Overview of Osteopathic Manipulative Principles

1. Overview of Osteopathic Manipulative Principles Col (sel) Heather R. Pickett, DO Capt. Christopher E. Jonas, DO Nellis/Eglin Air Force Base Family Medicine Residencies

2. Relevance Mix of DO/MD residents in Family Medicine Enhance awareness of Integrative Medicine modalities Understand basis for much of physical therapy & chiropractic Whom you refer to & what they do Your experience/interest?

3. Overview Definition and history of osteopathy Philosophy Demographics/trends/attitudes Challenges Noteworthy studies Osteopathic structural exam Osteopathic manipulative techniques practice (OMM,OMT) Neck and back pain considerations Red flags

4. What is Osteopathic Medicine? Complete and unique system of care that equates and correlates with the mainstream of medicine Includes standard allopathic diagnostic and treatment modalities Not voodoo�.really!

5. Perhaps you are thinking�

6. Osteopathic Principles Focus- structure & function of musculoskeletal systems Inter-relationship of somatic presentations and pathological processes Use of �manipulation� (OMM/OMT) for diagnosis and treatment

7. Andrew Taylor Still 1874 - Dr. A.T. Still (MD) from Missouri standard allopathic practices inadequate for many patient complaints US Army surgeon in Civil War 10 years developing techniques First school opened in Kirksville in 1892

8. Concurrent Historical Considerations Credibility for manual manipulation � OMT provided improved outcomes Spanish Flu Epidemic: 1917-1919 DOs: 1 in 16 death rate - OMM for lymphatic system included in medical treatment MDs: 1 in 2 death rate with no OMM (Journal of the American Osteopathic Association, 1919)

9. Still�s Initial Tenants Stressed �wellness� - preventive med., diet & exercise Unity of all body parts/systems Inherent ability of body to heal itself Spinal manipulation as means for

10. Evolution of osteopathic medicine's mission and identity 1892 to 1950 � Manual medicine 1951 to 1970 � Family medicine Manual therapy (OMM, OMT) 1971 to present � Full service care / multi-specialty orientation

11. Continued Evolution DoD- 1916 � 1966: "long and tortuous struggle� May 3, 1966 - Secretary of Defense Robert McNamara - authorized DOs into all military medical services on same basis as MDs 1996: Ronald Blanck, DO - Surgeon General of the Army

12. Current Demographic Trends 53,600+ practicing DOs in U.S. 25 osteopathic schools, 126 allopathic 50% entered Primary Care 1996, 32% in 2004 Much of philosophy is cornerstone of Family Medicine 200+ hours of manipulative and musculoskeletal medicine

13. Current Demographic Trends 1:5 US medical students is enrolled in an osteopathic medical school By 2020, the number of osteopathic physicians may grow to 95,400 (AMA) Similar trends noted in residency training 

14. Current Attitude Trends Increasingly positive attitude of patients and physicians (MD and DO) towards the use of manual therapy One month rotation for MD�s showed promise Journal of Continuing Medical Education: 81% of physicians and 76% of patients felt that OMM was safe 56% of physicians and 59% of patients felt that OMM should be available in primary care setting

15. Training and Interest Trends 40% of physicians reported any educational exposure to OMM 20% have administered OMM in their practice 71% respondents endorsed desiring more instruction in OMT/OMM

16. Challenges to the Profession Documenting efficacy of OMT Sound clinical research trials $$$$$$$$$$$

17. Other challenges�. Recognition and equal licensure worldwide Other countries confused by American osteopathic training model/licensure DOs considered chiropractors elsewhere

18. Currently Used to Address Pain (Chronic and Acute) Increase mobility Asthma Sinus problems Carpal tunnel syndrome Migraines Dysmennorhea Can complement�and even replace�drugs/PT or surgery

19. What does literature support? Increasing numbers of RCTs Published mostly in JAOA and PT journals Several noteworthy studies Pneumonia improvement Low Back Pain Functionality

