OMT for Asthma in Children Angela K Tyson, DO PGY-1 Oklahoma State University Medical Center - Pediatrics

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1 OMT for Asthma in Children Angela K Tyson, DO PGY-1 Oklahoma State University Medical Center - Pediatrics Objectives Review the background, epidemiology, anatomy, and physiology of asthma in children Learn why OMT is indicated for children with asthma Review the anatomy of a child s thoracic and abdominal cavity Review the 5 models of osteopathic medicine and how they apply to children with asthma Review common OMT techniques that are applicable to treat children with asthma What is Asthma? Chronic lung disease that inflames and narrows the airway - NIH Affects 7 million children in the US 80% of children develop symptoms by age 5 One of the most common chronic diseases of childhood worldwide 1

2 Most Common Symptoms of Asthma in Children Cough nocturnal occurs seasonally occurs with certain exposures prolonged cough (>3 weeks) Wheeze high-pitched, musical sound produced when air is forced through narrow airways polyphonic when severe, can occur with inspiration and expiration Triggers, Exposures, and Risks for Asthma Exacerbation Atopic kids are at risk for exacerbation: allergic rhinitis, atopic dermatitis, and asthma Family history of asthma Significant PMH Seasonal allergies and other allergens Irritant exposure Respiratory tract infections Exercise/Physical Activity Changes in weather The child s environment Psychosocial profile School attendance Stress Medications and adherence to them Example of an Asthma Exacerbation v=ek8nzkzdnim&ebc=anypxkqnxbx7diozqjxcwr Gb7Q0Bx9_ND2q6T- OiYdCy7oSjmuXfqz9JapCHzb_tGnnLjl0iO46DPwuc 4n74kFFgZv-gEsKwhA 2

3 Anatomy You begin with anatomy, and you end with anatomy, aknowledge of anatomy is all you want or need... -Andrew Taylor Still Anatomy of the Thoracic Cavity Rib Motion 3

4 Lymphatics Diaphragm 4

5 Biomechanical Model In severe asthma attacks, labored breathing can affect a child from the cranium to the pelvis There are over 146 joints in the thorax Infants have immature acetylcholinesterase production and increase contraction/relaxation time of muscles Children have a more flexible rib cage that are laterally splayed with a flatter diaphragm Respiratory-Circulatory Model The primary muscle of respiration is the diaphragm Movement of the diaphragm affects the cardiac and pulmonary pleura above, and the hepatic and gastric pleura below Fluid movement through the vena caval system depends on the effectiveness of diaphragmatic excursion Metabolic - Energy Model Discuss the patient s diet Avoid all allergens and triggers Discuss sleep healthyrecipesforweight.blogspot.com 5

6 Neurological Model Always consider the sympathetic and parasympathetic nervous system Sympathetic sympathetic chain ganglion at levels of T1-6. Parasympathetic vagus nerve The diaphragm is innervated by the phrenic nerve from the cervical plexus (C3-5) Innervation Table Organ/System Parasympathetic Sympathetic Ant. Chapman's Post. Chapman's EENT Nerves (III, VII, IX, X) T1-4, 2 nd ICS Suboccipital Cr T1-T4 Heart Vagus (CN X) T1-T4 T1-4 on L, T2-3 T3 sp process Respiratory Vagus (CN X) T2-T7 3 rd &4 th ICS T3-5 sp process Esophagus Vagus (CN X) T2-T Foregut Vagus (CN X) T5-T9 (Greater Splanchnic) Stomach Vagus (CN X) T5-T9 (Greater Splanchnic) 5 th -6 th ICS on L T6-7 on L Liver Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 5 on R T5-6 Gallbladder Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 6 on R T6 Spleen Vagus (CN X) T5-T9 (Greater Splanchnic) Rib 7 on L T7 Pancreas Vagus (CN X) T5-T9 (Greater Splanchnic), T9-T12 Rib 7 on R T7 (Lesser Splanchnic) Midgut Vagus (CN X) Thoracic Splanchnics (Lesser) Small Intestine Vagus (CN X) T9-T11 (Lesser Splanchnic) Ribs 9-11 T8-10 Appendix T12 Tip of 12 th Rib T11-12 on R Hindgut Pelvic Splanchnics (S2-4) Lumbar (Least) Splanchnics Ascending Colon Vagus (CN X) T9-T11 (Lesser Splanchnic) R hip T10-11 Transverse Colon Vagus (CN X) T9-T11 (Lesser Splanchnic) Near Knees --- Descending Colon Pelvic Splanchnic (S2-4) Least Splanchnic L hip T12-L2 Colon & Rectum Pelvic Splanchnics (S2-4) T8-L Behavioral Model Always treat the whole patient Tenets of osteopathy: The body is a unit; the person is a unit of body, mind, and spirit. The body is capable of self-regulation, self-healing, and health maintenance. Structure and function are reciprocally interrelated. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation, and the interrelationship of structure and function. Always evaluate a patient s physical, mental, emotional, and spiritual state 6

