AKOMA OMT Workshop Crystal Martin, DO May 2, 2019 Objectives - - PDF document

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AKOMA OMT Workshop

Crystal Martin, DO May 2, 2019

Objectives

• Discus and learn an osteopathic approach to common medical problems
• Describe underlying structure and function of why OMT works for various

clinical problems

• Apply osteopathic treatment principles to patients in a variety of settings

and clinical situations

• Demonstrate OMT for common clinical problems
• Otitis media
• Back pain
• Supplemental material will be provided on provided on: headache, ankle sprains and

post-op ileus

Otitis media

• Otitis media is the most common medical condition for which care is

provided in children under 5 years of age.

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Horizontal Eustachian Tubes

Notice that the Eustachian tube is much more vertical in adults allowing for better drainage

Lymphatic Treatments

• Always open the

thoracic inlet first!

• Next free up any
• bstructions
• Finally lymphatic pumps can

be considered

Galbreath Technique

• Galbreath Maneuver first

described in 1929 by William Otis Galbreath, DO

• A simple mandibular

manipulation, the Eustachian tube is made to open and close in a "pumping action" that allows the ear to drain accumulated fluid more effectively

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Acute Low Back Pain

• In 1990, the direct medical care costs for low back pain exceeded $24

billion

• When disability compensation and lost productivity are included the

total annual costs in the United States increases to approximately $100 billion

• The overall incidence of LBP has been reported to be 60 to 80 percent

in industrialized countries

Mechanical Vs. Non-Mechanical

• Mechanical represents 90% of disorders and dysfunction of

muscles, ligaments and connective tissue

• Non-mechanical can include serious and/or life threatening

medical and surgical disorders which require urgent evaluation and intervention

Non-Mechanical Back Pain

• Spinal Tumor
• Spinal infection
• Vertebral fractures – trauma, osteoporosis
• Primary cancers with bony metastasis
• Kidney dysfunction
• Ureteral obstruction
• Prostate or Bladder irritation
• Viscerosomatic reflex

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Non-Mechanical Back Pain

• Cauda Equina
• Pressure on spinal cord from space occupying lesion, disc, tumor, boney

elements, spinal stenosis

• Bowel and/or bladder dysfunction
• Perianal or saddle anesthesia
• Lower extremity neurologic deficits
• Surgical emergency
• Ruptured/dissecting abdominal aortic aneurysm
• Severe, sharp or tearing acute back pain
• Surgical emergency

Mechanical Back Pain

• Thoracic and Lumbar Spine Somatic dysfunction
• Short Leg/Sacral Base Unleveling Syndrome
• Gravitational Strain/Postural Decompensation
• Herniated or Degenerative Disc Disease (DDD)
• Degenerative Joint Disease (DJD)
• Myofascial pain syndromes
• Ligamentous Strains and Sprains
• Spondylolysis & Spondylolisthesis
• Spinal Stenosis

These are the patients who benefit from OMT!

‘RED FLAGS’ Suggestive of Serious Spinal Pathology

• Age <20 or >50
• Trauma
• ESR>25
• Constant and progressive non-mechanical pain
• Hx: Ca, HIV, systemic steroids, drug abuse
• Weight loss with undefined illness
• Persisting severe restriction with flexion
• Deformity, x-ray with vertebral destruction or collapse
• Progressive neurologic deficit

Remember that you are first and foremost a physician.

These are patient’s you need to work up!

OMT may be considered as an adjunct therapy.

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Soft Tissue

• Kneading
• Inhibition
• Stretching

A great way to prepare for other techniques.

A Quick Review of Fryette’s Diagnosis

Type I Dysfunctions

• Sidebending and rotation occur

in OPPOSITE directions

• There is no sagittal component

(dysfunctions are NEUTRAL)

• Usually a group
• Typically less painful and may

be compensatory from a Type II dysfunction.

Type II Dysfunctions

• Sidebending and rotation occur

in the SAME direction

• There is a FLEXION / EXTENSION

component

• Usually a single segment
• Typically more painful.

Balanced Ligamentous Technique (BLT)

• Can be done seated of supine
• Taking structures into a

position of ease

• Respiratory phase of ease can

also be used to help with the activating force.

