To understand how OMT can be used in the Mind-Body-Spirit approach to Total Pain relief.

Transcription

1 Robert Hunter, DO

2 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.

3 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.

4 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.

5 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

6 Emphasizes a whole person approach. Honors the physical, emotional, and spiritual aspects of wellness. Recognizes that the body is capable of self-regulation, selfhealing, 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.

7 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.

8 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.

9 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

10 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.

11 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 Dyspnea Nausea/Vomiting Anorexia Insomnia Fatigue Among many other symptoms

12 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.

13 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

14 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

15 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

16 Procedure: Palpate restriction muscle tension, tenderness, decreased range of motion Choose direct (traction) or indirect (compression) Add other forces (operator) Enhancers (patient) Release melt

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18 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.

19 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.

20 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

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22 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

23 Foundations for Osteopathic Medicine, p. 1065

24 Outline of Osteopathic Manipulative Procedures, The Kimberly Manual, p. 61

25 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.

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27 Foundations for Osteopathic Medicine, p. 1066

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29 Review the history and discuss advantages of Counterstrain treament Identify the conventional Counterstrain tenderpoints. Discuss steps of the Counterstrain treatment model.

30 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

31 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

32 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

33 Lawrence Jones DO I did it because it worked. Photos, Jones Strain Counterstrain

34 Cervical Spine Thoracic spine Ribs Upper Extremity Lumbar Spine Pelvis/Sacrum Lower Extremity

35 Convenient doesn t require a table Gentle for those frail patients who cannot tolerate manipulation Specific symptom relief Response may be rapid

36 Articular specificity may be decreased Some dysfunctions may be treated, but not all Patients must be passive

37 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

38 Jones mapping Anatomic correlations Pain or increased sensitivity may signal strain Additional Considerations Muscle origins / insertions Mid-belly of a muscle Neural referred pain

39 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

40 Tender points Anterior articular pillars Posterior: spinous processes /posterior articular pillars Tender point photos from Pocket Manual of OMT, LWW 2006

41 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)

42 Tender points over the spinous process or laterally From Beatty The Pocket Manual of OMT 2 nd Ed. LWW 2011

43 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

44 From

45 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

46 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

47 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

48 Anterior and Posteriour cruciate ligament Medial meniscus Lateral meniscus Rotated knee Knee extenders Patellar tendon Extension ankle Lateral Ankle Calcaneus Iliacus Sartorius Gluteus minimus and medius Inguinal ligament Adductors Pectineus Obturator Piriformis Lateral trochanter Gemelli Medial hamstring

49 The Pocket Manual of OMT, p 26 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

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51 Jones mapping Anatomic correlations Pain or sensitivity reflects strain Consider: muscle origins and insertions mid-belly of a muscle neural referred

52 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. Pansky and Allen, 1980, p. 207

53 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

54 From

55 Schuenke, 496

56 Position the gentleman in a position of ease while monitoring the tender point. After 90 seconds you return him to a neutral position.

57 The elderly man then states he feels better. And you look to the future for new adventures in OMT Photo Walt Disney Productions

58 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 Field, D Anatomy, Palpation and Surface Markers, 3 rd ed., Butterworth -Heinemann, Oxford Jones, L., Jones Strain-CounterStrain,Jones Boise ID 1995 Strain-CounterStrain, Inc., Moore,K., Dalley, A. 1999, Clinically Oriented Anatomy 4 th ed., Lippincott, Williams and Wilkins, Phila Netter, F. Atlas of Human Anatomy, Ciba-Geigy, Summit N.J 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

59 (Still the following to see application possibilities) Residents_and_Students/ DO OMT app

60 Photo Walt Disney Productions