-out.
Asked in
2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'Difference between contraindication and absolute contraindication to HVLA'
Lecture slide (1)
Week 6 · Written Review deck · slide 39
459top 215asked 2×Contraindications
Which of the following is a contraindication to muscle energy?
Ans: Down syndrome → rheumatologic joint instability → listed for ME, HVLA and direct MFR
Why: The 2026 review slide lists rheumatologic joint instability (RA, scleroderma, Down syndrome) as a contraindication for ME, HVLA and direct MFR. Lecture 6 lists rheumatologic cervical instability as a relative ME contraindication.
Heads up: The 2020 TA key marks A (excessive patient muscular contraction). Lecture 6 lists that under ME safety, not contraindications, while the 2026 review slide puts Down syndrome (rheumatologic joint instability) in the ME/HVLA/dMFR contraindication column, so B is the better answer. If this exact TA question appears, know that the TA intended A.
Explanation & sources
Explanation
Chiari malformation and achondroplasia are on the Lecture 6 HVLA (upper cervical) absolute list, not the ME list. Ehlers-Danlos is a hypermobility syndrome, a relative HVLA contraindication. Excessive patient contraction is a technique error (it can cause tendon avulsion or rib fracture), not a patient condition that rules out ME.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 149-150
2020 TA Review Exam 1 · TA review · slides 139-140
Lecture slide (1)
Week 6 · Written Review deck · slide 39
460asked 2×Contraindications
Which is a contraindication for counterstrain?
Ans: CS absolute contraindications: fracture or torn ligament in area, refusal
Why: A fracture in the area of treatment is an absolute contraindication to counterstrain, along with an unstabilized torn ligament and patient refusal.
Explanation & sources
Explanation
A, B and D are all listed CS indications: acute or chronic SD, use alone or with other modalities, and frail or hesitant patients. Relative CS contraindications include patients who cannot relax, children who cannot stay passive, severe osteoporosis and vertebral artery disease.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 155-156
2020 TA Review Exam 1 · TA review · slides 145-146
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 32
461Contraindications
A patient has a Type II thoracic dysfunction and a history of diabetes, hypertension and Chiari malformation. He requests a passive and direct treatment. What would you do?
Why: The only passive, direct option is HVLA (Texas Twist), and Chiari malformation is an absolute contraindication to HVLA, so none of the choices fits.
Explanation & sources
Explanation
Muscle energy is direct but active. Counterstrain is passive but indirect. Lecture 6 lists Chiari under the upper cervical HVLA contraindications, and the course indications handout lists it as an absolute HVLA contraindication.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 101-102
6.10 · 3 questions · Questions 462–464
Choosing a technique
No questions in this section match the current Show filter.
Learn firstWhat you need for 6.10
Pick the technique by asking what the patient's tissues and condition can tolerate:
Acute injury where damaged tissue could be hurt further (acute ankle sprain, acute strain) → avoid the direct techniques (ME, HVLA, direct MFR) → use counterstrain (indirect, gentle, well tolerated). A negative drawer sign and x-ray rule out a torn ligament or fracture, which would contraindicate CS too.
Goal is to shorten a hypertonic muscle → indirect → counterstrain (perpendicular stretch and ME lengthen it). Acute injury and spondylolisthesis are also relative HVLA contraindications.
Bony metastases in the painful region → no direct force (HVLA, ME: pathologic fracture risk) and avoid lymphatic pumping/diaphragm releases (may theoretically hasten spread) → a gentle indirect technique to the painful region, e.g. facilitated positional release to the lumbar spine (counterstrain to the neck treats the wrong region).
462top 215asked 3×2026Choosing a technique
A 14-year-old male presents with his mother with right ankle pain after twisting it playing basketball earlier today. Exam finds a preference for ankle inversion, tenderness of the anterior talofibular ligament, and bogginess over the lateral ankle. Negative ankle drawer sign; inversion and eversion still have hard end-feels. Ankle x-ray is negative. Which type of OMT would most likely be used to treat the patient's ankle?
Ans: Acute sprain → no direct techniques (ME, HVLA, dMFR) → indirect counterstrain
Why: An acute injury where damaged tissue could be further damaged is a contraindication to the direct techniques (ME, HVLA, direct MFR). Counterstrain is indirect and gentle, so it fits.
Explanation & sources
Explanation
A and C are direct myofascial release. D and E are direct techniques. The negative drawer and x-ray rule out a torn ligament or fracture, which would contraindicate counterstrain too. CS is well tolerated in acute and chronic patients.
A patient comes in with an acute injury with spondylolisthesis. You decide the best initial treatment is to shorten their hypertonic muscle. Which technique would you use?
Why: Shortening the hypertonic muscle is the definition of an indirect approach, and counterstrain is the indirect technique listed.
Explanation & sources
Explanation
Perpendicular stretch and muscle energy lengthen the muscle (direct). HVLA is direct, and both acute injury and spondylolisthesis are relative HVLA contraindications.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 93-94
Lecture slide (1)
Week 6 · IA6 ME, CS, HVLA · slide 17
464top 215asked 2×2026Choosing a technique
A 75-year-old male has chronic low back pain due to known metastatic prostate cancer to the lumbar vertebrae. The most appropriate osteopathic manipulative therapy is:
Ans: Bony mets → avoid direct force (HVLA, ME) and lymphatic pumping → gentle indirect FPR
Why: With bony metastases, direct techniques could cause a pathologic fracture, so a gentle indirect technique to the painful region, facilitated positional release, is most appropriate.
Explanation & sources
Explanation
HVLA and muscle energy are direct; metastases in the area of OMT are a contraindication. Counterstrain is indirect but the cervical spine is not where his pain is. Pelvic diaphragm release augments lymphatic flow, which may theoretically hasten metastatic spread.
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Learn firstWhat you need for 7.1
Category
Ribs
Defining feature
True
1–7
Attach directly to the sternum
False
8–12
Do not articulate directly with the sternum; 8–10 join the costal cartilage of the rib above (if no 8–12 choice, answer 8–10)
Floating
11–12
No anterior attachment; articulate only with the bodies of T11 and T12
Typical
3–9
Five parts: head (two demifacets), neck, tubercle, angle, shaft (with costal groove); costosternal attachment in front
Atypical
1, 2, 11, 12 (sometimes 10)
Memory tool: ribs with a “1” or a “2”
Why each atypical rib is atypical:rib 1: shortest, broadest, most sharply curved; one facet (T1 only), no angle, grooves for the subclavian vessels. Rib 2: rough tuberosity for serratus anterior (a tuberosity is not a part of a typical rib; don't confuse it with the tubercle). Rib 10: single facet (unifacet) on T10. Ribs 11–12: one facet, no neck, no costotransverse joint, no sternal attachment.
Conventions differ: older TA keys list typical 2–9 and atypical 1, 11, 12; the 2026 slides make rib 2 atypical. Use typical 3–9, atypical 1, 2, 11, 12, but if 1, 2, 11, 12 isn't offered, the best remaining choice is 1, 11, 12. Ribs 6–9 are all typical; rib 3 is the safest “typical” answer.
Lecture slide for this section (1)
Written Review slide 41: rib anatomy
465asked 3×Rib classification
Sort ribs 1-12 into each category: true, false, floating, typical, and atypical. Give the defining feature of each.
Ans: Sternum direct → true 1-7 · no direct sternum → false 8-12 · no front attachment → floating 11-12
Why:True ribs (1-7) attach directly to the sternum. False ribs (8-12) do not; 8-10 join the costal cartilage of the rib above. Floating ribs (11-12) articulate only with the bodies of T11 and T12.
Heads up: The 2022-2025 TA keys and the Lect 8 slide list typical 2-9 and atypical 1, 11, 12. The 2026 review deck and IA7 slides call rib 2 atypical (tuberosity for serratus anterior), so use typical 3-9 and atypical 1, 2, 11, 12 for this exam.
Explanation & sources
Explanation
The 2026 review deck memory tool: atypical ribs are the ones with a "1" or "2" (1, 2, 11, 12, sometimes 10). Rib 1 has one facet and no angle, rib 2 has a tuberosity for serratus anterior, rib 10 has a single unifacet, and ribs 11-12 have one facet, no neck, and no costotransverse joint.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 112-113
2024 TA Review (Harlem) Exam 1 · TA review · slides 93-94
2022 TA Review (Middletown) - Exam 1 · TA review · slides 246-247
A female with a history of asthma is receiving osteopathic manipulative treatment to improve her costal cage motion. The operator lastly palpates the false ribs. The most appropriate list of ribs examined is
Ans: False = no direct sternal attachment, not floating → 8-10
Why: Ribs 1-7 attach directly to the sternum (true). Ribs 8-10 reach it only through the costal cartilage of the rib above, so they are the false ribs in this narrow sense.
Explanation & sources
Explanation
Choices starting at 6 or 7 include true ribs (1-7). Choices running to 11 include a floating rib. 1-8 mixes true ribs with one false rib. The IA7 slide calls 8-12 false with 11-12 also floating; with no 8-12 choice, 8-10 is the answer.
Ans: True = attach directly to sternum → false = no direct sternal attachment
Why:True ribs (1-7) articulate directly with the sternum. False ribs (8-12) do not; the 2026 IA7 slide words it as "don't articulate with sternum."
Explanation & sources
Explanation
A reverses the relationship. All ribs connect to the vertebral column and none attach to the clavicle, so C is wrong. D describes location, not the definition. Strictly, ribs 8-10 reach the sternum indirectly through costal cartilage.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 164-165
Why: Rib 10 joins the costal cartilage of the rib above and does not articulate directly with the sternum, so it is a false rib.
Explanation & sources
Explanation
A and B wrongly say rib 10 reaches the sternum. Floating ribs are only 11 and 12. Rib 10's cartilage marks the lowest point of the rib cage in the midclavicular line.
Asked in
2022 TA Review - Exam 1 · TA review · slides 84-85
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 7
469top 215asked 5×2026Rib classification
Which of the following rib(s) is considered to be atypical?
Ans: Atypical = ribs with a "1" or "2" → rib 1
Why:Rib 1 is atypical: it is the shortest, broadest, most curved rib, with a single facet for T1 and no angle.
Explanation & sources
Explanation
Ribs 3-9 are typical, so A, B, and C are all typical ribs. Atypical ribs in the 2026 review deck: 1, 2, 11, 12, and sometimes 10.
A female with a history of asthma is receiving osteopathic manipulative treatment to improve her costal cage motion. Which of the following are considered atypical ribs?
Ans: Memory tool: ribs with a "1" or "2" → 1, 2, 11, 12
Why: The atypical ribs are 1, 2, 11, and 12. Rib 1 has one facet, rib 2 has a large tuberosity, and ribs 11-12 have no sternal or costotransverse articulation.
Explanation & sources
Explanation
Ribs 3 and 9 are typical, which rules out B, D, and E. C leaves out rib 2. Rib 10 is "sometimes" atypical because of its single facet, but the standard answer is 1, 2, 11, 12.
Which of the following ribs are considered atypical?
Ans: Rib 3 is typical → drop A, B, C → 1, 11, 12
Why: Ribs 1, 11, and 12 are atypical under every convention. D is the keyed answer and the only choice that lists no typical rib and includes both floating ribs.
Heads up: The 2022 TA key (D) follows the older "atypical 1, 11, 12" convention. The 2026 review deck adds rib 2 (atypical 1, 2, 11, 12). That full list is not offered here, so D remains the best choice.
Explanation & sources
Explanation
A, B, and C include rib 3, which is typical. E includes rib 2 but leaves out rib 11. Under the 2026 slides rib 2 is also atypical, so the complete list would be 1, 2, 11, 12.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 213-215
Lecture slide (1)
Week 7 · Written Review deck · slide 41
472asked 2×Rib classification
Which of the following is a typical rib?
Ans: Typical ribs = 3-9 → rib 3
Why:Rib 3 is a typical rib. It has a head with two demifacets (T2 and T3), a neck, a tubercle, an angle, and a shaft.
Explanation & sources
Explanation
Ribs 1, 11, and 12 are atypical in every source. Rib 2 is atypical in the 2026 slides because of its tuberosity for serratus anterior, so rib 3 is the only safe answer.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 192-193
2020 TA Review Exam 1 · TA review · slides 182-183
Lecture slide (1)
Week 7 · Written Review deck · slide 41
473Rib classification
Which of the following statements concerning ribs 6-9 is true?
Ans: Typical = 3-9 → 6, 7, 8, 9 all typical
Why: Ribs 6-9 are all within the typical range (3-9).
Explanation & sources
Explanation
Rib 9 is typical: it still has two demifacets (T8 and T9). Rib 6 is typical too. The atypical ribs are 1, 2, 11, 12 (sometimes 10).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 219-220
Why: A typical rib has a head (two demifacets), neck, tubercle, angle, and shaft.
Explanation & sources
Explanation
Every other choice either swaps the shaft for a "facet" or leaves out the head or neck. The facets are on the head, not separate parts. The 2026 review deck also lists the costal groove on the shaft.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 194-196
2020 TA Review Exam 1 · TA review · slides 184-186
Lecture slide (1)
Week 7 · Written Review deck · slide 41
475Rib classification
A typical rib will have all of the following landmarks except?
Why: A tuberosity (for serratus anterior) is the feature that makes rib 2 atypical. Typical ribs do not have one.
Explanation & sources
Explanation
Tubercle, head, neck, and angle are all standard parts of a typical rib. Do not confuse the tubercle (which articulates with the transverse process) with rib 2's tuberosity.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 217-218
Lecture slide (1)
Week 7 · Written Review deck · slide 41
476asked 2×2026Rib classification
A female with a history of asthma is receiving osteopathic manipulative treatment to improve her costal cage motion. The typical ribs are then palpated. Anatomic features consistent with a typical rib include
Why: Typical ribs have a costosternal attachment in front, directly for the true ribs and through costal cartilage for 8-9.
Explanation & sources
Explanation
The tubercle articulates only with its own transverse process, not the one above (A). The costal groove carries the intercostal vein, artery, and nerve, not the azygos (B). Typical ribs have two facets on the head (D), and the tubercle meets the transverse process, not the vertebral body (E).
Which statement is TRUE regarding the classification of ribs and their vertebral articulation?
Ans: 2026 slides: rib 2 atypical, rib 10 single unifacet (sometimes atypical) → C
Why: Rib 10 has a single unifacet on T10, and the 2026 review deck lists it among the atypical ribs ("sometimes rib 10"). Rib 2 articulates with T1 and T2 but is atypical because of its serratus anterior tuberosity.
Heads up: The 2025 TA key marks B (rib 2 typical). The 2026 IA7 slide says rib 2 "is still atypical," and the 2026 review deck lists rib 10 among the atypical ribs, so C fits the 2026 slides. The 2026 sources disagree on rib 10 (IA7 calls it "the only typical rib with a unifacet"), so expect the exam to avoid this exact question.
Explanation & sources
Explanation
Rib 1 is atypical and articulates only with T1 (A). Ribs 3-9 are typical with demifacets, not unifacets (D). B states the older "rib 2 is typical" convention.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 165-166
Lecture slide (1)
Week 7 · Written Review deck · slide 41
7.2 · 12 questions · Questions 478–489
Rib articulations & landmarks
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Learn firstWhat you need for 7.2
Two posterior joints: the costovertebral joint (rib head to the vertebral body facets) and the costotransverse joint (rib tubercle to the transverse process of its own vertebra). Ribs 11–12 have only a costovertebral joint.
Ribs
Head articulates with
2–9
Demifacets on its own vertebra and the one above (rib n → Tn and Tn−1): rib 3 → T2 + T3; rib 4 → T3 + T4; rib 6 → T5 + T6
1, 10, 11, 12
A single unifacet on its own vertebra only (rib 10 → T10; never the vertebra below)
Rib 2 has demifacets but is still atypical (tuberosity). The IA7 slide calls rib 10 “the only typical rib with a unifacet”; the review deck lists it as sometimes atypical.
Landmarks for finding ribs:
Landmark
Rib
Manubrium, just under the clavicle
Rib 1
Sternal angle (angle of Louis)
Rib 2
Spine of the scapula (posterior)
Rib 3
Inferior angle of the scapula
About rib 7
Rib 10 costal cartilage
Lowest point of the rib cage in the midclavicular line
First bone above and nearly parallel to the iliac crest (posterior)
Rib 12
Intercostal bundle: runs in the costal groove on the underside of each rib in VAN order, top to bottom: vein, artery, nerve. The nerve is lowest, so procedures (e.g. a chest tube in the 4th intercostal space) go just above the rib below.
478Rib articulations & landmarks
What is the name of the joint the blue arrow is pointing to? (The arrow points to where the rib head meets the vertebral body.)
Ans: Rib head + vertebral body → costovertebral joint
Why: The costovertebral joint is where the rib head meets the demifacets (or facet) of the vertebral body.
Explanation & sources
Explanation
The costotransverse joint is the rib tubercle against the transverse process, which is lateral to the arrow. "Vertebral-transverse" and "vertebral-neck" are not real joint names. The costotransverse joint is absent in ribs 11 and 12.
In rib articulation with the vertebral column, the head of the rib typically forms connections with:
Ans: Typical rib n → demifacets of Tn and Tn-1
Why: A typical rib head articulates with demifacets on its own vertebra and the vertebra above (rib n with Tn and Tn-1).