20. Improved Pneumonia Outcomes Journal Am Osteopath Assoc. 2008 Sep;108(9):508-16 Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) Prospective RCT to evaluate the efficacy of OMT as an adjunct to the current treatment of elderly patients hospitalized for pneumonia OMT vs.. �sham� protocol vs.. antibiotics only 58 patients Outcomes: Decreased length of hospital stay 6.6 vs.. 8.6 days Decreased length of IV antibiotics by 2 days

21. Less PT and MedicationsNew England Journal of Medicine, Nov 4, 1999 RCT trial for management of Sub acute LBP 1193 patients Standard treatment vs.. treatment with OMT Outcomes: Use of medication lower in OMT group Use of Physical Therapy lower in OMT group

22. Better Long term functionality and pain improvementBMJ, doi:10.1136/bmj.38282.669225.AE. 19 November Randomized Controlled Trial 1334 patients, LBP as chief complaint OMT vs. OMT plus exercise Outcome: �OMT + exercise� has greatest long term benefits

23. Coding Considerations MD�s and DO�s can code for these Ahlta coding is actually simple �Procedures� �Osteopathic� Code by # of body regions Boost RVU�s

24. Simple Enough?

25. Structural exam principles Perform the exam Look for �barriers� to motion Record findings of structure, motion and tissue Decide if somatic dysfunction (SD) is present Record if SD is present Appropriate OMT technique

26. Physical Exam History: Mechanism of injury Inspection: Static position, posture, asymmetry Palpation: Anatomic changes (TART) Range of motion (active and passive): Side bending, Rotation, Flexion, Extension Other Tests: Neurologic exam

27. Brief Discussion of Barriers Anatomic Barriers Swartzenegger Movies Fully Passive Physiologic Barriers Normal active barrier Restrictive Barriers Pathologic barrier due to pain etc What we treat!

28. Osteopathic Techniques Muscle Energy Counterstrain Soft Tissue

29. Muscle Energy Technique Muscle Energy Technique is a form of Osteopathic Manipulative Therapy that: 1. Uses patients muscles and effort 2. Works muscles in a specific direction OPPOSITE the barrier 3. Uses physician muscles as a counterforce 4. Attempts to improve function in patient

30. Sequence of Muscle Energy Technique Position patient at restrictive barrier Patient contracts muscles AWAY from barrier Physician opposes patient with equal force for 5 seconds Patient and physician ease forces 5 seconds relaxation Locate new barrier Repeat steps 1-6 three times Re-evaluate muscle group

31. Contraindications to Muscle Energy Technique Fracture Trauma Significant Pain Severe Sprain or Strain Ruptured Muscle Uncooperative or unresponsive patient

32. Common Errors in Muscle Energy Technique Inaccurate setup technique Incorrect force Poor patient effort Incorrect direction (Most Common)

33. Practice Example

34. Muscle Energy Practice Stabilize the arch of C1 with one hand while the other hand positions the occiput to the triplaner barrier Activate by turning head away or use occulocervical reflex (look away from rotation)

35. Muscle Energy for AA Practice Rotate to the barrier Patient isometrically rotates away

36. Strain/Counterstrain Involves location and treatment of tender points Can also be used for sore muscles No contraindications when done correctly

37. Strain/Counterstrain Locate tenderpoint Move to position of comfort Goal= 2/3 improved (i.e. 3 out of 10 pain) Hold for 90 seconds Return to neutral Recheck!

38. An Example Would be used to treat tenderpoint on ASIS A passive technique Note comfort in position

39. Soft Tissue Techniques Use to stretch and relax muscles Involves perpendicular stretching of muscle bellies Also involves slow deliberate massage Virtually no contraindications

40. Common Errors �Plucking� muscles Smashing muscle between hand and bone Too hard or too soft Sensitive areas Gender issues

41. Patient-Centered Problem Focused Approach Devise an appropriate treatment plan OMT Prescription for muscle relaxant Home stretching exercises Heat or ice for the sore muscles

42. Neck Pain About 2/3 of people will have an episode of neck pain during their lives 2nd most common musculoskeletal complaint (LBP is #1) Usually resolves within days or weeks Becomes chronic in about 10% of cases Causes severe disability in about 5%

