Osteopathic Manipulation Peter D. Muench, D.O. NCC PCSM Fellow

Outline History Principles of Osteopathy Basic Terminology Techniques Workshop A. T. Still, M.D., D.O.

Dr. Andrew Taylor Still Mid 19th Century frontier physician and Civil War surgeon Dissatisfied with conventional “heroic” medicine Devised new system of disease prevention and treatment through mechanical manipulation Wanted to treat cause instead of effect Founded first school of Osteopathy in Kirksville, MO in 1894

Osteopathic History 20th century struggle for recognition Unrestricted Medical License in all 50 states (1901-1989) Federal recognition 1966: entry into DoD Medical Corps AMA recognition 1969 LTG Ronald Blanck, DO

Core Principles 1. The body is a unit, and the person represents a combination of body, mind, and spirit. 2. The body is capable of self-regulation, self-healing, and health maintenance. 3. Structure and function are reciprocally interrelated. 4. Rational treatment is based on correct understanding of the above principles.

Somatic Dysfunction Impaired or altered function of ANY part of the soma: skeletal, myofascial, and related vascular, lymphatic and neural elements Diagnosed via PALPATION Freedom of motion vs. Restricted motion Findings T – tenderness A – asymmetry R – restricted range of motion T – tissue texture changes

Tissue Texture Changes Acute Immediate Vasodilation Edema/swelling Increased moisture Heat/redness Rough texture “Boggy” tissue Chronic Longstanding Fibrosis Pruritic Cool Ropy or stringy tissues Dryness Thin texture

Barriers to Motion Physiologic Barrier Physiologic Barrier Restrictive Anatomic Barrier Anatomic Barrier Tissue Damage N Active ROM Passive ROM

Manipulative Techniques Direct Soft Tissue Muscle Energy HVLA Myofascial Release Indirect Counterstrain Facilitated Positional Release Myofascial Release

Soft Tissue Techniques Relax hypertonic muscles Stretch passive fascial structures Enhance local circulation, improving local tissue nutrition, oxygenation, etc Identify somatic dysfunction Provide general state of relaxation

Muscle Energy Technique Direct technique Precisely controlled position Patient actives muscles on request Examiner provides a distinctly executed counterforce

High Velocity Low Amplitude Specific joint mobilization Corrects loss of normal ROM Not “putting back” something that is “out of place” Short, quick thrust through restricted barrier Does not require a “pop” for success Advanced technique that requires knowledge, practice, and experience

Strain / Counterstrain Spontaneous release by positioning Find tenderpoint Find position of comfort with patient relaxed Hold for 90 seconds Passive return to neutral position Recheck tenderpoint Safe, simple to perform, well tolerated

Myofascial Release Direct and Indirect technique Fascia is a seamless web of connective tissue surrounding and connecting muscles, organs, and skeletal structures Fascia can tighten in any plane of motion as a response to illness or injury – there is also a corresponding looseness Treatment uses varieties of traction, twist, shear, and compression forces applied three-dimensionally Integrated technique – requires experience

Questions?

Workshop – Soft Tissue Suboccipital Inhibition Patient supine Pads of examiners fingers in suboccipital tissues just inferior to nuchal line Lift and support patient’s head, gravity pulls down to table Repeat as necessary

Workshop – Soft Tissue Cervical stretching Patient supine Examiner crosses arms under patients heads with fingers on anterior shoulders of patient Can stretch in flexion, roatation, and sidebending Can combine with Muscle Energy Technique

Workshop – Soft Tissue Over/Under Thoracic Patient seated, examiner facing patient Patient crosses arms, examiner reaches under patient’s arms and over shoulders to t-spine soft tissues Examiner leans back drawing patient towards you while exerting downward and anterior pressure on soft tissue with pads of fingers Can combine with deep articulatory technique

Workshop – Soft Tissue Supine Lumbar Rotation with Counterleverage Patient supine with flexed knees and hips Pull patients knees toward you with caudad hand, reach under lumbar soft tissues with cephalad hand Pull up on lumbar soft tissues, push knees away from you Repeat, bilaterally if necessary

Workshop – Soft Tissue Prone Lumbar Pressure with Counterleverage Patient prone, stand at patient’s hip level Contact lumbar soft tissues on opposite side of patient with cephalad hand, grasp ASIS with caudad hand Pull up on ASIS, kneed down on lumbar soft tissues Repeat, bilaterally if necessary

Workshop – Soft Tissue Rhomboids Patient lateral recumbent, treatment side up Grasp superior shoulder with cephalad hand, reach under patients arm and grasp medial scapula with caudad hand Time stretching with patient inhaling Repeat as necessary Be sure to maintain positive control of shoulder girdle

Workshop – Muscle Energy Technique: Position bone, joint, body part at position of resistance (Restrictive Barrier) Instruct patient to lightly resist – away from the barrier with 20% to 30% of strength, while examiner provides equal counterforce (no movement) Hold for 3 to 5 seconds, then patient relaxes Take up slack, move to new barrier Repeat 2 to 4 times as necessary Reevaluate

Workshop – Muscle Energy Application: C-spine planes of motion T-spine planes of motion L-spine planes of motion Hip Flexors/Extensors Knee Flexors/Extensors Hip AB/Adductors Hip Internal and External Rotators

Workshop - Counterstrain Technique Find tenderpoint / triggerpoint Remember T.A.R.T. Find position of comfort with patient relaxed Attempt to find 75% to 100% relief in position Usually requires shorteneing of local musculature Hold for 90 seconds while lightly palpating/monitoring tenderpoint Passive return to neutral (patient relaxed) Recheck

Workshop - Counterstrain Application: C-spine tenderpoints T-spine tenderpoints L-spine tenderpoints Ribs Iliosacral points

Workshop - HVLA Thoracic Multiple Plane Seated, “Shotgun” Patient seated, stand behind patient Place small pillow between patient’s back and your epigastrum Patient’s fingers interlaced behind head Place your hands under patient’s axillae and contact dorsum of wrists Patient takes deep breath and exhales while bringing elbows together Examiner simultaneously exerts anterior-superior HVLA thrust through epigastrum and arms Retest range of motion

Workshop – HVLA Prone, Crossed Hand Thoracic, “Texas Twist” Patient prone, stand of symptomatic side of patient (side of prominent posterior thoracic process) Patient turns head towards you, arms at sides Cross your arms, near hand points towards patient’s head, hypothenar eminance over area of dysfunction Your oppostite hand contacts transverse process of segment below on contralateral side of spine, fingers point towards patient’s feet Patient takes deep breath, on exhalation apply gradual downward and torsional force to barrier, then quick HVLA thrust using momentary drop of body weight Recheck range of motion