Chaudhri, Parul, DO

Keister, Drew, MD

Lineman, Jeffrey, MD

Weaver-Agostoni, Jacqueline S, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Family MedicineBack to Basics: OMT WorkshopDrew Keister MDLehigh Valley Health Network, Drew_M.Keister@lvhn.orgJeffrey Lineman MDJacqueline S. Weaver-Agostoni DOParul Chaudhri DOFollow this and additional works at: http://scholarlyworks.lvhn.org/family-medicinePart of the Medical Specialties CommonsThis Presentation is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works byan authorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtKeister, D., Lineman, J., Weaver-Agostoni, J., & Chaudhri, P. (2106, March 9). Back to Basics: OMT Workshop. Presentation presentedat: The Pennsylvania Academy Family Physicians, Pittsburgh, PA.Pennsylvania Academy of Family Physicians Foundation & UPMC 43rd Refresher Course in Family Medicine CME Conference March 10-13, 2016  Back to Basics…OMT Workshop Drew Keister, MD, Jeffrey Lineman, MD, Jacqueline S. Weaver-Agostoni, DO & Parul Chaudhri, DO Disclosures:   Speakers have no disclosures and there are no conflicts of interest.   The speakers have attested that their presentation will be free of all commercial bias toward a specific company and its products.  The speakers indicated that the content of the presentation will not include discussion of unapproved or investigational uses of products or devices.    1PAFP/Refresher Course in Family Medicine OMT ReviewJackie Weaver-Agostoni, DO, MPH, FACOFPProgram Director, Osteopathic FM Residency, UPMC ShadysideJeff Lineman, DOProgram Director, Osteopathic FM Residency, UPMC St. MargaretDrew Keister, MD Program Director,  FM Residency Lehigh Valley Health NetworkParul Chaudhri, DOFaculty Development Fellow, UPMC Family Medicine1Disclosures The speakers have no conflict of interest, financial agreement, or working affiliation with any group or organization.2Goals/Objectives By the end of this workshop, you will be able to:1. Name at least 3 different categories of OMT treatments2. Perform manual medicine/OMT techniques to help treat common outpatient conditions3. Perform manual medicine/OMT techniques to help treat neck pain32Workshop Agenda Introductions (5 min) Brief review of Osteopathic Medicine history and principles (10 min) Review types of treatments (5 min) Review of common outpatient conditions with technique practice (40 minutes) Review of neck pain with technique practice (20 minutes) Basic billing/documentation (5 min) Wrap-Up/Questions (5 min)4BRIEF REVIEW OF OSTEOPATHIC MEDICINE HISTORY AND PRINCIPLES5What is Osteopathic Medicine A unique and comprehensive approach  More than just manipulation Congruent with current biopsychosocial model Not chiropractic with prescribing rights One of the fastest growing health professions  31 DO Medical Schools (more than 20% of medical students in the US) 45 Locations 30 States  70,000 + DO’s in the US PA with most Osteopathic Physicians (7,260 in 2012)63Distinctive Philosophy of Medicine1. The unity of the body2. The body’s inherent self-healing ability3. The somatic component of disease4. The relationship of structure and          function5. The use of manual therapy7UNITY OF THE BODY Basic principles = body is  a unit and functions as such.  