Integrating Osteopathic Manipulative Treatment into Clinical Care Helen Luce DO Marguerite Elliott DO, MS Mark Robinson DO University of Wisconsin Department of Family Medicine May 3, 2008

Welcome & Introductions Presenters Helen Luce DO Marguerite Elliott DO, MS Mark Robinson DO Purpose of seminar Overview of osteopathic philosophy, the use of OMT in specific clinical scenarios, and guidelines for the allopathic precepting physician.

Objectives Describe 3 clinical situations in which OMT can be performed to augment other medical therapy and improve patients’ health. Participate in OMT through observation or performance of 2 specific treatments. Discuss precepting methods for allopathic physicians who supervise osteopathic residents performing OMT.

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

Definition Osteopathic Medicine A system of diagnosis and treatment that recognizes the role of the musculoskeletal system in the healthy functioning of the human body. -From the 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 Supplied by physician Intrinsic Supplied by patient

OMT Includes many different techniques Requires additional training (200-600 hrs during med school) Requires ongoing practice and continuing education

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

Contraindications Case-by-case basis Fracture, dislocation, tumor, infection, and osteomyelitis are contraindications for OMT directly over that site Conditions to consider carefully: Down Syndrome, RA, pregnancy, strains & sprains, acute herniated disc, acute inflammatory situations, anatomic instability, hypermobility, joint prosthesis, and severe manifestations of visceral disorders

Common Techniques HVLA Muscle Energy Soft Tissue Counterstrain Facilitated Positional Release Lymphatic Visceral Myofascial Release Cranial Techniques of Still Balanced Ligamentous Tension & Ligamentous Articular Strain Articulatory

Soft Tissue Techniques Direct technique “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” Indications ↓muscle spasm; stretch and ↑elasticity; improve circulation; ↑ venous and lymphatic drainage; promote patient relaxation Absolute contraindications: none

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

Muscle Energy Techniques Direct technique “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” 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 at treatment site Patient unable to understand instructions or uncooperative

HVLA Direct technique Indications Absolute contraindications “Uses high-velocity/low-amplitude forces; also called mobilization with impulse treatment” Indications 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)

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

Visceral Techniques Direct, indirect, or combined Indications “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” Indications Multiple, depending on specific organ dysfunctions Cardiac, pulmonary, GI, GU, gyn, etc. Absolute contraindications: none

Lymphatic Techniques Technique classification Indications Techniques removing restrictions to lymphatic flow vs. those 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

Interactive Clinical Scenarios (small groups) 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 using OMT in specific clinical situations Guidelines for allopathic preceptors

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.

Questions?