Explanation & sources
Explanation
It is the vertebra above, not below (B). Unifacets occur only for ribs 1 and 10-12 (C, D). The cartilage is at the front end of the rib, not the head (E).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 161-162
480Rib articulations & landmarks
Which ribs fit each description? (a) Articulate with a demifacet of the corresponding vertebra and the one above; (b) costotransverse articulation is absent; (c) articulate with (uni)facets of the corresponding vertebra; (d) the only typical rib articulating with a unifacet.
Why: Ribs 2-9 sit between two vertebrae (demifacets). Ribs 1 and 10-12 meet only their own vertebra (unifacet). Ribs 11-12 have no costotransverse joint.
Explanation & sources
Explanation
Rib 2 has demifacets on T1 and T2 but is still atypical because of its tuberosity (IA7). The IA7 slide calls rib 10 "the only typical rib with a unifacet," though the 2026 review deck lists it as sometimes atypical.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 114-115
Lecture slide (1)
Week 7 · Written Review deck · slide 41
481top 215Rib articulations & landmarks
Upon palpation of the ribs, which thoracic vertebrae articulate with rib 3?
Ans: Rib n → Tn and Tn-1 → T2 and T3
Why: Ribs 2-9 articulate with demifacets on the vertebra of the same number and the one above, so rib 3 meets T2 and T3.
Explanation & sources
Explanation
B uses the vertebra below. C skips T3. D (single vertebra) applies only to ribs 1 and 10-12.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 194-195
482Rib articulations & landmarks
What does rib 4 articulate with?
Ans: Rib n → Tn + Tn-1 → T4 and T3 demifacets
Why: Rib 4 articulates with demifacets on T4 and T3 (its own vertebra and the one above).
Explanation & sources
Explanation
T5 is the vertebra below, so B is wrong. Unifacets (C, D) are only for ribs 1 and 10-12.
Asked in
2022 TA Review - Exam 1 · TA review · slides 82-83
483Rib articulations & landmarks
You find an inhalation somatic dysfunction of rib 6 on your friend. What is the posterior articulation of this rib?
Ans: Rib n → Tn and Tn-1 → T6 and T5
Why: Typical ribs articulate with the vertebra of the same number and the one above, so rib 6 meets T6 and T5.
Explanation & sources
Explanation
A and B use vertebrae below. D (one vertebra only) is true only for ribs 1 and 10-12. The rib's tubercle also forms a costotransverse joint with the T6 transverse process.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 98-99
484top 215asked 2×Rib articulations & landmarks
Your attending asks what facet(s) rib 10 articulates with. You tell her:
Ans: Rib 10 = single facet, own vertebra only → unifacet of T10
Why: Rib 10's head articulates with a single unifacet on T10. It does not reach T9.
Explanation & sources
Explanation
Demifacets on T9 and T10 (A) would be the pattern for ribs 2-9. Ribs never articulate with the vertebra below (C). The IA7 slide calls rib 10 "the only typical rib with a unifacet"; the 2026 review deck lists it as sometimes atypical for the same reason.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 163-164
2022 TA Review (Middletown) - Exam 1 · TA review · slides 196-197
Lecture slide (1)
Week 7 · Written Review deck · slide 41
485asked 2×Rib articulations & landmarks
Ribs 11 and 12 have which type of posterior articulation?
Ans: Ribs 11-12 have no tubercle joint → costovertebral only
Why: Ribs 11 and 12 have only a costovertebral joint (head to vertebral body). The costotransverse joint (tubercle to transverse process) is absent.
Explanation & sources
Explanation
B and C wrongly include the costotransverse joint. Ribs 11 and 12 also have no anterior sternal attachment, which is why they are "floating."
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 202-203
2020 TA Review Exam 1 · TA review · slides 192-193
486top 215asked 2×Rib articulations & landmarks
Which rib is at the angle of Louis?
Ans: Angle of Louis (manubriosternal joint) → rib 2
Why:Rib 2 articulates with the sternum at the angle of Louis (sternal angle), the junction of the manubrium and body.
Explanation & sources
Explanation
Rib 1 attaches to the manubrium under the clavicle. Rib 3 is at the level of the spine of the scapula posteriorly. Rib 7 is near the inferior angle of the scapula.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 199-200
2020 TA Review Exam 1 · TA review · slides 189-190
487Rib articulations & landmarks
A patient has restricted inhalation of his upper ribs. To localize which rib is dysfunctional, which bony landmark do you use to reach the 2nd rib?
Ans: 2nd rib → sternal angle (angle of Louis)
Why: The 2nd rib articulates with the sternum at the sternal angle (angle of Louis).
Explanation & sources
Explanation
The manubrium under the clavicle is rib 1 (A). The spine of the scapula is rib 3 posteriorly (B). The nipple line is not a rib landmark in the lecture.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 249-250
488Rib articulations & landmarks
To diagnose a patient's exhalation somatic dysfunction through caliper motion, you palpate posteriorly the first bony structure above and almost parallel to the iliac crest. What rib are you on?
Ans: First bone above iliac crest → 12th rib
Why: Posteriorly, the 12th rib is the first bony structure palpated above the iliac crests and runs almost parallel to them.
Explanation & sources
Explanation
Ribs 9-11 sit higher. The 10th rib's cartilage marks the lowest point of the rib cage anteriorly in the midclavicular line. Ribs 11-12 move in caliper motion.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 251-252
489Rib articulations & landmarks
True or false: the order of the vessels and nerve in the superior part of the intercostal space (top to bottom) is vein, artery, nerve.
Ans: VAN runs top to bottom under each rib → true
Why: The intercostal bundle runs in the costal groove in VAN order from superior to inferior: vein, artery, nerve.
Explanation & sources
Explanation
The nerve is the lowest structure, so procedures go just above the rib below. Lect 8: a chest tube usually goes in the 4th intercostal space just above the 5th rib.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 125-126
7.3 · 9 questions · Questions 490–498
Rib cage function & shape
No questions in this section match the current Show filter.
Learn firstWhat you need for 7.3
Four functions of the rib cage: protection of vital organs; respiration; a pump for venous and lymphatic return; a platform for the upper extremities. (Digestion is not one.)
Things that affect the ribs: visceral organs (hung from bone by ligaments/fascia), any surgery (even abdominal or pelvic), muscle spasm, and postural compensation (e.g. Dowager's hump). Genetics/family history is not on the list.
Chest deformity
Sternum
Cause
Barrel chest
Projects forward and upward; AP diameter increased
Pathological: emphysema, COPD, asthma
Pectus excavatum (funnel chest)
Pushed posteriorly (sunken) by an overgrowth of the ribs
Congenital
Pectus carinatum (pigeon chest)
Projects forward and downward
Congenital
Kyphotic deformity
Key feature
Round back
Pelvic inclination of 20°
Humpback (gibbus)
Anterior wedging of 1–2 vertebrae; normal pelvic inclination (~30°)
Dowager's hump
Postmenopausal osteoporosis with multiple anterior wedge fractures
Scheuermann's disease
Adolescent kyphosis
Pott's disease
Spinal tuberculosis
Lecture slide for this section (1)
Written Review slide 42: chest deformities
490Rib cage function & shape
Which function is NOT typically associated with the rib cage?
Ans: Rib cage: protect, breathe, pump, platform → not digestion
Why: The lecture's four rib-cage functions are protection of vital organs, respiration, a pump for venous and lymphatic return, and a platform for the upper extremities. Digestion is not one.
Explanation & sources
Explanation
A, B, and C are all on the Lect 8 list. The pump function is why rib treatment helps lymphatic and venous return.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 157-158
491Rib cage function & shape
Among the following, which is NOT associated with the ribs and their function?
Ans: Lecture list: viscera, surgery, spasm, posture → not genetics
Why: The lecture lists what can affect the ribs: visceral organs, any surgery (even abdominal or pelvic), muscle spasm, and postural compensation. Genetics and family history is not on the list.
Explanation & sources
Explanation
Pelvic surgery is on the list because it disturbs reciprocal tension through the body. Dowager's hump is a postural compensation. Visceral organs hang from the bones by ligaments and fascia, so problems spread in both directions.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 151-152
492Rib cage function & shape
A patient presents with a sternum that projects downward and forward. Describe this presentation.
Ans: Sternum forward + down → pigeon chest (pectus carinatum)
Why:Pectus carinatum (pigeon chest): the sternum projects forward and downward. It is congenital.
Explanation & sources
Explanation
Pectus excavatum (funnel chest) is a sternum pushed posteriorly by rib overgrowth. Barrel chest is forward and upward with an increased AP diameter (emphysema, COPD).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 204-205
Lecture slide (1)
Week 7 · Written Review deck · slide 42
493top 215Rib cage function & shape
A patient presents with the sternum pushed posteriorly. On exam there is overgrowth of the ribs. Describe this presentation and its etiology.
Ans: Sternum pushed back by rib overgrowth → funnel chest → congenital
Why:Pectus excavatum (funnel chest): the sternum is pushed posteriorly by an overgrowth of the ribs. It is congenital.
Explanation & sources
Explanation
Pectus carinatum projects forward (A). B has the right shape but the wrong etiology. Barrel chest is pathological, but its sternum projects forward and upward (C).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 206-207
Lecture slide (1)
Week 7 · Written Review deck · slide 42
494asked 2×Rib cage function & shape
A patient presents with the sternum pushed posteriorly by an overgrowth of the ribs. The patient has:
Ans: Sternum pushed back → funnel chest (pectus excavatum)
Why: A sternum pushed posteriorly by rib overgrowth is funnel chest (pectus excavatum), which is congenital.
Explanation & sources
Explanation
Pigeon chest and pectus carinatum (A, B) are the same thing: a sternum projecting forward and down. Barrel chest projects forward and up from emphysema or COPD.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 187-188
2020 TA Review Exam 1 · TA review · slides 177-178
Lecture slide (1)
Week 7 · Written Review deck · slide 42
495Rib cage function & shape
Which chest deformity is typically associated with pathological conditions rather than being congenital?
Ans: Pathological (emphysema/COPD) → barrel chest
Why:Barrel chest (sternum forward and upward, increased AP diameter) comes from pathological conditions such as emphysema and COPD.
Explanation & sources
Explanation
Pigeon chest and funnel chest are both congenital per the slides. Scoliosis is a spinal curve, not a chest wall deformity.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 153-154
Lecture slide (1)
Week 7 · Written Review deck · slide 42
496top 215Rib cage function & shape
A 70-year-old male with decreased FEV1/FVC and FEV1 is diagnosed with emphysema. Describe possible findings on an osteopathic structural exam.
Ans: Emphysema → barrel chest → sternum forward and up, ↑ AP diameter
Why: Emphysema produces a barrel chest: the sternum projects forward and upward and the AP diameter is increased.
Explanation & sources
Explanation
Forward and downward (A) is pectus carinatum. Posterior with a decreased AP diameter (C) is pectus excavatum. Both are congenital.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 208-209
Lecture slide (1)
Week 7 · Written Review deck · slide 42
497asked 3×Rib cage function & shape
An 83-year-old female presents with irritability, sleep difficulties, hot flashes, and night sweats, and is hunched over. Calcium is low and X-ray shows multiple anterior wedge fractures. What type of deformity will you most likely see?
Why:Dowager's hump results from postmenopausal osteoporosis with anterior wedge fractures, often with scoliosis.
Explanation & sources
Explanation
Scheuermann's disease is adolescent kyphosis. Round back has a pelvic inclination of about 20°. Humpback (gibbus) is anterior wedging of one or two vertebrae with a normal 30° pelvic inclination. Pott's disease is spinal tuberculosis.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 210-211
2020 TA Review (Middletown) Exam 1 · TA review · slides 190-191
2020 TA Review Exam 1 · TA review · slides 180-181
498Rib cage function & shape
Which spinal deformity is characterized by a pelvic inclination of 20 degrees?
Ans: Pelvic inclination 20° → round back
Why:Round back (kyphosis) has a pelvic inclination of 20 degrees.
Explanation & sources
Explanation
Humpback (gibbus) is anterior wedging of one or two vertebrae with a normal pelvic inclination of about 30°. Dowager's hump comes from postmenopausal osteoporosis and wedge fractures. Swayback is not one of the kyphotic deformities on the slide.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 155-156
7.4 · 16 questions · Questions 499–514
Pump, bucket, caliper motion
No questions in this section match the current Show filter.
Learn firstWhat you need for 7.4
All of ribs 1–10 have both pump- and bucket-handle components; each group is named for the motion that predominates.
Pump handle
Bucket handle
Caliper
Ribs
1–5 (upper)
6–10 (middle, more caudal)
11–12 (floating)
Axis
Transverse
AP (closer to a sagittal plane)
Moves in a horizontal plane (no costotransverse joint)
On inhalation
Anterior end elevates, posterior end fixed; pushes the sternum up and forward at the manubriosternal joint
Lateral portion elevates; anterior and posterior ends fixed
Lateral ends move posteriorly, inferiorly, laterally (anteriorly and medially on exhalation)
Diameter increased
AP
Transverse
AP and transverse; stabilizes the diaphragm's origins
Where to feel it
Anteriorly, midclavicular line
Lateral borders of the rib cage (midaxillary)
Posteriorly, lower ribs
On exhalation the motions reverse (e.g. bucket ribs 6–10: lateral portion descends with the ends fixed). Because the ribs slope downward, elevating them increases the AP diameter. The first rib moves up on inhalation, down on exhalation.
Palpating rib 1 (supine): thumbs push the trapezius posteriorly to reach the posterior first rib; index finger above the clavicle, middle finger below it near the sternoclavicular joint. Compare sides while the patient breathes.
Lecture slide for this section (1)
IA7 slide 11: rib motion
499Pump, bucket, caliper motion
Which ribs move primarily in pump-handle motion, primarily in bucket-handle motion, and primarily in caliper motion?
AnswerPump handle: ribs 1-5. Bucket handle: ribs 6-10. Caliper: ribs 11-12. Ribs 1-10 have both pump and bucket components; one predominates.
Why: Upper ribs (1-5) are mainly pump handle (↑ AP diameter). Middle ribs (6-10) are mainly bucket handle (↑ transverse diameter). Floating ribs (11-12) move in caliper motion.
Explanation & sources
Explanation
All ribs have both pump and bucket components; the classification names the predominant one. Caliper motion of 11-12 helps stabilize the origins of the diaphragm.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 116-117
Which of the following statements is true regarding rib motion?
Ans: Pump = transverse axis (AP diameter) · bucket = AP axis
Why:Pump-handle motion rotates around a transverse axis and increases the AP diameter. Bucket-handle motion rotates around an AP axis.
Explanation & sources
Explanation
Ribs 1-10 have both pump and bucket components, not one or the other (A). Caliper motion is ribs 11-12 (C). Caudal ribs are mostly bucket handle (D). Bucket handle is assessed at the lateral rib cage; pump handle is felt anteriorly (E).
Which of the following is TRUE regarding rib movements?
Ans: Ribs 6-10 → bucket → ↑ transverse diameter
Why:Ribs 6-10 move mainly in bucket-handle motion, which raises the lateral rib and increases the transverse diameter.
Explanation & sources
Explanation
Ribs 1-5 are pump handle and increase the AP diameter (A). In pump handle the anterior end rises, not the lateral portion (B). In inhalation, caliper ribs move posteriorly, inferiorly, and laterally (D). The anterior end rising with the posterior end fixed is pump handle (E).
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 152-153
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
502Pump, bucket, caliper motion
Which type of motion is associated with the more caudal ribs, where the axis is closer to a sagittal plane and increases the transverse diameter?
Why: The more caudal ribs move mostly in bucket-handle motion, which increases the transverse diameter of the rib cage.
Explanation & sources
Explanation
Pump handle dominates the cephalic ribs and increases the AP diameter. Caliper motion is limited to ribs 11-12 in a horizontal plane. Swayback is a posture, not a rib motion.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 159-160
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
503Pump, bucket, caliper motion
Billy was playing soccer when he was elbowed in the side of his rib cage, ribs 6-10. What motion is primarily affected?
Ans: Ribs 6-10 → bucket handle
Why:Ribs 6-10 move primarily in bucket-handle motion.
Explanation & sources
Explanation
Pump handle is mainly ribs 1-5 (AP diameter). Caliper is ribs 11-12. Bucket handle increases the transverse diameter; caliper changes both AP and transverse slightly.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 95-96
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
504top 215Pump, bucket, caliper motion
What is the motion of ribs 1-5 during inspiration?
Ans: Ribs 1-5 → pump: anterior end up, posterior fixed, ↑ AP
Why: In pump-handle motion the anterior end elevates while the posterior end stays fixed, increasing the AP diameter.
Explanation & sources
Explanation
The anterior end rises on inspiration, so A is wrong. The posterior end is the fixed pivot, not the end that elevates (B, D).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 198-199
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
505Pump, bucket, caliper motion
What is the motion of ribs 6-10 during expiration?
Why: In bucket-handle motion the lateral portion moves while the anterior and posterior ends stay fixed. On expiration the lateral portion descends.
Explanation & sources
Explanation
A is the same motion during inspiration. C and D wrongly move the anterior and posterior ends, which act as the handle's fixed points.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 200-201
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
506Pump, bucket, caliper motion
Name the ribs and the type of motion: these ribs have lateral ends that move posteriorly, inferiorly, and laterally to increase the AP and transverse diameters during inspiration.
