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Osteopathic Evaluation & Treatment The Patient with Respiratory Dysfunction. Developed for OUCOM CORE by Craig Warren, D.O. Edited by Clay Walsh, D.O. and the CORE Osteopathic Principles and Practices Committee Session #6 - Series B. Objectives.

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slide1

Osteopathic Evaluation & Treatment

The Patient with Respiratory Dysfunction

Developed for OUCOM CORE

by Craig Warren, D.O.

Edited by Clay Walsh, D.O.

and the

CORE Osteopathic Principles and Practices Committee

Session #6 - Series B

slide2

Objectives

  • Understand viscerosomatic reflexes as they relate to the respiratory system
  • Discuss the sympathetic and parasympathetic innervation of the respiratory tract
  • Properly document somatic dysfunction and OMT in the hospital chart
  • Demonstrate OMT that may favorably influence the somatic, lymphatic, and autonomic components of respiratory disorders.
goals of structural examination in visceral dysfunction
Find any S/D that may be related to the visceral dysfunction or significantly effect the body in some way as to impede homeostasis

Sympathetics

Parasympathetics

Respiration and Circulation

Related structural mechanics

Mobility and motility of the viscera

Goals of Structural Examination in Visceral Dysfunction
goals of omt in visceral dysfunction
Normalize sympathetic tone to that viscera.

Normalize parasympathetic tone to that viscera.

Improve venous and lymphatic return.

Improve the mechanical function of the contiguous structures.

Improve the mechanical environment of the viscera for visceral mobility and motility.

Remove any structural hindrance to respiration and circulation.

Goals of OMT in Visceral Dysfunction
cervical sympathetic ganglia
Cervical Sympathetic Chain Ganglia are associated with: C2 C6 C7

www.anatomy.tv

Cervical Sympathetic Ganglia

Superior cervical ganglion

Middle cervical ganglion

Inferior cervical ganglion

chapman s reflexes anterior reflex points
Neurolympatic Reflex which results in visceral dysfunction being manifested as a palpable knot in a somatotopic pattern. Used both diagnostically and therapeuticallyChapman’s Reflexes:Anterior Reflex Points

page 232 of Osteopathic Considerations in Systemic Dysfunction 2nd & 3rd editions by Michael Kuchera, D.O.

chapman s reflexes posterior reflex points
Chapman’s Reflexes:Posterior Reflex Points

page 233 of Osteopathic Considerations in Systemic Dysfunction 2nd 3rd editions by Michael Kuchera, D.O.

lymphatic return
Lymphatic Return

Osteopathic Considerations in Systemic Dysfunction 2nd & 3rd editions by Michael Kuchera, D.O pgs. 39 &40

mechanism of expiration
Primary

Elastic Recoil

Secondary

Muscles of Respiration

Rectus abdominus

Internal Intercostals

External Obliques

Transversus abdominus

Mechanism of Expiration
mechanism of inspiration muscular activity
Primary: Diaphragm

Attaches to lower 6 ribs

Attaches to lumbar vertebra and fascia of psoas major and quadratus L. post

Continuous with the pericardial fascia which attaches to T3 and T4

Secondary:

External intercostals – lift the rib

SCM – lift the sternum

Scalenes – lifts ribs 1 &2

Mechanism of Inspiration –Muscular Activity
opp for the lower respiratory tract patient
Cervicals C3-C5 (Phrenic Nerve)

Sternum

T1-12 and Ribs 1-12 (Somatic Nerves and Mechanisms of Respiration)

Thoracolumbar Junction (Diaphragm)

OPP for the Lower Respiratory Tract Patient

Somatic Dysfunction

Facilitated

Segment

Sympathetics

Parasympathetics

Rib Raising

T1-T6

Chapman’s Reflexes

OPP for the

LRT Patient

OA, AA, Cranial

Vagus Nerve

Lymphatics/Circulation

Thoracic Inlet Rib Raising

Abdominal/Pelvic Diaphragm Lymphatic Pumps

opp for the upper respiratory tract patient
Cervicals C3-C5 (Phrenic Nerve)

Sternum

T1-12 and Ribs 1-12 (Somatic Nerves and Mechanisms of Respiration)

Thoracolumbar Junction (Diaphragm)

