Overview of Osteopathic Manipulative Principles

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Overview of Osteopathic Manipulative Principles

• Col (sel) Heather R. Pickett, DO
• Capt. Christopher E. Jonas, DO
• Nellis/Eglin Air Force Base
• Family Medicine Residencies

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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?

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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

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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!

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Perhaps you are thinking
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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

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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

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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)

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Stills 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

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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

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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

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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

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Current Demographic Trends

• 15 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

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Current Attitude Trends

• Increasingly positive attitude of patients and
  physicians (MD and DO) towards the use of manual
  therapy
• One month rotation for MDs 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

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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

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Challenges to the Profession

• Documenting efficacy of OMT
• Sound clinical research trials

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Other challenges.

• Recognition and equal licensure worldwide
• Other countries confused by American osteopathic
  training model/licensure
• DOs considered chiropractors elsewhere

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Currently Used to Address

• Pain (Chronic and Acute)
• Increase mobility
• Asthma
• Sinus problems
• Carpal tunnel syndrome
• Migraines
• Dysmennorhea
• Can complementand even replacedrugs/PT or
  surgery

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What does literature support?

• Increasing numbers of RCTs
• Published mostly in JAOA and PT journals
• Several noteworthy studies
• Pneumonia improvement
• Low Back Pain
• Functionality

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Improved Pneumonia Outcomes Journal Am
Osteopath Assoc. 2008 Sep108(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

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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

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Better Long term functionality and pain
improvementBMJ, doi10.1136/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

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Coding Considerations

• MDs and DOs can code for these
• Ahlta coding is actually simple
• Procedures
• Osteopathic
• Code by of body regions
• Boost RVUs

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Simple Enough?
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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

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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

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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!

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Osteopathic Techniques

• Muscle Energy
• Counterstrain
• Soft Tissue

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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

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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

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Contraindications to Muscle Energy Technique

• Fracture
• Trauma
• Significant Pain
• Severe Sprain or Strain
• Ruptured Muscle
• Uncooperative or unresponsive patient

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Common Errors in Muscle Energy Technique

• Inaccurate setup technique
• Incorrect force
• Poor patient effort
• Incorrect direction (Most Common)

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Practice Example
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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)

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Muscle Energy for AA Practice

• Rotate to the barrier
• Patient isometrically rotates away

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Strain/Counterstrain

• Involves location and treatment of tender points
• Can also be used for sore muscles
• No contraindications when done correctly

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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!

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An Example

• Would be used to treat
• tenderpoint on ASIS
• A passive technique
• Note comfort in position

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Soft Tissue Techniques

• Use to stretch and relax muscles
• Involves perpendicular stretching of muscle
  bellies
• Also involves slow deliberate massage
• Virtually no contraindications

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Common Errors

• Plucking muscles
• Smashing muscle between hand and bone
• Too hard or too soft
• Sensitive areas
• Gender issues

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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

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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

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Typical Cervical Motion

• Flexion and Extension
• Rotational component dominates upper cervicals
• Side bending component dominates lower cervicals

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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

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T-Spine Anatomy Review
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T-Spine Anatomy Considerations

• External Landmarks
• Anterior
• Posterior
• Natural kyphosis of
• 40 degrees
• Bodys center of
• gravity lies anterior
• to the t-spine

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Red Flags of Back Pain

• Age 50
• Trauma
• Constant and progressive non-mechanical pain
• History of cancer, immunosuppression, systemic
  steroids, drug abuse
• Weight loss, night sweats, fever
• ESR25
• Deformity, x-ray with vertebral destruction or
  collapse
• Progressive neurologic deficit
• Night-time pain unaffected by position
• History of osteoporosis

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Good websiteshttp//www.osteopathic.org/http/
/amops.org/http//nccam.nih.gov/health/whatiscam
/manipulative/manipulative.htm
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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.
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• 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 2811298
  -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 112755 -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 851300 -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 77260
  -268.Abstract/Free Full Text
• 7. Birdi I, Regragui I, Izzat MB, Bryan AJ,
  Angelini GD. Influence of normothermic systemic
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References

• New England Journal of Medicine, Nov 4, 1999, Vol
  3411426-1431
• 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 Womens 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