Reductionist approach poses difficulties in evaluating / treating  and healing people  Can you describe /predict the characteristics of table salt by examining Na metal and Cl gas?8HEALING POWER OF BODY Natural state of the body is health Nature has provided all things necessary for maintenance of health Body has inherent capacity to maintain health and recover from disease94STRUCTURE AND FUNCTION INTERRELATIONSHIP Virchow 18th century Structure governs and influences function, and vice-versa10MANUAL THERAPY (MANIPULATION) Method by which physician can evaluate and treat dysfunction of the musculoskeletal system Such treatment influences local and distant tissues Macroscopic and microscopic level Restoration / optimization of tissue function maintains wellness and assists in recovery from disease11Historical perspectives: manual medicine Ancient Thailand (2000 B.C.) Ancient Egypt Hippocrates: described traction and leverage techniques Lost through middle ages - Role of plagues?125Manual medicine history Dr. Edward Harrison – London 1780’s –large manual medicine practice Bonesetting- Gained attention and acknowledgement by Paget and Hood 1800’s – manual medicine techniques described in U.S.13Osteopathic Medicine Developed by A.T. Still, M.D.(1828 -1917) Civil War  surgeon First proposed tenets in 1874 Response to his disenchantment with standard medical therapies of the day14The Basics Somatic Dysfunction◦ Found on the osteopathic structural exam◦ Abnormal palpatory findings◦ Restriction affecting joints, muscle, and fascia◦ Can affect blood supply, lymph flow, and nervous function Acute◦ Edema, redness, boggy, moist◦ Sharp/severe pain w/ restriction, tender◦ Asymmetry without compensation Chronic◦ Cool, dry, ropy◦ Less pain with restriction, burning, achy◦ Asymmetry with compensation156The Basics TART◦ Tissue Texture Change◦ Asymmetry◦ Restriction◦ Tenderness16Restriction Physiologic Barrier◦ Active motion Anatomic Barrier◦ Passive motion◦ Movement beyond causes injury Restrictive (Pathologic) Barrier◦ Before the physiologic barrier17Anatomic barrierActive range of motionPhysiologic barrierMotion LossPathologic barrier187Structural Exam Inspection Palpation◦ TART Motion Testing19REVIEW TYPES OF TREATMENTS20SOMATIC DYSFUNCTION Fundamental principle of osteopathic diagnosis Found upon osteopathic structural exam Involves abnormal palpatory findings of soft tissue and/or joint structures218INTERVENTION (OMT) 2 basic categories of techniques:1. Direct = Barrier is engaged directly2. Indirect = Energy is directed away from barrier“ unstick the drawer “22COMMONLY USED TECHNIQUES1. Soft tissue / myofascial release2. Counterstrain3. Muscle energy4.  Articulatory5. High velocity, low amplitude (HVLA)23When is OMT indicated? Most commonly used as primary or adjunctive treatment for musculoskeletal complaints ( acute or chronic ) Mostly axial skeleton, but periphery also Headaches Fibromyalgia TMJ Sinus dysfunction Improve respiratory function in COPD / Asthma249CONTRAINDICATIONS Absolute : for neck = OA instability as found in RA, Down’s Relative : for HVLA = osteoporosis, acute injury, elderly, metastases, Pt. fear Overall, OMT very safe ; in fact safer than many standard therapies 25SOFT TISSUE Energy directed at soft tissues, especially skin, fascia and muscles Involves lateral stretching, linear stretching, deep pressure, or separation of muscle origin and insertion. Improves fluid ( lymph, blood ) mobility, stimulates mechanoreceptors = decrease  pain,spasm26COUNTERSTRAIN Tenderpoints are identified and monitored Pt. is placed in position of maximum comfort Gentle focal fingertip pressure applied for 90 seconds Theorized to reduce / reset afferent input to spinal cord and cortical centers2710MUSCLE ENERGY Active and direct Joint placed in restriction of movement Patient gently pushes in opposite direction for 3-5 seconds then relaxes Physician passively place the joint further into barrier of motion Process repeated 3 times28MYOFASCIAL TECHNIQUES Passive techniques◦ Linear stretch◦ Perpendicular stretch Direct active  Indirect active29REVIEW OF COMMON OUTPATIENT CONDITIONS WITH TECHNIQUE PRACTICE3011TENSION HEADACHE31RELEVANCE Most frequently experienced headache (HA) More prevalent in women Prevalence: 30 – 80% Associated with limited ability to function in more than 40% May cause disability