Medial pterygoids

Hyoid Soft Tissues

OPP for the Upper Respiratory Tract Patient

Somatic Dysfunction

Facilitated

Segment

Sympathetics

Parasympathetics

OPP for the

URT Patient

Rib Raising

T1-T6

Chapman’s Reflexes

C2, C6, C7

OA, AA, Cranial

Sphenopalatine Ganglion

Lymphatics/Circulation

Thoracic Inlet Rib Raising

Abdominal/Pelvic Diaphragm Lymphatic Pumps/Effleurage

integrate opp into your standard medical care
Remember a Rule of 3’s

Any physician, any patient, any setting

3 Minutes

3 Area

3 Techniques

Integrate OPP Into Your Standard Medical Care
opp research
Patients with S/D at C3-C4

Greater incidence of post-operative pulmonary complications

109 patients undergoing upper abdominal surgery

Patients had S/D at C3-C4

OMT vs Sham-OMT randomization

Sham-OMT had 16 times the incidence of post-operative complications

OPP Research

Henshaw. The D.O. September 1963, pages 132-133

henshaw s study
Henshaw’s Study
  • Association of C3-C5 S/D with Post-operative Complications
henshaw s study1
Surgical Populations with Pre-op C3-C5 Somatic DysfunctionHenshaw’s Study

109 Cases

OMT Prior to Surgery

Sham -OMT Prior to Surgery

3 / 5 Cases

29/34 Cases

5.3 %

85.3 %

Post-op Pulmonary Complication

Post-op Pulmonary Complication

opp research pneumonia
58 elderly patients (>60 yrs) hospitalized with CAP

Two treatment groups

All received standard medical care

Experimental group – OMT for 10 -15 minutes BID

Control group – Sham OMT for 10-15 minutes BID

OPP Research: Pneumonia

Noll DR, Sholes JH, Gamber RG, Slocum PC. The efficacy of adjunctive OMT in the elderly hospitalized with pneumonia. JAOA 98(7):389. 1998

noll et al research pneumonia
Noll et al Research: Pneumonia

Conclusions: Adjunctive OMT reduces significantly the duration of IV antibiotics and the length of hospital stay of the elderly patient with community acquired pneumonia

general mfr of thoracic cage
Patient: seated, supine or reclining position

Physician: Hand position

Anterior hand at sternomanubrial junction

Posterior hand spans T2-T5

Action:

Slight AP Compression

Engage indirect barrier (ease)

Superior/Inferior Shear

Right/Left Lateral Shear

Clockwise/CCW Torque

Reaction: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your force)

Goal: Normalize sympathetics and improve the mechanics of respiration

General MFR of Thoracic Cage
mfr thoracic vertebra
Patient: Supine

Physician: Seated at patient’s head; hands under thorax with fingers contacting the TP of the vertebra to be treated

Action: Fingers will push on TP to engage the direct or indirect barrier

Anterior to rotate

Cephalad to flex

Caudal to extend

CW or CCW torque to SB

Release: Hold at direct or indirect barrier with constant force until stretch stops or hold with constant stretch until the force becomes constant.

Goal: Mobilize thoracic vertebral segment, normalizing sympathetics and improving the mechanics of respiration

MFR: Thoracic Vertebra
rib raising normalizing sympathetics
Patient: Seated

Physician: Stands in front of patient; Hands at the rib angles

Action: 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

Goal: Normalize sympathetics and improve the mechanics of respiration

Rib Raising: Normalizing Sympathetics
rib raising supine position
Patient: Supine

Physician: Seated at patient’s side. Both hands under thorax (palms up) with fingers perpendicular to the table and pushing up on the angles of the ribs

Action: Using wrist and forearm as a fulcrum, cyclically lift up on the ribs so as to lift the thorax on that side. Hold for 3-5 seconds and let back down. Repeat for 30 seconds on each side.

Release: Increased motion of thoracic spine and ribs

Goal: Normalize sympathetics and improve the mechanics of respiration

Rib Raising: Supine Position
suboccipital release normalizing parasympathetics
Patient: Supine or Reclining

Physician: Seated at the head of the table, hold the occiput in your palms, curling your fingers up to meet the O/A junction.

Action: Flex your wrists so that the weight of the head rests on your fingertips.

Release: Muscles and fascia will relax with time.

