Osteopathy 101: Our Manipulation Techniques Jon P. Burdzy, D.O. Board Certified in Family Medicine and Neuromusculoskeletal Medicine Assistant Clincial Professor of Medicine, KCUMBS

First Lesson in Osteopathy

Other Possible Titles Osteopathy and You – Perfect Together OMT in a Nutshell Hippity Hoppity Osteopathy Crackety Poppity Osteopathy

“To think implies action of the brain.” – At Still, The Philosophy and Mechanical Principles of Osteopathy, p. 41 “Motion is not life. Motion is a manifestation of life.” Roland Becker, Life in Motion, p. 62 “To find health should be the object of the doctor. Anyone can find disease.” -At Still, Philosophy of Osteopathy, p.2

Tenets of Osteopathic Medicine The body is a unit. The body possesses self-regulatory mechanisms. Structure and function are reciprocally inter-related. Rational Therapy is based upon the understanding of body unity, self-regulatory mechanisms, and the inter-relationship of structure and function.

Tenets of Osteopathic Medicine First, do no harm. A thoughtful diagnosis should be made before exposing the patient to any potentially harmful procedure. Look beyond the disease for the cause. Treatment should center on the cause, with effect addressed only when it benefits the patient in some tangible way. The practice of medicine should be based on sound medical principles. Only therapies proven clinically beneficial in improving patient outcome should be recommended. The body is subject to mechanical laws. The science of physics applies to humans. Even a slight alteration in the body’s precision can result in disorders that overcome natural defenses. The body has the potential to make all substances necessary to insure its health. No medical approach can exceed the efficacy of the body’s natural defense systems if those defenses are functioning properly. Therefore, teaching the patient to care for his own health and to prevent disease is part of a physician’s responsibility. The nervous system controls, influences, and/or integrates all bodily functions. Osteopathy embraces all known areas of practice. Excerpted from A Historical Perspective on the Philosophy of Osteopathic Medicine, by Robert E. Suter, D.O., based on the writing of A.T. Still.

“First, there is the material body; second the spiritual being; third, a being of mind which is far superior to all vital motions and material forms, whose duty is to wisely manage this great engine of life” -AT Still, the Philosophy and Mechanical Principles of Osteopathy, pp. 16-17

“You begin with anatomy, and you end with anatomy, a knowledge of anatomy is all you want or need” – At Still, The Philosophy and Mechanical Principles of Osteopathy, p. 16

Somatic dysfunction: Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures, and their related vascular, lymphatic, and neural elements. Somatic dysfunction is treatable using osteopathic manipulative treatment. The positional and motion aspects of somatic dysfunction are best described using at least one of three parameters: 1). The position of a body part as determined by palpation and referenced to its adjacent defined structure, 2). The directions in which motion is freer, and 3). The directions in which motion is restricted.

TART T.A.R.T. A mnemonic for four diagnostic criteria of somatic dysfunction: -tissue texture abnormality -asymmetry -restriction of motion -tenderness

“It may be that by measurement we can discover a variation one-hundredth of an inch from the normal, which, though infinitely small, is nevertheless abnormal” -At Still, The Philosophy and Mechanical Principles of Osteopathy, p.33

Barrier Concept (this is how somatic dysfunction looks on paper)

Direct Technique Direct method (D/DIR), an osteopathic treatment strategy by which the restrictive barrier is engaged and a final activating force is applied to correct somatic dysfunction. (we move through the restrictive barrier to release the tissue)

I ndirect Technique Indirect method (I/IND), a manipulative technique where the restrictive barrier is disengaged and the dysfunctional body part is moved away from the restrictive barrier until tissue tension is equal in one or all planes and directions. (we move tissues away from the barrier until they release)

– At Still, Autobiography of AT Still, P. 191 “An intelligent head will soon learn that a soft hand and a gentle move is the head and hand that gets the desired result” – At Still, Autobiography of AT Still, P. 191

Contraindications and Precautions for Manipulative Techniques Acute Trauma Congenital or Acquired Malformations Friable, acutely inflamed or infected tissues Hemarthrosis Hypermobility Nearby thrombosis, aneurysm or dissection Primary joint, metabolic or cancerous bone disease -from Seffinger, Evidence Based Manual Medicine, A Problem-Oriented Approach, p . 61

Contraindications and Precautions for Manipulative Techniques Patient hesitation or lack of consent!!!

