Osteopathic Evaluation

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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
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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.

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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

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Goals of OMT in Visceral Dysfunction

1. Normalize sympathetic tone to that viscera.
2. Normalize parasympathetic tone to that viscera.
3. Improve venous and lymphatic return.
4. Improve the mechanical function of the contiguous
   structures.
5. Improve the mechanical environment of the viscera
   for visceral mobility and motility.
6. Remove any structural hindrance to respiration
   and circulation.

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Autonomics to the Respiratory System

• Heart Lungs
• T1-T5

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Cervical Sympathetic Ganglia
Superior cervical ganglion

• Cervical Sympathetic Chain Ganglia are associated
  with C2 C6 C7
• 
  www.anatomy.tv

Middle cervical ganglion
Inferior cervical ganglion
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Chapmans ReflexesAnterior Reflex Points

• Neurolympatic Reflex which results in visceral
  dysfunction being manifested as a palpable knot
  in a somatotopic pattern. Used both
  diagnostically and therapeutically

page 232 of Osteopathic Considerations in
Systemic Dysfunction 2nd 3rd editions by
Michael Kuchera, D.O.
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Chapmans ReflexesPosterior Reflex Points
page 233 of Osteopathic Considerations in
Systemic Dysfunction 2nd 3rd editions by Michael
Kuchera, D.O.
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Lymphatic Return
Osteopathic Considerations in Systemic
Dysfunction 2nd 3rd editions by Michael
Kuchera, D.O pgs. 39 40
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Mechanism of Expiration

• Primary
• Elastic Recoil
• Secondary
• Muscles of Respiration
• Rectus abdominus
• Internal Intercostals
• External Obliques
• Transversus abdominus

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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

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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)

Somatic Dysfunction
Facilitated Segment Sympathetics
Parasympathetics
Rib Raising T1-T6 Chapmans Reflexes
OPP for the LRT Patient
OA, AA, Cranial Vagus Nerve
Lymphatics/Circulation
Thoracic Inlet Rib
Raising Abdominal/Pelvic Diaphragm Lymphatic
Pumps
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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

Somatic Dysfunction
Parasympathetics
Facilitated Segment Sympathetics
OPP for the URT Patient
Rib Raising T1-T6 Chapmans Reflexes C2, C6, C7
OA, AA, Cranial Sphenopalatine Ganglion
Lymphatics/Circulation
Thoracic Inlet Rib
Raising Abdominal/Pelvic Diaphragm Lymphatic
Pumps/Effleurage
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Integrate OPP Into Your Standard Medical Care

• Remember a Rule of 3s
• Any physician, any patient, any setting
• 3 Minutes
• 3 Area
• 3 Techniques

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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

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

• Association of C3-C5 S/D with Post-operative
  Complications

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Henshaws Study

• Surgical Populations with Pre-op C3-C5 Somatic
  Dysfunction

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
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OPP Research Pneumonia

• 58 elderly patients (gt60 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

Noll DR, Sholes JH, Gamber RG, Slocum PC. The
efficacy of adjunctive OMT in the elderly
hospitalized with pneumonia. JAOA 98(7)389. 1998
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Noll et al Research Pneumonia
OUTCOMES Sham OMT (30) OMT (28) p Value
Duration of IV Abx 7.33 Days 5.25 Days lt0.005
Hospital Stay 8.57 Days 6.61 Days lt0.005
Conclusions Adjunctive OMT reduces
significantly the duration of IV antibiotics and
the length of hospital stay of the elderly
patient with community acquired pneumonia
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Osteopathic Manipulative Treatment

• Lower Respiratory Tract

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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

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MFR Thoracic Vertebra

• Patient Supine
• Physician Seated at patients 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

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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

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Rib Raising Supine Position

• Patient Supine
• Physician Seated at patients 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

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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

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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

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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

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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.

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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.

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Lymphatic PumpChest Compression

• Patient Supine
• Physician Stands at patients 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.

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Pedal Lymphatic Pump

• Patient Supine
• Physician Standing at patients 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

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Pectoral Traction for Lymphatic Drainage

• Patient Supine
• Physician Standing at patients 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

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Osteopathic Manipulative Treatment

• Upper Respiratory Tract

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Venous Sinus Drainage

• Transverse Sinus
• Straight Sinus
• Superior Sagittal Sinus
• Metopic Suture

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Galbreath Mandibular Drainage Technique
(Eustachian tube dysfunction Otitis Media)

• Patient Supine with effected ear up
• Physician Standing at the patients 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

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Sphenopalatine Ganglion Stimulation(Used for any
URI)

• Patient Supine
• Physician Standing at patients 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

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QUESTIONS ?

• The End