Why: This is caliper motion of ribs 11-12. It increases both the AP and transverse diameters and stabilizes the origins of the diaphragm.
Explanation & sources
Explanation
Bucket-handle motion (ribs 6-10) raises the lateral rib and mainly increases the transverse diameter. Ribs 11-12 are not bucket handle.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 202-203
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
507Pump, bucket, caliper motion
Fill in the blanks: caliper motion of ribs 11 and 12 consists of the lateral ends moving ____, increasing the ____ and ____ diameters and stabilizing the origins of the diaphragm. Caliper motion moves along a ____ plane.
AnswerPosteriorly-inferiorly-laterally; AP and transverse; horizontal plane.
Why: In inhalation the lateral ends of ribs 11-12 move posteriorly, inferiorly, and laterally, increasing the AP and transverse diameters. The motion is in a horizontal plane because there is no costotransverse joint to limit it.
Explanation & sources
Explanation
On exhalation the caliper ribs move anteriorly and medially. Rib 12's caliper motion helps anchor the diaphragm.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 243-244
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
508top 215asked 2×Pump, bucket, caliper motion
What type of motion do ribs 11 and 12 exhibit (the motion monitored when diagnosing the floating ribs)?
Ans: Floating ribs 11-12 → caliper
Why: The floating ribs (11-12) move in caliper motion.
Explanation & sources
Explanation
Pump handle is mainly ribs 1-5 and bucket handle mainly ribs 6-10. "Floating motion" is not a recognized rib motion.
2023 TA Review - Written Exam 1 · TA review · slides 185-186
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
509Pump, bucket, caliper motion
Fill in the blanks: during inspiration, the anteroposterior diameter of the thorax is ____ when the ribs are ____. Because the ribs slope ____, any elevation during inspiration results in an ____ movement of the sternum at the ____ joint.
Ans: Ribs slope down → elevation pushes sternum up/forward → ↑ AP diameter
Why: Ribs slope downward, so raising them during inspiration pushes the sternum upward and forward at the manubriosternal joint and increases the AP diameter.
Explanation & sources
Explanation
This is pump-handle motion of the upper ribs. Bucket-handle motion of the lower ribs instead increases the transverse diameter.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slide 221
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 11
510Pump, bucket, caliper motion
As a patient breathes in and out, you assess the movement of the first rib. How would you describe its movement?
Ans: Rib 1 (like ribs 2-10) → up on inhalation, down on exhalation
Why: The first rib moves upward on inhalation and downward on exhalation, like ribs 2-10.
Explanation & sources
Explanation
Posterior/anterior (B) and lateral/medial (C) describe caliper-type motion of the floating ribs, not rib 1. Rib 1 articulates only with T1 and is elevated by the anterior and middle scalenes.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 223-224
511top 215Pump, bucket, caliper motion
Where is pump-handle motion of the ribs best evaluated?
Ans: Pump = anterior end rises → feel at midclavicular line
Why: Pump-handle motion is the anterior end rising, so it is felt anteriorly at the midclavicular line.
Explanation & sources
Explanation
The sternoclavicular joint is used for ribs 1-2. Bucket-handle motion is felt at the lateral (midaxillary) rib cage. The AC joint is not a rib motion landmark.
A female with a history of asthma is receiving osteopathic manipulative treatment to improve her costal cage motion. In examining for bucket-handle motion of her ribs, the optimal placement of the operator's hands is over the
Why: Bucket-handle motion is elevation of the lateral part of the rib, so the hands go over the lateral borders of the rib cage, fingers along the intercostal spaces.
Explanation & sources
Explanation
The anterior margin and sternum are where you feel pump handle. The rib angles and transverse processes are posterior landmarks for rib and spine SD, not respiratory bucket motion.
In the image below, what is the physician evaluating? (Supine patient; the physician's hands are at the base of the neck, just above the clavicles.)
Ans: Thumbs behind trapezius, fingers by clavicle → first rib
Why: The physician is evaluating the first rib: the thumbs push the trapezius back to contact the posterior first rib while the fingers rest near the clavicle.
Explanation & sources
Explanation
The scalenes and trapezius are soft tissues the hands pass over, not the target. Upper thoracics are assessed at the spinous and transverse processes, usually with the patient seated or prone.
What are the contact points when palpating the first rib?
AnswerPatient supine. Thumbs push the trapezius posteriorly to contact the posterior first rib; index finger rests above the clavicle; middle finger below the clavicle beneath the sternoclavicular joint.
Ans: Rib 1 hides under trapezius and clavicle → thumbs behind, fingers around clavicle
Why: The first rib sits under the trapezius and clavicle. The thumbs push the trapezius back to reach it posteriorly, and the fingers straddle the clavicle near the sternoclavicular joint.
Explanation & sources
Explanation
Compare the two sides as the patient breathes: a rib that stops first on inhalation is an exhalation SD, and one that stops first on exhalation is an inhalation SD.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 178-179
7.5 · 7 questions · Questions 515–521
Muscles of respiration
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Learn firstWhat you need for 7.5
Inhalation
Exhalation
Primary
Diaphragm (with its crura; 100% of quiet and ~60% of deep inspiration) and external intercostals
Internal intercostals (quiet exhalation is largely passive recoil)
Accessory (forced breathing)
SCM, scalenes, pectoralis major and minor, serratus anterior, latissimus dorsi, serratus posterior superior, iliocostalis
Traps: internal intercostals are the primary expiratory muscle, not accessory. The diaphragm is primary, not accessory. Trouble inhaling with upper-rib involvement → an accessory inspiratory muscle on those ribs, e.g. serratus anterior (ribs 2–9).
Phrenic nerve (C3–C5) supplies the diaphragm. Irritation → hiccups and referred ipsilateral shoulder pain.
Why: Inhalation uses the diaphragm (with its crura) and external intercostals, helped by accessory muscles such as the SCM and scalenes.
Explanation & sources
Explanation
Rectus abdominis and transversus abdominis are expiratory (A, B). Internal intercostals are the primary expiratory muscle (C). B is the list of expiratory accessory muscles.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 109-110
Why: The primary inspiratory muscles are the diaphragm and the external intercostals.
Explanation & sources
Explanation
Scalenes, pectoralis minor, and serratus anterior are accessory inspiratory muscles for forced breathing. Internal intercostals are the primary expiratory muscle. The diaphragm does 100% of quiet inspiration and about 60% of deep inspiration.
2020 TA Review (Middletown) Exam 1 · TA review · slides 211-212
2020 TA Review Exam 1 · TA review · slides 202-203
517Muscles of respiration
A patient presents with upper back pain and trouble breathing. You notice difficulty during inhalation. Which muscle might be causing this dysfunction?
Ans: Inhalation problem → inspiratory muscle → external intercostals
Why: The external intercostals are a primary muscle of inhalation, so they are the only choice tied to the inspiratory phase.
Explanation & sources
Explanation
Internal intercostals are the primary expiratory muscle. Transversus abdominis, rectus abdominis, and external oblique are accessory expiratory muscles.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 121-122
518Muscles of respiration
A patient comes in and you auscultate their breath sounds. As they breathe in normally, what muscles are they using? What about for breathing out normally?
AnswerIn: diaphragm and external intercostals. Out: internal intercostals (quiet exhalation is largely passive recoil).
Ans: Quiet in → diaphragm + external intercostals · quiet out → internal intercostals
Why: Quiet inspiration uses the diaphragm and external intercostals. The lecture lists the internal intercostals as the primary expiratory muscle.
Why:Rectus abdominis and serratus posterior inferior are accessory expiratory muscles that help with forced exhalation.
Explanation & sources
Explanation
The internal intercostals are the primary expiratory muscle, not accessory, so A and E are wrong. Other accessory expiratory muscles: transversus and obliques, iliocostalis (lowest fibers), longissimus, quadratus lumborum.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 213-214
2020 TA Review Exam 1 · TA review · slides 204-205
520Muscles of respiration
Which of the following would indicate a dysfunctional phrenic nerve?
Why: The phrenic nerve (C3-C5) supplies the diaphragm. Irritation shows up as hiccups and referred pain to the ipsilateral shoulder.
Explanation & sources
Explanation
Finger numbness points to the brachial plexus (C5-T1). Bilateral leg weakness is a cord or lumbar problem. Jaw pain and dysphagia are cranial nerve or cardiac issues.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 178-179
521Muscles of respiration
An older man has a really hard time inhaling, and his key rib is rib 3 (exhalation somatic dysfunction). Which accessory muscle likely has impaired function?
Why:Serratus anterior is an accessory muscle of inspiration that attaches to ribs 2-9, including the restricted upper ribs.
Explanation & sources
Explanation
Internal intercostals are the primary expiratory muscle. The diaphragm is a primary (not accessory) inspiratory muscle. Rectus abdominis is an accessory expiratory muscle.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 105-106
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
7.6 · 16 questions · Questions 522–537
Muscles that move ribs
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Learn the course slide's list of muscles that move each rib. These are also the muscles used for muscle energy of an exhalation rib dysfunction.
Rib 1 attachments (MASS):Middle scalene, Anterior scalene, Subclavius, Serratus anterior. From the neck only the anterior and middle scalenes; from the anterior chest wall the subclavius and serratus anterior. The posterior scalene goes to rib 2; pectoralis minor to 3–5; the SCM attaches to no rib. If asked which muscles attach to (move) rib 1 and both serratus anterior and the anterior/middle scalenes are offered, choose the scalenes.
Clinical links: a hypertonic anterior scalene (e.g. from coughing) holds rib 1 up in an inhalation SD. QL depresses rib 12 (forced exhalation) and fixes it during inhalation, so increased QL tone pulls rib 12 down; low back pain toward the iliac crest + restricted ribs 11–12 → QL. Ribs 6–7 → serratus anterior and rectus abdominis (rectus to costal cartilages 5–7). Ribs 11–12 → posterior muscles (QL, latissimus, serratus posterior inferior, iliocostalis, longissimus), not rectus abdominis/external oblique. Tender pectoralis minor after MI is ruled out → ribs 3–5. Rectus abdominis attaches to ribs 5–7.
Lecture slide for this section (1)
IA7 slide 28: muscles that move ribs
522top 215asked 2×Muscles that move ribs
Which muscles attach to the first rib?
Ans: Rib 1 → anterior + middle scalenes (MASS)
Why: The anterior and middle scalenes attach to rib 1. MASS: Middle and Anterior Scalenes, Subclavius, Serratus anterior.
Explanation & sources
Explanation
Pectoralis minor attaches to ribs 3-5. Serratus anterior does reach rib 1 in the MASS list, but the muscles used to move rib 1 are the scalenes. The posterior scalene goes to rib 2, which rules out C.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 168-169
What are the neck muscle attachments to the first rib?
Ans: Neck → rib 1: anterior + middle scalenes only
Why: Only the anterior and middle scalenes run from the neck to rib 1.
Explanation & sources
Explanation
The posterior scalene inserts on the outer surface of rib 2, so C and D are wrong.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 225-226
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
524Muscles that move ribs
What are the anterior chest wall muscle attachments to the first rib?
Ans: MASS: chest wall part = Subclavius + Serratus anterior
Why: From the anterior chest wall, the subclavius and serratus anterior attach to rib 1 (the "SS" of MASS).
Explanation & sources
Explanation
Pectoralis minor attaches to ribs 3-5. Pectoralis major attaches to the clavicle, sternum, and costal cartilages and has no first-rib attachment in the MASS list.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 227-228
525asked 2×Muscles that move ribs
Which of the following does not attach to rib 1?
Ans: MASS = attach to rib 1 → posterior scalene goes to rib 2
Why: The posterior scalene inserts on rib 2, not rib 1.
You come down with the flu and notice that your rib 12 feels stuck. What muscle is causing that?
Ans: Rib 12 → quadratus lumborum
Why:Quadratus lumborum attaches to rib 12 and is the muscle linked to rib 12 dysfunction.
Explanation & sources
Explanation
Serratus posterior inferior and latissimus dorsi also reach the lower ribs, but the course pairs rib 12 with the QL. Serratus anterior works on the upper ribs.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 107-108
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
532Muscles that move ribs
A patient has persistent low back pain radiating toward the iliac crest and difficulty breathing. The 11th and 12th ribs are restricted during inhalation. What muscle would you expect to have a somatic dysfunction that could explain the dyspnea?
Why: The quadratus lumborum runs from the iliac crest to rib 12. A tight QL holds the lower ribs down and causes pain toward the iliac crest.
Explanation & sources
Explanation
Erector spinae do not anchor rib 12 to the crest. Serratus anterior works the upper ribs. The diaphragm is a primary breathing muscle but does not explain the iliac crest pain. Rectus abdominis attaches to ribs 5-7.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 240-241
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
533Muscles that move ribs
A patient has marked somatic dysfunction of ribs 6-7. Which muscles are likely hypertonic?
Why:Serratus anterior attaches to ribs 2-9 and rectus abdominis to costal cartilages 5-7, so both reach ribs 6-7.
Explanation & sources
Explanation
The QL attaches only to rib 12 (A, D). The anterior and middle scalenes go to rib 1 (B). Latissimus dorsi and longissimus work the lowest ribs.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 158-159
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
534Muscles that move ribs
A patient has a rib 11 or 12 somatic dysfunction. Which muscles are NOT likely hypertonic?
Ans: Lower posterior ribs → QL, lat, SPI, iliocostalis, longissimus → not anterior abdominals
Why: The muscles that pull on ribs 11-12 are posterior: QL, latissimus dorsi, serratus posterior inferior, iliocostalis, and longissimus. Rectus abdominis attaches to ribs 5-7, so the abdominal pair is the least likely.
Explanation & sources
Explanation
A, B, and D all list muscles the lecture ties to the lowest ribs. External oblique does slip onto the lower ribs, but paired with rectus abdominis this is still the weakest match.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 160-161
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
535asked 2×2026Muscles that move ribs
A 54-year-old male presents with crushing retrosternal chest pain of 2 hours' duration. A myocardial infarction is ruled out, but some pain persists in the left chest. It is worse with extension, shoulder abduction, and trunk movement, and there are tender points in the pectoralis minor. Dysfunction of which of the following could account for this?
Ans: Pec minor tenderness → pec minor attaches ribs 3-5
Why:Pectoralis minor attaches to ribs 3-5, so tenderness there points to a rib 3-5 dysfunction.
Explanation & sources
Explanation
Rib 1 goes with the anterior and middle scalenes and rib 2 with the posterior scalene. Ribs 6-9 go with serratus anterior and rib 10 with latissimus dorsi. Always rule out MI first.
An 18-year-old female has a non-productive cough of 3 days' duration and sore ribs from coughing. She is febrile with scant rhonchi bilaterally. Structural exam shows the right first rib is held in inhalation and ribs 7-10 on the left are held in exhalation. A likely cause of the right rib dysfunction is
Ans: Rib 1 held up + coughing → scalenes (attach rib 1) in spasm
Why: The anterior and middle scalenes attach to rib 1 and are strained by coughing. A scalene spasm holds rib 1 up in inhalation.
Explanation & sources
Explanation
Infiltrates do not displace ribs. The first intercostal space lies between ribs 1 and 2, so intercostal spasm would not hold rib 1 up. Pectoralis minor attaches to ribs 3-5. A somatovisceral reflex goes from soma to viscera, the wrong direction here.
While examining your patient's thoracic inlet, you find that during deep breathing the right first rib stays stuck higher than the left. You diagnose an inhalation somatic dysfunction of the right first rib. What muscle is likely hypertonic and causing it?
Ans: Rib 1 held up → hypertonic scalene on rib 1 → anterior scalene
Why: The anterior scalene (with the middle scalene) attaches to rib 1 and pulls it up. When hypertonic it holds the rib in inhalation.
Explanation & sources
Explanation
The posterior scalene goes to rib 2. Trapezius does not attach to the ribs. Serratus posterior superior attaches to ribs 2-5. The diaphragm attaches to the lower 6 ribs.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 101-102
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
7.7 · 3 questions · Questions 538–540
Thoracic outlet syndrome
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Thoracic outlet syndrome (TOS): compression of the brachial plexus (ventral rami C5–T1) and/or the subclavian vessels in the space between the clavicle and the first rib (the thoracic outlet). Symptoms: arm pain, numbness and paresthesias; venous compression can cause swelling (even facial edema).
Site of compression
Structures
Scalene triangle
Anterior and middle scalenes over the first rib (not the posterior scalene, which goes to rib 2)
Differential: thumb and arm numbness with facial edema and equal, reactive pupils → thoracic inlet/outlet syndrome. Horner's syndrome and a Pancoast tumor cause miosis; Erb's palsy (C5–C6) weakens the biceps and its reflex; Klumpke's palsy (C8–T1) affects the ulnar hand. The cervical plexus controls neck and upper torso muscles and occiput/neck/shoulder skin; the brachial plexus supplies the shoulder, arm and hand.
Lecture slide for this section (1)
Written Review slide 44: thoracic outlet syndrome
538top 215asked 6×2026Thoracic outlet syndrome
A 44-year-old male presents to the ED with right upper extremity pain and paresthesias. You determine he has thoracic outlet syndrome. Which of the following structures has been implicated as a potential cause?
Ans: TOS = compression between collarbone and 1st rib → clavicle + 1st rib
Why: TOS is compression of the brachial plexus and subclavian vessels in the space between the clavicle and the first rib. Entrapment there is the costoclavicular type.