and         decreased quality of life 32PATHOLOGY Very little research has been published on osteopathic treatment Relaxation therapies have been shown to be superior to no treatment Progressive muscular relaxation exercises◦ Reduce HAs◦ Home-based programs3312RED FLAGS Fundamental change or progression in pattern First and/or worst Abrupt onset of attack Awaken out of sleep Abnormal PE (general or neuro) Neurological symptoms lasting > 1        hour34RED FLAGS New HA in individuals aged < 5 yrs or > 50 yrs New HA in patients with cancer, immunosupression or pregnancy Associated with alteration of loss of consciousness Triggered by exertion, sex or valsalva maneuver35ANATOMY Suboccipital and upper cervical area are crucial◦ Sensory fibers of the first three cervical vetebrae◦ First cervical nerve provides motor innervation to suboccipital triangle◦ CN 5, 9 and 10 referred pain◦ Three CNs and second (and third)          cervical nerve mediate the referral                 of excessive connective tissue tension            in the cervical area3613MUSCLES Neck and occiput◦ Strap◦ SCM◦ Trapezius◦ Others Temporal bone◦ More than 10 muscles connected here37EXAM Restriction in cervical vertebral motion Paravertebral contractures Tender points◦ Often a series of tender points along the inferoposterior portion of occiput between the inion and mastoid process38TREATMENT Any form of OMT is appropriate as long as the patient tolerates it◦ Myofascial release◦ Counterstrain◦ Muscle energy◦ Trigger point pressure◦ HVLA Soft tissue techniques should precede any direct action techniques3914Myofacial release Soft Tissue Gentle, sustained pressure40Suboccipital Release, Supine41COUNTERSTRAIN Indirect and passive Tender points found and muscle shortened for 90 seconds Returned to normal position passively too Tender points anterolateral Key is to find point in which the muscle is most relaxed4215Muscle Energy Active and direct Joint placed in restriction of movement Patient gently pushes in opposite direction for 3-5 seconds then relaxes Physician passively place the joint further into barrier of motion Process repeated 3 times43SINUS TECHNIQUES44Sinus Anatomy4516Sinus OMT Goals:◦ To relieve obstruction and pain◦ Improve venous and lymphatic flow from the area (jugulodigastric node)◦ Effect reflex changes◦ Improve mucociliary clearance 46Sinus OMT Indications:◦ Sinusitis◦ URI Symptoms◦ Nasal Congestion◦ Headache◦ Otitis Media Relative Contraindications◦ Bacterial infection with temp > 102 degrees47Treatment Techniques1. Direct Pressure and “milking”2. Indirect Pressure3. Nasal Decongestion4. Counterstrain TechniquesPosition:◦ Patient: Supine on table◦ Physician: Seated at head of table4817Direct Pressure Frontal Sinuses Supraorbital Notch Maxillary Sinuses Temporal Areas49Other Techniques Indirect Pressure: Occiput Nasal Decongestion: Bridge of the nose Counterstrain: Maxillary,           Supraorbital50EUSTACIANTUBE DYSFUNCTIONANDOTITIS MEDIA5118Eustacian Tube Dysfunction Auricular Drainage Technique◦ “V” with fingers◦ Clockwise and counterclockwise massaging52Auricular Drainage Techniquefor otitis media/externa53TEMPOROMANDIBULAR JOINT (TMJ) DYSFUNCTION5419Temporomandibular joint (TMJ) dysfunction Scope:  20% of Americans 3:1 Females55TMJ : Anatomy Synovial joint w/ fibrocartilaginous disk Disk margins merge w/ joint capsule Temporomandibular ligament = zygoma to mandible 4 muscles of mastication (chewing): Temporalis, Masseter,  Medial and Lateral Pterygoid56TMJ movement: Depression/ elevation of jaw via condylar rotation Anterior / Posterior glide Protraction / Retraction Side – to – side glide5720TMJ dysfunction- causes: Malocclusion (dentures, teeth) Trauma – acute, chronic, repetitive Bruxism (nocturnal grinding) Mastication muscular imbalance58Signs / Symptoms of dysfunction