Direct Techniques HVLA Muscle Energy Articulatory Soft tissue Myofascial Release

HVLA A rapid,therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint,and that engages the restrictive barrier in one or more planes of motion to elicit release of restriction. Kirksville Crunch, Texas Twist, Etc.

“Use force enough to remove all obstructions; be careful that you do not bruise any of the delicate parts….” – AT Still, Autobiography of AT Still, p. 191 “I put my elbow in his back and pulled him backwards over it with force” – AT Still, Autobiography of AT Still, p. 113

Cervical HVLA Since 1925, there have been approximately 275 cases of adverse events reported with cervical spine manipulation. It has been suggested by some that there is an under-reporting of adverse events . A conservative estimate of the number of cervical spine manipulations per year is approximately 33 million and may be as high as 193 million in the US and Canada. The estimated risk of adverse outcome following cervical spine manipulation ranges from 1 in 400,000 to 1 in 3.85 million The estimated risk of major impairment following cervical spine manipulation is 6.39 per 10 million manipulations. NSAIDs are the most commonly prescribed medications for neck pain. Approximately 13 million Americans use NSAIDs regularly. 81% of GI bleeds related to NSAID use occur without prior symptoms. Research in the United Kingdom has shown NSAIDs will cause 12,000 emergency admissions and 2,500 deaths per year due to GI tract complications. The annual cost of GI tract complications in the US is estimated at $3.9 billion, with up to 103,000 hospitalizations and at least 16,500 deaths per year. This makes GI toxicity from NSAIDs the 15th most common cause of death in the United States.

Cervical HVLA A study done in 1999 reviewing 367 cases of VBA reported from 1966-1993 showed 115 cases related to cervical spine manipulation; 167 were spontaneous, 58 from trivial trauma and 37 from major trauma. It has been proposed that thrust techniques that use a combination of hyperextension, rotation and traction of the upper cervical spine will place the patient at greatest risk of injuring the vertebral artery.

Cervical HVLA Conclusion Osteopathic manipulative treatment of the cervical spine, including but not limited to High Velocity/Low Amplitude treatment, is effective for neck pain and is safe, especially in comparison to other common treatments. Because of the very small risk of adverse outcomes, trainees should be provided with sufficient information so they are advised of the potential risks. There is a need for research to distinguish the risk of VBA associated with manipulation done by provider type and to determine the nature of the relationship between different types of manipulative treatment and VBA. Therefore, it is the position of the American Osteopathic Association that all modalities of osteopathic manipulative treatment of the cervical spine, including High Velocity/Low Amplitude, should continue to be taught at all levels of education, and that osteopathic physicians should continue to offer this form of treatment to their patients.

Muscle Energy Patient voluntarily moves the body as specifically directed by the osteopathic practitioner. This directed patient action is from a precisely controlled position against a defined resistance by the practitioner.

Articulatory A low velocity/moderate to high amplitude technique where a joint is carried through its full motion with the therapeutic goal of increased range of movement. The activating force is either a repetitive springing motion or repetitive concentric movement of the joint through the restrictive barrier.

Soft Tissue A direct technique that usually 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.

Myofascial Release Direct MFR, a myofascial tissue restrictive barrier is engaged for the myofascial tissues and the tissue is loaded with a constant force until tissue release occurs.

Indirect Techniques Functional Strain-counterstrain Myofascial Release Balanced ligamentous tension Most cranial techniques

Functional Techniques An indirect treatment approach that involves finding the dynamic balance point and one of the following: applying an indirect guiding force, holding the position or adding compression to exaggerate position and allow for spontaneous readjustment. The osteopathic practitioner guides the manipulative procedure while the dysfunctional area is being palpated in order to obtain a continuous feedback of the physiologic response to induced motion. The osteopathic practitioner guides the dysfunctional part so as to create a decreasing sense of tissue resistance.

