Integrating Osteopathic Manipulative Treatment into Clinical Care Helen Luce DO Mark Robinson DO University of Wisconsin Department of Family Medicine STFM Annual Meeting – Denver, CO April 29, 2009

Welcome & Introductions Presenters Helen Luce DO Mark Robinson DO Purpose of workshop Overview of osteopathic philosophy and the use of OMT in specific clinical scenarios.

Objectives Describe the osteopathic philosophy. Review clinical situations in which OMT can augment other medical therapy and improve patients’ health. Participate in OMT through observation or performance.

Overview Osteopathic medicine Osteopathic philosophy OMT (Osteopathic Manipulative Treatment) Overview of some common techniques

Definition Osteopathic Medicine “A complete system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery and obstetrics. Emphasizes the interrelationship between structure and function, and has an appreciation of the body’s ability to heal itself.” From: Glossary of Osteopathic Terminology Usage Guide A system of diagnosis and treatment that recognizes the role of the musculoskeletal system in the healthy functioning of the human body. From: AMA Encyclopedia of Medicine

Osteopathic Philosophy Four basic principles Body functions as a unit – body, mind, spirit Structure and function are interrelated Body is capable of self-regulation, self-healing, and health maintenance Rational treatment is based on understanding these principles

Somatic Dysfunction Impaired or altered function of related components of somatic system (body framework) Skeletal and myofascial structures Related vascular, lymphatic, & neural elements

Palpatory Diagnosis T: Tissue texture abnormalities A: Asymmetry R: Restriction of motion T: Tenderness

Barrier Concepts Anatomic Barrier Physiologic Barrier Restrictive Barrier Anatomic Physiologic Restrictive Physiologic Anatomic Barrier Barrier Barrier Barrier Barrier

Direct and Indirect Techniques Technique that engages the most restrictive barrier Indirect Technique that engages the least restrictive barrier

Forces Applied in OMT Extrinsic Intrinsic Supplied by physician Supplied by patient

OMT Includes many different techniques Requires additional training (300+ hrs during med school) ongoing practice and continuing education

Safety of OMT Low rate of complications ~1 in 1 million Careful patient and modality selection Most serious complications Vertebrovascular accidents Cauda Equina syndrome Modality most associated with complications is HVLA

Contraindications to OMT Case-by-case basis Fracture, dislocation, tumor, infection, and osteomyelitis (directly over that site) Age Non-fused growth plates

Contraindications (2) Careful consideration: Down Syndrome, RA, pregnancy, strains & sprains, acute herniated disc, acute inflammatory situations, anatomic instability, hypermobility, joint prosthesis, and severe manifestations of visceral disorders

Avoiding Complications Thorough H & P keep possible pathology in mind Rule out what can cause serious damage to the patient, if manipulated Understand the anatomy, physiology, and biomechanics of the region

Red Flags Medical conditions that may lead a patient to experience serious injury, paralysis or death Need further exploration with: History & physical exam Imaging studies Laboratory studies Consultation Before OMT can be performed safely

Red Flag Summary V FIRST F: fracture V: vessel disease F: fracture I: infection (in bone or disc)/instability R: radiculopathy/spinal cord injury or risk of S: stroke or history of stroke/spinal stenosis T: trauma (severe)/tumors/thrombus

Common Side effects Transient Dizziness Decrease of symptoms Soreness No change in symptoms

Common Techniques HVLA Muscle Energy Soft Tissue Counterstrain Facilitated Positional Release Lymphatic Visceral Myofascial Release Cranial Still Techniques Balanced Ligamentous Techniques Articulatory

Soft Tissue Techniques Direct technique Indications ↓muscle spasm; stretch and ↑elasticity; improve circulation; ↑ venous and lymphatic drainage; promote patient relaxation Absolute contraindications: none “Involves lateral stretching, linear stretching, deep pressure, traction, and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation”

Suboccipital Release, Supine

Rib Raising, Supine Extension

Myofascial Release Techniques Direct, indirect, or combination of both Indications ↓ muscle and fascial tension; stretch and ↑ elasticity in tight tissues; improve circulation to specific region; ↑ venous and lymphatic drainage Absolute contraindications: none “Designed to stretch and reflexly release patterned soft tissue and joint-related restrictions”

Myofascial Release Techniques

Muscle Energy Techniques Direct technique Indications 1º = Somatic dysfunction of myofascial or articular origin 2º = Improve circulation, balance neuromuscular relationships, and ↑ tone in hypotonic/weak muscles Absolute contraindications Fracture, dislocation, or joint instability Patient unable to understand instructions or uncooperative “system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the physician; from a precisely controlled position, against a defined resistance by the physician”

Psoas and Iliacus muscles

Psoas Muscle Dysfunction

Piriformis Muscle

Piriformis Muscle Dysfunction

HVLA Direct technique Indications Absolute contraindications Somatic dysfunction of articular origin Absolute contraindications Joint instability; severe osteoporosis; bony metastasis, osteomyelitis, other infection, or joint replacement in the treatment area; osteoarthritic joint with ankylosis; severe herniated disc with radiculopathy; congenital anomalies; Down syndrome (esp. c-spine); RA of c-spine; achondroplastic dwarfism (c-spine) “Uses high-velocity/low-amplitude forces; also called mobilization with impulse treatment”

Left L5—S1 Dysfunction

Balanced Ligamentous Techniques Indirect technique Indications Somatic dysfunctions of articular or myofascial basis; areas of lymphatic congestion or local edema Absolute contraindications: none

Carpal Tunnel Syndrome

Visceral Techniques Direct, indirect, or combined Indications Multiple, depending on specific organ dysfunctions Cardiac, pulmonary, GI, GU, gyn, etc. Absolute contraindications: none “system of diagnosis and treatment directed to the viscera to improve physiologic function; typically the viscera are moved toward their fascial attachments to a point of fascial balance”

Singultus (Hiccups)

Sacral Rock for Dysmenorrhea

Lymphatic Techniques Technique classification Indications Removing restrictions to lymphatic flow vs. promoting lymphatic flow Indications Lymphatic congestion (postsurgical edema), mild to moderate CHF, URI/LRI, other infections, asthma, COPD, pain due to lymphatic congestion & swelling Absolute contraindications Fracture, dislocation, or osteoporosis; acute hepatitis; malignancy; organ friability (inf. Mono); acute indurated lymph node

Auricular Drainage Technique for otitis media/externa

Ischiorectal Fossa Release, Prone

Pedal Pump for lymphatic congestion/edema

Small Group Session Ideas Headaches Post-op ileus Pneumonia GERD Asthma Sinusitis Hiccups Otitis media Constipation Back pain in pregnancy Edema in pregnancy Dysmenorrhea Carpal Tunnel Syndrome Others…

Summary Osteopathic Medicine and Osteopathic Philosophy Review of common OMT techniques Examples of integrating OMT in specific clinical situations

Resources Nicholas, A and Nicholas, E. Atlas of Osteopathic Techniques. Philadelphia: Lippincott Williams & Wilkins, 2008. Ward, R (ed). Foundations for Osteopathic Medicine. Philadelphia: Lippincott Williams & Wilkins, 2003. Greenman, P. Principles of Manual Medicine. Philadelphia: Lippincott Williams & Wilkins, 2003. Nelson, K and Glonek, T (ed). Somatic Dysfunction in Osteopathic Family Medicine. Philadelphia: Lippincott Williams & Wilkins, 2006.