1. 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

2. 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.

3. 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.

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

5. 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

6. 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

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

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

9. Barrier Concepts Anatomic Barrier Physiologic Barrier
Restrictive Barrier
Anatomic Physiologic Restrictive Physiologic Anatomic
Barrier Barrier Barrier Barrier Barrier

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

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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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

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

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

21. 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”

22. Suboccipital Release, Supine

23. Rib Raising, Supine Extension

24. 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”

25. Myofascial Release Techniques

26. 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”

27. Psoas and Iliacus muscles

28. Psoas Muscle Dysfunction

29. Piriformis Muscle

30. Piriformis Muscle Dysfunction

31. 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”

32. Left L5—S1 Dysfunction

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

34. Carpal Tunnel Syndrome

35. 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”

37. Singultus (Hiccups)

39. Sacral Rock for Dysmenorrhea

40. 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

41. Auricular Drainage Technique for otitis media/externa

43. Ischiorectal Fossa Release, Prone

44. Pedal Pump for lymphatic congestion/edema

45. 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…

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

47. 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.