Lecture: Pediatric OMM and Disease Management. Clare Galin, DO et al.

Transcription

1 Lecture: Pediatric OMM and Disease Management Clare Galin, DO et al.

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3 OMM in Disease Management in the Pediatric Population Claire M. Galin, DO ACOFP March 15,2015 Objectives The learner will be able identify and describe the history of osteopathic manipulative medicine in the care of children The learner will be able to identify indications and contraindications for the application of OMM in the pediatric population The learner will be able to discuss research related to OMM in the pediatric population The learner will be able to discuss the use of OMT for disease management in certain clinical conditions including constipation, colic, respiratory conditions and plagiocephaly 1

4 History of OMM in Pediatric Population AT Still wrote about using his techniques on sick children William Sutherland- As the Twig is Bent so is the Tree Inclined Beryl Arbuckle student of Dr Sutherland s. Pediatrician at PCO(M) who started a clinic for children with cerebral palsy Viola Frymann- Osteopathy s Promise to Children Jane Carreiro- An Osteopathic Approach to Children Some Indications for OMM in the Pediatric Population Neonate/infant Plagiocephaly Poor suck Failure to thrive Developmental delay Colic Constipation Torticollis Children Otitis media Acute and chronic respiratory illness Gait abnormalities Constipation Learning disorders Strabismus Adolescents Sports injuries Headaches Musculoskeletal pain syndromes Dysmenorrhea Scoliosis 2

5 Patients Seen in Medical School Based OMM Children s Clinics Lund and Carreiro found during a one year study period 407 patients generated 1500 clinic visits. Ages ranged from newborn to 18 years of age with the mean age of first visit 7.3 years. Diagnoses included 43.5 % non-musculoskeletal At the TUNCOTC we see almost the same distribution of both ages and diagnoses Contraindications to OMM in Pediatric Populations Dependent on the patient and technique- utilize clinical judgment Patient/parental refusal Lack of ability of the physician 3

6 Efficacy and Safety Numerous publications have shown efficacy of OMT in pediatric population for a variety of conditions such as Otitis media Colic Nipple feeding dysfunction Asthma Constipation One meta analysis has stated that the evidence of the effectiveness of OMT for pediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies. Pediatrics 2013;132: Safety- Incidence of Iatrogenesis Associated with OMT of Pediatric Patients Hayes and Bezilla JAOA. 106/10. October OMT appears to be safe in the pediatric population when administered by physicians with expertise in OMT. Pediatric OMT Skill Set The often used phrase that children are not just small adults is especially true when performing OMT Must have an understanding of developmental anatomy as well as the patience and skills to deal with the practical issues in doing OMT on children 4

7 Developmental Anatomy Practical Issues In the Treatment of Children Allow the child time to assess and accept you before you begin the treatment Have an office that is child friendly and safe Do not expect the child to just lie quietly Should parents be in the room Treatments are often shorter and more frequent than for adults Especially with significant birth trauma, the sooner the better 5

8 Recommended Modalities for Pediatric Patients Soft tissue Myofascial release Balanced ligamentous/balanced membranous tension Cranial Osteopathic Manipulative Medicine Lymphatic treatment Gallbreath technique Rib raising Lymph pumps Visceral (mesenteric lifts) Muscle energy Counterstrain (on older cooperative patients) Limit HVLA to mature adolescents avoid vigorous thrusts as joint space is increased and there is active end plate growth Pediatric OMT Treatment Plan History, physical exam, tests as appropriate Use OMT to support the patient s physiology Do not limit OMT to treatment of pain or injuries Treatment time for each visit is often shorter than for adults Follow up visits are closer together After initial findings have resolved recheck infants and children periodically especially after growth or developmental spurts, teething or injury 6

9 Selected Clinical Cases with Suggested Treatment Protocols Colic/GERD Justin- 2 month old boy with generalized fussiness, and screaming fits shortly after feeding especially in the late afternoon. Sleeps only in a swing bed. Arches his back excessively when held. Mom is exhausted and stressed. Treatment Protocol Address vagal nerve function-release OA Treat thoracoabdominal diaphragm 7

