Osteopathic Manipulative Treatment (OMT) Workshop

1. Osteopathic Manipulative Treatment (OMT) Workshop Sean N. Martin, DO Some Material Adapted, With Permission, From “OMT for Allopaths” Course by Shawn Kerger, DO

2. What Does “Osteopathy” Mean? • Comes from the Latin prefix of ‘osteo’, referring to bone and ‘pathos’, which later came to mean disease, but initially meant ‘knowledge’. • It is this latter definition to which osteopathy was termed by Andrew Taylor Still, MD.

3. 4 Tenets of Osteopathic Philosophy • The body is a unit. • The body possesses self-regulatory, self-healing, and health maintenance mechanisms. • Structure and function are reciprocally interrelated. • Rational therapy is based on an understanding of body unity, self-regulatory mechanisms, and the interrelationship of structure and function.

4. What It Is • Today’s Agenda, We’re “Going Lavorpa”: • Combination of Didactic and Tactile Assimilation of Basic OMT Concepts Into The Cerebral Cortices of Providers with Moderately Advanced Knowledge of Musculoskeletal Anatomy • In other words, a custom course built for Sports Medicine Fellows , Faculty, and Physical Therapists at Dewitt Army Community Hospital for Thursday Didactics

5. What It Is Not • Not on today’s agenda • History of OMT • Spinal Mechanics/Dyfunction/Correction • Sacral Mechanics/Dysfunction/Correction • High Velocity Low Amplitude (HVLA) Techniques • A Discourse on Evidence (or Lack Thereof) Behind This Field

6. Disclaimers • This is not a standardized field of medicine • Learn a lot of techniques, get good at some, regularly use a few… • When in doubt, shotgun!!

7. Plan • Foundation Principles • A Palpatory “Warm Up” • Tissue/Myofascial • Strain-Counterstrain • Muscle Energy • Approach to the Low Back Pain Patient

8. Some guidelines • Remember to explain what you’re doing and why when treating a patient for the first time • Hygiene • Short, clean nails • Hand-washing • Your touch communicates as well as diagnoses and treats – be careful what you say! • Match the treatment to the problem

9. Somatic dysfunctions – Huh? • T.A.R.T. • Tenderness • Asymmetry • Range of Motion changes • Tissue texture changes • Like a syndrome – not really defined, but described…

10. Somatic Dysfunction • Impaired or altered function of related components of the somatic (body framework) system: • skeletal, arthrodial, and myofascial structures • related vascular, lymphatic, and neural elements

11. Palpation • Information • Tissue changes • Will go more in depth in a moment • Communication • Patient • Physician • Treatment

12. Palpation - Information • Skin • Temperature • Fluid status • Oily/dry – measure of autonomous nervous tone • Hyperesthesia

13. Palpation - Information • Muscular layers • Tension / Spasticity • Fresh injury • Softer • Hot • Edematous • Painful • Old injury • Hard • Cold • “Ropy” • Sore

14. Palpation - Information • Trigger Points • Usually located at or in muscular layers and reproduce a referred pain with pressure • Tender Points • As above without referred pain

15. Palpation • More of training your mind to listen to your hands. • Try to identify the sides of a coin (heads/tails) • Can you feel the date line? Try it with your eyes closed. • Could you distinguish between a human bone and a solid plastic replica? How?

16. Palpation Exercises • Touch the dorsum of the other hand – • Test for temperature difference • “Skin Drag” • Calluses on palmar aspect • Veins vs. arteries vs. tendons • Check before and after squeezing your hand firmly several times • Shear stress in subcutaneous tissues

17. Palpation Exercises • Palpate Partner’s Forearm • Compare skin differences of volar and dorsal aspects (which is smoother, thicker, warmer, or drier?) • SubQ fascial layer just below the skin. How thick, plastic, loose? In which directions are ease vs. drag? • Deep fascia is next layer down. Can you identify / separate the different muscle bundles of the forearm?

18. Palpation Exercises • Palpate Partner’s Forearm • How does the underlying muscle feel? Tight? Soft? Strained? • Have your partner open/close the hand slowly, then with more and more force. With sustained force, this muscle is what muscles feel like when associated with a somatic dysfunction.

19. Palpation Exercises • Palpate Partner’s Forearm • Move your hand down slowly toward the musculotendinous junction. Then move past this to the tendons – notice the change as it becomes tendon. • Follow the tendons as they mesh with the transverse carpal ligament and palmar carpal ligament – notice the fiber direction!

20. Soft Tissue/Myofascial

21. Soft Tissue • Can be classified as direct or indirect • Addresses the muscular and fascial structures of the body with their associated neural and vascular elements (especially lymphatics) • Most of us have applied these techniques to a friend or family member, but not a patient!

