Osteopathic Manual Manipulation W. Joshua Cox, D.O., FACOFP Chair, - - PowerPoint PPT Presentation

Osteopathic Manual Manipulation

• W. Joshua Cox, D.O., FACOFP

Chair, Department of Primary Care KCUMB

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Disclosure Statement

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME session. All faculty and staff in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

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Learning Objectives

1. Describe use of manipulative medicine techniques in treatment of musculoskeletal problems through a case-based approach. 2. Demonstrate manipulative techniques to assist patients in recovering from injuries or enhancing their performance. 3. Describe physical therapy approaches/modalities for common musculoskeletal problems and how to prescribe specific treatment regimens. 4. Become familiar with basic manipulation techniques, their application, and contraindications.

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Osteopathic Medicine

AT Still, MD, DO 4 Principles of Osteopathy – Body is a dynamic unit of function – Body possesses self-regulating mechanisms – Structure and function are inter-related at all levels – Treatment is based on understanding of these 3 principles

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Osteopathic Approach

“To find health should be the object of the doctor. Anyone can find disease.”

A.T. Still, M.D.,D.O.

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Osteopathic Manipulative Treatment (OMT)

Somatic Dysfunction:

Altered or impaired function of the related components of the somatic system, including skeletal, arthroidal, and myofascial structures and the related vascular, neural, and lymphatic components

Osteopathic Manipulative Treatment:

Therapeutic application of manual forces used to improve physiologic function and support homeostasis Variety of techniques/modalities Treat “somatic dysfunction” Communicate while treating Applied to more than just spine

Head, Cervical, Thoracic, Lumbar, Rib, Abdomen, Upper Ext, Lower Ext, Innominate (Pelvis), Sacrum

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Somatic Dysfunction

TART

• Tissue texture changes/abnormalities (acute, chronic)
• Asymmetry (static, dynamic/motion)
• Restriction of motion (active/passive ROM)
• Tenderness to palpation

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American Osteopathic Association Guidelines for OMT for Patients with Low Back Pain – (July 2009)

• Recommends that osteopathic physicians use OMT in the care of

patients with low back pain

• Evidence: systematic reviews and meta-analyses of randomized

clinical trials (Evidence Level 1a)

• OMT for somatic dysfunction has not demonstrated harm in any

clinical trials to date

• Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back
• pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders 2005, 6:43.

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Clinical Guideline – OMT in Low Back Pain

The patient population

– Low back pain patients of MS origin

• LBP referred from visceral origin is excluded from these

guidelines

• Other exclusions

– Vertebral fracture/dislocation, muscle tears/lacerations, spinal ligament rupture, discitis, sacroiliitis, ankylosing spondylitis, masses, inflammation of facets/muscles/fascia – This does not imply that OMT is contraindicated in all of these conditions

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Clinical Guideline – OMT in Low Back Pain

7 trials met criteria for inclusion Each trail was independently evaluated by 2 reviewers to abstract data – Methodological characteristics – OMT & control treatments – Low back pain outcomes

• Significant reduction in pain
• Analgesic effect comparable to NSAIDs
• Less referral, imaging, and rx

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OMT in Low Back Pain

John C. Licciardone, DO, MS, MBA; Dennis E. Minotti, DO; Robert J. Gatchel, PhD; Cathleen M. Kearns, BA; Karan P. Singh, PhD. Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial. ANNALS OF FAMILY MEDICINE ✦

WWW.ANNFAMMED.ORG ✦ VOL. 11, NO. 2 ✦ MARCH/APRIL 2013 OMT regimen met or exceeded the Cochrane Back Review Group criterion for medium size effect in relieving chronic low back pain. It was safe and well accepted by patients. Improvement in LBP Patient satisfaction Less prescription drug use

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OMT Considerations

• When to Consider Osteopathic Manipulation

– Sarah Cole, DO; Jeremy Reed, DO – Patients with low back pain, headache, and neck pain can benefit from this approach – Vol 59, No 5 | MAY 2010 | The Journal of Family Practice