43. Typical Cervical Motion Flexion and Extension Rotational component dominates upper cervicals Side bending component dominates lower cervicals

44. Sources of Pain Ant. Longitudinal Lig. Post. longitudinal lig. Yellow ligaments Interspinous ligaments Intervertebral joint capsules Vertebral disc Periosteum of vertebrae Fascia of vertebrae Paravertebral musculature

45. T-Spine Anatomy Review

46. T-Spine Anatomy Considerations External Landmarks Anterior Posterior Natural kyphosis of 40 degrees Body�s center of gravity lies anterior to the t-spine

47. Red Flags of Back Pain Age <20 or >50 Trauma Constant and progressive non-mechanical pain History of cancer, immunosuppression, systemic steroids, drug abuse Weight loss, night sweats, fever ESR>25 Deformity, x-ray with vertebral destruction or collapse Progressive neurologic deficit Night-time pain unaffected by position History of osteoporosis

48. Good websites:http://www.osteopathic.org/http://amops.org/http://nccam.nih.gov/health/whatiscam/manipulative/manipulative.htm#

49. References KCOM OMM CME, 2006-2007 . Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997;349:1498 -1504.[Medline] 2. Nalysnyk L, Fahrbach K, Reynolds MW, Zhao SZ, Ross S. Adverse events in coronary artery bypass graft (CABG) trials: a systemic review and analysis [review]. Heart.2003; 89: 767-772. Available at: http://heart.bmjjournals.com/cgi/content/full/89/7/767. Accessed August 27, 2005.[Abstract/Free�Full�Text] 3. Rumsfeld JS, MaWhinney S, McCarthy M Jr, Shroyer AL, VillaNueva CB, O'Brein M, et al. Health-related quality of life as a predictor of mortality following coronary artery bypass graft surgery. Participants of the Department of Veterans Affairs Cooperative Study Group on Processes, Structures, and Outcomes of Care in Cardiac Surgery. JAMA.1999; 281:1298 -1303.[Abstract/Free�Full�Text] 4. Cheng DC, Karski J, Peniston C, Asokumar B, Raveendran G, Carroll J, et al. Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg.1996; 112:755 -764.[Abstract/Free�Full�Text] 5. Cheng DC, Karski J, Peniston C, Raveendran G, Asokumar B, Carroll J, et al. Early tracheal extubation after coronary artery bypass graft surgery reduces costs and improves resource use. A prospective randomized controlled trial. Anesthesiology.1996; 85:1300 -1310.[Medline] 6. Crowe JM, Bradley CA. The effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Phys Ther.1997; 77:260 -268.[Abstract/Free�Full�Text] 7. Birdi I, Regragui I, Izzat MB, Bryan AJ, Angelini GD. Influence of normothermic systemic perfusion during coronary artery bypass operations: a randomized prospective study. J Thorac Cardiovasc Surg. 1997;114:475 -481.[Abstract/Free�Full�Text]

50. References New England Journal of Medicine, Nov 4, 1999, Vol 341:1426-1431 Journal of American Osteopathic Association, Dec 2000, Vol 100, No. 12, p 782 American Osteopathic Association, Foundations of Osteopathic Medicine, pp. 691-696, 1997, Lippincott, Williams &Wilkins. Kimberly, Paul E., Outline of Osteopathic Manipulative Procedures, pp. 20-21, 31, Walsworth Publishing Company. Physical Medicine Institute, Complimentary and Alternative Medicine Clinical Research, pp. 8-9. Osteopathic Health and Wellness Institute, Muscle Energy I, pp. 1-35, OWHI, 1997-2005. Young Women�s Health, Internet Article, www.youngwomenshealth.org/fitness, pp. 3 All Cartoons from Kaz online medical cartoons. http://www.kazcartoonstore.com Marcus Alon. Foundations for Integrative Musculoskeletal Medicine. Berkeley, Calif: North Atlantic Books; 2004 American Osteopathic Assn and American Academy of Osteopathy website Wikipedia: Osteopathic Medicine 2009 Ward, Robert. Foundations for Osteopathic Medicine. Williams & Wilkins; 1997