The Schiowitz Approach

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1 The Schiowitz Approach American Academy of Osteopathy Annual Convocation March 23 rd, :00-3:30 PM & 4:00 5:30 PM Dennis J. Dowling, D.O., M.A., F.A.A.O.

4 F.P.R. Developed by Stanley Schiowitz, D.O., F.A.A.O. NYCOM

6 Stanley Schiowitz, D.O., F.A.A.O. Graduated from high school at age 15 St. John s University started PCOM at age 18 Graduated at age 22 in 1944 Internship/Apprenticeship with his mentor, M.W. Levy, D.O Private Practice in Brooklyn DME Interboro Hospital Chair of NYCOM OPP Department Director of Medical Education Director of Family Practice Associate Dean for Clinical Rotations Dean NYCOM Dean Emeritus

8 Someday, someone will explain to me what the hell I am doing.

9 I.O. INSTANT OSTEOPATHY How Long? A few seconds

10 Basic Rules of F.P.R. Diagnose Put region/joint into Neutral (flatten curves) places joint into idling position Monitor continuously Add facilitating force (usually compression or torsion) reduces proprioceptive noise Add freedoms in all three planes (Flexion/Extension, Sidebending, rotation) reduces muscle spindle activity allows reduction of gamma gain If compression doesn t work, try traction. If it doesn t work going to the right, go to the left. Simple philosophy.

11 Basic Rules of F.P.R. Hold position for five seconds Determine alteration of tissue tension Return to Neutral Reassess Barriers can then be challenged ( wiggle jiggle ) Reassess Any mechanical dysfunction in the body can affect any other part of the body and therefore can affect any system of the body (and vice versa). When treating a patient, never treat them for a diagnosed medical condition. Treat the musculoskeletal change, and if the patient feels better then you are both lucky. Maybe it will help, maybe it won t.

12 Basic Rules of F.P.R. Hold position for five seconds Determine alteration of tissue tension Return to Neutral Reassess Barriers can then be challenged ( wiggle jiggle ) Reassess But, Stan, you never wrote about challenging the barriers. What gives? PASSIVE INDIRECT & DIRECT

13 Still Technique I don t treat the way I teach, I get down to smaller and smaller motions. Facilitated Positional Release

14 Still Technique TWIN TECHNIQUES with DIFFERENT FATHERS Facilitated Positional Release

15 Did Stan Schiowitz know that his FPR was the third iteration of the Still Technique? No, he didn t He knew that it was the second.

F.P.R. J Am Osteopath Assoc. 1990 Feb;90(2):145-6, 151-5.

16 F.P.R. J Am Osteopath Assoc Feb;90(2):145-6, Still Technique J Am Osteopath Assoc Oct;96(10):

Contraindications Localized pathological tissue conditions Infection Cellulitis Osteomyelitis Cysts Tumors Fracture Increase or significant alteration of symptoms

17 Contraindications Localized pathological tissue conditions Infection Cellulitis Osteomyelitis Cysts Tumors Fracture Increase or significant alteration of symptoms Inability to tolerate position Learned from Moe Levy, D.O. (his mentor): 1. Always do a complete H&P 2. Always do a rudimentary structural exam 3. Always use OMT whenever you can.

18 A form of Myofascial Release Counterstrain & Functional techniques are positional techniques Facilitated Positional Release and Still technique rely on both the positional component and a facilitating force They both start INDIRECT and then become DIRECT They are both very TIME EFFICIENT It is important to learn efficiency in time and effort.

19 Type of Technique Passive - the patient does nothing Indirect - Treatment is directed primarily away from the barriers (Direct - barriers can be challenged afterwards) (Occasionally we ask the patient to do something [i.e. isometrics])

20 For FPR it is especially useful to use pillows Assists in the curves

21 It is important to learn efficiency in time and effort. Three Ds of Osteopathy Diagnosis Diagnosis Diagnosis When talking about restriction in motion, somatic dysfunction, osteopathic lesion, the great majority of limitation is created in the accessory (slide) motion of an articulation/segment.

22 DIAGNOSIS speedbumps Suspect that there is a Flexion dysfunction when there is a sudden increase (bump) in an anterior posterior curve The simpler you make it, the easier your life will be.

Don t think of it as I have a flexion lesion, think of it as a translation problem.

23 DIAGNOSIS potholes POTHOLES Suspect that there is an Extension dysfunction when there is a sudden decrease (dip) in an anterior posterior curve. accessory and coupled motion are not the same. Don t think of it as I have a flexion lesion, think of it as a translation problem. If you think that way, then you ll know what to do. Go with the flow but remember what your motion is and go with that.