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Discussion

Barriers to the application of the recommendations

– Poor reimbursement for OMT

• Medicare has reimbursed DOs for OMT >30 years

– ICD-9 code 98926-9 with a 25 modifier attached to the E&M code

– Time constraints – Lack of confidence or loss in skills – Inadequate office space – Some specialties

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Clinical Case 1

A 26 y/o male professional indoor soccer player is “walled” by an opponent as he is striking the ball for a defensive clear/pass. The patient’s posterior gluteal region makes contact with first the wall then the floor. When he tries to get up from the incident, he notices pain in the post and lat hip region, as well as pain with ambulation. Exam reveals no motor/sensory/reflex deficit, or specific point tenderness. Good stability, but he does have diffuse mild tenderness around the SI, altered gait, and global hip ROM

• reduction. Which of the following is the most likely diagnosis:
• A. Gluteus medius disruption
• B. Somatic dysfunction of the lumbar
• C. Abductor spasm
• D. Somatic dysfunction of the pelvis
• E. Labral tear of the hip

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Clinical Case 1

• Other considerations – contusion, fracture, soft tissue disruption……
• Complete evaluation performed
• Somatic Dysfunction of Pelvis – Innominate, sacrum

SI restriction – treated with gentle articulation/ROM OMT

• Restoration of motion, resolution of discomfort
• Immediate return to play

Side note - he scored a goal 15 seconds after returning to play

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Clinical Case 2

A 25 y/o female runner presents with progressive left hip region pain since beginning a marathon training program several weeks ago. Exam reveals a negative scour and labral loading test, but a weakly positive jump sign and a +

• ber’s test. Which of the following is the most likely diagnosis for this patient?

A. Labral tear of the hip B. Hip flexion somatic dysfunction C. Hip extension somatic dysfunction D. Hip adduction somatic dysfunction E. Hip abduction somatic dysfunction

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Clinical Case 2

• Other considerations – fracture, overuse stress reaction, CAM/pincer

deformity, soft tissue injury…..

• Complete evaluation performed
• Somatic Dysfunction:

Named for position of ease/freedom, “where it likes to live”

• IT band syndrome
• Mild greater trochanteric bursitis
• Hip Abduction Somatic Dysfunction – treated with Myofascial Release, Muscle
• Energy. Home stretches, roller recommended
• Pt able to complete marathon

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Clinical Case 3

A 21 y/o male college basketball player presents with L shoulder pain and tightness the day after the game. He feels that his shot has been affected. He reports getting tangled up with an opponent while going for a lay-up and having his shot blocked. Exam shows ROM restriction in multiple planes of the L shoulder, most notable with internal rotation. He has no motor/sensory/reflex

• deficits. Drop arm, empty can, apprehension, Yergason tests were all negative.

Which of the following is the most likely diagnosis? A. Glenohumeral instability B. Biceps tendonitis with subluxation C. Shoulder external rotation somatic dysfunction D. Shoulder internal rotation somatic dysfunction E. Shoulder abduction somatic dysfunction

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Clinical Case 3

Other considerations – strain, sprain, other ST injury, subluxation, cuff…. Complete evaluation ER somatic dysfunction L shoulder/IR restriction – treated with spencer technique

gentle artic (ext/flex/circumduction w compression/circum w traction/abd, adduction/IR, traction stretch)

and Muscle Energy Also found to have scapulothoracic, cervical and thoracic dysfunction Scoring average for the season did not suffer/decrease Of note, pt wanted you to know the defender was called for a foul and he made the free throws

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Clinical Case 4

An 19 y/o female gymnast presents with a 3 yr h/o progressive LBP. She states the pain is in the bilat Lumbar region with radiation posteriorly into the gluteal region. Exam reveals no motor/sensory/reflex

• deficit. She has a negative straight leg raise, and neg Thomas test. She

has a + apprehension (FABER), + c-sign, and + scour. Which of the following is the most likely diagnosis? A. Labral tear B. Psoas spasm C. Iliotibial band bursitis D. Lumbar somatic dysfunction E. Lower extremity somatic dysfunction

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Clinical Case 4

• Labral pathology most likely given + central hip compartment

signs/tests

• Can have accompanying somatic dysfunction and strain patterns
• Dx made with TART findings