Clicking/popping Pain in front of ear Decreased ROM of jaw /pain Tenderness to palpation Anterior earache Headache “tightness” of jaw59TMJ : Office evaluation1. Facial symmetry2. Jaw opening / tracking (open & close mouth)3. Palpate for tenderness /crepitus4. Dental evaluation6021Manual Medicine techniques:1. Muscle energyActive (requires patient utilization of force)Direct (engages the barrier) Promotes muscle relaxation by activating the golgi tendon reflex 2. Counterstrain61Counterstrain Tenderpoints are identified and monitored Pt. is placed in position of maximum comfort Gentle focal fingertip pressure applied for 90 seconds Theorized to reduce / reset afferent input to spinal cord and cortical centers62CARPAL TUNNEL6322Carpal Tunnel Incidence in U.S. adults15-20%64Carpal TunnelMyofascial Wrist Retinaculum Release65PLANTAR FASCIITIS6623Plantar FasciitisMyofascial release of plantar fascia67SHOULDER PAIN68Articulatory  Low velocity, high amplitude Treats dysfunctional joint  Full range of motion Goal to increase mobility and range of motion6924Shoulder Pain Spencer Technique◦ Useful when restriction or fibrosis has developed in soft tissue Early adhesive capsulitis Healed fractures Anything causing restrictions in glenohumeral motion70Spencer Technique Used for both evaluation and treatment Can combine with muscle energy to treat 7 motions Physician uses cephalad hand to stabilize clavicle and scapula against thorax while using caudal hand to introduce the motions Patient lays on unaffected side717 Stages of Spencer1. Extension2. Flexion3. Circumduction with Compression4. Circumduction with Traction5. Abduction6. Internal Rotation7. Stretching Tissues and Pumping Fluids with Arm Extended72257 Stages of Spencer73FIBROMYALGIA74Fibromyalgia18 Tenderpoints- Counterstrain7526BACK PAIN76Differential Dx• Mechanical low back pain 97%:-Lumbar strain 70%-Degenerative discs and facets 10%-Herniated discs 4%-spinal stenosis 3%Recent studies1 showed in patient’s with low back pain:85% had evidence  of abnormality in the areas of the psoas and quadratus lumborum based on Functional MRI77Osteopathic Exam Order1. Seated/ Standing flexion test2. Sacral dysfunction3.‘TART’ paraspinal musculature and  quadratus lumborum4. Psoas restriction5. Piriformis restriction6. Innominate/ Iliosacral dysfunction7. Segmental motion testing L1-L57827Back Pain-Soft Tissue Techniques-Linear Stretch79NECK PAIN80Motion and Mechanics OA◦ Motion of occipital condyles on the atlas (C1)◦ Flexion, Extension◦ Sidebending and rotation to OPPOSITE sides ◦ Test with translation AA◦ Motion of C1 on C2◦ Rotation◦ Test flexed 45 degrees C2-C7◦ Both Flex/Ext and Rotation◦ Sidebending and rotation to SAME side8128Typical Cervical Motion Flexion and Extension Upper Cervicals-Rotational component dominates Lower Cervicals- Side bending component dominates82Naming Somatic Dysfunction Named for freedom/ease of motion Fryette’s laws I and II do NOT apply to cervical vertebrae OA sidebending and rotation to opposite sides with flex/ext (FRRSL) AA rotation only C2-C7◦ Sidebend and rotate toward same side83Common Causes of Neck Pain Systemic Dz◦ RA, spondyloarthritis, PMR, bone mets DJD #1  Cervical Strain Spondylosis◦ Correlation b/t degree of x-ray change and severity of pain is poor Discogenic pain Whiplash Myofacial pain8429Radiculopathy Spurling Test- Ext/Sidebend- + sx in ipsilateral arm85Non-Spinal Causes of Neck Pain Thorasic outlet syndrome Herpes zoster Diabetic neuropathy Other◦ Vascular◦ Cardiac◦ Infection◦ Referred shoulder pain◦ Neurologic86“Red Flags” for Neck Pain Older patient w/ associated headache, shoulder/hip girdle pain, vision sx◦ Rheum- PMR, giant cell arteritis H/o f/c, unexplained weight loss, immunosuppression, CA, IVDA◦ Tumor or infection With Neuro sx (arm clumsiness, gait