26 Real segmental motion is very small.

28 TEST RELATIVE FLEXION

29 TEST RELATIVE EXTENSION

30 CERVICAL

31 Patient Supine Doctor at the head of the table A Pillow can be used on the doctor s lap

32 CERVICAL MOTION TESTING

34 PILLAR

37 SPINOUS PROCESS FACET/PILLAR TRANSVERSE PROCESS

41 EXTENSION

43 FLEXION

45 Increased resistance: extension = FLEXION dysfunction flexion = EXTENSION dysfunction

46 RIGHT TRANSLATION creates LEFT SIDEBENDING

47 RIGHT SIDEBENDING LEFT TRANSLATION creates

48 Increased resistance in sidebending: left = RIGHT (ease) dysfunction right = LEFT (ease) dysfunction

49 ROTATION

50 Lifting the left side creates RIGHT ROTATION

51 Lifting the left side creates RIGHT ROTATION

52 Lifting the right side creates LEFT ROTATION

53 Lifting the right side LEFT ROTATION creates

54 FPR CERVICAL

55 CERVICAL Soft Tissue Treatment FINDINGS Posterior cervical muscle hypertonicity (soft tissue texture abnormalities). When practicing Osteopathy, you want to treat the hard stuff and the hard stuff doesn t have a name. Just treat what you find.

56 Cervical Segmental Somatic Dysfunction FINDINGS C3 ES L R L and C7 FS L R L PATIENT POSITION Supine, with the patient's head beyond the end of the table, resting on a pillow on the physician's lap.

57 O-A Dysfunction. (Example ESLRR) FINDINGS OA ES L R R PATIENT POSITION Supine, with the patient's head beyond the end of the table, resting on a pillow on the physician's lap Can motion be introduced, that is what is important.

58 THORACIC

59 THORACIC MOTION TESTING

61 Real segmental motion is very small.

63 TEST RELATIVE FLEXION

64 TEST RELATIVE EXTENSION

65 THORACIC Thoracic Spine, Seated FINDINGS T6 FS L R L. PATIENT POSITION The patient is seated on the end of the table. When you put a spinal segment into neutral it opens the facets and the articulation moves freely.

66 Alternative Thoracic Spine (Extension dysfunctions), Prone FINDINGS T6 ES L R L. PATIENT POSITION Resultant vector When treating the key is the angle of the vector force.

67 Treatment of an S or C shaped scoliosis of the thoracolumbar spine: S or C shaped scoliosis of the thoracolumbar spine FINDINGS T1-9 NS L R R and T10-L5 NS R R L T1-L5 NS L R R.

68 FIRST RIB

69 FIRST RIB FINDINGS First rib elevated on left. PATIENT POSITION The patient is Supine

70 CLAVICLE

71 STERNOCLAVICULAR/ACROMIOCLAVICULAR DYSFUNCTIONS Shoulder restrictions Left anteriorly rotated clavicle with the lateral clavicle anterior and inferior PATIENT POSITION The patient is seated

72 RIBS

73 FPR RIBS - SEATED FINDINGS Soft tissue and/or dysfunctions of the ribs. PATIENT POSITION The patient is seated

74 FPR RIBS & THORACIC - SIDELYING FINDINGS Soft tissue and/or dysfunctions of the thoracic and ribs. PATIENT POSITION The patient is sidelying with the side to be treated up

75 MIDDLE RIBS SERRATUS POSTERIOR RHOMBOIDS PVM

76 LUMBAR

77 FPR LUMBAR- SIDELYING FINDINGS Right Soft tissue and/or dysfunctions of the lumbar. PATIENT POSITION The patient is sidelying with the side to be treated up When treating muscles the muscles will tell you which way to go.

78 QUADRATUS LUMBORUM LATISSIMUS DORSI

LUMBAR Soft Tissue Treatment FINDINGS Hypertonic right paravertebral

POSITION The patient is prone, close to the right edge of the table,

flattening of the lumbar lordosis 1 Patient prone with pillow beneath

79 LUMBAR Soft Tissue Treatment FINDINGS Hypertonic right paravertebral lumbar muscles. POSITION The patient is prone, close to the right edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis 1 Patient prone with pillow beneath abdomen 2 Patient s lower half is sidebent towards the side to be treated 3 The opposite leg is further adducted and crossed at the ankle

80 LUMBAR Extension Somatic Dysfunction FINDINGS L3 ES R R R. POSITION The patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis THE LUMBAR VERTEBRA OF THE SOMATIC DYSFUNCTION RELATIVELY ROTATES TOWARD THE SAME SIDE

81 LUMBAR Flexion Somatic Dysfunction FINDINGS L4 FS R R R. POSITION The patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis. THE ADDUCTION CAUSES INTERNAL ROTATION WHICH LOCKS THE FEMORAL HEAD INTO THE ACETABULUM OF THE PELVIS THE LUMBAR VERTEBRA OF THE SOMATIC DYSFUNCTION RELATIVELY ROTATES TOWARD THE SAME SIDE

83 LUMBAR Discogenic Pain Syndrome Treatment FINDINGS Right lumbar disk herniation or bulge with right radiculitis. POSITION The patient is prone, close to the left edge of the table, with a sufficient number of pillows beneath the abdomen to cause flattening of the lumbar lordosis THE PHYSICIAN PUSHES THE PATIENT S FOOT TOWARDS THE FLOOR THE PHYSICIAN RAISES HIS OUTER KNEE AND PUTS LATERAL PRESSUREON THE PATIENT S POSTERIOR KNEE I don t treat herniated discs of the lumbar spine. I do treat (essentially) lateral stenosis. I don t want you to say; oh he taught me to pop a disc back, no I didn t.