7 Goals of OMT Relieve tension from accessory muscles of respiration Free fascial restrictions Restore thoracic inlet and diaphragm function Increase lymphatic flow and blood flow Balance autonomic function through parasympathetic and sympathetic response Treat the whole patient Areas to Treat with OMT 1.Occipito-atlantal junction and the course of the vagus nerve that supplies parasympathetic input to the pulmonary tree 2. Anterior cervical fascia 3. Accessory muscles of respiration 4. Upper thoracic vertebrae, ribs, sternum T1-6 because of sympathetic innervation to the lungs T10-L2 and the lower ribs 5. Thoracic diaphragm The diaphragm is innervated by the phrenic nerve from the cervical plexus (C3-5), and its mobility is influenced by the lower six ribs, L1-2 and the sternum. 6. Chapman s reflexes for the lungs, sinuses, and adrenal glands 7. The cranial-sacral mechanism Suboccipital Release Patient is supine with physician at head of bed Place index and middle fingers in the occipital sulcus on both sides. Apply linear traction until a release is felt (about one minute) 7

8 Suboccipital Release Counter - Lateral Traction Place one hand on the frontal bone, the other hand on the lateral aspect of the cervical spine along the articular facets. While applying pressure on the frontal bone away from you, the other hand stretches the muscles of the neck toward you. Counter - Lateral Traction 8

9 Soft Tissue to the Paraspinal Muscles Patient is prone Physician is standing on the opposite side of the patient to which they will treat Place the thenar and hypothenar eminences of the physician s dominant hand between the spinous processes and paraspinal muscles on the contralateral side to which you are standing, and are aiming to treat. The physician places the other hand over the hand above The physician leans forward applying a lateral force to the paraspinal muscles. Soft Tissue to the Paraspinal Muscles Rib Raising Patient is supine The physician is at the side they are treating Physician s hands are under the patient s back, palms up, with fingers close to the spinous process For asthma, focus on T1-6 The pads of the fingers elevate as the forearms are used as the fulcrum, making a come here motion Patient is seated The physician is standing in front of the patient The physician reaches around the patient, and contacts the patient s posterior rib angles on both sides with hands bilaterally The physician is to lean back applying a gentle traction For asthma, focus on T1-6 9

10 Rib Raising Lymphatic Drainage The patient is supine with knees flexed, and the physician is at the head of the patient The physician hands are spread flat over the anterior superior chest wall Pressure is applied, equally distributed over the entire surface of the anterior superior chest with both hand in downward and caudad rhythmic manner Lymphatic Drainage 10

11 Thoracoabdominal Diaphragm Release Patient is supine The physician is standing behind the patient s head The physician is to place palms bilaterally over the lower margin of the ribcage, with thumbs lateral to the sternum one inch below the 10th rib Apply a slow, progressive pressure to the fascia of the anterior abdomen and diaphragm, allowing the thumbs to sink under the ribs. After this is achieved, apply an upward pressure Hold until a release is felt (approximately one minute) Thoracoabdominal Diaphragm Release Thoracic Inlet Myofascial Release The patient is supine The physician is to be seated at the patient s head behind the patient The physician is to place hands with 2nd - 5th digits over the chest wall, over the thoracic inlet at the levels of the first and second ribs. The thumbs of the physician should posterior to the thoracic inlet, at the same level upon the chest anteriorly With slight pressure over the anterior chest, introduce translation to the left/right, rotation, and/or twisting motion to evaluate for any myofascial restrictions Hold a point of balance within the above induced motions until a release is felt (about one minute) 11

12 Thoracic Inlet Myofascial Release References Allen TW, D Alonzo GE, Investigating the role of osteopathic manipulation in the treatment of asthma. J Am Osteopath Assoc 1993;93: , 659. Chila, Anthony, et. al. Foundations of Osteopathic Medicine. Rev 3rd Ed. 2011: 53-55, , , , Hostoffer, Robert and Hegybeli, Eric. Pediatric OMT Chest Module. Powerpoint Presentation. Retrieved from: Kuchera ML, Kuchera WA. Osteopathic Considerations in Systemic Dysfunction. Rev. 2nd Ed. 1994: Nelson, Kenneth. Somatic dysfunction in Osteopathic Medicine. Rev 2nd Ed. 2014: pg 285, Openshaw P, Edwards S, Helms P. Changes in rib cage geometry in childhood. Thorax 1984;39:624. Sawicki, Gregory, et al. Asthma in Children Younger Than 12 Years Initial Evaluation and Diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on March 25, 2016.) Panton J, Barley EA. Family therapy for asthma in children. Cochrane Database Syst Rev 2005:2. 12