• Position is held until a release
• ccur

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Muscle Energy

• Structures are brought into the

“feather’s edge” of the restrictive barrier

• Patient tries to return to neutral

for 3-5 seconds and physician resists (post-isometric relaxation) then following a 1-2 second pause the new restrictive barrier is engaged. “The Osteopathic Salute“ can be a bit awkward for patients, but it works great for type I dysfunctions!

Type II dysfunction are treated by reaching over the patient’s arm

Modified MET for Flexed Thoracic SD

• This modified technique works best

in mid to upper thoracics

• The patient’s hand on the side of

posterior transverse process is placed on opposite shoulder. physician rotates the patient into the barrier and gently extends.

• The patient is instructed to push

his elbow into the physician’s hand which activates flexion or rotation for post isometric relaxation MET.

Modified MET for Flexed Thoracic SD

Can be done seated... Or Supine.

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High Velocity, Low Amplitute (HVLA)

The Kirksville Crunch

Shotgun Techniques

• Texas Twist
• Lumbar Roll
• Chicago Roll

Not very comfortable body mechanics…

Modified HVLA for Flexed and Neutral Thoracic Somatic Dysfunctions

• Works well for flexed and

neutral dysfunctions T4-T11

• Patient supine with arms
• pposite usual Kirksville Crunch
• The physician’s thenar

eminence is placed on posterior transverse process

• The patient must turn head

fully toward side of rotation to achieve a lock out for the HVLA thrust.

Not all mechanical back pain is from thoracic

• r lumbar somatic dysfunction
• Remember to also check
• Ribs
• Neck
• Sacrum
• Pelvis
• Leg length

The body is a unit!

Dysfunction in one area can cause pain in another area of the body.

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Research on OMT and Back Pain

• OSTEOPATHIC Trial
• My current research project at PNWU: The short-term outcomes of

OMT in migrant farmworkers with back pain

• Measuring quantitative back range of motion (BROM) prior to and

following 3 OMT sessions scheduled two weeks apart.

• Also measuring baseline Quality of Life, Functional Status,

medication use, and pain scale then repeating at final OMT treatment and 4 weeks after final OMT treatment

Rib Movement

3 main types of movement

• Pump handle

○

Primarily Ribs 1-5

• Bucket handle

○

Primarily Ribs 6-10

• Caliper

○

Primarily Ribs 11-12

Ribs 1-10 have some of all 3 motions, but do have a primary component of motion

Which rib is the Key Rib?

• Remember BITE

○

Bottom inhaled, Top exhaled

• Bottom rib is the key rib in an

inhalation dysfunction

○

It’s holding the rest of the group up

• Top rib is the key rib in an

exhalation dysfunction

○

It’s holding the rest of the group down

Inhalation dysfunction bottom rib is “key rib” Exhalation dysfunction top rib is “key rib”

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Modified Position for BLT and MET of Ribs

• Works best for treating inhaled or

exhaled bucket handle ribs

• Have patient place his or her elbow on

your shoulder. Traction the key rib and bring into position of balance to treat with BLT

• You can also treat with MET in this

position by using hands to position the key rib at the restrictive barrier and ask the patient to push his or her elbow down into your shoulder.

• Fine tune by adjusting the angle at which

you have the patient press elbow down.

Fitting OMT into your clinical practice

• OMT takes time, but you can make up for

the time by billing for a procedure when you take time to perform OMT.

• Billing is done by number of body areas

treated, not how much time you spend.

• Effective OMT can easily be done in less

than 10 minutes.

• Often even in less than 5 minutes
• If you don’t have time or skills for OMT,

refer your patient to someone who does.

Billing for OMT

• The diagnosis of somatic dysfunction in the assessment justifies the use of OMT.
• Describe specific somatic dysfunctions in the MSK section of your physical exam (Objective)
• example: T3 F SRRR, thoracic paraspinal muscle hypertonicity
• A somatic dysfunction diagnosis must be present in order to bill for OMT that was performed.
• Your note in the Plan should state that OMT was used for somatic Dysfunction identified.
• “The procedure (OMT) and the E/M visit may both be billed with the same

diagnosis code and during the same encounter, if the decision to perform the procedure was made at the time of the encounter. Modifier -25 is used with the E/M code.”