Explanation & sources
Explanation
The third TOS site is pectoralis minor, not major. The posterior scalene goes to rib 2 and is not part of the scalene triangle (anterior + middle scalenes). The other two TOS sites are the scalene triangle and the pectoralis minor near the coracoid.
Why: The plexus and subclavian artery can be compressed in the scalene triangle between the anterior and middle scalenes over the first rib. The 2026 review deck lists these as the abnormal muscles in TOS.
Explanation & sources
Explanation
The pectoral site is pectoralis minor, not major (A). The posterior scalene goes to rib 2 (B). Costoclavicular TOS involves the clavicle and first rib, not the second (D).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 166-167
Lecture slide (1)
Week 7 · Written Review deck · slide 44
540asked 2×Thoracic outlet syndrome
A 66-year-old female has headaches and left otitis media. Exam: numbness of the left thumb and along the left arm; the left face is slightly more edematous; biceps reflex 2/4, strength 5/5; pupils equal and reactive. What is the most likely cause?
Ans: Arm numbness + facial venous congestion, no Horner's → thoracic inlet/outlet syndrome
Why: Compression at the thoracic inlet (thoracic outlet syndrome) can squeeze the brachial plexus (arm and thumb numbness) and the venous drainage (facial edema).
Explanation & sources
Explanation
Equal reactive pupils argue against Horner's syndrome and a Pancoast tumor, which usually causes Horner's. Erb's palsy (C5-C6) would weaken the biceps and reduce its reflex. Klumpke's palsy (C8-T1) affects the ulnar hand, not the thumb.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 208-209
2020 TA Review Exam 1 · TA review · slides 198-199
Lecture slides (2)
Week 7 · Written Review deck · slide 44Week 7 · Written Review deck · slide 43
7.8 · 7 questions · Questions 541–547
Inhalation vs exhalation SD
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Rib dysfunctions are named for their freedom, just like vertebrae. Find the phase in which a rib stops moving first compared with the others; that is its restriction, and the SD is named for the opposite phase.
Inhalation SD
Exhalation SD
Rib is held
Up (elevated) in inhalation
Down (depressed) in exhalation
Moves freely into
Inhalation
Exhalation
Stops first during
Exhalation (= exhalation restriction)
Inhalation (= inhalation restriction)
Patient
Can't breathe out fully; painful
Can't breathe in fully; pain at maximum inhalation
Key rib (BITE)
Bottom rib of the group
Top rib of the group
Reading your hands (supine, compare sides): if one side doesn't rise on inhalation (the other hand rises more), that side has an exhalation SD. If one side stays up (doesn't fall) on exhalation, that side has an inhalation SD. Don't confuse the SD name with the restriction: ribs that inhale easily but can't exhale = inhalation SD (an exhalation restriction). An exhalation-SD rib feels depressed relative to its neighbors during inspiration.
Lecture slides for this section (2)
IA7 slide 24: inhalation vs exhalation SDWritten Review slide 45: evaluation and diagnosis
541Inhalation vs exhalation SD
Fill in the blank: if a rib stops moving relative to others on inhalation, it is classified as an ____ somatic dysfunction. If a rib stops moving relative to others on exhalation, it is classified as an ____ somatic dysfunction.
AnswerStops on inhalation = exhalation SD (depressed rib). Stops on exhalation = inhalation SD (elevated rib).
Ans: Stops early in a phase → free in the other → named for the freedom
Why: Rib SDs are named for the freedom. A rib that stops first on inhalation moves freely into exhalation, so it is an exhalation SD (depressed). A rib that stops first on exhalation is an inhalation SD (elevated).
Explanation & sources
Explanation
Exhalation SD = inhalation restriction; inhalation SD = exhalation restriction. Do not mix the SD name with the restriction name.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 238-239
When evaluating your patient's rib cage, you discover ribs 3-8 on the left have ease of inhaling but difficulty exhaling. What type of somatic dysfunction do they have?
Ans: Free into inhalation → SD named for freedom → inhalation SD
Why: Somatic dysfunction is named for the freedom. These ribs move freely into inhalation, so this is an inhalation SD.
Explanation & sources
Explanation
"Exhalation restriction" (A) correctly names the barrier but not the SD, which is what the question asks. B and C are the opposite pattern.
In evaluating the first rib, you discover your patient's right rib stops moving into inhalation well before the left. How would you name the rib on the right?
Ans: Stops first on inhalation → free into exhalation → right 1st rib exhalation SD
Why: The right rib stops first on inhalation, so it is free into exhalation: a right first rib exhalation somatic dysfunction.
Explanation & sources
Explanation
The left rib moves normally, so B and D are wrong. C uses the wrong term: this rib has an *inhalation* restriction.
A 76-year-old male with an inoperable lung mass complains of rib pain and shortness of breath, with frequent coughing of frothy, blood-tinged sputum. Coarse breath sounds are heard. Ribs 5 and 6 on the right demonstrate reduced motion during inhalation. The most likely diagnosis is
Which of the following is true about exhalation somatic dysfunctions?
Ans: Exhalation SD = stuck down → depressed on inspiration
Why: In an exhalation SD the rib is stuck in the exhaled (depressed) position, so during inspiration it feels lower than the ribs around it.
Explanation & sources
Explanation
The key rib for an exhalation SD is the top rib, not the bottom (A; BITE). B and C describe an inhalation SD (a rib that cannot fully exhale). E describes no real pattern.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 155-156
A patient has difficulty breathing. With your hands on the upper chest, you notice that as the patient breathes in, your left hand rises more than the right. When the patient breathes out, both hands go down evenly and are symmetrical. The patient has:
Ans: Right lags on inhalation → right restricted in inhalation → right exhalation SD
Why: The right side fails to rise on inhalation, so it is restricted in inhalation and free into exhalation: an exhalation SD on the right.
Explanation & sources
Explanation
The left side moves normally, so A and C are wrong. B is the opposite pattern: an inhalation SD lags on exhalation.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 168-169
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Each rib SD has palpable findings at the rib and its intercostal spaces. Elevated ribs narrow the space above (and widen the space below); depressed ribs narrow the space below.
Inhalation SD (elevated)
Exhalation SD (depressed)
Pump handle (ribs 1–5)
Rib moves cephalad on inhalation, restricted on exhalation; anterior narrowing of the intercostal space above; superior edge of the posterior rib angle prominent
Anterior rib moves caudad on exhalation, restricted on inhalation; anterior narrowing of the space below; inferior edge of the posterior rib angle prominent
Bucket handle (ribs 6–10)
Lateral part moves up on inhalation, restricted on exhalation; lateral narrowing of the space above; lower edge of the rib shaft prominent
Lateral part moves down on exhalation, restricted on inhalation; lateral narrowing of the space below
Tenderness
Rib angle, costochondral and costosternal junctions (pump); intercostal muscles and rib angle (bucket)
Worked case: after a horse kick, the space between ribs 2 and 3 is increased, the inferior edges of the rib angles of 3–7 are prominent, and ribs 3–7 move less on inhalation → exhalation SD, pump-handle predominant (key rib 3). A depressed rib holds the ribs below it from rising on inhalation. Then apply BITE (7.10): an exhalation SD of ribs 6–10 is bucket handle with key rib 6.
Osteopathic structural exam of your patient reveals: ribs 3-5 on the right move freely on inhalation and are restricted in exhalation; anterior narrowing of the right 2nd intercostal space; prominence of the superior edge of the angles of right ribs 3-5 posteriorly; tenderness at the angles of ribs 3-5 on the right. What is the correct diagnosis of right ribs 3-5?
Ans: Free into inhalation + narrowing above + superior edge → pump-handle inhalation SD
Why: Ribs 3-5 are pump-handle ribs held up (free into inhalation). An inhalation pump-handle SD shows anterior narrowing of the space above and a prominent superior edge of the rib angle.
Explanation & sources
Explanation
Bucket-handle findings are lateral (lateral narrowing, prominent lower edge of the shaft). An exhalation SD would show narrowing below and a prominent inferior edge. A-P compression is a rare trauma pattern.
Which statement does NOT describe a pump-handle inhalation somatic dysfunction?
Ans: Pump inhalation SD → ANTERIOR narrowing above, not posterior
Why: In a pump-handle inhalation SD the narrowing is anterior, in the intercostal space above the dysfunction. "Posterior narrowing" is the false statement.
Explanation & sources
Explanation
Moving cephalad on inhalation, a prominent superior edge of the posterior rib angle, and an anteriorly elevated rib are all correct findings.
Asked in
2022 TA Review - Exam 1 · TA review · slides 88-89
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 31
550Rib SD findings
A 45-year-old female has shortness of breath, pain when breathing in, and accessory muscle use. Supine A/P rib motion: her right upper ribs do not fall like her left upper ribs when breathing out. How would you describe this somatic dysfunction?
Ans: Upper ribs don't fall → right pump-handle inhalation SD → findings
Why: The right upper ribs are stuck up, so this is a pump-handle inhalation SD: anterior narrowing above, the rib moves cephalad on inhalation, and the superior edge of the rib angle is prominent.
Explanation & sources
Explanation
Narrowing is anterior, not posterior (A). The rib moves cephalad on inhalation, not exhalation (A, C, D). A prominent inferior edge belongs to an exhalation SD (C).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 233-234
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 31
551Rib SD findings
When diagnosing an elevated rib on the anterior thoracic cage, you would expect the space between the affected rib and the rib below it to be:
Ans: Elevated rib → narrows space above → widens space below
Why: An elevated (inhalation SD) rib narrows the intercostal space above it, so the space below it is increased.
Explanation & sources
Explanation
Narrowing below would point to a depressed rib (exhalation SD). "Lateral" is not a description of the space.
Which is/are true for a depressed rib? (Select all that apply.)
Ans: Depressed = exhalation SD → holds ribs below down → space below narrows
Why: A depressed rib (exhalation SD) is the top/key rib of its group and holds the ribs below it from rising on inhalation. The intercostal space below it narrows.
Explanation & sources
Explanation
B gets the direction wrong: the group lies below the key rib. D, narrowing above, is the finding for an elevated (inhalation SD) rib.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 268-269
2020 TA Review Exam 1 · TA review · slides 260-261
A 35-year-old male has chest pain after a horse kicked him in the right anterior chest wall. The pain is worse with inhalation. Lungs are clear, ribs without point tenderness, and X-ray is negative. Structural exam: increased intercostal space between ribs 2 and 3 anteriorly on the right; inferior edge of the rib angle prominent from ribs 3-7; decreased excursion of ribs 3-7 on the right during inhalation. The most likely dysfunction in ribs 3-7 on the right is
Why: Ribs 3-7 are restricted in inhalation, so this is an exhalation SD. A prominent inferior edge of the rib angle is the exhalation pump-handle finding, and most of ribs 3-7 are pump-handle ribs.
Explanation & sources
Explanation
Inhalation SD choices get the freedom backward. Bucket-handle findings are lateral, with lateral narrowing. Torsional SD is not supported by these findings.
A 56-year-old female has chest pain and difficulty breathing, with tenderness at the angle of rib 6 and its intercostal muscles. Anterior ribs move caudad on exhalation and are restricted on inhalation, with anterior narrowing of the intercostal space below the dysfunction and a prominent posterior rib angle. How would you diagnose this somatic dysfunction?
Why: Restriction on inhalation with narrowing below is an exhalation SD, and the key rib is the top rib (BITE). Only C pairs an exhalation SD with the top rib (6) of the group.
Explanation & sources
Explanation
A and B are inhalation SDs. D calls rib 6 the key of ribs 2-6, but the top rib (2) would be key. The findings are written for a pump-handle rib, but ribs 6-10 move mainly in bucket-handle motion.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 257-258
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BITE: the key rib (the one to treat first) is the Bottom rib for an Inhalation SD and the Top rib for an Exhalation SD. Treating the key rib usually releases the rest of the group. The key rib is never a middle rib.
Name a rib SD in order: side → ribs → inhalation/exhalation → pump/bucket/caliper → key rib.
Which phase is restricted? Pain or restriction at maximum inhalation, “fail to rise”, “hand doesn't rise” → exhalation SD. “Stays up / doesn't fall on exhalation” → inhalation SD.
Which motion? Ribs 1–5 pump; 6–10 bucket; 11–12 caliper.
On structural examination of your OMM lab partner, you find an exhalation somatic dysfunction involving bucket-handle motion of ribs 6-10 on the left. The key rib(s) to treat with osteopathic manipulation is/are:
Ans: BITE: exhalation → top rib → rib 6
Why:BITE: Bottom rib for Inhalation SD, Top rib for Exhalation SD. The top rib of 6-10 is rib 6.
Explanation & sources
Explanation
Rib 10 would be the key for an inhalation SD. Ribs 5 and 11 are outside the group. The key rib is a single rib, not the middle ribs. Treating the key rib usually releases the rest of the group.
A 40-year-old male reports right-sided thoracic pain after a work injury about one week ago. The pain has improved but is still present and exquisite at maximum inhalation. Structural examination reveals dysfunction of ribs 6-9. Radiographs are negative for fracture. Which statement describes the most appropriate diagnosis and treatment?
Ans: Pain/restriction at full inhalation → exhalation SD → BITE top → rib 6
Why: Pain at full inhalation means the ribs are restricted in inhalation, which is an exhalation SD. BITE: the top rib (6) is the key rib.
Explanation & sources
Explanation
Rib 9 would be the key for an inhalation SD (B, D). C pairs inhalation SD with the top rib, which mixes the two rules. Nothing suggests torsion (E). Other versions of this question give ribs 6-10 "restricted in inhalation"; the answer is the same: exhalation SD, treat rib 6.
A 24-year-old female has right-sided thoracic pain after a fall one week ago, most severe at maximum inhalation. Ribs 4-6 on the right are restricted with inhalation. Which correctly describes the diagnosis and treatment?
A 23-year-old has difficulty breathing. Rib exam: both sides of the rib cage rise evenly, but the left side stays higher during expiration. Ribs 2-5 are restricted in A/P springing on the left. What is your diagnosis?
Ans: Left stays up on expiration → left inhalation SD → pump (2-5) → bottom = rib 5
Why: The left ribs fail to fall on expiration, so they are a left inhalation SD. Ribs 2-5 are pump handle, and the key rib for an inhalation SD is the bottom rib, 5.
Explanation & sources
Explanation
Rib 2 would be the key for an exhalation SD (A, C). Exhalation SD choices (C, D) get the freedom backward. Name it in order: side, ribs, inhalation/exhalation, pump/bucket, key rib.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 229-230
On your patient, you feel ribs 2-5 rise bilaterally but only fall on the left during exhalation. How would you diagnose the somatic dysfunction and its key rib?
Ans: Right fails to fall → right inhalation SD → bottom rib 5
Why: The right ribs fail to fall on exhalation, so this is a right ribs 2-5 inhalation pump-handle SD with key rib 5 (bottom rib, BITE).
Heads up: Options A and B are word-for-word identical in the source (likely a typo); the source key marks A, and B is equally correct.
Explanation & sources
Explanation
The left side moves normally (C). An exhalation SD would show the ribs failing to rise, with the top rib (2) as key (D).
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 236-237
A patient has difficulty breathing. With your hands on the upper ribs, your left hand rises more than the right on inhalation, and both fall evenly on exhalation. Springing localizes the dysfunction to ribs 2-5. The primary motion is ___ and the key rib is ___.
Ans: Right exhalation SD · ribs 2-5 → pump · exhalation → top → rib 2
Why: The right ribs fail to rise, so this is a right exhalation SD. Ribs 2-5 are pump-handle ribs, and the exhalation key rib is the top rib, rib 2.
Explanation & sources
Explanation
Rib 5 would be the key for an inhalation SD. Bucket handle is mainly ribs 6-10, and caliper is only ribs 11-12.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 171-172
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 26
563Key rib (BITE)
As the patient inhales your hands expand equally, but as the patient breathes out, your hands lose symmetry and one hand stays higher. A/P springing localizes ribs 6-9 on the right. What is your diagnosis?
Ans: Stays up on exhalation → inhalation SD · ribs 6-9 bucket · bottom → rib 9
Why: The right ribs stay up on exhalation, so this is an inhalation SD. Ribs 6-9 move in bucket-handle motion, and the key rib is the bottom rib, 9.
Explanation & sources
Explanation
Pump handle is ribs 1-5 (A, C, D). An exhalation SD would lose symmetry on inhalation, with the top rib as key (C, E).
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 173-174
A 40-year-old has right-sided pain after weightlifting one week ago. The pain has improved but is still present at maximum inhalation. Exam reveals a winged scapula on the right. Fill in: an ____ somatic dysfunction at ribs ____ with treatment directed at rib ___ using this muscle ____.
Ans: Winged scapula → serratus anterior · pain on inhalation → exhalation SD → top rib 6
Why: Medial scapular winging points to serratus anterior (long thoracic nerve). Pain at full inhalation means an exhalation SD, so the key rib is the top rib (6) of ribs 6-9.
Explanation & sources
Explanation
B gives an exhalation SD but takes the bottom rib (5) as key. C, D, and E are inhalation SDs, which would hurt on exhalation. They also use muscles unrelated to scapular winging.
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Learn firstWhat you need for 7.11
Rib muscle energy is direct and uses three things: a muscle contraction, force that moves the rib into the barrier, and respiratory assistance.