─ Lumbar, LE, Pelvis, Thoracic…… ─ OMT will not correct the labral tear, but can help with compensation and improve pain and function ─ Remember structure/function relationship

• Pt has delayed surgery, and restored function, as well as pain

reduction with OMT

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OMT for athletes

• Back pain, neck pain – Somatic dysfunction
• A few other examples:
• Radial head dysfunction – muscle energy tx

associated forearm restrictions

• Fibular head dysfunction – muscle energy tx

associated ankle problems

• Hamstring tension – Hip ext dysfunction – muscle energy tx

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Work Shop Plan

• Observation/posture, palpation
• Soft Tissue techniques

– Lymphatic techniques – Myofascial techniques

• Muscle energy techniques
• Still technique
• HVLA technique demonstration

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Observation: Visualization and Postural exam

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Goals

• Be able to determine your dominant eye and

dominant palpating hand

• Understand how to observe your patients
• Know what to look for in observing patients

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Observation: Comparative Analysis

• The goal of this observation is to compare right versus

left in regard to: – Symmetry – Heights – Deviation from midline

• Always do a structural examination in context of a

complete H & P of the patient

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Observation: Comparative Analysis

What factors create asymmetry? – Bone/joint deformity – Kyphoscoliosis – Dress, occupation, mental attitude, habit – Sacral base unleveling – Lower extremities – Somatic dysfunction

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Observation: Comparative Analysis

Anterior View

– head carriage – eye level – nose angle to midline – ear lobe level – ear prominence – shoulder height – clavicle angle to midline – carriage of arms – fingertip level

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Observation: Comparative Analysis

Anterior view

– angle of rib cage – Iliac crest – ASIS – greater trochanter – angle of patella – medial malleolus – lateral malleolus

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Observation: Comparative Analysis

Posterior view

– carriage of head – shoulder level – inferior angle of scapulae – arm carriage – waist crease – iliac crest heights – PSIS – greater trochanter – popliteal space – Achilles tendon – malleoli

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Observation: Comparative Analysis

Lateral view – Lordosis - convexity anterior – Kyphosis - convexity posterior Gravitational line – Ear lobe – Acromion of shoulder – Body of L2 vertebra – Greater trochanter – Lateral malleolus

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Palpation

Basis of physical diagnosis

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Somatic Dysfunction

TART

• Tissue texture changes/abnormalities (acute, chronic)
• Asymmetry (static, dynamic/motion)
• Restriction of motion (active/passive ROM)
• Tenderness to palpation

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ACUTE CHRONIC Recent occurrence Long standing Pain is acute, severe, cutting, sharp Pain is dull, achy, paresthesias Vascular: Vasodilation, inflammation Vascular: Constricted via sympathetic tone Skin: Warm, moist, red, inflamed Skin: Pale, cool Muscles: Increased tone, contraction, spasm Muscles: Decreased tone, flaccid, limited motion Tissue: Boggy edema, acute congestion Tissue: Doughy, stringy, fibrotic, ropey

Tissue Texture Changes

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Exercises

Light touch – Temperature – Texture – Moisture Layered palpation – Vascular – Connective tissue – Muscular fibers

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Exercises

• Spine - gross ROM
• Segmental ROM

“load and spring”

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Soft Tissue Techniques

Treatment for releasing stress in the non-skeletal aspect of the musculoskeletal system

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General

• Used alone or with other modalities
• Useful in acute and chronic problems
• Types

– Direct – Indirect – Lymphatic

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Barrier Concept

Neutral Range of motion Anatomic Barrier

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Barrier Concept

Neutral Restrictive Barrier Altered Range of Motion Altered Neutral

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Direct Technique

Neutral Restrictive Barrier

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Indirect Technique

Neutral Restrictive Barrier

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Underlying Principles

• f

Soft Tissue

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Underlying Principles

Stretch and kneading – Slow, do not “surprise” muscle or tissues – Not too much – Causes realignment over time of collagenous fibers, lengthening of muscle fibers – Helps move fluids

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Underlying Principles

Pressure – Moves fluids – May cause reflex inhibition of nociceptive inputs – May cause golgi tendon organ inhibition of muscle activity

