brown bag omt 3 [read-only] - unmc
TRANSCRIPT
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Osteopathic Manipulative Treatment (OMT) for the OB-GYN PatientMarch 2021 Brown Bag Lecture Kelsie Cabrera, DO, MS, Assistant ProfessorUNMC Dept. of OB-GYN
I have no financial disclosures.
Objectives1. Discuss the philosophy of Osteopathic Manipulative
Treatment (OMT)2. Describe physiological changes in pregnancy that
impact women’s musculoskeletal system3. Articulate how OMT may be used in the OBGYN
clinical setting
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Main Sections• Osteopathic Philosophy• Physiological Changes in Pregnancy• Osteopathy in Pregnancy• Osteopathy in Gynecology• OMT Techniques• Research: OMT in Pregnancy
Osteopathic Philosophy
https://www.kirksvilledailyexpress.com/news/20191104/dr‐at‐still‐‐‐americas‐healthcare‐disruptor‐premieres‐thursday‐in‐kirksville
How It Began• Founder: Andrew Taylor Still, MD, DO (1828-1917)• Convinced patient care was inadequate
• Desired to improve surgery, obstetrics, and general treatment of disease
• Began in-depth study of anatomy, physics, chemistry and biology
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What is Osteopathy?“It is a scientific knowledge of anatomy and physiology in the hands of a person of intelligence and skill, who can apply that knowledge to the use of man when sick or wounded by strains, shocks, falls or mechanical derangement or injury of any kind to the body” - A.T. Still
General Philosophy• The human being is a dynamic unit of function• The body possesses self-regulatory mechanisms that
are self-healing in nature• Structure and function are interrelated at all levels• Rational of treatment is based on these principles
Osteopathic Approaches to Patient Care• Biomechanical model: muscles, spine, posture, motion• Respiratory-Circulatory model: rib cage, diaphragm,
respiration, circulation, venous and lymphatic drainage• Neurological model: head, brain, spinal cord, control,
coordination, sensation• Metabolic-Energy model: internal organs, endocrine
glands, metabolic processes, homeostasis, energy, regulatory processes, digestion, removal of waste
• Behavioral model: patient’s lifestyle, environmental stressors, values and choices
The 5 coordinated body functions
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Somatic Dysfunction• Impaired or altered function of related components of
the somatic (bodywork) system including: the skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements.
• Diagnosed using “TART”• Tissue texture changes• Asymmetry• Restriction of motion• Tenderness
Physiological changes in pregnancy
https://theexpectingmamasnetwork.com/pregnancy‐memes‐new‐mom‐memes/
Spinal Column• Balance points or fulcrums
• C7-T1, T12-L1, L5-S1• Pelvis tilts forward
• Increased lumbar lordosis as counterbalance• Increased thoracic kyphosis
• Anterior/Posterior curve changes reduce the efficiency of the spinal system
• Shifts stresses from ligamentous and disk-oriented to strenuous muscle-controlled
https://www.physio‐pedia.com/File:Pregnancy.png
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Spinal Column• Distension of abdomen reduces muscular capacity to
counterbalance • SI joints and ligaments become more lax• Pubic symphysis widens
https://www.physio‐pedia.com/File:Pregnancy.png
MusclesIliopsoas• Major contributor in the
column support system• Crosses L5-S1
• Originates at transverse processes of L1-L5, anterolateral surfaces of vertebral bodies T12-L5
• Distributes forces to the sacrum
• Supports viscera and growing uterus
Psoas Syndrome:• Central lower back pain• Flexed forward, list to
one side
MusclesPiriformis Syndrome:• Aching pain in gluteal
region• Aggravated by sitting• Paresthesia down
posterior aspect of thigh
Piriformis• Originates on anterior
surface of sacrum • Inserts on upper aspect
of greater trochanter• Distal and lateral to
lumbosacral junction
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Respiratory • Normal breathing is anatomically dependent on a
level pelvis and straight spine• Thoracic cage is suspended from spine
• Changes in mechanical configuration of thoracic cage• Circumference increases 5-7cm• Subcostal angle widens from 68 to 103 degrees• Diaphragm pushed superiorly 4cm
• Decreased expiratory reserve volume and residual volume
• Increased tidal volume
Neurological • Peripheral nerves susceptible to injury due to
compression, traction and ischemia• Uterus puts pressure on pelvic organs, ligaments,
lumbosacral plexus and lower limb peripheral nerves• Example: lateral femoral cutaneous nerve
compression
Lymphatic• Increase of interstitial fluids
• Increase 6.5L over course of pregnancy• 3.5L from fetus, placenta and amniotic fluid• 3L from maternal blood volume and size of
uterus and breasts• Increased demand to pelvic organs for
metabolic needs of fetus • Increase in estrogen, progesterone and adrenal
hormones• Promotes fluid retention (tissue edema)
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Resulting Symptoms• Low back pain• Thoracic/mid-back pain• Anterior head and neck causing tension headache• Loss of balance• Pain with upright posture• Psoas syndrome• Fatigue• Edema• Neuropathy• Pubic symphysis pain
https://www.boredpanda.com/pregnancy‐memes/?utm_source=google&utm_medium=organic&utm_campaign=organic
Osteopathy in Pregnancy
https://me.me/
Osteopathy in Pregnancy• Enhances homeostasis• Facilitates adaption to structural and hormonal
changes• Alleviates discomfort• Saves patient energy
• Musculoskeletal dysfunction increases demands up to 300%
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Indications• Somatic dysfunction • Scoliosis or structural
condition associated with pregnancy
• Edema or congestion• Other pregnancy-
associated condition amendable to OMT
https://familydoctor.org/back‐pain‐pregnancy/
Contraindications• Premature rupture of
membranes• Premature labor
Absolute
• Undiagnosed vaginal bleeding
• Prolapsed umbilical cord
• Placental abruption• Ectopic pregnancy• Placenta previa• Threatened or
incomplete abortion• Severe pre-
eclampsia/eclampsia
Relative
Osteopathy in Gynecology
https://www.pinterest.com/pin/32017847330101959/
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Osteopathy in Gynecology • May reduce severity of pelvic pain
• Endometriosis
• Assists with PMS symptoms• Headaches
• Bloating/bowel frequency
OMT Techniques
www.webmd.com
Note: Links to videos of techniques are available at the end of this presentation.