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References

• Chila, A. G., & American Osteopathic Association. (2011). Foundations of osteopathic medicine. Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins.

• DiGiovanna, E. L., Schiowitz, S., & Dowling, D. J. (2005). An osteopathic approach to diagnosis and treatment.

3rd editon. Philadelphia, Pa: Lippincott Williams and Wilkins.

• Nicholas A, Nicholas E., Atlas of Osteopathic Techniques. Philadelphia: Lippincott Williams & Wilkins, 2008.
• American Academy of Colleges of Osteopathic Medicine (AACOM). Glossary of Osteopathic Terminology.

Educational Council on Osteopathic Principles (ECOP)

• In Nelson, K. E., In Glonek, T., & American College of Osteopathic Family Physicians,. (2015). Somatic

dysfunction in osteopathic family medicine.

• Carreiro, J. (2009) An Osteopathic Approach to Children. 2nd edition.
• Kimberly, PE. (2008) Outline of Osteopathic Manipulative Procedures: The Kimberly Manual. Walsworth

Publishing, ATSU-KCOM.

• Photo credits to my friend Dave Dalton and his son & to my OMS1 students Emily Eddy and Carsten Kirby.

Thank you!

Supplemental Materials for Personal Study of OMT

• Includes material on:
• Ankle Sprains
• Headaches
• Bowel Ileus
• Prepared by Crystal Martin, DO for AKOMA OMT Workshop participants
• We can cover these during today’s workshop if participants are interested and time permits.

Ankle Sprains

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Acute Ankle Sprains

• Up to 40% of individuals

have residual symptoms due to chronic instability

• Most frequent in individuals

with irregular activities

http://www.emedicine.com/pmr/topic11.htm

Chronic Ankle Sprains

• 85% are inversion

sprains (lateral)

• 5% are eversion

sprains (deltoid)

• 10% are syndesmosis

injuries.

Foot Motion

Foot motion is a composite of motions of the hind foot (subtalar and tibiotalar) and the forefoot. Supination = Inversion + Plantar flexion + Adduction Pronation = Eversion + Dorsiflexion + Abduction

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Ankle Sprains

Inversion ankle sprain

Supination = Inversion + Plantar flexion + Adduction

Eversion ankle sprain

Pronation = Eversion + Dorsiflexion + Abduction

Lower Extremity Motion

At right heel strike

• Foot is dorsiflexed
• Proximal fibular is anterior
• Tibia internally rotates
• Femur rotates externally
• Right innominate rotates

posteriorly At right toe off

• Foot is planter flexed
• Proximal fibular is posterior
• Tibia externally rotates
• Femur rotates internally
• Right innominate rotates

anteriorly

• Inversion of subtalar joint
• Planter flexion of

talotibial joint

• Posterior proximal fibula
• External tibial rotation
• Internal femur rotation
• Posterior innominate

rotation

Inversion Ankle Sprains

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Inversion Ankle Sprains

• More common

because the foot is less stable in plantarflexion

• Anterior margin of the

talus is wider than the posterior margin

• Anterior talofibular

ligament – most commonly injured

Muscle Energy –Posterior Fibula

• Dorsiflex and evert

foot

• Apply anterior force
• n fibular head
• Patient plantar

flexes against resistance

• Repeat 3-5 times

Muscle Energy – Anterior Fibula

• Plantar flex and

invert foot

• Apply posterior

force on fibular head

• Patient dorsiflexes

against resistance

• Repeat 3-5 times

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Muscle Energy –Anterior talus

• Maximally dorsiflex foot
• Patient plantarflexes foot

against physician resistance 3-5 seconds

• Repeat 3-5 times

Articular Treatment

• Apply traction to calcaneus
• Take joint through full range of

motion

Exercises

• Flexibility/ROM
• Alphabet ROM
• Isometric

strengthening

• Elastic bands or tubing
• Proprioceptive

retraining

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Balance Retraining

• Stand with shoulder

width apart

• Hold on to a chair for

support if needed

• Rock the board forwards

and backwards, then side to side.

• 2 to 3 minutes.

Wobble Boards

Prolotherapy

• Injection treatment to

strengthen weakened ligaments and muscular attachment points

Headaches

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Types of Primary Headaches

• Tension Headaches are most common

and what this will mostly cover.

