1. OMT for LBP Samuel A. Yoakum, DO, MS, FAAPMR Tennessee Orthopaedic Clinics: TOC Spine Knoxville, TN

2. Disclosures none

3. Outline Background Definitions Diagnosis Techniques

4. Manual therapy ● Acupressure ● Bodywork ● Bowen technique ● Chiropractic ● Craniosacral therapy ● Indian head massage ● Lomilomi ● Manual lymphatic drainage ● Massage therapy ● Naprapathy ● Osteopathic medicine ● Physical therapy ● Rolfing structural integration ● Shiatsu ● Thai massage ● Tui na ● Watsu

5. Osteopathic Medicine Definitions: Osteopathy = Osteopathic medicine Osteopathic manipulative medicine = OMM Osteopathic manipulative treatment/techniques = OMT Doctor of Osteopathic Medicine = DO According to the World Osteopathic Health Organization, Osteopathy is a “…system of healthcare which relies on manual contact for diagnosis and treatment. It respects the relationship of body, mind and spirit in health and disease; it lays emphasis on the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.”

6. Osteopathic Medicine Andrew Taylor Still Founded Osteopathy 1870’s Previously trained as an MD Lost entire family to meningitis Devoted to the study of anatomy and physiology Early Hipster

7. Tenets of Osteopathy ●The body is a unit o Understanding this concept allows the treatment of patients as a functional whole. ●Structure and Function are interrelated o Still’s philosophy: “Disease is the result of anatomical abnormalities followed by physiologic discord” ●The body possesses self-regulatory and self-healing mechanisms ●Rational treatment is based on applying these principles

8. Diagnosis Somatic Dysfunction ●Tissue Texture Changes o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed, atrophied, rigid, moist, dry ●Asymmetry o Macro and Micro ●Restriction of motion = a deeper look at ROM o Named for FREEDOM Of MOTION o Restricted motion is the BARRIER ●tenderness o Tenderpoints vs. Triggerpoints

9. Tissue Texture Changes ●Acute o Edematous o Erythematous o Boggy o Slick, sweaty ●Chronic o Flat o Cool o Leathery, low tone o Flaccid, ropy, fibrotic

10. Asymmetry ● Group curvature ● Single segment disfunction ● Compare Side-to-side ●Mastoid ●Acromion ●Lower ribs ●Iliac crests ●Greater trochanters ●Lateral femoral condyles ●Lateral malleoli

11. Restriction of motion Alignment vs Restriction - everyone has some asymmetries - sometimes it points to dysfunction - sometimes it is normal Symmetry is less of a goal than improving restriction

12. The Barrier Concept ●BARRIER stops motion ●FREEDOM Of MOTION is opposite the barrier ●Barriers o Anatomical o Physiological o Restrictive

13. Anatomical & Physiological Barriers

14. So what is wrong? Assessment and Diagnosis -Observe gait -Structural exam: standing, seated -Axial spine exam -Extremities -Tenderness and Tissue Texture change are homing beacons -Asymmetry sets the stage -Restriction of motion answers the question

15. Common LBP Problems Diagnosis -Soft tissue injury -Myofascial strain / tenderpoints -Muscular: iliopsoas, QL, paraspinals, hamstrings, piriformis, gluts, multifidi -Malrotated Sacrum and/or Ilium -Lumbar Segmental restriction

16. Key: Know What You Are Treating ●Soft tissue – skin, adipose, superficial fascia ●Deep Fascia – layers, lines, planes, strain patterns ●Muscle – follow the fibers ●Joint – vertebral segments, articulations, syndesmoses

17. Know how you are treating ● Direct Techniques o Engage (go into) the dysfunctional barrier o Goal is moving through the barrier to restore normal motion ● Indirect Techniques o Disengage (go away from) the barrier o Using the path of least resistance ● Combined Techniques o Begin indirect, then go direct

18. OMT ●Soft tissue mobilization / Articulatory Techniques o Direct ●Myofascial Release (MFR) o Direct or Indirect ●Muscle Energy (contract-relax) o Direct ●Jones Counterstrain & FPR o Indirect ●High Velocity Low Amplitude (HVLA) o Direct ●Craniosacral o Direct or Indirect

19. Soft Tissue Mobilization High Yield Targets: Lumbar paraspinals, T-L junction, flank ● Allows treatment to other parts of the body to be more effective. ● Gently and directly applying pressure through the soft tissue layers: skin, fascia, adipose, muscle. ● Deep articulation, in contrast, engages joint motion

20. Myofascial Release (MFR) High Yield Targets: Fascial restrictions TL junction, iliolumbar ligament, sacral ● MFR is an umbrella term encompassing several types of osteopathic manipulative techniques (OMT) that stretch and release muscle and fascia restrictions. ● MFR first involves palpating a restriction in the fascia/soft tissue. ● Direct MFR = practitioner engages the restrictive barrier and holds until a release is felt in the tissue. ● Indirect MFR = practitioner moves the myofascial structures away from the restrictive barrier.

21. Counterstrain High Yield Targets: Tenderpoints Iliolumbar ligament, piriformis, hamstring lumbar and sacral TP What is a tenderpoint? ●Tenderpoints are small tense edematous areas of tenderness typically located near tendon attachments, ligaments, or in the belly of some muscles.

22. Counterstrain ● Jones Counterstrain = passive indirect technique o Muscle being treated is positioned at a point of balance or ease, away from the restrictive barrier. o “Fold and hold” for 90 sec ● This is a neurosensory approach to the treatment of tenderpoints. If you can put it into a position of comfort, you can probably treat it with counterstrain

23. Facilitated Positional Release (FPR) High Yield Targets: SI-joint fascia, piriformis, lumbosacral junction ● Indirect technique ● Set up is similar to counterstrain ● Add activating force (compression or distraction) ● Takes 3-4 seconds to induce a release Great techniques for spine and joint dysfunctions

24. Muscle Energy High Yield Targets: Iliopsoas, hamstring, quad, piriformis anterior/posterior ilium, sacral torsion lumbar segmental dysfunction ● Muscle energy ~ “contract-relax” ● Direct technique o Barrier engaged o Patient contracts against holding force o Relax, muscle lengthens o Engage a new barrier o Repeat

25. High Velocity, low amplitude High Yield Targets: Anterior/Posterior sacrum or Ilium Lumbar segmental dysfunction ● Confronts restricted articulations “head on” ● Don’t try it if you don’t know how ● Barrier is engaged, fine-tuned in multiple planes to minute specificity ● Final thrust in nearly ALL cases should be quick (high velocity) but short (low amplitude) ● “shotgun” techniques are discouraged ● Don’t do it if you don’t know how