Exhalation SD (rib stuck down)
Inhalation SD (rib stuck up)
Key rib
Top rib
Bottom rib
Physician contact
Posterior rib angle of the key rib (rib 1: posterosuperior first rib)
Anterior key rib (rib 1: between the two heads of the SCM)
Positioning
Patient supine; the attached muscle is set up to pull (e.g. hand/forearm on forehead)
Flex the head and trunk down to the key rib (add sidebending for bucket ribs)
Action
On inhalation the patient contracts the muscle against resistance (isometric) while the physician pulls the posterior rib caudad, so the anterior rib rises into inhalation
Resist inhalation; on exhalation push the rib inferiorly (into exhalation)
Key rib (exhalation SD)
Muscle to activate
Patient effort
Rib 1
Anterior and middle scalenes
Lifts the head into the physician's hand (hand on forehead)
Rib 2
Posterior scalene
Head/neck effort against resistance
Ribs 3–5
Pectoralis minor
Hand on forehead, pushes the arm/elbow against resistance (straight up toward the ceiling, or elbow toward the opposite hip)
Ribs 6–9
Serratus anterior
Pushes the hand against the physician's at a 45° angle (reaching forward); physician sits beside the patient facing cephalad, contacting the back of the top rib
Ribs 10–11
Latissimus dorsi
Arm overhead, adducts against resistance
Rib 12
Quadratus lumborum
Prone (below)
Ribs 2–9 as one group
Serratus anterior (spans 2–9)
As for ribs 6–9
Ribs 11–12 are treated prone: physician stands opposite the dysfunction, caudad hand lifts the ASIS, cephalad hand pushes the ribs laterally, legs drawn toward the physician. Inhalation SD → push during exhalation; exhalation SD → arm overhead (latissimus) and work during inhalation.
Rib HVLA: for a posterior rib, the thenar eminence goes on the rib just lateral to the costotransverse joint (rib angle), not on the TP or SP. First-rib HVLA is done seated: the patient's arm drapes over the physician's flexed knee, the head is locked (rotated away from the dysfunction; TA notes: sidebent toward it; the keyed choice reads “sidebent and rotated away”, so pick that over “toward”), and the thrust goes down and medial through the rib.
Picture cues: supine with hand/forearm on forehead and a posterior upper-rib contact = rib 1 (upper rib) exhalation SD ME, i.e. treating an inhalation restriction. Physician flexing the head/torso while contacting anterior ribs = inhalation SD ME (carrying the rib into exhalation).
565Rib ME & HVLA techniques
In muscle energy, what three items are used to correct inhalation and exhalation restrictions of the ribs?
Ans: ME = direct: contract muscle + push into barrier + breathing
Why: Rib ME is direct: an isometric muscle contraction, force that moves the rib into the barrier, and respiratory assistance.
Explanation & sources
Explanation
ME uses contraction, not relaxation (A, C). Guiding the rib into its freedom (A, D) would be an indirect approach, and ME is direct.
Where does your hand (the "applicator") go when you treat an exhalation SD of the ribs with muscle energy?
AnswerOn the posterior rib angle of the key (top) rib, pulling it caudad on inhalation while the patient contracts the attached muscle (e.g., arm or hand on forehead for pectoralis minor).
Ans: Exhalation SD → key = top rib → contact posterior angle → patient pulls rib up
Why: For an exhalation SD the physician contacts the posterior rib angle of the top (key) rib. The patient contracts the muscle attached to that rib (scalenes, pectoralis minor, serratus anterior, or latissimus) to lift the rib into inhalation.
Explanation & sources
Explanation
For an inhalation SD the contact is on the anterior bottom (key) rib, which is pushed down on exhalation with the trunk or head flexed to it.
Asked in
2022 Instructor Exam Review (Dr. Banihashem) - Exam 1 · Instructor review · p.1, 'ME - Thoracic and rib ME set ups'
A 30-year-old male with allergic rhinitis sneezes frequently. Structural exam reveals an exhalation dysfunction of rib 2. Which of the following would be most useful in correcting this with a direct method?
Why: The posterior scalene inserts on rib 2. Contracting it pulls rib 2 up into inhalation, which is the direct ME correction.
Explanation & sources
Explanation
The middle scalene treats rib 1. Pectoralis minor treats ribs 3-5. Latissimus dorsi works the lowest ribs. Pectoralis major is not one of the rib ME muscles.
Which muscle do you use if treating rib 1 with muscle energy?
Ans: Rib 1 → anterior + middle scalene
Why:Rib 1 is moved by the anterior and middle scalenes (IA7 slide 28). In rib 1 exhalation ME, the patient lifts the head into resistance to fire them.
Heads up: The 2020 TA answer slide marks A (SCM). The 2026 IA7 slide lists rib 1's muscles as the anterior and middle scalene, so B and C are correct.
Explanation & sources
Explanation
The SCM attaches to the sternum and clavicle, not rib 1, so it cannot lift the rib. The posterior scalene is the muscle for rib 2.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 266-267
2020 TA Review Exam 1 · TA review · slides 258-259
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
569Rib ME & HVLA techniques
Match the muscle energy steps for the first rib to exhalation SD vs inhalation SD: A. Physician's hand contacts the first rib posteriorly; B. The patient's head and neck are flexed; C. Physician contacts the first rib between the two heads of the SCM; D. Patient places hand on forehead, palm up, with physician's hand on top; E. Physician pulls rib down during inhalation; F. Physician pushes the rib inferiorly during exhalation; G. Patient pushes head into hand during inhalation while physician resists; H. Physician resists the movement of the rib during inhalation.
AnswerExhalation SD: D, A, G, E. Inhalation SD: C, B, H, F.
Ans: Exhalation SD → scalenes lift rib (head into hand) · inhalation SD → push rib down on exhale
Why:Exhalation SD: hand on forehead, contact rib 1 posteriorly, patient lifts head against resistance on inhalation (scalenes pull rib 1 up), physician pulls the posterior rib caudad. Inhalation SD: contact rib 1 anteriorly between the SCM heads, flex the head and neck, resist inhalation, push the rib inferiorly on exhalation.
Explanation & sources
Explanation
This pattern holds for all ribs: exhalation SD uses a muscle to pull the top rib up, and inhalation SD uses breathing to push the bottom rib down.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 182-183
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
570Rib ME & HVLA techniques
In the image, which answer best describes the physician's action during this muscle energy treatment for rib exhalation somatic dysfunction? (Patient supine with hand on forehead; physician's hand behind the first rib.)
Why: The physician grasps the posterosuperior first rib and pulls it caudad while the patient lifts the head. Lowering the posterior rib helps the anterior rib rise into inhalation.
Explanation & sources
Explanation
Lifting the posterior rib cephalad (B) moves it the wrong way. Anterior-lateral pushing (C) is not part of this technique. Lifting "into its freedom" (D) would be indirect, and ME is direct.
In the photo, what is a possible somatic dysfunction being treated by this muscle energy technique? (Patient supine with right forearm on forehead; physician behind the upper ribs.)
Ans: Hand on forehead, upper rib contact → rib 1 exhalation SD
Why: Hand on forehead with resisted head or arm lift and a posterior contact on the upper rib is ME for a right 1st rib exhalation SD.
Explanation & sources
Explanation
B gets BITE backward: an exhalation SD's key rib is the top rib, and ribs 3-5 are pump, not bucket. C is an inhalation SD, which is treated by flexing down to the key rib and pushing it down on exhalation. D pairs pump handle with rib 10, a bucket-handle rib. Ribs 11-12 (E) are treated prone.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 171-172
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
573Rib ME & HVLA techniques
An older man is having a really hard time inhaling. His key rib is rib 3. What is his somatic dysfunction, what position do you put him in, and what muscle are you activating?
Ans: Can't inhale → exhalation SD (top rib 3) → pec minor → hand on forehead pushing up
Why: Trouble inhaling with a top key rib is an exhalation SD. Rib 3 is moved by pectoralis minor, activated with the patient supine, hand on forehead, pushing the arm up against resistance.
Explanation & sources
Explanation
Inhalation SD choices (B, D) are wrong because rib 3 as key means the top rib. Head and neck flexion pushing into exhalation is the inhalation SD setup (B, C). Serratus anterior is for ribs 6-9.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 103-104
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
574Rib ME & HVLA techniques
Your patient has difficulty with full inspiration. You note that ribs 3-6 on the left fail to rise during inhalation. Describe the ME setup to treat this.
Ans: Fail to rise → exhalation SD → top rib 3 → pec minor
Why: Ribs that fail to rise are an exhalation SD. The key rib is the top rib (3), and rib 3 is lifted by pectoralis minor.
Explanation & sources
Explanation
A and C contact rib 6, the bottom rib, which is the key for an inhalation SD. Scalenes move ribs 1-2 (A). Prone trunk extension (D) is not a rib ME setup.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 173-174
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
575Rib ME & HVLA techniques
Four months later the patient returns after being hit in the chest by a basketball. On exam, ribs 3-6 are restricted in inhalation on the right. What is the treatment?
Ans: Restricted inhalation → exhalation SD → resist down on exhale, guide up on inhale · top rib 3
Why: Restricted inhalation is an exhalation SD (stuck down) with key rib 3. On exhalation, resist the rib dropping, and on inhalation, guide it up.
Explanation & sources
Explanation
For an inhalation SD you would guide the rib down on exhalation and use the bottom rib (C). B and D pick the wrong key rib (5, 6).
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 175-176
A 35-year-old male has chest pain after a horse kicked him in the right anterior chest wall, worse with inhalation. X-ray is negative. Structural exam: increased intercostal space between ribs 2 and 3 anteriorly on the right; inferior edge of rib angle prominent from ribs 3-7; decreased excursion of ribs 3-7 on the right during inhalation. Which muscle will most likely assist in treating these ribs with muscle energy?
Ans: Exhalation SD 3-7 → key = top rib 3 → pec minor (ribs 3-5)
Why: This is an exhalation SD of ribs 3-7, so the key rib is rib 3 (top). Pectoralis minor attaches to ribs 3-5 and is used to lift rib 3.
Explanation & sources
Explanation
Anterior scalene treats rib 1, and posterior scalene treats rib 2. Serratus anterior is the ME muscle for ribs 6-9. Serratus posterior is not used for rib ME.
A 40-year-old male has right-sided thoracic pain after a work injury one week ago, still present at maximum inhalation. Structural exam reveals dysfunction of ribs 6-9. The physician elects muscle energy. The most appropriate muscle to activate is the
Why: The key rib is rib 6 (top of an exhalation SD), and serratus anterior is the ME muscle for ribs 6-9.
Explanation & sources
Explanation
Pectoralis minor is for ribs 3-5. Latissimus dorsi is for ribs 10-11 (10-12 on the IA7 slide). Quadratus lumborum is for rib 12. Pectoralis major is not a rib ME muscle.
How would you set up and perform muscle energy for a rib 7-9 exhalation somatic dysfunction?
Ans: Exhalation SD → top rib 7 → posterior contact, pull caudad on inhale → serratus (45°)
Why: Exhalation SD: sit at the side of the supine patient, contact the back of the top rib (7), and pull caudad on inhalation while the patient pushes the hand against yours at a 45° angle (serratus anterior).
Explanation & sources
Explanation
A and B are the inhalation SD setup (flex the patient and push the rib down). A also uses rib 9. D uses rib 9 and exhalation. E's "straight up from the forehead" is the pectoralis minor setup for ribs 3-5.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 119-120
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
580top 215Rib ME & HVLA techniques
Which muscle is used to treat an exhalation dysfunction of rib 11 with a muscle energy technique?
Ans: Rib 11 → latissimus dorsi (QL = rib 12)
Why:Latissimus dorsi is the ME muscle for ribs 10-11 (IA7: ribs 10-12). The patient's arm goes overhead to stretch and fire it.
Explanation & sources
Explanation
Quadratus lumborum is used for rib 12. Serratus anterior is for ribs 6-9. Serratus posterior and iliocostalis are not rib ME muscles.
Asked in
2023 TA Review (Harlem) - Exam 1 · TA review · slides 102-103
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 28
581Rib ME & HVLA techniques
Regarding the technique in the image, which statement is true? (Patient supine; physician flexes the patient's head and upper torso while contacting the anterior ribs.)
Ans: Flexion to key rib + push down on exhale → inhalation SD ME
Why: This is ME for an inhalation SD. The physician flexes the torso down to the key rib to help carry the rib into exhalation.
Explanation & sources
Explanation
Extension into inhalation (B) is the opposite. Ribs 11-12 are treated prone (C). For an inhalation SD the physician resists inhalation and carries the rib into exhalation, not the reverse (D).
On your patient, you feel ribs 2-5 rise bilaterally but only fall on the left. Which describes the muscle energy technique?
Ans: Right inhalation SD → key = rib 5 → flex to rib 5, push down on exhale
Why: The right ribs fail to fall, so this is a right inhalation SD, key rib 5. Flex the patient until motion reaches rib 5, then push the rib down during exhalation.
Explanation & sources
Explanation
B uses rib 2, the exhalation key rib. C pushes during inhalation, which is the wrong phase. D and E are the rib 1-2 exhalation SD setup (hand on forehead, pull caudad on inhalation).
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 221-222
2020 TA Review Exam 1 · TA review · slides 212-213
Lecture slide (1)
Week 7 · IA7 Clinical Ribs · slide 26
583Rib ME & HVLA techniques
You treat a patient who has a right inhalation SD of ribs 6-9 (bucket handle, key rib 9) with muscle energy. What must be done?
Ans: Inhalation SD ME → flex head/trunk down to key rib → push rib down on exhale
Why: For an inhalation SD, the physician flexes the patient's head and trunk down to the key rib (with sidebending for bucket ribs) and pushes the rib into exhalation.
Explanation & sources
Explanation
The patient is supine, not prone (A). Hand on forehead (B) and pulling the posterior rib down (C) are exhalation SD steps.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 175-176
584Rib ME & HVLA techniques
Your patient's left ribs 11 and 12 fully come up as they breathe in but don't fall as they breathe out. How do you set up ME for this somatic dysfunction?
Ans: Don't fall on exhale → inhalation SD → push ribs during exhalation, no arm overhead
Why: This is an inhalation SD of ribs 11-12. With the patient prone, stand on the opposite side, curve the legs toward you, and push the ribs laterally while pulling the ASIS during exhalation.
Explanation & sources
Explanation
B raises the arm overhead (latissimus) and works on inhalation, which is the setup for an exhalation SD of ribs 11-12.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 122-123
585Rib ME & HVLA techniques
Describe the muscle energy technique for ribs 11 and 12.
Ans: Ribs 11-12 ME → prone, ASIS lift + rib push
Why: Ribs 11-12 are treated prone. The physician stands opposite the dysfunction, the caudad hand lifts the ASIS, and the cephalad hand pushes the ribs laterally with breathing.
Explanation & sources
Explanation
Ribs 11-12 are not treated seated or supine (A, B). D describes no standard rib technique.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 187-188
586Rib ME & HVLA techniques
When treating a posterior rib head somatic dysfunction with HVLA thrust, where does the physician place the thenar eminence?
Ans: Rib HVLA → contact the rib, not the vertebra → lateral to costotransverse joint
Why: For rib HVLA the thenar eminence goes on the rib, just lateral to the costotransverse joint (at the rib angle).
Explanation & sources
Explanation
Over the transverse process (C) or spinous process (D) is the contact for a thoracic vertebral thrust. The cervicothoracic junction (B) is not a rib contact.
What technique is being used in the figure? (Patient seated; her arm is draped over the physician's knee while he sidebends her head and contacts the first rib.)
Ans: Seated, arm over knee, head locked, rib contact → first rib HVLA
Why: This is the seated HVLA for the first rib: the head is locked by sidebending and rotation, then a thrust is delivered through the rib contact.
Explanation & sources
Explanation
Rib 1 ME is done supine with the hand on the forehead. Counterstrain and FPR are passive positioning techniques without a thrust setup.
How do you correctly perform HVLA of the first rib?
Ans: Seated, arm over physician's knee → lock head → thrust rib down and medial
Why: First-rib HVLA is done seated, with the patient's arm draped over the physician's flexed knee. The head is locked so that rotation is away from the dysfunction, and the thrust goes down and medial through the rib.
Heads up: The 2023 TA answer explanation says the head is sidebent TOWARD and rotated AWAY from the dysfunction. Option D says sidebent and rotated away, so it is not exact, but it is the keyed and closest answer.
Explanation & sources
Explanation
A and B are supine setups, not the taught HVLA. C rotates toward the dysfunction, which does not lock the rib.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 180-181
No questions in this section match the current Show filter.
Learn firstWhat you need for 8.1
Sympathetic
Parasympathetic
Outflow
Thoracolumbar: cell bodies in the intermediolateral (lateral horn) column T1–L2
Craniosacral: cranial nerves III, VII, IX, X + pelvic splanchnic nerves S2–S4
No thoracic or lumbar level is parasympathetic. The vagus (CN X) provides the most parasympathetic innervation: heart, lungs and the gut down to about the splenic flexure (CN III: pupil and ciliary muscle; CN VII: lacrimal and salivary glands; CN IX: parotid; pelvic splanchnics: descending/sigmoid colon, rectum, bladder, genitals). The vagus is up to 90% afferent and connects to the spinal cord at C1–C2, which is why OA–C2 findings are linked to vagal viscera.