• Will also touch on migraines, with

emphasis on cervicogenic headaches.

Tension Headaches

• Episodic (<15 days a month)
• Infrequent <12 per year
• Frequent <15 per month
• Chronic (>15 days a month)
• Typically bilateral, “band-like”
• Not aggravated by physical activity
• Often overlap with migraines
• Musculoskeletal triggers
• Cervical spine, lumbar, thoracic,

sacrum, ribs

• Myofascial structures
• Cranial bones
• Teeth
• Jaw
• Sinuses

Research

“Spinal Manipulation in the Treatment of Episodic Tension-Type Headache: A Randomized Controlled Trial”

Bove, G and Nilsson, N, JAMA, Nov 1998 280(18):1576-1579.

No significant differences between combined soft tissue and HVLA and soft tissue alone for the treatment of tension type headaches. However both groups demonstrated a reduction in both headache hours and analgesic use. No change in headache intensity noted in either group.

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Tension Headaches

• OMT
• Treat vertebral somatic dysfunction
• Treat myofascial dysfunction
• Fascial dysfunction
• Muscular dysfunction
• Treat cranial dysfunction
• Cranial dysfunction can result in dural dysfunction and musculature imbalance

Migraine Headaches

• Exact pathophysiology unknown
• Disordered neurogenic control of craniocerebral circulation

accompanies attack

• Cerebral, meningeal, basilar, and vertebral arteries may be affected by

trigeminal, vagal, and upper cervical nerves which all converge in the trigeminal nucleus caudis in the brainstem

Cervicogenic Headaches

• Variant of migraine that originates in the back of the head and

spreads to the front

• Pain is unilateral, of moderate severity, and, because it is triggered by

neck movement, can be precipitated mechanically

• May be caused by facet joint pain 2° OA

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Cervicogenic Headaches

Diagnostic Criteria (International Headache Society)

A. Pain, referred from a source in the neck and perceived in one or more regions of the head and/or face, fulfilling criteria C and D B. Clinical, laboratory and/or imaging evidence of a disorder or lesion within the cervical spine or soft tissues of the neck known to be, or generally accepted as, a valid cause of headache1 C. Evidence that the pain can be attributed to the neck disorder or lesion based on at least one of the following: 1. demonstration of clinical signs that implicate a source of pain in the neck 2. abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo- or other adequate controls D. Pain resolves within 3 months after successful treatment of the causative disorder or lesion

Research

“The Effect of Spinal Manipulation in the Treatment of Cervicogenic Headache”

Nilsson, N et al., JMPT, June 1997 20(5)326-330.

Volunteers who received two HVLA treatments each week for 3 weeks reported significantly less analgesic use, decreased headache intensity and total number of headache hours than a group that had only soft tissue.

Research

“Manual therapies for cervicogenic headache: a systematic review.”

Chaibi et al. J Headache Pain. 2012 Jul;13(5):351-9.

Mobilization, manipulation - both are efficacious for treatment of cervicogenic headaches

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OMT for Migraine Headaches

• Aggressive OMT often not tolerated
• Gentle OMT usually tolerated well
• Target
• Vertebral dysfunction
• Myofascial dysfunction
• Suboccipital muscles
• Sternocleidomastoid
• Cranial dysfunction
• Cranial dysfunction can result in dural dysfunction and CNV irritation

Cranial Treatment

• Condylar decompression
• Venous sinus drainage
• CV4
• Frontal, parietal lifts
• Temporal balancing
• SBS compression/decompression
• Stacking technique

Headache Nutrition

• Keep a headache diary of foods eaten and

headache times

• Remove foods from diet and compare headache

activity

• May consider complete elimination diet
• Consider a low Tyramine diet
• Tyramine is produced in foods by the natural breakdown
• f the amino acid tyrosine
• National Headache Foundation
• Magnesium and/or B2 (riboflavin) supplementation

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Headache Treatment

• Specific Measures including good

posture, stress avoidance and proper sleep.

• Try to identify headache triggers

(diary helps with this). Patients often have food triggers they don’t realize.