Common Types of OMT• Muscle Energy: patient’s muscles are actively used
in a specific direction against a counterforce• Engage barrier, patient resists for 3-5 seconds, both
relax and then further engage barrier. Repeat.
• Soft Tissue/Myofascial Release: direct techniques by engaging a loaded, constant, direction force until tissue releases.
• High Velocity Low Amplitude (HVLA): rapid, therapeutic force of brief duration that engages restrictive barrier to elicit release of restriction. “popping technique”
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Positions• Supine• Lateral recumbent• Seated • Prone
https://www.thoughtco.com/anatomical‐position‐definitions‐illustrations‐4175376
Areas of Focus- OB• Areas of transition- serve as fulcrums
• C7-T1
• T12-L1
• L5-S1
• Iliopsoas muscle• mainstay in column support and crosses L5-S1
• Piriformis muscle • Pelvis/Sacrum/Pubic Symphysis• Mechanics of Pulmonary Respiration
• Helps venous blood return and lymphatic drainage
Areas of Focus- GYN• Dysmenorrhea: Patient may self-treat utilizing knee-
chest position• Helps to decompress pelvis• Increases drainage• Lifts uterus out of the pelvis
• PMS symptoms• Headaches- cervical/suboccipital region • Bloating/bowel frequency- lymphatics
• Pelvic pain• Thoracic and lumbar spine• Sacrum• Pelvic diaphragm relieves pelvic congestion• Trigger points
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Cervical SpineSuboccipital ReleaseParaspinal Muscles
Thoracic/Lumbar SpineParaspinal Muscles
Thoracic CageRib Raising
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PelvisIliopsoas Muscle
PelvisPiriformis
Sacrum– Patient supine, doctor at
side – Patient’s hips and knees
flexed with feet together, knees fall to side
– Doctor contacts sacrum– Sacrum taken to point of
ligamentous balance with respiratory assistance
– Patient holds breath and straightens legs
Frog Leg Sacral Articulation
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Pubic Symphysis
Carpal Tunnel
ExtremitiesEffleurage/Petrissage
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Research: OMT in Pregnancy
Osteopathic Manipulative Treatment of Back Pain and Related Symptoms During Pregnancy
• Randomized trial • Usual obstetrical care (UOBC)• + OMT (UOBC-OMT)• + Sham Ultrasound (UOBC-SUT)
• 30 minute treatment (32, 34, 36, 37, 38 and 39 weeks)• 146 total subjects (49, 49, 48 respectively)• Mean pain levels decreased in the UOBC+OMT group,
remained unchanged in the UOBC+SUT group, and increased in the UOBC only group
American Journal of Obstetrics and Gynecology, January 2010 J. Licciardone, et al
Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE)
• Randomized Trial• Usual care only• +OMT• +Placebo Ultrasound Treatment (PUT)
• 20 minute treatments started at 30 week gestation (30, 32, 34, 36, 37, 38, 39)
• 400 participants• Slower rate of deterioration of back-specific functioning in
participants receiving an OMT protocol compared with participants receiving UCO. • It also showed that OMT mitigated pain progression compared
with UCO. • No statistically significant difference was found between the
OMT group and the PUT group
JAOA November 2016K. Hensel, et al.
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Conclusion• OMT can be used for various complaints throughout
pregnancy and certain gynecologic conditions• Simple techniques can be taught to family members
for continued relief• Keep in mind relative and absolute contraindications
to OMT in pregnancy
Resources1. Tettambel, M. "Low Back Pain in Pregnancy." Foundations of
Osteopathic Medicine. 3rd ed. Wolters Kluwer.2. DiGiovanna, E. (2005). Gynecologic Considerations. In An
Osteopathic Approach to Diangosis and Treatment (3rd ed., pp. 651-657). Philadelphia: Lippincott WIlliams & Wilkins.
3. Hensel, DO, K., Buchanan, DO, S., Brown, S., Rodriguez, M., & Cruser, D. (2015). Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: The PROMOTE study. Am J Obstet Gynecol.
4. Hensel, DO, K., Pacchia, C., and Smith, M. Acute improvement in hemodynamic control after osteopathic manipulative treatment in the third trimester of pregnancy, 2013-12-01Z, Volume 21, Issue 6, Pages 618-626
5. Licciardone, DO, J. et al. (2010). Osteopathic Manipulative Treatment of Back Pain and Related Symptoms during Pregnancy: A Randomized Controlled Trial. Am J ObstetGynecol.
6. Cunningham, F. G. (2014). Williams Obstetrics. New York: McgrawHill Medical
Video Resources• Suboccipital Release:
https://www.youtube.com/watch?v=AcnBZsM6qjI• Paraspinal muscles:
https://www.youtube.com/watch?v=yOa9NlIzyCs• Rib Raising: https://www.youtube.com/watch?v=A4lW9K7v5TA• Psoas: https://www.youtube.com/watch?v=4ao-5CibplY• Pubic Symphysis:
https://www.youtube.com/watch?v=ky5GQt5ypE0
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Questions?
https://marsandstarsbaby.com/9‐pregnancy‐memes‐mom‐future‐mom‐can‐totally‐relate/