MOA 118th Annual Spring Convention

OMT In the Geriatric Patient

Hollis H. King, DO, PhD

May 19, 2017

Learning Objectives:

After receiving the presentation the participant

will be able to:

1. Describe the OMT research on a number of

conditions frequently encountered in geriatric

practice

2. Describe directions for research on OMT in

geriatric conditions

Shannon s. A rising tide of older patients: Preparing future DOs. J Amer

Osteopath Assoc. 2013;113:262-64 [Editorial]

~ Number of US citizens aged ≥ 65 increasing (baby boomer

born 1946-1964)

~ 2010 – older adults = 13% of population – 40.2M

~ By 2050 will be 20% - 88.5M

“All physicians and other health care professional need

more extensive training and experience with the geriatric

population. Given current trends, training focused on

diseases associated with obesity, such a diabetes, should

be a priority.”

Shannon (2013) cited Noll DR, Channell MK, Basehore PM, et al. Developing osteopathic

competencies in geriatrics for medical students. J Amer Osteopath Assoc. 2013;113:276-289.

1. Identify posture and gait abnormalities that contribute to gait and

balance disorders.

2. List and explain the relative contraindications and adverse effects of

specific OMT techniques in the elderly.

3. Apply OMT as a nonpharmaceutical treatment of somatic

manifestations of physical, cognitive and behavioral disorders, including

pain relief and common end-of-life symptoms (eg, nausea, constipation,

anxiety).

4. Describe and demonstrate the positional modifications of PE and

OMT for use in elderly patients with limited or minimal mobility such as

in the hospital or nursing home.

5. Evaluate and treat somatic dysfunction that limit patient range of

motion and the ability to perform ADL.

Channell MK, Wang Y, McLaughlin, et al. Osteopathic manipulative treatment for older patients: a

national survey of osteopathic physicians. J Amer Osteopath Assoc. 2016;116:136-143.

~ AOA survey to determine use of OMT by DOs in older patients

compared to younger patients.

~ Anonymous online survey – how many provide OMT and what

techniques used?

~ Response rate 197 of 629 AOA members (31.3%)

~ OMT used at same rate for all ages.

~ Used most in respiratory and neurological conditions in elderly

~ HVLA was avoided in patients ≥ 65.

Pulmonary & Respiratory

Conditions

Preliminary Studies – 1990’sNoll D, Shores J, Bryman P, Masterson E.

Adjunctive osteopathic manipulative

treatment in the elderly hospitalized with

pneumonia: A pilot study. J Amer

Osteopath Assoc. 1999;99:143-145.

Noll DR, Shores JH, Gamber RG, Herron

KM, Swift J Jr. Benefits of osteopathic

manipulative treatment for hospitalized

elderly patients with pneumonia. J Am

Osteopath Assoc.2000; 100:776 -782.

Donald Noll, D.O.

F.A.C.O.I

Pneumonia Noll et al. 2010

11

12

MOPSE Protocol

Noll DR, Degenhardt BF, Johnson JC, et al. Immediate effects of osteopathic manipulative

treatment in elderly patients with chronic obstructive pulmonary disease. J Amer Osteopath

Assoc. 2008;108:251-259.

Age ≥ 65, N = 35 (OMT = 18, Sham = 17)

OMT showed a statistically significant decrease in forced

expiratory flow at 25% and 50% of vital capacity and at the

midexpiratory phase.

OMT group also had significant increase in the residual

volume.

Data suggested an overall worsening of air trapping during

the 30 minutes immediately following one OMT session

relative to sham group.

Falls and Fall Management

Fraix M. Role of the musculoskeletal system and the prevention of falls. J Amer Osteopath

Assoc. 2012;112(1):17-21.

Noll DR. Management of falls and balance disorders in the elderly. J Amer Osteopath Assoc.

2013;113(1):17-22.

~ Approximately 30% of older adults fall at least once per year.

~ Falls are the leading cause of fatal and nonfatal injuries for

people ≥ 65.

~ Annual cost of fatal and nonfatal fall-related injuries is estimated

to reach $32.4 billion in 2020.

~ Falls like due to an interaction of multiple risk factors

~ Vitamin D deficiency

~ Diminished strength and coordination

~ Depression

~ Multiple medications

~ Home hazards

J Am Osteopath Assoc. 2011;111:382-388.

N = 40, Healthy elders age ≥ 65 years old

OMT Group N = 20

No OMT N = 20

Each group had 4 OMT or No OMT visits in which

balance was measured.

MeasurementsCenter of Pressure (COP) average of the pressure between the feet.

3 balance tests:

• Eyes open,

• Eyes closed

• With arms extended 90 degrees in front of

them and their eyes closed (modified

Rhomberg).

• AMTI Model #OR6-7-2000, Advanced Mechanical Technology, Inc.,

Watertown, MA

• They were barefoot in a self-chosen foot position (not wider apart than

the distance between their hip joints).

• Their chosen foot stance was traced on paper to ensure subsequent

balance trials maintained similar foot positioning

OMT Protocol Lopez et al 2010

1. Soft tissue and myofascial release T1 to L5 and sacral “rock”-prone (3-4 minutes)

2. Shoulders and scapulae myofascial release bilaterally- lateralrecumbent (4-5 minutes)

3. Cervical spine myofascial, counterstrain, muscle energy orsoft tissue for release and correction- patient supine (3-4minutes)

4. Occipito-atlantial (OA) and condylar decompression (1-2minutes)

5. Venous sinus technique (5-6 minutes)

6. V-spread and/or frontal and parietal lifts (2-3 minutes)

7. CV4 (3-4 minutes)

8. Recheck 2-3 minutes for other “key” tender points and treatfindings

J Am Osteopath Assoc. 2013;113(5):394-403

Ave age = 49

N = 16

A composite score

Musculoskeletal Conditions

Knebl JA, Shores JH, Gamber RG, et al. Improving functionality in the elderly via the Spencer

technique, an osteopathic manipulative treatment: a randomized controlled trial. J Amer

Osteopath Assoc. 2002;102:387-296.