• Medication – start or stop as needed
• NSAIDS may cause rebound headaches
• OMT – treatment plan will depend

upon the type of headache

• Rest or ice packs

Note: I do not recommend trepanning, but thought this was a fun picture.

Bowel Ileus

Colonic Muscular Activity

Affected by

• sleep and wakefulness
• eating habits
• emotion
• contents of the colon
• drugs
• sympathetic nerves
• parasympathetic sacral outflow

Chronically constipated individual have reduced peristalsis

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Bowel Ileus

Definition

• Partial or complete non mechanical blockage of the bowel – loss of peristalsis

Results in transit delay of enteral contents

• abdominal distention
• pain
• nausea
• vomiting
• intestinal cramping

Brent W Miedema, Joel O Johnson, “Methods for decreasing postoperative gut dysmotility” , The Lancet Oncology, Vol 4:6 June 2003

Postoperative Bowel Ileus

Also known as postoperative gut dysmotility

Postoperative bowel ileus is the primary determinate of length of hospital stay after abdominal surgery. It is thought to contribute more than a billion dollars a year to direct health-care cost in the USA. Leads to increased incidence of aspiration pneumonia, anastomotic leaks, and bowel necrosis.

Post Operative Ileus

General Features

• shortly after surgery bowel shows electrical and muscular activity

indicating the potential for movement

• caused by a lack of normal motility, rather than absence of motility
• Generally, without treatment postoperative ileus resolves in 4–5 days
• Colonic transit (bowel movements) tends to occur 1–2 days after

flatus.

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OMT for Constipation and Bowel Ileus

Treatment Targets

 Lymphatic system  Sympathetics Nervous System  Parasympathetics Nervous System  Somatic System

Lymphatic System

 Lymphatic vessels from colon travel within mesentery  Tissue congestion interferes removal of cellular waste products and results in tissue edema  Congestion increases likelihood of stasis, fibrosis and scarring  Drainage from lower body occurs through thoracic duct

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Thoracic Inlet Release

1. Place your hands so that your fingers overly the clavicles and your thumb contact the transverse processes of T1. 2. Evaluate compression, rotation and sidebending for ease of motion. 3. Position the tissues at the indirect motion barrier. 4. Allow a myofascial unwinding to

• ccur by constantly reassessing

the position of ease and maintaining the tissues at the indirect motion barrier.

Abdominal Diaphragm Release

1. Place one hand on each side on the lower ribs. 2. Evaluate compression, rotation and sidebending for ease of motion. 3. Position the tissues at the indirect motion barrier. 4. Allow a myofascial unwinding to

• ccur by constantly reassessing

the position of ease and maintaining the tissues at the indirect motion barrier.

Pelvic Unwinding

Decrease fluid congestion of pelvic tissues

• Stand facing the patient. Place your hands
• ver the ilia bilaterally.
• Apply medial compression and gently

rotate anteriorly and posteriorly to determine preferential motion (the ilia will usually prefer rotation in opposite directions).

• Position at the indirect motion barrier.
• Allow a myofascial unwinding to occur by

constantly reassessing the position of ease and maintaining the tissues at the indirect motion barrier.

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Colon Release

• 1. Release the sigmoid colon first by cupping

the left lower quadrant of the abdomen in your hands and gently pulling medially.

• 2. Hold the tissues until a gentle give or

softening of the tissues occurs.

• 3. To release the descending colon, cup the

left lateral margin of the abdomen and gently pull medially until a softening of the tissues in felt.

Abdominal Massage for Constipation

Ernst E: Abdominal Massage Therapy for Chronic Constipation: A Systematic Review of Controlled Clinical Trials. Forsch Komplementärmed 1999;6:149-151 Emly, M., Cooper, S., Vail, A., Colonic Motility in Profoundly Disabled People: A comparison of massage and laxative therapy in the management of constipation. Physiotherapy, April 1998, vol 84, no 4 178 -183 Miedema BW; Johnson JO, Methods for decreasing postoperative gut dysmotility. Lancet Oncol - 01-JUN-2003; 4(6): 365-72 Preece J Introducing abdominal massage in palliative care for the relief of constipation.Complement Ther Nurs Midwifery 01- MAY-2002; 8(2): 101-5 Le Blanc-Louvry I; Costaglioli B; Boulon C; Leroi AM; Ducrotte P Does mechanical massage of the abdominal wall after colectomy reduce postoperative pain and shorten the duration of ileus? Results of a randomized study. J Gastrointest Surg