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Types of Techniques

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Types

Force applied as steady pressure to spastic tissue

–Reflex Inhibition

Lymphatic techniques

–Effleurage, Pétrissage, Tapotement –Thoracic and pedal pump

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Types

Lateral Stretch

– Force the tissue at right angles to the long axis

• f the muscle or tissue

Linear or Longitudinal Stretch

– Force tissue in direction of long axis or moving from origin and insertion

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How to Perform

• Doc needs to be comfortable
• Patient in relaxed position
• Use finger pads and thenar eminence
• Palmar aspect of the thumb
• Avoid pressure directly over the spinous processes
• Easy start and easy finish

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How to Perform

Rate, rhythm, and length of treatment – Listen with your hands and fingers – Slow/steady: inhibitory – Fast/vigorous: stimulatory

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Summary

• Soft tissue techniques vital to successful treatment
• May be only modality patient can handle
• Perfect combination tool
• Has wide sweeping effects

– Relaxation – Immune function – Pain relief

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The Lymphatic System: A Brief Introduction

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Introduction

• A second circulatory system
• Passive system
• Function can be altered extrinsically

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Function of the Lymphatic System

• Fluid balance
• Purify/cleansing
• Defense
• Nutrition

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Application

Indications: Edema, CHF, URI, frail patients, during and after periods of immobilization. Contraindications: Open wounds, recent abdominal surgery, friable skin, fractures, inflammation in the area of treatment, febrile illness without antibiotics.

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Summary

• Lymph system vital to our continued existence
• System is readily affected by external compression
• OMT inherently involved with improving fluid

movement

• Many clinical applications

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Practice Time

Lymphatic Techniques – Thoracic duct – Thoracic pump – Pedal pump – Sinus technique – Effleurage – Pétrissage

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Myofascial Release Technique

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Introduction

Fascia – Supports – Stabilizes – Helps maintain balance (postural function) Fascia acts as “big bandage” for body

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Introduction

• Continuous integrity of fascia/connective tissues

forms foundation for fascial patterns to occur in the body

• Abnormal patterns (strain) may affect function

– Local level – Entire movement pattern

• Myofascial release techniques become useful to

resolve abnormal patterns

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Myofascial Release

Treatment goals – Release tightness – Restore 3 dimensional patterns to functional symmetry Direct and indirect treatments

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Myofascial Release

Direct treatments – Define areas of tightness by holding tissue firmly into barrier of restriction – Wait for tissue release (tissue creep) – Art lies in being able to follow tissue response as release begins

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Myofascial Release

Indirect treatments – Move the tissue in 3 dimensions 180 degrees from restrictive barrier – Subtle release of tissue – Art lies in being able to keep the tissues in a “loose” fashion while the body “unwinds”

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Myofascial Release

Post treatment discomfort (infrequent) – Temporary increase of pain – On 1st or 2nd treatment – Analogous to post exercise soreness

• Lupus and fibromyalgia patients can have repeated flares

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Myofascial Release

Techniques – Must be consistent in stretching or strengthening to maintain progress – Not to the point of aggravating pain or instability – Restore proprioceptive input for long-term success

• f treatment

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Myofascial Release

Indications: To restore motion, release contractures, preparation for other treatments. Contraindications: Acute inflammation at/near the treatment area, fractures, friable skin.

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Practice Time

Myofascial release techniques – Shoulder – Cervical spine – Perpendicular and parallel release of the thoracolumbar spine

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Muscle Energy

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Definition

• A form of OMT wherein pt’s muscles are actively used
• n request, in a specific direction and against specific

counterforce from a specific position

• A direct technique

– Engages the restrictive barrier and then carries the dysfunctional component into the restrictive barrier

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Basics

• Using pt’s “muscle energy” as activating force
• Dr. counteracts pt’s force
• Isometric = no movement in active phase

– muscles remain the same length – achieve relaxation after contraction of muscles