Goal: Normalize parasympathetics via Vagus Nerve

Suboccipital Release: Normalizing Parasympathetics
mfr of cervical spine
Patient: Supine or reclining position

Physician: Hands under the neck with pads of middle fingers in contact with the posterior surface of the lateral pillars

Action: Lift head to flex or extend the segment and use pads of fingers on lateral pillars to side bend and rotate the segment

Engage the indirect barrier

Flex/Extension

Side bending

Rotation

Release: Hold at the indirect barrier with either constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch)

Goal: Reduce any irritation to Vagus Nerve, Phrenic nerve or Cervical Chain Ganglia and improve the mechanics of respiration

MFR of Cervical Spine
thoracic inlet release
Patient: Supine, seated or reclining position

Physician: Hands encircle the thoracic inlet

Action: Engage indirect barrier (ease)

Side bending

Clockwise/CCW rotation

Release: Hold at the indirect barrier with either constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch)

Goal: Improve the mechanics of respiration and remove restrictions to lymphatic flow

Thoracic Inlet Release
mfr abdominal diaphragm
Patient: Supine or reclining position

Physician: Anterior hand is just inferior to xiphoid; Posterior hand at thoracolumbar junction

Action: Slight A/P Compression

Engage Indirect Barrier (ease)

Clockwise/CCW Rotation

Release: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch)

Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow.

MFR: Abdominal Diaphragm
mfr pelvic diaphragm
Patient: Supine or reclining position

Physician: Anterior hand is just superior to pubes; Posterior hand under the sacrum

Action: Slight A/P Compression

Engage Indirect Barrier (ease)

Clockwise/CCW Rotation

Release: Hold with constant force or constant stretch until the tissues release (increased motion or decreased resistance to your stretch)

Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow.

MFR: Pelvic Diaphragm
lymphatic pump chest compression
Patient: Supine

Physician: Stands at patient’s head; Palmar surface of hands on upper Chest with thumbs on the sternum and fingers in axilla.

Action: Have patient take deep breaths. Resist the chest expansion in inhalation and compress the chest during exhalation. Repeat 3-4 cycles. On last cycle quickly slide hands off the chest at the peak of inhalation causing a “gasp”

Goal: Improve the mechanics of respiration and remove restriction to lymphatic flow.

Lymphatic Pump:Chest Compression
pedal lymphatic pump
Patient: Supine

Physician: Standing at patient’s feet; Palms on ball of foot

Action: Rhythmic Flexion (or extension) at ankles. Effective rhythm causes a rhythmic “sloshing” of the belly.

Goal: Mobilize lymphatic fluid from the lower extremities and lower trunk into central circulation

Pedal Lymphatic Pump
pectoral traction for lymphatic drainage
Patient: Supine

Physician: Standing at patient’s head

Action: Hands grasp the pectoralis muscles at the axillary fold and lean back putting a stretch on the muscles. Have patient take deep breaths. On inhalation pull on the muscles and with exhalation hold the tension. Repeat 3-4 cycles

Goal: Stretch and release the pectoralis muscles facilitating lymphatic flow back to central circulation

Pectoral Traction for Lymphatic Drainage
venous sinus drainage
Transverse Sinus

Straight Sinus

Superior Sagittal Sinus

Metopic Suture

Venous Sinus Drainage
galbreath mandibular drainage technique eustachian tube dysfunction otitis media
Patient: Supine with effected ear up

Physician: Standing at the patient’s head

Action: One hand stabilizes the head at the frontal bone while the other grasps the angle of the mandible on the effected side. Rhythmically draw the mandible anteriorly and release. Repeat for 1 minute

Goal: Facilitate eustachian tube drainage and aeration of middle ear

Galbreath Mandibular Drainage Technique (Eustachian tube dysfunction & Otitis Media)
sphenopalatine ganglion stimulation used for any uri
Patient: Supine

Physician: Standing at patient’s head with gloved hand. Slide fifth finger posteriorly past the last upper molar letting the tip of the finger go medial and superior into the Sp-Pal fossa where you contact the SPG (will be very tender)

Action: Push on SPG for 3 seconds and release. Repeat 3 times

Goal: Stimulate the parasympathetic output to the URT

Sphenopalatine Ganglion Stimulation(Used for any URI)