22. Soft Tissue • Relaxes hypertonic muscles • Stretches passive fascial structures • Enhances circulation • Improves local tissue nutrition, oxygenation, and removal of metabolic wastes

23. Soft Tissue • Improves local & systemic • immune responsiveness • Identifies areas of somatic dysfunction • Observes tissue response to application of manipulative technique • Improves abnormal somatosomatic and somatovisceral reflex activity

24. Soft Tissue • Provides a general state of relaxation • Provides a general state of tonic stimulation • Way of introducing confidence with a new patient • Evaluate patient’s response to physical contact

25. Soft Tissue • Various applications • Rapid, short massage maneuvers (like a boxer before the fight) • Long, slow stretches • Longitudinal to fibers • Perpendicular to fibers

26. Soft Tissue • Tractional technique • Stretching • Origin and insertion of a myofascial structure is separated longitudinally • Can be both therapeutic and diagnostic

27. Soft Tissue • Kneading • A rhythmic, lateral stretching of a myofascial structure, in which the origin and insertion are held stationary and the central portion is stretched like a bowstring

28. Soft Tissue • Inhibition • Sustained deep pressure over a hypertonic myofascial structure • Can be gentle…or not!!

29. Thoracic Prone Traction • Anatomy • Great for: • Kyphosis • General massage • Prep for HVLA • Treat hypertonicity of thoracic visceral disease (asthma, COPD, HTN, CAD)

30. Thoracic Prone Traction • Pt Prone • Place thumbs of both hands just lateral to the spinous processes, on the paravertebral muscles, with your fingers fanned out. Don’t lock out elbows! • Exert an anterior pressure, allowing muscle to relax and stretch, finishing with a lateral sweeping motion • A kneading motion or inhibitory pressure may also be used • Repeat as needed

31. Lumbar Prone Traction • Anatomy • Great for: • Low back pain • Lumbago • Rotated pelvis • Prep for another technique • General starting technique • Treat pelvis and abdominal viscerosomatic tone (constipation, dysmenorrhea, IBS, hemorrhoids, etc)

32. Lumbar Prone Traction • Pt prone • Use the heel of your cephalad hand to contact the opposite paravertebral musculature • Gently grasp the ASIS with your caudad hand and pull upward, inducing rotation • Apply a counterforce with your cephalad hand • May use a kneading motion, or deep inhibitory pressure • Repeat as needed

33. Strain-Counterstrain

34. Strain-Counterstrain • Developed by Lawrence H. Jones, DO, FAAO in 1955 • “…relieving spinal or other joint pain by passively putting the joint into its position of greatest comfort.” • Relieving pain by reduction and arrest of the continuing inappropriate proprioceptor activity.

35. Strain-Counterstrain • Works utilizing the neuroanatomy and neurophysiology of the gamma efferent loop • Involves the gamma efferent fibers, the intrafusal fibers, the alpha motor neurons, and the small anterior horn cells which terminate on the intrafusal muscle fibers within the spindles.

36. Gamma Loop • Tendon stretches the spindle muscle fibers • This activates the afferent nerve fibers which synapse in the anterior horn (I’m skipping the numerous interneurons for simplicity) on the alpha motor neurons in the same and adjacent spinal segments, simultaneously inhibiting the antagonists. (+) (-)

37. Strain-Counterstrain • Find the specific tender point (TP) • Place the patient in the position of optimal comfort (POC) • Maintain the POC for 90 seconds • Slowly (& passively on the patient’s part) return to neutral position • Recheck

38. Strain-Counterstrain • Key points: • Find the MOST painful tender point (TP) and treat that one first • You (the doc) need to be comfortable and supported • Go for ≥ 90% improvement in TP • Wait at least 90 seconds • These four tips will greatly improve your success rate!!

39. Suboccipital Release • Great for: • MT headaches • Sinus congestion • Upper cervical pain • Opening technique • Stress relief • *** Pt can do at home safely with two tennis balls taped together or tied off in the end of an athletic sock • Anatomy

40. Suboccipital Release • Suboccipital Release • Pt. Supine • Place the pads of your fingers just inferior to the superior nuchal line in the suboccipital muscles. • Lift the head so that the pt’s weight is supported on the pads of your fingers (not the palms!) • Maintain position until you feel the desired relaxation in the soft tissues

41. 3 Examples of Techniques Commonly Employed in Sports Medicine

42. Levator Scapula Strain • Pt prone with head turned away • Internally rotate arm and apply LARGE amount of traction • Fine tune with degrees of extension, adduction and abduction • Hold for 90 secs • Return patient passively and slowly to neutral position

43. Lateral Epicondylitis • Better for subacute injuries/shorter duration of symptoms • Extension at the wrist with a mild amount of valgus positioning with lesser degrees of internal or external rotation (although external rotation is more frequently necessary) • Hold for 90 secs • Return patient passively and slowly to neutral position

44. Rhomboid lesion • Tender point above T6 • Externally rotate the humerus at 90 degrees abduction and hold for 90 seconds • May need a little more compression, distraction, abduction or adduction through the glenohumeral joint • Return patient passively and slowly to neutral position

45. Muscle Energy

46. Active range of motion Physiologic barrier Anatomic barrier

47. Motion Loss Active range of motion Pathologic barrier Physiologic barrier Anatomic barrier

48. Shift of midline Active range of motion Pathologic barrier Loss of motion

49. Muscle Energy • Utilize the patient’s active cooperation to correct a dysfunction • Cannot be used in: • Too young • Uncooperative • Unconscious • Fresh muscular injury • Relatively contraindicated in low vitality patients who might be compromised by muscular exertion: • Postop • Post-MI

50. Muscle Energy • Works via reestablishing a new tone in the slow-twitch/tonic musculature via the γ-efferent and extrafusal fiber systems. • This is why you don’t need to use too much force – the slow-twitch fibers are earlier in the recruitment selection. Too much force and you’ll reset the wrong motor units. (+) (-)