10 OA Decompression/Base Spread Physician sits at the head of the patient Patent's head is in physicians hand so that pinkies meet on occiput just below inion, ring fingers approximate condyles, middle fingers are on upper cervical spine and index fingers are on the temporal bones The ring fingers bring the occiput towards the table while the middle fingers hold the atlas stable allowing the occiput to come posterior and cephalward The craniocervical junction can also be addressed more simply using suboccipital inhibition Constipation Lourdes presented as a 20 month female with a history of constipation after switching from formula to milk 3-4 months ago. Goes at least 3-4 days between bowel movements and cries and strains when she does go. After 1 treatment Lourdes was no longer straining and she was moving bowels daily. Sample Treatment Protocol Linea Alba release Mesenteric lifts Sacral rock Thoracoabdominal and pelvic diaphragm release 8

11 Mesenteric Lifts Patient supine, physician at patient s right side Bend patient s knees with feet placed on table to relax the abdomen. Gently allow your fingers to sink into the abdomen at the region of the restricted mesentery and underlying portion of bowel Gently lift the mesentery away from any fascial entrapment by pushing in the direction of ease Hold tissues gently until a sense of relaxation is palpated, or hold for approximately 90 seconds to allow time for visceral tissues to decongest. URI/ Sinusitis Tyce is a 2 y/o boy who has had OMT since birth. He presents today with coughing, nasal congestion. He had a slight fever yesterday but is afebrile currently. His appetite is slightly decreased but he is active and alert. To improve lymphatic drainage release the diaphragm and thoracic inlet If cervical lympahadenopthy is present cervical soft tissue or milking is recommended Remember to release the cranialcervical junction 9

12 Seated Diaphragm Release 1.Patient is seated. Stands behind the patient and place your hands around the rib cage. The fingertips and hypothenar eminence are introduced under the costal margin. 2.Diapraghmatic motion is tested as you passively rotate the diaphragm to the left and right to determine the direction of ease. You made add some superior motion or translatory motion to find the ease. 3. Find the position of ease. You may add respiratory cooperation. Hold until release or follow the unwinding of the tissue until symmetry is palpated. Asthma Blake- 5 y/o male with coughing on exercise and nocturnal. Responds to bronchodilation but it makes him hyperactive so mom wants to keep medication to a minimum Treatment Protocol Optimize rib and diaphragm motion to decrease work of breathing Balance autonomics by releasing T2-T4 and upper cervical spine Treat scalenes 10

13 Rib Raising Stand or sit at the side of the supine patient Place your hands under the patient s thorax with the pads of your fingers contacting the rib angles Flex your fingers to achieve contact with the rib angles and disengage the costotransverse junctions. Apply lateral traction as tolerated by the tissue under your hands. You may hold until you feel the tissue release or you may repeat the rib raising motion once or twice at the same level until the tissue releases. In order to save your strength push your forearms down to raise your hands upward. Avoid bending your wrists. Once the ribs under your hands are moving more freely move your hands to the next set of ribs. Your speed will depend upon the amount of resistance in the tissue. You may start superior and end at the diaphragm or vice versa. Treat both sides You may perform a deep inhibition variation of this technique. This technique can also be performed facing the seated patient Ankle Pain/Dysmenorrhea Cierra a 15 y/o female who presented with ankle pain and swelling from a volleyball injury ne month earlier. On osteopathic musculoskeletal exam somatic dysfunction was diagnosed in the lower extremity, sacrum and pelvis. On further questioning it was discovered that she was missing at least one day of school/month for dysmenorrhea OMT performed and on follow up both ankle pain and swelling and dysmenorrhea were markedly improved Treatment Protocol for Dysmenorrhea Gold standard OMT is Sacral Rock Balance the sacral autonomics Increase lymphatic drainage through fascial release of the viscera and releasing diaphragms to optimize motion 11