Cervical sympathetic ganglion
Location
Superior
Anterior to the C2/C3 transverse process (many connections with CN IX and X)
Middle
Anterior to the C6 transverse process
Inferior
C7–T1; often fuses with T1 to form the stellate ganglion
All cervical ganglia receive their preganglionic fibers from T1–T4 and all send fibers to the cardiac plexus. (The cervical spine itself has no sympathetic outflow.)
589top 215asked 2×ANS anatomy
What nerves in the body are parasympathetic?
AnswerCranial nerves III, VII, IX, and X, plus the pelvic splanchnic nerves from S2-S4 (craniosacral outflow).
Ans: Parasympathetic = craniosacral → CN III, VII, IX, X + S2-S4
Why: The parasympathetic system is craniosacral: cranial nerves III, VII, IX, and X and the pelvic splanchnic nerves (S2-S4).
Explanation & sources
Explanation
No thoracic or lumbar level is parasympathetic; sympathetic cell bodies sit in the intermediolateral column from T1 to L2. The vagus connects to the spinal cord at C1-C2, which is why OA-C2 findings are linked to vagal viscera, and S2-S4 findings to the pelvic organs and distal colon.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 133-134
2024 TA Review (Harlem) Exam 1 · TA review · slides 114-115
590ANS anatomy
Which nerve provides the most parasympathetic innervation to the body?
Ans: Largest parasympathetic territory → heart, lungs, most of gut → vagus (CN X)
Why: The vagus nerve carries parasympathetic supply to the heart, lungs, and the gut down to about the splenic flexure, far more territory than any other parasympathetic nerve.
Explanation & sources
Explanation
CN III (pupil, ciliary muscle), CN VII (lacrimal and salivary glands), and CN IX (parotid) serve only head structures. The pelvic splanchnics (S2-S4) cover only the descending and sigmoid colon, rectum, bladder, and genitals. The vagus is up to 90% afferent and connects to the spinal cord at C1 and C2.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 194-195
591asked 2×ANS anatomy
Match each cervical sympathetic ganglion (superior, middle, inferior) to its usual location. A. Typically lies anterior to the C6 transverse process. B. Typically lies anterior to the transverse process of C2/C3. C. Typically lies in relation to C7-T1, often fusing with T1 to become the stellate ganglion.
AnswerSuperior cervical = B (anterior to C2/C3 TP); middle cervical = A (anterior to C6 TP); inferior cervical = C (C7-T1, fuses with T1 to form the stellate ganglion).
Ans: Superior high at C2-3 → middle at C6 → inferior at C7-T1 = stellate
Why: The superior cervical ganglion lies in front of the C2/C3 transverse process, the middle in front of C6, and the inferior at C7-T1, where it often fuses with T1 as the stellate ganglion.
Explanation & sources
Explanation
All cervical sympathetic ganglia receive their preganglionic fibers from T1-T4, and all send fibers to the cardiac plexus. The superior cervical ganglion has many connections with CN IX and X.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 140-141
2024 TA Review (Harlem) Exam 1 · TA review · slides 116-117
8.2 · 7 questions · Questions 592–598
PANs & reflexes
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Learn firstWhat you need for 8.2
Name a reflex by its origin first, then its target:
Reflex
Meaning
Example
Viscerosomatic
Localized visceral stimuli → palpable reflex changes in segmentally related somatic tissue (via the SNS)
MI causing left jaw/arm pain; gallbladder → right T7–8 TART
PANs (peripheral afferent nociceptors) are naked nerve endings in the viscera. They respond to thermal, mechanical and chemical stimuli through inflammatory mediators. When activated they release substance P, somatostatin and CGRP (neurogenic inflammation). With repeated stimuli they become sensitized and fire at a lower threshold (never higher). Visceral pain is carried by afferents traveling with the sympathetics; the PAN cell body is in the dorsal root ganglion and it synapses in the dorsal horn (laminae I and II), where it can drive spinal facilitation. (Sympathetic efferents synapse in the para-/prevertebral ganglia; their cell bodies are in the lateral horn.)
Viscerosomatic reflex in sequence: organ irritation → PANs → dorsal horn → facilitated segment → more sympathetic and motor outflow → paraspinal TART. OMT is adjunctive; the organ still needs medical care.
Don't mix up the nodules: a Chapman point is a small, pea-sized nodule beneath the subcutaneous tissue (on the deep fascia); a Jones tender point is dime-sized, in muscle, tendon, ligament or fascia.
Lecture slide for this section (1)
Written Review slide 48: the four reflexes
592top 215PANs & reflexes
What is the definition of a viscerosomatic reflex?
Ans: Viscero → somatic: organ stimulus → SNS → palpable changes in segmental soma
Why: In a viscerosomatic reflex the visceral stimulus comes first and produces palpable reflex changes in segmentally related somatic tissue through the SNS.
Explanation & sources
Explanation
A reverses the direction; that is a somatovisceral reflex. B describes a Chapman point (pea-sized, beneath the subcutaneous tissue). D describes a Jones tender point (dime-sized, in muscle, tendon, ligament, or fascia).
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 183-184
Lecture slide (1)
Week 8 · Written Review deck · slide 48
593top 215asked 3×2026PANs & reflexes
A male patient presents with indigestion and is found to have tissue texture changes along the posterior spinal column. It is determined that his symptoms resulted from somatic sensory stimulation with segmental spinal facilitation that is mediated through autonomic efferent nerves. This is a description of which of the following?
Why: The trigger is somatic and the result is a visceral symptom (indigestion), so this is a somatovisceral reflex. Name the reflex by origin first, then target.
Explanation & sources
Explanation
D is the reverse direction (organ drives the somatic findings). B and E stay within one system. Central facilitation is a spinal cord process, not a named reflex arc. Review deck example of a somatovisceral reflex: tissue injury in the T1-T5 muscles worsening COPD.
Ans: Pain is sensory → afferent → PANs run with sympathetic fibers
Why: Pain is sensory, so it travels in afferents. Visceral nociceptive afferents (PANs) run along the sympathetic fibers back to the dorsal horn.
Explanation & sources
Explanation
B and D are efferents, which carry motor output, not sensation. A is tempting because the vagus is largely afferent, but most visceral pain travels with the sympathetics. This is why visceral pain and viscerosomatic findings map onto the sympathetic levels T1-L2.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 251-252
2020 TA Review Exam 1 · TA review · slides 243-244
595asked 3×PANs & reflexes
Visceral afferents contain naked nerve endings known as PANs (peripheral afferent nociceptors). How do they respond to thermal, mechanical and chemical stimuli?
Ans: PANs sense thermal, mechanical, chemical damage → via inflammatory mediators
Why: PANs respond to three forms of potentially damaging stimuli (thermal, mechanical, chemical) through inflammatory mediators.
Explanation & sources
Explanation
A is too vague. B is unrelated. D is a downstream result of PAN activity, not how PANs sense the stimulus. When activated, PANs release substance P, somatostatin, and CGRP, which is called neurogenic inflammation.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 272-273
2020 TA Review (Middletown) Exam 1 · TA review · slides 239-240
2020 TA Review Exam 1 · TA review · slides 231-232
596top 215asked 5×2026PANs & reflexes
Which of the following is NOT a feature of PANs?
Ans: Repeated stimuli sensitize PANs → threshold LOWERS, not rises → A false
Why: With repetitive stimuli PANs become sensitized and fire at a lower threshold (peripheral sensitization). Raising the threshold is the opposite.
Explanation & sources
Explanation
B is true: PANs respond to thermal, mechanical, and chemical stimuli. C is true: activated PANs release substance P, somatostatin, and CGRP (neurogenic inflammation). D is true: PAN hyperactivity triggers spinal facilitation in the dorsal horn.
Ans: Afferent → passes through DRG (cell body) → synapses in dorsal horn
Why: PANs travel with the sympathetic fibers, pass through the dorsal root ganglion, and synapse in the dorsal horn of the spinal cord, connecting with the interneuron pool.
Explanation & sources
Explanation
B holds the PAN cell body; nothing synapses there. C and D are where sympathetic efferents synapse, not afferents. E holds the sympathetic preganglionic cell bodies (efferent side). PANs end mainly in laminae I and II of the dorsal horn.
2020 TA Review (Middletown) Exam 1 · TA review · slides 242-243
2020 TA Review Exam 1 · TA review · slides 234-235
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 19
598PANs & reflexes
What are viscerosomatic reflexes?
AnswerVisceral irritation (inflammation) is carried by PANs along sympathetic fibers to the dorsal horn. The segment becomes facilitated, and increased sympathetic and motor outflow produce palpable TART changes in segmentally related somatic tissue.
Ans: Organ irritation → PANs → dorsal horn → facilitation → paraspinal TART
Why: A viscerosomatic reflex is a local afferent reflex from a viscus to the spinal cord that creates a segmental pattern of somatic findings. Activated PANs release substance P, somatostatin, and CGRP and become sensitized with repeated firing.
Explanation & sources
Explanation
The visceral problem is the initiating drive; the paraspinal findings are its reflection. OMT is adjunctive: it removes the somatic part of the nociceptive load and reduces sympathetic and motor outflow, but the organ still needs medical or surgical treatment.
Asked in
2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'What are Viscero-somatic reflexes?'
Lecture slide (1)
Week 8 · Written Review deck · slide 48
8.3 · 8 questions · Questions 599–606
Spinal facilitation
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Learn firstWhat you need for 8.3
Spinal facilitation: after ongoing abnormal afferent input (a sick organ, a strained muscle, somatic dysfunction), a spinal segment enters a state where less afferent stimulation is needed to trigger a discharge: its threshold is lowered. Sensitivity up, threshold down, pain up.
Mechanism: PANs release substance P in the dorsal horn (laminae I and II) → glutamate voltage-gated channels open → Ca²⁺ influx (not sodium) → increased dynorphin synthesis → sensitized dorsal horn cells. If a question offers both “substance P release” and “opening of glutamate voltage-gated channels”, the key is the glutamate channels opening.
Results:
Hyperalgesia (noxious feels worse) and allodynia (non-noxious feels painful), not hypoalgesia.
Increased efferent output, out of proportion to the input: more lateral horn outflow → sympathicotonia (↑ sympathetic tone, with vasoconstriction and blood-flow changes) at T1–L2; more ventral horn (alpha motor) outflow → increased tone in segmentally related muscles.
These changes produce TART. The hypertonic muscle adds more nociceptive input, keeping the cycle going.
Once established, facilitation can be sustained by normal CNS activity.
The thoracolumbar cord has no parasympathetic outflow, so “decreased/increased parasympathetic tone” is not an effect of facilitation there.
Lecture slide for this section (1)
IA8 slide 14: facilitation summary
599Spinal facilitation
What is the basis of spinal facilitation?
Ans: Facilitated = hyperexcitable → lower threshold → less input fires it
Why: A facilitated segment has a lowered threshold, so less afferent input is needed to make it discharge.
Explanation & sources
Explanation
A is the opposite. B reverses the time course: inflammatory mediators come first (acute), fibrosis comes later (chronic). D is wrong because facilitation comes from abnormal, increased afferent input (for example a strained or overstretched muscle or a sick organ), not normal input.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 34-35
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 14
600Spinal facilitation
What is spinal facilitation?
Ans: Facilitation: sensitivity UP → threshold DOWN → pain UP
Why: Facilitation means increased sensitivity, a lower threshold for firing, and more pain (hyperalgesia and allodynia). All three must point the same way.
Explanation & sources
Explanation
A, B, and C each pair the directions inconsistently. Strictly, sensitization of the PANs themselves is called peripheral sensitization, and spinal facilitation is the resulting sensitization of the dorsal horn neurons; D is still the only option with all directions correct.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 196-197
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 14
601Spinal facilitation
What is the physiology behind spinal facilitation?
Ans: Substance P → glutamate channels OPEN → Ca2+ in → ↑ dynorphin → sensitized
Why: PANs release substance P in laminae I and II, which opens glutamate voltage-gated channels. Calcium flows in and dynorphin synthesis rises, sensitizing the dorsal horn cells.
Heads up: The TA key marks E. D (substance P release in the dorsal horn) is also a true step in the same cascade per the 2026 ANS lecture, so know the full sequence: substance P → glutamate channels open → Ca2+ influx → more dynorphin → facilitation.
Explanation & sources
Explanation
A names the wrong ion (calcium, not sodium). B says closure instead of opening. C is backwards; dynorphin synthesis increases.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 275-276
Why: Facilitated circuits fire so easily that non-noxious stimuli are felt as painful (allodynia) and noxious stimuli hurt more (hyperalgesia).
Explanation & sources
Explanation
A is the opposite; it causes hyperalgesia. C is backwards; less input is needed. D is wrong because the altered ventral horn and sympathetic outflow produce muscle tone, motion, vasomotor, and sudomotor changes, which are the TART findings.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 278-279
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 14
603top 215asked 2×Spinal facilitation
All of the following are true concerning a facilitated segment EXCEPT:
Ans: Facilitated = LOW threshold → 'high threshold' is the false one
Why: A facilitated segment has a low threshold of excitation, so E is false.
Explanation & sources
Explanation
A and C are the core features: less input needed and increased output. D is true: sustained afferent input (from a sick organ or somatic dysfunction) starts it. B is true: once established, even normal activity can keep the segment facilitated, which is why the findings persist.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 137-138
2022 TA Review - Exam 1 · TA review · slides 93-94
Why: Facilitation in the thoracic and upper lumbar cord increases outflow from the lateral horn, producing sympathicotonia (increased sympathetic tone).
Explanation & sources
Explanation
C is backwards: motor efferent activity to segmental muscles increases (hypertonicity). D is backwards: increased sympathetic tone causes vasoconstriction and reduced blood flow to the viscera. A is not a stated effect; the thoracolumbar cord has no parasympathetic outflow. Since A, C, and D are false, E is out.
Facilitation in the thoracic and upper lumbar segments of the spinal cord results in:
Ans: T1-L2 facilitated → lateral horn fires more → sympathicotonia
Why: The slide summary: facilitation at T1-L2 causes sympathicotonia (increased sympathetic tone, with blood flow changes) and increased efferent activity to segmental muscles.
Explanation & sources
Explanation
A is the opposite. B is the opposite; motor outflow increases. D is wrong because the thoracic and upper lumbar cord carries sympathetic, not parasympathetic, outflow.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 135-136
2022 TA Review - Exam 1 · TA review · slides 91-92
2020 TA Review (Middletown) Exam 1 · TA review · slides 246-247
2020 TA Review Exam 1 · TA review · slides 238-239
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 14
606Spinal facilitation
What is spinal facilitation?
AnswerPANs release substance P in the dorsal horn → glutamate channels open → Ca2+ influx → more dynorphin → sensitized dorsal horn cells. Less input triggers a response (hyperalgesia, allodynia), increasing sympathetic and alpha motor outflow and producing TART changes.
Ans: Ongoing PAN input → dorsal horn sensitized → low threshold → ↑ SNS + motor output
Why: Spinal facilitation is a lowered firing threshold of a spinal segment after ongoing afferent input. The output is out of proportion to the input: more lateral horn (sympathetic) and ventral horn (alpha motor) outflow.
Explanation & sources
Explanation
Results: hyperalgesia (noxious feels worse), allodynia (non-noxious feels painful), increased muscle tone and restricted motion, and sympathetic vasomotor and sudomotor changes, i.e., TART. The hypertonic muscle then adds more nociceptive input, keeping the cycle going; OMT aims to break that somatic part.
Asked in
2022 Instructor Written Review (Dr. Banihashem) notes - Exam 1 · Instructor review · section 'What is Spinal Facilitation?'
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 14
8.4 · 6 questions · Questions 607–612
Acute vs chronic findings
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Learn firstWhat you need for 8.4
Acutely facilitated segment / acute VSR
Chronically facilitated segment / chronic VSR
Temperature
Increased (warm)
—
Skin
Increased moisture and skin drag (↑ sweating)
Thickened skin
Subcutaneous
Fluid extravasation from inflammatory mediators → boggy
—
Muscle
Hypertonicity, boggy (“swollen”); usually fusiform, in the deep muscles (multifidus, rotatores) of a couple of segments
Sympathetic activity reduces blood flow to the viscera, so “increased visceral blood flow”, “decreased muscle tone” and “decreased sweating” are wrong for an acute reflex. Example: acute cholecystitis → acute, fusiform hypertonicity at T7–8 on the right.
Lecture slide for this section (1)
IA8 slide 6: acute vs chronic facilitated segment
607asked 2×Acute vs chronic findings
What changes do you expect to see in an acute viscerosomatic reflex?
Why: In an acute reflex, inflammatory mediators cause subcutaneous fluid extravasation, which is why the tissue feels warm and boggy.
Explanation & sources
Explanation
Each distractor is backwards: sympathetic activity reduces blood flow to the viscera, muscle tone increases (alpha and gamma outflow), and sweating increases. Also expect increased skin drag and tissue texture changes.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 145-146
2024 TA Review (Harlem) Exam 1 · TA review · slides 121-122
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 6
608top 215asked 2×Acute vs chronic findings
Which of the following would you expect to find in an acute viscerosomatic dysfunction?
Ans: Acute = warm, moist, boggy, prolonged red reflex
Why: An acutely facilitated segment shows a prolonged red reflex, along with increased temperature, moisture, skin drag, hypertonicity, and boggy muscles.
