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Robert Hunter, DO
• To understand how OMT can be used in the Mind-Body-Spirit
approach to Total Pain relief.
• To identify simple OMT techniques that both osteopathic and
non-osteopathic practitioners can use to treat their patients'
pain.
• To comfortably reproduce the techniques demonstrated under
the supervision of the presenters.
• Osteopathy recognizes that all parts of the body work together to create healing.
• Osteopathic Manipulative Treatment (OMT) is a set of manual medicine techniques used to relieve pain and other symptoms, restore range of motion and function, and enhance the body's capacity to heal.
• There are barriers to patients being able to receive this beneficial adjunct therapy.
• As of 2010, there are only 70,480 DOs, very unevenly distributed in the United States.
• Not all DOs practice OMT; Osteopathic physicians sometimes feel they cannot practice OMT because of difficulty mastering techniques or because they do not know how to integrate OMT into their practice.
• In geriatrics specifically, OMT is a useful adjunct pain treatment that has no drug-drug interactions and may provide immediate relief.
• Most osteopathic techniques require significant specialized education
and supervised practice over time to achieve mastery.
• Few techniques are easy to reproduce by a non-osteopathic
practitioner, occasionally even by the patient themself.
• Myofascial release, soft tissue stretching and strain-counterstrain
techniques specifically are easy to learn and reproduce in many
different areas of geriatric practice (home to inpatient settings).
• Since learning these techniques does require practice, this
presentation will encourage the attendee to participate in supervised
use of the techniques in small groups with a partner.
• This symposium will serve as an introduction to simple OMT techniques
that can be reproduced by both novices and skilled learners.
• Osteopathic Medicine was developed 130 years ago by Andrew
Taylor Still, MD, DO.
• A.T. Still is considered the “father of osteopathic medicine”, as well
as the founder of the first college of osteopathic medicine.
• Dr. Still’s philosophy of medicine recognizes the interrelationship of
all body parts and the key role of the musculoskeletal system in
health and well being.
• He echoed Hippocrates view that the body has an innate ability to
heal itself and restore balance.
Biography of Andrew Taylor Still, Founder of Osteopathic Medicine. American Osteopathic Association.
Retrieved from http://www.osteopathic.org/index.cfm?PageID=ost_still
• Emphasizes a “whole person” approach.
• Honors the physical, emotional, and spiritual aspects of wellness.
• Recognizes that the body is capable of self-regulation, self-
healing, and health maintenance.
• Identifies that structure affects function, and the musculoskeletal
system is regarded as the “conductor” that organizes and
coordinates the different systems to act in concert with each
other to optimize wellness in the total being.
1. The body is a unit; the person is a unit of body, mind, and
spirit.
2. The body is capable of self-regulation, self-healing, and
health maintenance.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based upon an understanding of the
basic principles of body unity, self-regulation, and the
interrelationship of structure and function.
• Osteopathic manipulative treatment involves the use of a
practitioner’s hands to diagnose, treat, and prevent illness or
injury.
• Muscles and joints are mobilized using gentle techniques,
including stretching, light pressure, and resistance.
• When appropriate, OMT can complement or even serve as an
alternative to drugs or surgery, providing an added dimension
to traditional medical care.
1. Myofascial Techniques
2. Muscle Energy Techniques
3. Counterstrain Techniques
4. Facilitated Positional Release
5. High-Velocity, Low-Amplitude Thrusting
6. Craniosacral Therapy
7. Articulatory Techniques
• An advanced application of OMT is demonstrated in end of life
care and comfort care.
• Osteopathic medicine partners very well with geriatric care
because both approaches value the interrelationship of mind,
body, and spirit in efforts to relieve suffering, restore dignity,
and enhance quality of life.
• Research studies have shown the effectiveness of OMT in
geriatric care, and more studies are currently underway.
• Along the geriatric pathway, not all of the osteopathic
manipulative techniques are appropriate for symptom
management.
• A specialized subset of manipulative techniques has been found
to be effective in treating symptoms, such as:
Pain Anorexia
Dyspnea Insomnia
Nausea/Vomiting Fatigue
Among many other symptoms…
• JK is 60 YO F with metastatic breast cancer, never treated per patients choice. Lifelong sensitivity to any medication and chose alternative treatment for cancer. Questions Buddhist beliefs related to suffering. Now at EOL, pt has fungating breast wound on L, contracting L pectoral muscles, enlarging R mass causing neuropathic pain, lung and brain metastases.