Strain-Counterstrain Somatic dysfunction, diagnosed by (an) associated myofascial tenderpoint(s), is treated by using a passive position, resulting in spontaneous tissue release and at least 70 percent decrease in tenderness.

Myofascial Release Indirect MFR, the dysfunctional tissues are guided along the path of least resistance until free movement is achieved.

Cranial A system of diagnosis and treatment by an osteopathic practitioner using the primary respiratory mechanism and balanced membranous tension.

Balanced Ligamentous Tension According to Sutherland’s model, all the joints in the body are balanced ligamentous articular mechanisms. The ligaments provide proprioceptive information that guides the muscle response for positioning the joint and the ligaments themselves guide the motion of the articular components.

Combined Direct and Indirect Still Technique Myofascial Release

Still Technique 1. Determine where the tissue moves most easily. 2. Move the tissue into the direction of ease until it releases. 3. Introduce a vector of force of about 5 lbs. Into affected tissue. 4. Use the force vector as a lever maintaining compression, carry tissue in the opposite direction through the restrictive barrier. 5. Remove force vector and compression and return tissue to neutral. 6. Retest and repeat if necessary. From Foundations of Osteopathic Medicine, 2nd. Edition, p. 1094

Affected tissue may be manipulated directly through the barrier Myofascial Release Affected tissue may be manipulated directly through the barrier

Other Types Fulford Percussion Hammer Lymphatic Techniques Biodynamic Visceral PINS

Percussion Vibratory (Fulford) A manipulative technique involving the specific application of mechanical vibratory force to treat somatic dysfunction.

Biodynamic The therapeutic powers of the Dynamic Stillness, the Breath of Life, the tidal potency, fluids and other Natural Laws at work supporting and generating life.

Visceral A 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.

Lymphatic Technique

PINS Progressive inhibition of neuromuscular structures (PINS), A system of diagnosis and treatment in which the osteopathic practitioner locates two related points and sequentially applies inhibitory pressure along a series of related points.

BIBLIOGRAPHY Foundations of Osteopathic Medicine, 2nd Edition, Lippincott Williams and Wilkins, 2003 Seffinger, Hruby, Evidence Based Manual Medicine, A Problem Oriented Approach, Saunders, 2007 Autobiography of AT Still At Still, Philosophy of Osteopathy AT Still, The Philosophy and Mechanical Principles of Osteopathy Becker, Life in Motion, Eastland Press Becker, Stillness of Life, Eastland Press

Web Resources academyofosteopathy.org do-online.org eastlandpress.com cranialacademy.com

Billing and Coding OMT CPT codes [inpatient & outpatient] 98925 1-2 body regions 98926 3-4 body regions 98927 5-6 body regions 98928 7-8 body regions 98929 9-10 body regions Body region codes: head, sacral, rib cage area, cervical, pelvis, abdomen, thoracic, lower extremities, visceral region, lumbar, upper extremities ICD Codes -739.0 Head region 739.1 Cervical region 739.2 Thoracic region 739.3 Lumbar region 739.4 Sacral region 739.5 Pelvic region 739.6 Lower extremities 739.7 Upper extremities 739.8 Rib cage 739.9 Abdomen and other

.25 Modifier In General First give a code for the complaint (e.g. low back pain Then code the somatic dysfunction (739 codes) Attach the .25 modifier (for separate, distinctly identifiable services from other services or procedures rendered during the same visit) to the ICD code Then bill the appropriate CPT

From Philosophy of Osteopathy, Chapter IV, Ear Wax and its Uses “I asked myself to try and get a reason of why nature had made and placed in a person’s head so much fine machinery just to make a little ear war. If nothing is made in vain, what is that bitter stuff made for ? It is always there, and more being made all the time . . I consider earwax one of the most important questions before the minds of our physiologists.”

“All through life I have been ever been ready to buy a better plow ” -AT Still, Autobiography of AT Still, p.187