Explanation & sources
Explanation
A, B, C, and E are all on the chronic list: thickened skin, ropey muscles, rapidly fading red reflex, hypersensitive muscles, and stiff joints with a firm end-feel.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 233-234
2020 TA Review Exam 1 · TA review · slides 224-225
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 6
609Acute vs chronic findings
Which of the following is related to an acutely facilitated segment?
Why: In an acute viscerosomatic reflex the restrictive barrier is soft and ambiguous, not firm. A firm barrier points to a chronic reflex.
Explanation & sources
Explanation
A is wrong; acute segments are warm. C (thick skin), D (red reflex that fades quickly), and E (ropey muscles) are chronic findings.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 284-285
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 6
610top 215asked 5×2026Acute vs chronic findings
A 44-year-old female presents with right upper abdominal pain that radiates to her back. An abdominal ultrasound reveals inflammation of her gallbladder secondary to gallstones. Which of the following best describes the expected somatic dysfunction findings?
Ans: Acute cholecystitis → acute VSR → fusiform hypertonicity of deep segmental muscles
Why: Acute VSR muscle changes are usually fusiform in shape and involve the deep muscles of a couple of vertebral segments (multifidus, rotatores).
Explanation & sources
Explanation
A (ropey) and B (firm barrier) are chronic findings; the acute barrier is soft. D is wrong because acute skin is warm and moist. E is backwards; acute inflammation causes subcutaneous fluid extravasation (bogginess).
Why: A chronically facilitated segment shows stiff joints with a firm end-feel, plus thickened skin, ropey and hypersensitive muscles, and a rapidly fading red reflex.
Explanation & sources
Explanation
A, C, D, and E are all acute findings (warm, prolonged red reflex, boggy, moist with increased drag). A 2023 version of this question also offered hypertonic muscles; simple hypertonicity is listed under acute, while chronic hypertonicity becomes ropey.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 198-199
2020 TA Review (Middletown) Exam 1 · TA review · slides 231-232
2020 TA Review Exam 1 · TA review · slides 222-223
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 6
612asked 2×Acute vs chronic findings
Match each item (acute VSR restrictive barrier; chronic VSR restrictive barrier; acutely facilitated segment; chronically facilitated segment) to its findings: A. Not a firm barrier. B. Ropey muscles. C. Thickened skin. D. Increased temperature. E. Boggy muscles. F. Prolonged red reflex. G. Firm restrictive barrier.
AnswerAcute VSR barrier = A (not firm); chronic VSR barrier = G (firm); acutely facilitated segment = D, E, F; chronically facilitated segment = B, C.
Other acute findings: increased skin moisture and drag, muscle hypertonicity. Other chronic findings: hypersensitive muscles, stiff joints with a firm end-feel, rapidly fading red reflex.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 147-148
2024 TA Review (Harlem) Exam 1 · TA review · slide 123
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 6
8.5 · 23 questions · Questions 613–635
Sympathetic levels
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A visceral problem shows up as TART in the paraspinal tissue at the levels that carry that organ's sympathetic supply. Learn the table, then use side to choose between organs at the same level.
Schematic: T1–T6 organs above the diaphragm; T5–T9 just under it; T9–T12 in between; T12–L2 just above the pelvic diaphragm. Sympathetic outflow ends at L2, so L3–L5 and cervical levels are never sympathetic viscerosomatic levels.
T5–T9 left; textbook heartburn pattern: C2 left (vagus), T3 right (esophagus), T5 left (stomach)
Appendicitis (Rovsing sign), right colon cancer
T10–T11 right (e.g. T11)
Kidney, upper ureter, testicular torsion, ovary
T10–T11
Pheochromocytoma (adrenal medulla)
T10
Sigmoid diverticulitis
T12–L2; inferior mesenteric ganglion
BPH (hesitancy, nocturia), dysmenorrhea
T12–L2 (L1, T12)
Clue: back pain that improves with OMT briefly and returns the next day suggests a visceral origin; convert any spinous-process landmarks to vertebral levels with the rule of 3s, then match the level and side.
Lecture slides for this section (2)
Written Review slide 34: sympathetic innervation by levelWritten Review slide 35: general organ schematic
613Sympathetic levels
A 25-year-old woman comes to your office complaining of feeling down after her boyfriend broke up with her. On examination, her left paraspinal muscles are warm and erythematous at the levels of T1-T6. These palpatory findings indicate further investigation into which organ system?
Ans: T1-T6 = heart and lungs → left-sided → heart
Why: T1-T6 supplies the heart and lungs, and the heart tends to show left-sided findings.
Explanation & sources
Explanation
Lungs share T1-T6 but are not specifically left-sided. Appendix is T10-T11 right; kidneys T10-T11; liver T5-T9 right; colon T10-L2; bladder T12-L2.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 186-187
Lecture slide (1)
Week 8 · Written Review deck · slide 34
614top 215asked 2×Sympathetic levels
A patient with pericarditis comes into your office. Where will you expect to palpate tissue texture changes along the spine?
Ans: Heart → T1-T6 → heart findings tend to be left-sided
Why: The heart's sympathetic level is T1-T6, and heart findings tend to be left-sided.
Explanation & sources
Explanation
A (T5-T9 right) is liver, gallbladder, duodenum, head of pancreas. B (T12-L2) is descending and sigmoid colon, lower ureter, and pelvic organs. C has the right level but the wrong side.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 223-224
2020 TA Review Exam 1 · TA review · slides 214-215
Lecture slide (1)
Week 8 · Written Review deck · slide 34
615Sympathetic levels
A 32-year-old man presents with chest pain, chest tightness, and shortness of breath. On examination, his bilateral paraspinal muscles feel cool and ropey at the level of T1-T6. What organ do you suspect to be the cause of his condition?
Why: T1-T6 covers the heart and lungs. Bilateral findings fit the paired lungs; the heart usually gives left-sided findings.
Explanation & sources
Explanation
Cool and ropey tissue is a chronic picture (the TA scenario was chronic vaping). Stomach and liver are T5-T9; kidneys and small intestine T10-T11; bladder T12-L2.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 192-193
Lecture slide (1)
Week 8 · Written Review deck · slide 34
616Sympathetic levels
A patient presents with back pain that improves with manipulation only briefly, then returns the next day. On forward bending you find a rib hump on the right that begins at the spinous process of T3 and ends at the spinous process of T6. The TPs in that area are all rotated to the right and do not change in flexion or extension. You suspect a visceral origin. What is highest on your differential?
Why: Somatic dysfunction that keeps returning after OMT suggests a visceral source. T3-T6 sits in the T1-T6 heart and lung range, so pneumonia fits.
Explanation & sources
Explanation
Hepatitis and gallbladder disease are T5-T9 right. Gastritis is T5-T9 left. The upper ureters are T10-T11. The IA5 version of this vignette puts the hump at T10-T12, which points to the upper ureters instead.
Asked in
2022 TA Review - Exam 1 · TA review · slides 60-61
A 15-year-old male presents to your office with an acute asthmatic exacerbation. Structural examination will most likely reveal tissue texture changes at
Ans: Asthma → lungs → T1-T6 → T2-T6
Why: The lungs' sympathetic level is T1-T6 in the course (T2-T7 in the textbook), so T2-T6 fits.
Explanation & sources
Explanation
C2-C7 has no sympathetic outflow (cervical ganglia get fibers from T1-T4). T5-T10 centers on the upper GI organs. T9-T11 is small bowel, kidney, and gonads. T12-L2 is the lower colon and pelvis.
A 44-year-old female presents with right upper abdominal pain that radiates to her back. An abdominal ultrasound reveals inflammation of her gallbladder secondary to gallstones. Where would you expect to find palpable evidence of acute somatic dysfunction in this patient?
Ans: Gallbladder → celiac, T5-T9 → right side → T7-8 right
Why: The gallbladder is upper abdominal viscera (T5-T9, celiac ganglion) and sits on the right. The lecture's own example: gallbladder inflammation causes acute changes at T7-8 on the right.
Explanation & sources
Explanation
A and C (T1-T4) are head, neck, heart, and lungs. D (T10-T12 right) is appendix, cecum, ascending colon, kidney. E points to vagal (parasympathetic) reflexes, not the expected sympathetic finding. The 2023 TA version offered 'T6-8 on the right' as the answer; same idea.
Your patient is having pain. You palpate his back and find that he is having gallbladder pain. At what levels and on what side does that correspond to?
Ans: Gallbladder → celiac T5-T9 → right-sided organ → T5-T9 right
Why: The gallbladder belongs to the T5-T9 upper abdominal group, on the right with the liver, duodenum, and head of pancreas.
Explanation & sources
Explanation
B runs too low (T10-T11 is small bowel, kidney, gonads). C has the wrong side; left T5-T9 is stomach, spleen, and tail of pancreas. D is the heart and lung level.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 142-143
2024 TA Review (Harlem) Exam 1 · TA review · slides 118-119
Lecture slide (1)
Week 8 · Written Review deck · slide 34
620Sympathetic levels
A man woke up and did not feel well; it turned out his gallbladder was rupturing. His pain corresponded to the levels of:
Why: The gallbladder is an upper abdominal organ, sympathetic level T5-T9 (celiac ganglion).
Explanation & sources
Explanation
A and D overlap the heart and lung range (T1-T6). B is lower GI, kidney, and gonads. Gallbladder pain can also refer to the right shoulder or scapula.
Asked in
2024 TA Review (Harlem) Exam 1 · TA review · slides 78-79
Lecture slide (1)
Week 8 · Written Review deck · slide 34
621Sympathetic levels
A patient presents with abdominal pain worse after eating greasy foods and RUQ tenderness. Suspecting gallbladder, where would you expect to find somatic dysfunction/TART changes on his spine?
Why: The gallbladder maps to the T5-T9 upper abdominal group; T6-T9 is the only option inside that range.
Explanation & sources
Explanation
T1-T6 is heart and lungs. T10-T12 and T10 are small bowel, kidney, appendix, and gonads. The 2026 slides use T5-T9 for the gallbladder; this older TA deck wrote T6-T9.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 76-77
Lecture slides (2)
Week 8 · Written Review deck · slide 34Week 8 · Written Review deck · slide 35
622asked 3×2026Sympathetic levels
A 42-year-old obese female presents with right upper quadrant pain that radiates to the tip of the right scapula. Examination reveals severe pain while the patient inhales with your fingers beneath the right subcostal margin. At which vertebral levels would you expect to find somatic changes?
Why: This is a positive Murphy sign, so think cholecystitis. The gallbladder's reflex is T5-T9 (greater splanchnic nerve, celiac ganglion).
Explanation & sources
Explanation
T1-T4 is head and neck. T9-T11 is small bowel and kidney. T11-L2 is the lower GI and pelvis. L1-L4 extends below sympathetic outflow, which ends at L2.
A 41-year-old man presents to the ER with severe abdominal pain after eating 70 hot dogs in 10 minutes. He appears pale, cool, and diaphoretic with right paraspinal tenderness and bogginess at T5-T9. Based on your palpatory findings, what do you suspect?
Ans: Right T5-T9 → liver, GB, duodenum, head of pancreas → cholecystitis
Why:Right T5-T9 is the liver, gallbladder, duodenum, and head of pancreas. Acute bogginess fits acute cholecystitis.
Explanation & sources
Explanation
B (stomach) is T5-T9 but on the left. C (appendicitis) is T10-T11 right. A (kidney) is T10-T11. D and F are upper thoracic (T1-T6). G (prostate) is T12-L2.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 188-189
Lecture slide (1)
Week 8 · Written Review deck · slide 34
624Sympathetic levels
A patient presents to your office with back pain. On forward flexion test, you notice a rib hump on the right that begins at T5 and ends at T9 that is also warm upon skin drag test. You suspect this somatic dysfunction to be visceral in origin. Which complication seems to be the most likely?
Ans: Right T5-T9 + warm (acute) → gallbladder → cholecystitis
Why:Right T5-T9 maps to the liver and gallbladder, and warmth suggests an acute process, so cholecystitis fits.
Explanation & sources
Explanation
MI and COPD are T1-T6 (heart left-sided). Appendicitis is T10-T11 right. The bladder is T12-L2.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 115-116
A patient's back pain improves with OMM briefly but returns the next day. On forward bending there is a rib hump on the left from the SP of T5 to the SP of T9. The TPs are all rotated left and do not change in flexion or extension. You suspect a visceral origin. What is highest in your differential?
Ans: Left T5-T9 → stomach, spleen, tail of pancreas → GERD
Why:Left T5-T9 is the stomach, spleen, and tail of the pancreas, so an acid or stomach problem like GERD fits best.
Explanation & sources
Explanation
Prostate is T12-L2. Pneumonia is T1-T6. A UTI involving the upper ureters is T10-T11, lower ureter and bladder T12-L2. The recurring dysfunction after OMT is the clue to look for a visceral cause.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 113-114
2020 TA Review Exam 1 · TA review · slides 102-103
A middle-aged male alcoholic presents with vague abdominal pain. Physical examination reveals scleral icterus, abdominal distension, and caput medusae. Sympathetic innervation to the pathologic organ passes through the
Why: The signs point to liver disease (alcoholic hepatitis or cirrhosis). The liver is T5-T9, via the greater splanchnic nerve to the celiac ganglion.
Explanation & sources
Explanation
E (superior mesenteric) is T10-T11 midgut. B (inferior mesenteric) is T12-L2 hindgut and pelvis. C (otic) is a parasympathetic head ganglion for the parotid. D is not a standard sympathetic ganglion.
A middle-aged male presents with epigastric discomfort and heartburn. Structural examination will most likely find tissue texture abnormalities at which of the following?
Why: The textbook pattern for gastritis or heartburn is C2 left (vagus), T3 right (esophagus), and T5 left (stomach).
Explanation & sources
Explanation
The other options describe right-sided, block, or lower patterns that do not match the esophagus and stomach. This specific pattern comes from the textbook chapter; the 2026 slides only teach the broader rule that the stomach is T5-T9 left and vagal viscera relate to OA-C2.
You palpate the left lower quadrant of your patient's abdomen and they feel pain in the right lower quadrant, indicating appendicitis. Where would you expect tissue texture changes?
Ans: Rovsing sign → appendix → superior mesenteric, T10-T11 right
Why: The appendix, cecum, and ascending colon map to T10-T11 on the right (superior mesenteric ganglion).
Explanation & sources
Explanation
T12-L2 is the descending and sigmoid colon and pelvic organs. Left T5-T9 is stomach and spleen. T1-T4 is head and neck. The Chapman point for the appendix is at the tip of the right 12th rib.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 281-282
2020 TA Review (Middletown) Exam 1 · TA review · slides 225-226
2020 TA Review Exam 1 · TA review · slides 216-217
Lecture slide (1)
Week 8 · Written Review deck · slide 34
629top 215asked 3×2026Sympathetic levels
A viscerosomatic reflex resulting from a right colon cancer would be associated with somatic changes at which spinal segment?
Ans: Right (ascending) colon = midgut → superior mesenteric → T10-T11
Why: The right (ascending) colon is midgut, mapped to T10-T11 on the right via the lesser splanchnic nerve and superior mesenteric ganglion.
Explanation & sources
Explanation
T5 and T8 are upper GI (T5-T9). L2 is the left (descending, sigmoid) colon. E is a trap: the colon's Chapman points lie along the IT band on the lateral thigh, but that is a Chapman point, not the spinal VSR level.
A teenage male presents with acute right-sided testicular pain. A Doppler ultrasound of the scrotum reveals testicular torsion. This is most associated with tissue texture changes at
Ans: Gonads descend from the abdomen → T10-T11
Why: The gonads (testes and ovaries) map to T10-T11, reflecting their abdominal origin.
Explanation & sources
Explanation
T7-T10 is mainly upper GI. L2-L5 and L5-S1 fall below the sympathetic outflow, which ends at L2. The iliac crest is not a viscerosomatic level. Ovaries also map to T10-T11.
A 45-year-old male presents for a follow-up blood pressure check. Past medical history is pertinent for paroxysmal hypertension secondary to an adrenal pheochromocytoma. Structural examination will most likely reveal tissue texture changes at which spinal level?
Ans: Pheochromocytoma → adrenal medulla → T10
Why: The textbook puts the adrenal medulla reflex at T10, in the same band as the kidney (T10-T11).
Explanation & sources
Explanation
OA relates to vagal (parasympathetic) reflexes. T8 is upper GI. T12 and L2 are the lower colon and pelvic organs. The adrenal is not on the 2026 level slide; learn T10 from the textbook and remember the kidney band T10-T11.
Why: The descending and sigmoid colon map to T12-L2 (inferior mesenteric ganglion), along with the lower ureter and pelvic organs.
Explanation & sources
Explanation
OA-C2 is vagal, which stops before the descending colon. T1-T5 is head, neck, heart, lungs. T5-T9 is upper abdominal viscera. T10-T12 is small bowel, kidney, gonads, and the right colon. Asymptomatic diverticulosis without inflammation usually gives no significant VSR findings.
A 25-year-old male comes to the ER with abdominal pain, nausea, fever, and constipation. He is diagnosed with diverticular disease of the sigmoid colon. His muscles are warm and erythematous at the level of T12-L2. Which ganglion is most likely affected?
Why:T12-L2 organs (descending and sigmoid colon, lower ureter, pelvic organs) are served by the inferior mesenteric ganglion.