• Physical Assessment
• Rib dysfunction
• Myofascial dysfunction
• Nerve impingement
• Active problems
• Pain: L mass, open wound and muscle contractions R mass, neuropathic pain, impingement
• Dyspnea: Secondary to lung mets and restricted rib cage
• True opioid allergy with anaphylaxis, highly sensitive to benzodiazepine and antipsychotics at very low doses
• Pharmacological Management:
• Lorazepam 0.2 mg po q 12 hr prn (sleep, headache)
• Fentanyl 200 mcg stick, use 15 seconds
• Last day of life used Phenobarbital suppository x 1
• Osteopathic Treatment: • More acute patients short, frequent treatment
• Myofascial release chest wall, thoracic inlet, abdominal diaphragm
• Myofascial unwinding, single and two operator
• Pedal pump for lymphatic flow
Outcome: Improved comfort, improved respiration, improved sleep
• Can be direct or indirect
• Goal is to restore functional balance and to improve lymphatic
flow
• Indications – gentle, acutely ill patients, patients with limited
movement
• Contraindications – Infection, fracture, advanced cancer (risk of
metastatic spread), visceral rupture
• Procedure:
• Palpate restriction – muscle tension, tenderness, decreased
range of motion
• Choose direct (traction) or indirect (compression)
• Add other forces (operator)
• Enhancers (patient)
• Release – “melt”
• LL 64 YO F with two primary cancers: lung and ovarian cancer.
Pain in R arm, shoulder, upper back. Methadone 10 mg BID
plus morphine prn, using approximately 80 mg morphine daily
in breakthrough dosing.
• Physical assessment:
• Limited ROM R UE, limited scapular movement
• Point tenderness at T3 in paraspinal muscles
• Rib dysfunction
• Active problems:
• Pain: Bone (femur), ribs, R UE/back pain
• Anorexia: Due to fatigue and disease progression
• Dyspnea: Fatigues easily
• Goals of care: “Avoiding” getting things done.
• Pharmacologic management:
• Increase methadone to 15 mg BID
• Osteopathic management:
• Rib raising
• Sternum balance
• Abdominal diaphragmatic release
• Psychosocial management: POLST/AD
Outcome: Improved ROM, improved pain, improved
peace of mind
• Goal to stimulate sympathetic chain ganglia
• Seated or Supine
• Procedure:
• Patient Seated
• Physician stands in front, places hands at rib angles
• Pull the patient towards you extending the thoracic
spine and “raising” the ribs. Reposition hands
segmentally up the spine and repeat
• Release: Increased motion of thoracic spine and ribs
Foundations for Osteopathic Medicine, p. 1065
Outline of Osteopathic Manipulative Procedures, The Kimberly Manual, p. 61
• Goal
• Procedure
• Have patient inhale and then exhale
• Thumbs gently carry the costal margin slightly lateral and superior
• Thumbs can simultaneously resist the drop of the diaphragm during the
inhalation phase of respiration.
Foundations for Osteopathic Medicine, p. 1066
• Review the history and discuss advantages of
Counterstrain treament
• Identify the conventional Counterstrain tenderpoints.
• Discuss steps of the Counterstrain treatment model.
You are a caregiver and come
across an elderly individual
who has had to sit for long
periods of time.
The gentleman reports of pain
in his left buttocks and low
back
Photo Walt Disney Productions
• You immediately reply “I know Counterstrain! This
appears to be a piriformis spasm secondary continued
sitting with your hip externally rotated.”
Photo Walt Disney Productions
• Counterstrain began as an unexpected discovery in 1955
• Lawrence H Jones DO, FAAO theory for the mechanism of action is that the initial injury produces a sudden “panic” of lengthening of the antagonist muscle that was originally strained
• Jones treated the tender point associated with the asymptomatic antagonist muscle by shortening the muscle.
• Consequently, the muscle strained and painful muscle is placed back into a stretched position
• Thus, the mechanism produces a “counter to the strain”
Lawrence Jones DO
“I did it because it worked.”
Photos, Jones Strain Counterstrain
• Cervical Spine
• Thoracic spine
• Ribs
• Upper Extremity
• Lumbar Spine
• Pelvis/Sacrum
• Lower Extremity
• Convenient doesn’t require a table
• Gentle for those frail patients who cannot tolerate
manipulation
• Specific symptom relief
• Response may be rapid
• Articular specificity may be decreased
• Some dysfunctions may be treated, but not all
• Patients must be passive
• If it hurts, don’t do it
• Fractures in area used to treat somatic dysfunction
• Torn ligaments
• All other contraindications for not using
counterstrain are relative
• Note severe OP where positioning the patient for
treatment may risk a fracture is contraindicated
although this is typically not an issue due to the
position for treatment is usually within the patients
ROM and there for shouldn’t cause problem
• Jones’ mapping
• Anatomic correlations
• Pain or increased sensitivity may signal strain
• Additional Considerations • Muscle origins / insertions
• Mid-belly of a muscle
• Neural referred pain
http://fitnessmen.blogspot.com/2011/01/ronny-rockel.html
• Diagnosis by tender-point
• Assess regionally, treat the worst tenderpoint first
• Treatment completed through passive
positioning
• Neuromuscular resetting is key
• Time element is essential
Jones
• Tender points
• Anterior articular pillars
• Posterior: spinous processes /posterior articular pillars
Tender point photos from Pocket
Manual of OMT, LWW 2006
• Start with complete / thorough history
• Identify most significant or relevant tender point, sometimes indicated by palpable nodular edema or muscle tension
• Survey of adjacent tender points.