84 SACRUM & PELVIS

86 SACRUM & PELVIS DIAGNOSIS RIGHT ANTERIOR PELVIC ROTATION FINDINGS RIGHT + STANDING FLEXION TEST RIGHT ASIS LOW RIGHT PSIS HIGH The patient is supine

87 SACRUM & PELVIS DIAGNOSIS RIGHT POSTERIOR PELVIC ROTATION FINDINGS RIGHT + STANDING FLEXION TEST RIGHT ASIS HIGH RIGHT PSIS LOW The patient is supine

88 Treat what you find, try to avoid naming it because the bad ones (somatic dysfunction) have no name.

89 SACRUM DIAGNOSIS LEFT SACRAL RESTRICTION FINDINGS LEFT + SEATED FLEXION TEST LEFT SACRAL RESTRICTION The patient is prone The Physician's cephalad hand thenar and hypothenar region is on the ILA of the sacrum on the same side as the dysfunction. The index &/or the pads of the index and middle fingers are medial to the PSIS on the same side The Physician's other hand grasps the patient s lower leg above the ankle on the same side.

90 SACRUM DIAGNOSIS LEFT SACRAL RESTRICTION FINDINGS LEFT + SEATED FLEXION TEST LEFT SACRAL RESTRICTION The patient is prone The Physician's cephalad hand maintains pressure on the sacrum with a slight anterior and cephalad force. The Physician's hand on the patient s lower leg introduces slight abduction of the hip by deviating the leg laterally and external rotation of the hip until motion is felt by the hand on the sacrum. Slight compression is introduced up to the pelvis and sacrum.

91 FPR SACRUM The Physician's cephalad hand maintains pressure on the sacrum with a slight anterior and cephalad force. The Physician's hand on the patient s lower leg introduces internal rotation of the hip until motion is felt by the hand on the sacrum. Traction is introduced. The Patient is instructed to inhale deeply. The physician increases the cephalad pressure on the ILA and can even introduce a slight cephalad/anterior thrust. The patient exhales and the dysfunction is reassessed

92 ALTERNATIVE PROINE SACRAL TECHNIQUE DIAGNOSIS RIGHT SACRAL RESTRICTION FINDINGS RIGHT + SEATED FLEXION TEST RIGHT SACRAL RESTRICTION The patient is prone

93 You have motion, you re through. The name of the game is motion.

94 FPR SIDELYING SACRUM

95 E/M Office Visit Codes New pt Established pt nurse evaluated/treated without doctor face-to-face involvement nurse evaluation or easy low complexity mod complexity high complexity

96 Modifier 25 The -25 modifier is used when additional E/M services are provided on the same day as a procedure is provided Modifier -25 Significant, separately identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service E/M services required above and beyond the other service provided, or beyond the usual pre- and post-operative care associated with the procedure performed. Different diagnoses are not required.

97 OMT Procedural Codes CPT for OMT Procedure CODES OMT; one to two regions involved OMT; three to four regions involved OMT; five to six regions involved OMT; seven to eight regions involved OMT; nine to ten regions involved They can include any 10 body regions combinations: cranial, cervical, thoracic, lumbar, sacral, innominate, upper extremity, lower extremity, rib cage, visceral

98 Osteopathic Diagnostic Codes Osteopathic ICD-10 Diagnostic Codes (10 Regions) Listed as: Segmental somatic dysfunctions or Non-allopathic dysfunction M99.00 Head region Occipito-cervical region M99.01 Cervical region Cervicothoracic region M99.02 Thoracic region Thoracolumbar region M99.03 Lumbar region Lumbosacral region M99.04 Sacral region Sacrococcygeal and Sacroiliac regions M99.05 Pelvic region Pelvic and Pubic regions M99.06 Lower extremities Hip, Knee, Ankle & Foot M99.07 Upper extremities Shoulder, Elbow, Wrist & Hand M99.08 Rib cage Costovertebral, Costochondral, and Sternochondral regions M99.09 Abdominal & other (Visceral) Abdominal, Pelvic, etc.

DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET)

DIAGNOSIS ANTERIOR PELVIC ROTATION DIAGNOSIS DIAGNOSIS. Direct techniques to treat sacrum and pelvis somatic dysfunction (HVLA, MET) American Academy of Osteopathy Convocation PHYSICIAN STUDENT Thursday, March 18, 2010 Friday, March 19, 2010 2:30 4:00 PM 8:00 9:30 AM 4:30 6:00 PM 10:00 11:30 AM Direct techniques to treat sacrum and