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Utility

• Mobilize joints where movement is restricted
• Stretch tight muscles and fascia
• Improve local circulation
• Balance neuromuscular relationships to alter muscle

tone

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Indications

Use alone or to prepare pt for HVLA (High Velocity/Low Amplitude) – after ME, may find HVLA not needed – great for acute torticollis – also good for chronic pain, HA, etc

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Contraindications

• Open wounds
• Broken bones
• Uncooperative patients
• Unresponsive patients
• Severe pain in muscle group utilized

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Goals of ME

• Strengthen weaker side of asymmetry
• Decrease hypertonicity
• Lengthen muscle fibers
• Reduce restriction of motion
• Alter related respiratory and circulatory function

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Technique Simplified

• Position body part into position of initial resistance

(barrier)

• As pt. moves body part away from restriction, Dr.

provides equal counterforce to achieve isometric contraction, while monitoring pt to ensure proper position

• Hold for about 5 seconds, then both pt and Dr. relax

simultaneously

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Technique Simplified

• After 1 second, Dr. takes up slack and moves body

part further toward pt’s restriction

• Repeat approximately 3-5 times, until no further

restrictions are noted or a full range of motion is

• btained
• Recheck

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Physiology

Post-isometric relaxation – neuromuscular bundle is in a refractory state immediately after contraction, allowing passive stretching to occur Reciprocal inhibition – as one muscle is contracting, the antagonist is relaxing (biceps and triceps)

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Variables

Accurate diagnosis – need to be sure you are directing forces at the correct level Amount of force – varies by individual and by body part being treated

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Variables

• Consider the different amounts of strength needed to

counter a pt’s legs vs. neck

• Only need enough force for isometric contraction
• May need to use your body weight or brace yourself

with the table

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Variables

Localization – need to isolate the segment you are treating – your chance of a successful tx is greatly decreased if you are directing forces above or below the site of dysfunction – this is why you need to monitor

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Practice Time

Muscle Energy Techniques – Hamstring release – Cervical spine rotational release – Thoracic spine – Forearm restriction

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Still Technique

Indirect & Direct Articulation Any Somatic Dysfunction Examples: Pelvis/SI joint Thoracic spine

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Demonstration

High Velocity Low Amplitude (HVLA) – Treatment modality which utilizes a rapid (high velocity) thrust, but in which the segment being treated is intended to only move a few millimeters (low amplitude) – Must be aware of indications/contraindications

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Demonstration

High Velocity Low Amplitude (HVLA) – Thoracic Spine

• Thrust is on transverse process of rotated segment
• If vertebra rotated L, thrust vector on L transverse process

– Lumbar Spine

• Since it has larger vertebral bodies than thoracic spine,

thrust utilizes segments above and below dysfunctional

• segment. If rotated L, thrust vector toward R

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Physical Therapy

To improve function related to bone, joint, muscle, nerve Impaired function injury, overuse, age, degenerative 2-3 sessions/wk 4-6 weeks Home stretches/exercises focused, tailored

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Physical Therapy

ROM – active/passive joint stiffness, loss of flexibility Strength – illness, injury, overuse, age Gait – unsteady, device assisted Posture – asymmetry, poor balance, falls Core – difficulty with transfer Function/ability – energy conservation, deconditioning (illness)

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Physical Therapy

Post-op

Protection Motion Strength Advanced activity

Core strength Region above/below

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CORE

Evaluation Assess core strength and stability Exercises 3 sets/exercise at 30-45 seconds each OR as long as you can hold 1 leg mini squat Side bridge Planks Superman Curl-up Wall push-up Scapular slides Wall wash Overhead pull

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Workout Considerations

MUSCULAR STRENGTH – minimum of two 20-minute sessions per week, include all the major muscle groups – Lifting weights is the most effective way to increase strength – Don’t work same body part/muscle group 2 days in a row MUSCULAR ENDURANCE – at least three 30-minute sessions each week

Weight Training Fat Loss

• 1-3 sets of 10-12 reps

Muscle gain

• 3+ sets of 6-8 reps

Health/Endurance

• 1-3 sets of 12-16 reps

Rest period 30 seconds - 5 min

• Varies based on goals

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Answers

• 1. D
• 2. E
• 3. C
• 4. A

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Thank you!

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