Explanation & sources
Explanation
C (celiac) is T5-T9. D (superior mesenteric) is T10-T11. A (cervical ganglia) supply the head, neck, and heart from T1-T4. The source called this diverticulosis, but fever and warm, red tissue imply inflammation (diverticulitis); plain diverticulosis usually gives no significant VSR.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 190-191
Lecture slide (1)
Week 8 · Written Review deck · slide 34
634top 215asked 3×2026Sympathetic levels
A 75-year-old male presents to your office with urinary hesitancy and nocturia of 6 months' duration. Treatment to which of the following spinal segments will best alleviate his symptoms?
Ans: Hesitancy + nocturia in older man → BPH → prostate T12-L2 → L1
Why: This is likely benign prostatic hyperplasia. The prostate and other pelvic organs map to T12-L2, so L1 is the answer.
Explanation & sources
Explanation
T5 and T8 are upper GI. T11 is kidney, upper ureter, and gonads. S2 is parasympathetic (pelvic splanchnics), not the sympathetic viscerosomatic level the key is looking for.
A 25-year-old female presents to your office with dysmenorrhea. Viscerosomatic reflex changes associated with uterine dysfunction may be at which spinal level?
Ans: Uterus = pelvic organ → T12-L2 → T12
Why: The uterus is a pelvic organ, sympathetic level T12-L2 in the course (T10-L2 in the textbook). T12 is the only option in range.
Explanation & sources
Explanation
AA relates to vagal reflexes, which do not reach the uterus. C7 has no sympathetic outflow. L4 is below L2. Uterine parasympathetics come from S2-S4, not S1.
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The parasympathetic system has two spinal-related reflex zones:
Zone
Nerve
Viscera
OA, C1, C2 (AA)
Vagus (CN X)
Heart, lungs, upper and middle GI tract (to about the splenic flexure, incl. the midgut and appendix), pancreas, liver, gallbladder, kidney, proximal ureter
Sacrum, S2–S4
Pelvic splanchnic nerves
Descending and sigmoid colon, rectum, bladder, distal ureter, pelvic organs/genitals
The vagus exits the skull through the jugular foramen (with CN IX, XI and the internal jugular vein), at the occipitomastoid suture. Restriction there can irritate the vagus → upper GI effects such as gastritis; treating the occiput and atlas may affect vagal viscera such as the pancreas. Vagal effects never include the bladder, rectum or distal colon (S2–S4), and vagal tone slows the heart (bradycardia, not tachycardia).
Don't confuse the two levels for one organ: the appendix's sympathetic level is T10–T11 right, but its parasympathetic supply is vagal, linked to OA/AA (C1–C2).
636top 215asked 3×2026Parasympathetic levels
A newborn receives a structural examination and a restriction of the occipitomastoid suture at the jugular foramen is identified. This somatic dysfunction is most associated with
Why: The vagus nerve exits the jugular foramen, so occipitomastoid restriction irritates it. Vagal (OA-C2) reflexes include the upper and middle GI tract, so gastritis fits.
Explanation & sources
Explanation
A, C, and D involve the distal colon, rectum, and bladder, which get parasympathetics from S2-S4, not the vagus. E is wrong because the vagus slows the heart (bradycardia). CN IX, X, XI and the internal jugular vein pass through the jugular foramen.
A newborn receives a structural examination and a restriction of the occipitomastoid suture at the jugular foramen is identified. Treatment is then focused on the occiput and atlas. This may affect which of the following visceral structures?
Ans: Occiput/C1 → vagal reflexes → upper/middle GI incl. pancreas
Why: The occiput, C1, and C2 carry the vagal parasympathetic reflexes for the heart, lungs, upper and middle GI tract, pancreas, liver, gallbladder, kidney, and proximal ureter.
Explanation & sources
Explanation
B (bladder) gets parasympathetics from S2-S4. A (adrenal) is a sympathetic T10 target. D and E are not on the vagal OA-C2 list.
A young female presents with periumbilical discomfort which later migrated to the right lower quadrant. She has an associated fever and is experiencing anorexia and nausea. Which of the following spinal segments may alter the parasympathetic innervation to the diseased organ?
Why: This is appendicitis. The appendix is midgut, whose parasympathetics come from the vagus, linked to the OA, C1, and C2 (AA).
Explanation & sources
Explanation
C and D are sympathetic levels (the appendix sympathetic level is T10-T11 right). E (S2-S4) covers the descending colon, rectum, and pelvic organs, not the appendix. C7 has no autonomic role here.
Level clues: T3 is in the head/neck/heart/lung range → sympathetic stimulation there contributes to tachycardia. T10 supplies the gonads, kidneys, adrenal medulla, middle GI and lower extremities → ejaculation. A panic attack (sympathetic overdrive) → ↑ respiratory rate. If a question asks for the effect of vagal (parasympathetic) stimulation, choose the only parasympathetic effect offered (e.g. pupillary constriction, even though the pupil's parasympathetics are really CN III).
639top 215asked 3×2026SNS vs PNS effects
A young female presents for osteopathic manipulation. During the structural exam a lesion at T3 is identified. Stimulation of the sympathetic chain ganglia at this region may contribute to
Why: T3 lies in the head, neck, heart, and lung range. Sympathetic stimulation there speeds the heart (tachycardia).
Explanation & sources
Explanation
A, B, C, and D are all parasympathetic effects. Sympathetic effects at this level would be bronchodilation, mydriasis, reduced glandular secretion, and sweating. Detrusor contraction comes from S2-S4.
A teenage male presents to urgent care with an acute panic attack. The autonomic nervous system is most likely in sympathetic overdrive. This is associated with which of the following?
Ans: Panic → fight or flight → tachypnea, tachycardia, mydriasis
Why: Fight or flight raises the respiratory rate and heart rate and dilates the pupils and bronchi.
Explanation & sources
Explanation
A is backwards; the sympathetic system drives glycogenolysis to free energy. B is backwards; GI motility falls. D and E are parasympathetic effects.
A young female presents with periumbilical discomfort which later migrated to the right lower quadrant. She has an associated fever and is experiencing anorexia and nausea. An increase in the sympathetic tone to the abdominal cavity will result in an increase in
Ans: Sympathetic → mobilize fuel, slow gut → gluconeogenesis up
Why: Sympathetic tone makes the liver release fuel through gluconeogenesis and glycogenolysis.
Explanation & sources
Explanation
Sympathetic tone slows the gut: it decreases motility (A), absorption (B), and secretions (D, E), relaxes the gut wall, and contracts sphincters. Digestive activity is parasympathetic.
A 45-year-old male presents for a follow-up blood pressure check. Past medical history is pertinent for paroxysmal hypertension secondary to an adrenal pheochromocytoma. Sympathetic stimulation of the involved segment (T10) may cause
Ans: T10 includes gonads → sympathetic = ejaculation ('point and shoot')
Why: T10 supplies the gonads, kidneys, adrenal medulla, middle GI, and lower extremities. Sympathetic stimulation of the reproductive tract causes ejaculation.
Explanation & sources
Explanation
Erection is parasympathetic ('point' = parasympathetic, 'shoot' = sympathetic). Sympathetic activation via the adrenal causes tachycardia, not bradycardia. Sympathetic tone decreases lymph flow and pancreatic secretion.
A newborn receives a structural examination and a restriction of the occipitomastoid suture at the jugular foramen is identified. Osteopathic manipulation is focused on stimulation of the vagus nerve. Treatment will most likely lead to:
Ans: Vagal = parasympathetic → pick the only parasympathetic effect → miosis
Why: Vagal stimulation is parasympathetic. Pupillary constriction is the only parasympathetic effect listed.
Heads up: Textbook key is D. Strictly, the pupil gets its parasympathetic supply from CN III, not the vagus; D wins only because it is the one parasympathetic effect among the choices.
Explanation & sources
Explanation
Parasympathetic tone relaxes GI sphincters and increases motility (A and B are sympathetic). It slows the heart and lowers contractility (C is sympathetic). The vagus does not innervate the bladder, and urinary retention is a sympathetic effect.
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Efferent sympathetic nerves synapse in the paravertebral (chain) or prevertebral ganglia before reaching their target organ. The thoracic chain ganglia lie directly anterior to the rib heads, in close relation to the costotransverse articulation (not posterior to the ribs). They hang from the spinal nerves by the white and gray rami communicantes, lateral to the T1–T12 vertebral bodies; upper lumbar chain ganglia lie lateral to the lumbar vertebrae.
Consequences:
Somatic dysfunction of a thoracic vertebra and/or rib can irritate or inhibit a thoracic sympathetic nerve (at the costotransverse joint, not the facet, disc or PLL).
To treat the ganglion, treat both the rib and the thoracic vertebra.
When treating viscerosomatic reflexes, OMT aims to reduce sympathetic outflow, and the area of particular importance is the costotransverse articulation (e.g. rib raising).
Lecture slide for this section (1)
IA8 slide 28: sympathetic outflow and the chain ganglia
644Chain ganglia & OMT
True or false: The sympathetic trunk lies anterior to the thoracic TPs and posterior to the ribs.
Ans: Chain ganglia sit anterior to rib heads → 'posterior to ribs' is false
Why: The thoracic chain ganglia lie directly anterior to the rib heads, near the costotransverse articulation, not behind the ribs.
Explanation & sources
Explanation
This anterior relationship to the rib-vertebra articulation is why rib raising and treating both the rib and the vertebra can influence sympathetic outflow.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 125-126
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 28
645Chain ganglia & OMT
Sympathetic chain ganglia are located close to the ____ part of the ribs.
AnswerThe head of the ribs (not the neck); the chain ganglia lie just anterior to the rib heads, near the costotransverse articulation.
Ans: Thoracic chain ganglia → directly anterior to rib head → near costotransverse joint
Why: The thoracic paravertebral ganglia lie directly anterior to the corresponding rib head, in close relation to the costotransverse articulation.
Explanation & sources
Explanation
They hang from the segmental spinal nerve by the white and gray rami communicantes, lateral to the T1-T12 vertebral bodies. Upper lumbar chain ganglia lie lateral to the lumbar vertebrae and are reached with deep paraspinal soft tissue work.
True or false: Somatic dysfunction of the thoracic vertebrae and/or ribs can irritate a thoracic sympathetic nerve.
Ans: Ganglia lie in front of rib-vertebra joint → SD there irritates/inhibits SNS
Why: The sympathetic ganglia sit anterior to the rib-vertebra articulation, so somatic dysfunction of a thoracic vertebra or rib can irritate or inhibit a thoracic sympathetic nerve.
Explanation & sources
Explanation
This is why, to treat the ganglion, you treat both the rib and the thoracic vertebra. Efferent sympathetic nerves synapse in these paravertebral or prevertebral ganglia before reaching their target organ.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 125-126
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 28
647Chain ganglia & OMT
Irritation or inhibition of thoracic efferent sympathetic nerves can occur at which of the following joints?
Ans: Chain ganglia anterior to rib head/costotransverse joint → costotransverse
Why: The thoracic chain ganglia lie anterior to the rib heads and costotransverse articulations, so dysfunction there can irritate or inhibit sympathetic outflow.
Explanation & sources
Explanation
Zygapophyseal (facet) joints are posterior, away from the chain. The disc and posterior longitudinal ligament are midline, related to the canal. The thoracolumbar junction is a region, not the joint next to each ganglion.
Asked in
2025 TA Review Exam 1 (Middletown) · TA review · slides 199-200
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 28
648top 215asked 5×2026Chain ganglia & OMT
With viscerosomatic reflexes, OMT has the goal of reducing sympathetic outflow. What anatomic area do most of these treatments target?
Why: The sympathetic chain ganglia lie in front of the costotransverse articulation, so treating the rib and thoracic vertebra there (for example with rib raising) targets sympathetic outflow.
Explanation & sources
Explanation
Facet joints are posterior to the chain. The psoas is a lumbar muscle, not a sympathetic target. The dorsal horn cannot be reached directly. E is tempting, but the slide names the costotransverse articulation as the area of particular importance.
Why: The course names the costotransverse articulation as the area of particular importance, because the chain ganglia rest just anterior to it.
Explanation & sources
Explanation
Costochondral and costosternal joints are at the front of the chest, far from the chain. Costovertebral (rib head) is the trickiest distractor since the ganglia lie anterior to the rib head, but the course language and rib-raising rationale point to the costotransverse joint.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 287-288
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 28
8.9 · 6 questions · Questions 650–655
Chapman points
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Chapman reflex points are a form of viscerosomatic reflex. Each organ has points in predictable locations, usually present both anteriorly and posteriorly.
Feature
Chapman point
Feel
A nodule like a “pea” or “BB”, 2–3 mm: smooth, firm, discretely palpable (in chronic cases points coalesce and feel bigger)
Depth
Beneath the subcutaneous tissue, on the deep fascia (not superficial fascia, not muscle)
Tenderness
Usually tender to the patient, but it is not a Jones tender point (those are dime-sized, in muscle)
Location
Anterior points: intercostal spaces near the sternum. Posterior points: lateral to the spinous processes (the course wording; don’t pick “medial to the transverse process”). Exceptions: colon points along the IT band (lateral thigh); appendix at the tip of the right 12th rib
Links
The lymphatic system and the sympathetic nervous system (Chapman: a ganglioform contraction that blocks lymphatic drainage)
Treatment
Firm, circular pressure for 20–30 seconds; either the anterior or the posterior point can be treated; Chapman said to treat innominate dysfunction first
Lecture slide for this section (1)
IA8 slide 31: the Chapman point
650top 215asked 5×2026Chapman points
Which of the following best describes Chapman reflex areas or 'points'?
Ans: Chapman point = pea-sized nodule beneath subQ tissue on deep fascia
Why: Chapman points are usually beneath the subcutaneous tissue, on the deep fascia.
Explanation & sources
Explanation
B is half right: they are pea-sized (2-3 mm) but usually tender. C and D are wrong; points occur both anteriorly and posteriorly. E is wrong; anterior points are in the intercostal spaces near the sternum and posterior points are lateral to the spinous processes.
Ans: Chapman = discrete pea or BB, 2-3 mm, beneath subQ, on deep fascia
Why: A Chapman point is a smooth, firm, discretely palpable 'pea' or 'BB' (2-3 mm) beneath the subcutaneous tissue on the deep fascia.
Explanation & sources
Explanation
A is wrong because Chapman points are usually tender. B describes a Jones counterstrain tender point, which lies in muscle. D is wrong; Chapman points are a form of viscerosomatic reflex and reflect visceral dysfunction.
Asked in
2023 TA Review - Written Exam 1 · TA review · slides 201-202
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 31
652top 215asked 2×Chapman points
Which best describes the Chapman's point?
Ans: Chapman point → usually tender, firm, 2-3 mm, on deep fascia
Why: Chapman points are usually tender to the patient.
Explanation & sources
Explanation
A is wrong; they lie beneath the subQ tissue on the deep fascia. B is wrong; they are smooth and firm. D is wrong; they are 2-3 mm. In chronic cases points coalesce and feel bigger. Being tender does not make them Jones tender points, which are in muscle.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 228-229
2020 TA Review Exam 1 · TA review · slides 219-220
Lecture slide (1)
Week 8 · IA8 Autonomics · slide 31
653Chapman points
Which of the following describes a Chapman point?
Ans: Slide: Chapman points occur in predictable locations, anterior AND posterior
Why: The slides state that Chapman points tend to occur in predictable locations, usually present both anteriorly and posteriorly.
Explanation & sources
Explanation
A is wrong; they are not in muscle (that is a tender point). B is wrong; they are usually tender. D is wrong; they are on the deep fascia. C is not how the course words it: posterior points are described as lateral to the spinous processes, near the transverse processes.
Asked in
2022 TA Review (Middletown) - Exam 1 · TA review · slides 290-291
Lecture slide (1)
Week 8 · Written Review deck · slide 51
654asked 2×Chapman points
True or false: Chapman's points are only found on the posterior aspect of the body.
Ans: Chapman points come in anterior AND posterior pairs → false
Why: Chapman points are usually present both anteriorly and posteriorly.
Explanation & sources
Explanation
Anterior points are in the intercostal spaces near the sternum; posterior points are lateral to the spinous processes. Colon points are an exception, found along the lateral thigh (IT band). Current thinking is that either the anterior or the posterior point can be treated.
Asked in
2020 TA Review (Middletown) Exam 1 · TA review · slides 236-237
2020 TA Review Exam 1 · TA review · slides 228-229
Lecture slide (1)
Week 8 · Written Review deck · slide 51
655asked 2×Chapman points
Chapman points: What does one feel like? Where is it located? Is it a tender point? Are they located anterior, posterior, or both? What two systems does it link?
AnswerA pea-like nodule 2-3 mm, smooth and firm; beneath subQ tissue on the deep fascia; not a (Jones) tender point and not in muscle, though usually tender; both anterior and posterior; links the lymphatic and sympathetic nervous systems.
Ans: Pea, 2-3 mm → deep fascia → not a muscle tender point → front + back → lymphatic + SNS
Why: Chapman described the point as a ganglioform contraction that blocks lymphatic drainage; current thinking links the lymphatic system with the sympathetic nervous system. It is a form of viscerosomatic reflex.
Explanation & sources
Explanation
Tender to the patient does not mean it is a Jones tender point, which lies in muscle. Treat with firm, circular pressure for 20-30 seconds; Chapman said to treat innominate dysfunction first.
Asked in
2025 TA Review Exam 1 (Harlem) · TA review · slides 149-150
2024 TA Review (Harlem) Exam 1 · TA review · slide 125