problems, bowel/bladder, Babinski’s)◦ Cervical myelopathy8730“Red Flags” for Neck Pain Shock-like paresthesia w/ neck flexion (Lhermitte’s phenomenon)◦ Cord compression Midline disc herniation Spondylosis Intramedullary pathology (MS plaque) Anterior neck pain◦ Non-spinal causes  Trauma hx88Cervical Nerve Roots89Supporting Evidence Strain-counterstrain decreased pain (p=.014) vs. sham in patients with cervical tenderpoints2 Sytematic review3◦ Mobilization, manipulation and soft tissue techniques decreased pain and improved satisfaction vs. short wave diathermy◦ Tx + advice/exercise improved global perceived effect and satisfaction vs. advice/exercise alone for acute neck pain Whiplash study4 – clinically relevant and statistically significant improvement in Neck Pain and Disability Scale w/ osteopathic treatment period vs. without◦ 37% improvement, including both mental and physical components9031OMM Techniques Soft Tissue/Myofascial Release Muscle Energy Counterstrain◦ Tenderpoints differ from trigger points in that tenderpoints don’t radiate pain elsewhere when compressed HVLA Lymphatic Chapman’s reflex inhibition  Facilitated Positional Release Craniosacral91Treatment Order Approach In general, treat more centrally first◦ Thorasic prior to cervical◦ Thorasic prior to ribs◦ Axial before extremities Cranial before other treatments If acute issue, start peripherally92Cervical Spine Practice Structural Exam OA Release Soft Tissue Techniques Muscle Energy Counterstrain9332Cervical Structural Exam Practice OA◦ Motion of occipital condyles on the atlas (C1)◦ Flexion, Extension◦ Sidebending and rotation to OPPOSITE sides ◦ Test with translation AA◦ Motion of C1 on C2◦ Rotation◦ Test flexed 45 degrees C2-C7◦ Both Flex/Ext and Rotation◦ Sidebending and rotation to SAME side94Suboccipital Release95Soft Tissue9633Muscle Energy for AA Practice Rotate to the barrier Patient isometrically rotates away97Counterstrain Tenderpoints are identified and monitored Pt. is placed in position of maximum comfort Gentle focal fingertip pressure applied for 90 seconds98Billing E&M ◦ Ex. 99213- office visit established patient ICD-9 ◦ Ex. 723.1 Neck Pain◦ Ex. 739.1- somatic dysfunction of cervical region .25 modifier◦ Additional procedure CPT◦ OMT procedure (based upon number of regions treated)9934Useful Resources Channell, MK, Mason DC.  The 5-Minute Osteopathic Manipulative Medicine Consult.   ACOFP DO OMT app for smartphones100References1. Clark BC, Walkowski S, Conatser RR, Eland DC, Howell JN. Muscle functional magnetic resonance imaging and acute low back pain: a pilot study to characterize lumbar muscle activity asymmetries and examine the effects of osteopathic manipulative treatment.  Osteopathic Medicine and Primary Care 2009;3:7. 2. Brose SW, Jennings CD, Kwok J, et al.  Sham Manual Medicine Protocol for Cervical Strain-CounterstrainResearch.  PM&R 2013;5:400-407.3. D’Sylvia J, Miller J, Gross A, et al.  Manual therpy with or without physical medicine modalities for neck pain: A systematic review.  Man Ther 2010;15:415-433.4. Schwerla F, Kaiser AK, Gietz R, et al.  Osteopathic Treatment of Patients with Long-Term Sequelae of Whiplash Injury: Effect on Neck Pain Disability and Quality of Life.  J Alt Comp Med 2013;19(6):543-549.101References DiGiovanna E, Schiowitz S.  (1997).  An Osteopathic Approach to Diagnosis and Treatment.  Philadelphia, PA: Lippincott-Raven; 373-375. Ward, Robert C et al.  (1997).  Foundations for Osteopathic Medicine.  Baltimore, MD: Williams & Wilkins; 778-779. Savarese RG, Capobianco JD, Cox, Jr., JJ.  (2003).  OMT Review; 125-126.102

Back to Basics: OMT Workshop

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Back to Basics: OMT Workshop

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Lehigh Valley Health Network: LVHN Scholarly Works