• 01-JAN-2002; 6(1): 43-9

Sympathetic Nervous System

• Viscerosomatic innervation to

the small and large bowel is T10- T11 and T12-L2

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Sympathetic Nervous System

 Heightened sympathetic activity may result decreased peristalsis leading to constipation, ileus, and flatulence.  Heightened sympathetic activity may also lead to increased vascular tone and decreased O2 and nutrient delivery to tissues.  Sympathetic nervous system controls diameter of lymphatic channels.

Collateral Ganglia Release

To decrease sympathetic tone

• 1. With fingertips in a row, apply gentle

posterior pressure along the linea alba from the xiphoid process to the umbilicus.

• 2. Concentrate forces over the specific

ganglia to be inhibited if necessary.

• 3. Hold until a softening is felt.
• Avoid pressure on the aorta
• Avoid in ventral abdominal surgical incisions

Paraspinal Muscle Inhibition

To decrease sympathetic tone

• 1. With you fingertips in a row, gradually

apply anterior pressure into the paraspinal musculature until softening is felt

• 2. Move fingertips inferiorly and repeat.
• 3. Repeat on the other side

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Parasympathetic Nervous System

 Heightened parasympathetic activity leads to increased peristalsis and glandular secretions leading to diarrhea.  Parasympathetic hypoactivity leads to decreased bowl motility and glandular secretions.  Hyperactivity of both sympathetic and parasympathetic systems may result in irritable bowel syndrome.

“Neostigmine: Safe and Effective Treatment for Acute Colonic Pseudo-Obstruction”

Trevisani, G T.; Hyman, N H.; Church, J M. Diseases of the Colon & Rectum. 43(5):599-603, May 2000.

Twenty-eight patients were treated for acute colonic pseudo-obstruction (hospital acquired) with neostigmine 2.5 mg IV. Neostigmine enhances excitatory parasympathetic activity by enhancing cholinergic action. Complete clinical resolution of large bowel distention occurred in 26 of the 28 patients. Time to pass flatus varied from 30 seconds to 10 minutes after administration

• f neostigmine.

Increased Parasympathetic activity increases gut motility

Suboccipital Release

To normalize vagal tone

• 1. Patient is supine
• 2. With your hands in parallel, curl

your fingers into the patient’s suboccipital musculature.

• 3. Allow the patient’s hand to rest on

your fingers until the musculature softens

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Sacral Rocking

To relax muscles at lumbosacral junction and increase parasympathetic tone

• 1. Position your hand directly over the sacrum with the other

hand over top of the first hand.

• 2. Apply a gentle anterior force over the entire surface of the

sacrum.

• 3. Gently induce sacral flexion with increase pressure over the

sacral base, and then alternate to sacral extension with pressure over the apex.

• 4. Repeat until sacral demonstrates even motion.
• Motion made be done with synchronization with breathing or cranial rhythmic impulse.
• May be performed in lateral recumbent, supine or prone positions
• For bedridden inpatients consider a variable pressure mattress to decrease sacral pressure causing inhibition of sacral motion

Somatic System

 Postural changes are very common and result in long term somatovisceral changes or segmental facilitation.  Treat underlying postural problem to make a lasting effect can be obtained through treating compensatory somatic dysfunctions.  This may be addressed on an inpatient basis with regards to patient positioning.  This may be addressed an outpatient basis for those patients with chronic problems.

Post Operative Pain

Piotrowski MM; Paterson C; Mitchinson A; Kim HM; Kirsh M; Hinshaw DB Massage as adjuvant therapy in the management of acute postoperative pain: a preliminary study in men. J Am Coll Surg - 01-DEC-2003; 197(6): 1037-46

This prospective randomized clinical trial compared pain relief after major operations in 202 patients who received one of three nursing interventions: massage, focused attention, or routine care. Interventions were performed twice daily starting 24 hours after the operation through postoperative day 7. Perceived pain was measured each morning.

The rate of decline in the unpleasantness of postoperative pain was accelerated by massage (p = 0.05).