14 MFR- Sacral Rock This technique is especially useful for constipation, diarrhea, dysmenorrhea, dysuria Patient prone, stand at the side of the patient, facing patient Place the cephalic hand on the sacral base with the fingers pointing toward the coccyx (not the other way around). Place the caudal hand on top of the cephalic hand with the fingers pointing toward the opposite direction. Palpate the motion of the sacrum with respiration. Diagnosis- in which direction is sacral motion restricted? (nutation/counternutation) Now follow the motion of the sacrum in nutation and counternutation movement and gently augment this movement using your top hand (the one that isn t touching the patient). Use your hand on the patient to monitor. If sacral nutation is reduced, increase this movement during exhalation and resist counternutation movement during inhalation. If sacral counternutation is reduced, increase this movement during inhalation and resist nutation movement. This is direct MFR and ART where you are actively trying to increase restricted motion. General Treatment Pearls Review the underlying pathophysiology of a condition Use OMT to address to address to optimize function of: Circulation Autonomic innervation Biomechanics 12

15 Additional Research Mills M, Henley C, Barnes L, Carreiro J, Degenhardt B. The Use of Osteopathic Manipulative Treatment as Adjuvant Therapy in Children with Recurrent Acute Otitis Media. Arch Pediatric Adolescent Medicine, Vol 157, Spt Degenhardt B, Kuchera M,. Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A Pilot Study. JAOA; June 2006; 106(6): Guiney PA, Chou R, Vianna A, Lovenheim J. Effects of Osteopathic Manipulative Treatment on Pediatric Patients With Asthma: A Randomized Controlled Trial. J Am Osteopath Assoc Jan; 105(1): 7-12 Sergueef N, Nelson K, Glonek, T. Palpatory Diagnosis of Plagiocephaly. Complementary Therapies in Clinical Practice 2006 (12): Philippi H, Faldum A, Schleupen A, Pabst B et al. Infantile Postural Asymmetry and Osteopathic Treatment: A Randomized Therapeutic Trial. Developmental Medicine and Child Neurology; Jan 2006; 48, 1 Hayden C, Mullinger B. A Preliminary Assessment of the Impact of Cranial Osteopathy for the Relief of Infantile ColicComplementary Therapies in Clinical Practice (2006) 12, B. Duncan, L. Barton, D. Edmonds and B. M. Blashill. Parental Perceptions of the Therapeutic Effect from Osteopathic Manipulation or Acupuncture in Children with Spastic Cerebral Palsy. Clin Pediatr (Phila) 2004; 43; 349 King H, Tettambel MA, Lockwood MD, Johnson KH, Arsenault DA, Quist, R. Osteopathic Manipulative Treatment in Prenatal Care: A Retrospective Case Control Design StudyA Vol 103 No 12 December 2003 Hayden C, Mullinger B. A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic. Complement Ther Clin Pract. 2006;12(2): Wyatt K, Edwards V, Franck L, et al. Cranial osteopathy for children with cerebral palsy: a randomised controlled trial [published online ahead of print February 24, 2011]. Arch Dis Child. 2011;96(6): Additional Resources (From DO Magazine) An Osteopathic Approach to Children, a textbook written by Jane E. Carreiro, DO, and published in 2003 by Elsevier. General Pediatrics, a chapter in the second edition of the AOA s textbook Foundations for Osteopathic Medicine, published in 2002 by Lippincott Williams & Wilkins. Osteopathic Center for Children and Families, San Diego, CAhttp:// The Collected Papers of Viola M. Frymann, DO Legacy of Osteopathy to Children, published in 1998 by the American Academy of Osteopathy (AAO). This book can be ordered through the AAO s Web site at (See the accompanying article on Page 26.) The Cranial Academy s pediatric brochures, including Osteopathic Treatment for Children With Down Syndrome, Osteopathic Treatment for Digestive Problems, Osteopathic Treatment for Ear Infection, Osteopathic Treatment for Orthodontia, Osteopathic Treatment for Orthopedic Problems, An Osteopathic Treatment of the Newborn and Respiratory Health Through Osteopathic Treatment. These brochures can be ordered through The Cranial Academy s Web site by logging onto and clicking on the Books link on the home page. 13

16 Recommended Reading 14