• Label this “10“ (not to be confused with pain scale)
Tender points over
the spinous process
or laterally
From Beatty The Pocket Manual of OMT 2nd Ed.
LWW 2011
• Identify and scale tender point as 10
• Passive positioning to “2” or less is target for treatment
• Monitor location, do not remove finger
• Hold for 90 seconds, ribs 120 seconds
• Passive return to neutral position
• Retest, retreat as needed
• Limit treatment to 6 tenderpoints per visit
http://www.goingtomedschool.com/2011/08/09/what-is-osteopathic-medicine/
From www.i.ehow.com http://www.drbambach.de/osteopathie/counterstrain.htm
• Inspect the anatomy
• Inquire “How did this tissue get in trouble?” Muscle?,
Tendon? Ligament?
• Be familiar with conventional tender points
• Determine / evaluate anatomical correlations for
treatment alternatives
http://forums.pelicanparts.com/off-topic-discussions/425070-nasty-injury-olympics.html
Everything that is tender is not necessarily a counterstrain
tender point ◦ Tissue inflammation / destruction
◦ Reflexive tenderness / pain may be possibility
◦ Psychogenically amplified pain intolerance should always be
considered
◦ Correlates to location of structural diagnosis or does it?
◦ Always treat patient, not tender point
http://orthodoc.aaos.org/drrickwalker/about.cfm
A counterstrain tender point acts like a counterstrain
tender point.
◦ If at a sensible location near the area of strain
◦ Correlates with injury
◦ Responds to treatment for counterstrain therapy
http://www.flickr.com/photos/dave_idstewart/4194805602/
• Iliacus
• Sartorius
• Gluteus minimus and medius
• Inguinal ligament
• Adductors
• Pectineus
• Obturator
• Piriformis
• Lateral trochanter
• Gemelli
• Medial hamstring
• Anterior and Posteriour
cruciate ligament
• Medial meniscus
• Lateral meniscus
• Rotated knee
• Knee extenders
• Patellar tendon
• Extension ankle
• Lateral Ankle
• Calcaneus
1 lateral trochanter tp
2 tibial tuberosity
3 patellar tendon tp
4 medial meniscus tp
5 medial ankle tp
6 metatarsal heads
7 fibular head
8 extension ankle tp
9 lateral ankle tp
10 calcaneus tp The Pocket Manual of OMT, p 26
• Jones’ mapping
• Anatomic correlations
• Pain or sensitivity reflects strain
• Consider: • muscle origins and insertions
• mid-belly of a muscle
• neural referred
http://www.t-nation.com/testosterone-magazine-638
Pansky and Allen, 1980, p. 207
The dominant present
hypothesis to help
explain the cause of
somatic dysfunction
in the counterstrain model is
that trauma
or sudden strain causes
proprioceptive
dysregulation.
• Position of ease, 2 or less often corresponds to a position of injury
• Keep monitoring finger in place until retest
• Hold position of ease passively for 90 seconds
• Return patient to resting position passively
• Re-evaluate, retreat with fine tuning or progress to adjacent areas
From www.waybuilder.net
Schuenke, 496
• Position the
gentleman in a
position of ease while
monitoring the tender
point. After 90
seconds you return
him to a neutral
position.
• http://www.jaoa.org/content/108/11/657/F8.expansion
The elderly man then states he feels better. And
you look to the future for new adventures in OMT
Photo Walt Disney Productions
References •DiGiovanna EL, Schiowitz S. (1997). An Osteopathic Approach toDiagnosis and
Treatment, Second Edition. Philadelphia: Lippincott-Raven Publishers.
•Essig-Beatty, D. The Pocket Manual of OMT, Lippincott, Phila. 2011
•Field, D. 2001 Anatomy, Palpation and Surface Markers, 3rd ed., Butterworth
-Heinemann, Oxford
•Jones, L., Jones Strain-CounterStrain,Jones Strain-CounterStrain, Inc.,
Boise ID 1995
•Moore,K. , Dalley, A. 1999, Clinically Oriented Anatomy 4th ed., Lippincott, Williams and Wilkins, Phila
•Netter, F. Atlas of Human Anatomy, Ciba-Geigy, Summit N.J. 1989
•Rennie, P., Counterstrain and Exercise: an integrated approach , 2nd ed
RennieMatrix, Williamson MI, 2004
•Schuenke,M., Anatomy, Atlas of Anatomy, Thieme, New York, NY 2006
(Still looking @ the following to see application possibilities)
http://www.acofp.org/OMT_and_OMM_Resources/OMT_for_
Residents_and_Students/
DO OMT app
Photo Walt Disney Productions