~ N = 29 with pre-existing shoulder somatic dysfunction

(OMT = 16, Control = 15)

~ OMT received Spencer’s techniques. Placebo shoulder

placed in same positions as Spencer but no activation of OMT

Treated weekly for 14 weeks

~ Assessment done blind to the patient’s experimental group

Outcome measures: 1) ROM, 2) physical functioning (dressing,

bathing, grooming, 3) perceived pain

~ Results:

ROM: all planes of motion improved for OMT group (P ≤ .05)

Function: improved for OMT group (P ≤ .05)

Pain: reduced for OMT group (P ≤ .05)

Noll DR. Leg length discrepancy and osteoarthritic knee pain in the elderly: an observational

study. J Amer Osteopath Assoc. 2013;113(9):670-678.

N = 32 who had reported osteoarthritic knee pain (Male = 4;

Female 28)

Results:

Right knee pain = 17; 10 had right short leg & 7 left leg

Left knee pain = 15; 13 had short left leg & 1 had right leg & 1

was equal

Knee pain was most severe in the short leg for 23 of 32

participants (71.9%)

The most common pattern was for both iliac crests to be

equal and the short leg to be concordant with a superior ASIS

– 23 of 32 (71.9%).

LLD range: 0 to 2.1 cm

Snider KT, Snider EJ, Johnson JC, et al. Preventive osteopathic manipulative

treatment and the elderly nursing home resident: a pilot study. J Amer Osteopath

Assoc. 2012;112(8):489-501.

N = 21 (OMT = 8; light touch (LT) = 6; treatment as usual

(TAU) = 7)

Interventions delivered twice a month for 5 months for total of

10 treatments. TAU – no TX

Results:

OMT and LT had fewer hospitalizations (P = .04) and

decreased medication usage (P = .001) compared to the TAU

group.

Parkinson’s Disease

Wells MR, Giantinoto S, D’Agate D, et al. Standard osteopathic manipulative treatment acutely

improves gait performance in patients with Parkinson’s disease. J Amer Osteopath Assoc.

1999;99(2):92-98.

Ten patients with idiopathic Parkinson's disease and a group of eight age-

matched normal control subjects were subjected to an analysis of gait

before and after a single session of an OMT protocol.

A separate group of 10 patients with Parkinson's disease was given a

sham-control procedure and tested in the same manner.

In the treated group of patients with Parkinson's disease, statistically

significant increases were observed in stride length, cadence, and the

maximum velocities of upper and lower extremities after treatment.

There were no significant differences observed in the control groups. The

data demonstrate that a single session of an OMT protocol has an

immediate impact on Parkinsonian gait.

Osteopathic manipulation may be an effective physical treatment method in

the management of movement deficits in patients with Parkinson's disease.

Yao S. “Effects of osteopathic manipulative medicine on Parkinson’s disease.” U.S

National Institutes of Health. New York Institute of Technology, n.d. Web. 11 Apr.

2016

https://clinicaltrials.gov/ct2/show/NCT02107638?term=NCT02107638&rank=1

AOA has funded two clinical trials on the impact of OMT on

Parkinson’s disease.

One to Dr. Sheldon Yao at NYIT

One to Dr. Kendi Hensel at UNTHSC-TCOM

DiFrancesco-Donoghue J, Apoznanski T, de Vries K, et al. Osteopathic manipulation as a

complementary approach to Parkinson’s disease: a controlled pilot study.

NeuroRehabilitation 2017;40(1):145-151.

A randomized controlled trial to test OMM on balance and

motor function in PD measured by the Mini-Balance

Evaluation Systems Test (Mini-BESTest), Sensory

Organization Test (SOT), and Movement Disorder Society-

Unified Parkinson’s Disease Rating Scale MDS-UPDRS.

11 Subjects (age 75±16) were randomly assigned to either

bi-weekly OMM treatments first for 6 weeks or weekly

counseling sessions from a medical provider for 6 weeks as

a placebo-control. 9 subjects completed this study.

RESULTS:

There were no significant changes in SOT or Mini BESTest in

either group (p < 0.05). There was significant improvement in

the OMM group for MDS-UPDRS.

Promising Areas of Research

Any TBI

Dementia/Alzheimers

Stimulation of Glymphatic System

Then Lymphatic Vessels Were Found

In The Brain Also

Antoine Louveau, Igor Smirnov, Timothy J. Keyes, Jacob D.

Eccles, Sherin J. Rouhani, J. David Peske, Noel C. Derecki,

David Castle, James W. Mandell, Kevin S. Lee, Tajie H.

Harris, Jonathan Kipnis. (2015). "Structural and functional

features of central nervous system lymphatic vessels.". Nature

https://dx.doi.org/10.1038%2Fnature14432

Aleksanteri Aspelund, Salli Antila, Steven T. Proulx, Tine

Veronica Karlsen, Sinem Karaman, Michael Detmar, Helge

Wiig, Kari Alitalo. (2015). "A dural lymphatic vascular system

that drains brain interstitial fluid and macromolecules.". The

Journal of Experimental Medicine.

https://dx.doi.org/10.1084%2Fjem.20142290