Robert Hunter, DO

• To understand how OMT can be used in the Mind-Body-Spirit

approach to Total Pain relief.

• To identify simple OMT techniques that both osteopathic and

non-osteopathic practitioners can use to treat their patients'

pain.

• To comfortably reproduce the techniques demonstrated under

the supervision of the presenters.

• Osteopathy recognizes that all parts of the body work together to create healing.

• Osteopathic Manipulative Treatment (OMT) is a set of manual medicine techniques used to relieve pain and other symptoms, restore range of motion and function, and enhance the body's capacity to heal.

• There are barriers to patients being able to receive this beneficial adjunct therapy.

• As of 2010, there are only 70,480 DOs, very unevenly distributed in the United States.

• Not all DOs practice OMT; Osteopathic physicians sometimes feel they cannot practice OMT because of difficulty mastering techniques or because they do not know how to integrate OMT into their practice.

• In geriatrics specifically, OMT is a useful adjunct pain treatment that has no drug-drug interactions and may provide immediate relief.

• Most osteopathic techniques require significant specialized education

and supervised practice over time to achieve mastery.

• Few techniques are easy to reproduce by a non-osteopathic

practitioner, occasionally even by the patient themself.

• Myofascial release, soft tissue stretching and strain-counterstrain

techniques specifically are easy to learn and reproduce in many

different areas of geriatric practice (home to inpatient settings).

• Since learning these techniques does require practice, this

presentation will encourage the attendee to participate in supervised

use of the techniques in small groups with a partner.

• This symposium will serve as an introduction to simple OMT techniques

that can be reproduced by both novices and skilled learners.

• Osteopathic Medicine was developed 130 years ago by Andrew

Taylor Still, MD, DO.

• A.T. Still is considered the “father of osteopathic medicine”, as well

as the founder of the first college of osteopathic medicine.

• Dr. Still’s philosophy of medicine recognizes the interrelationship of

all body parts and the key role of the musculoskeletal system in

health and well being.

• He echoed Hippocrates view that the body has an innate ability to

heal itself and restore balance.

Biography of Andrew Taylor Still, Founder of Osteopathic Medicine. American Osteopathic Association.

Retrieved from http://www.osteopathic.org/index.cfm?PageID=ost_still

• Emphasizes a “whole person” approach.

• Honors the physical, emotional, and spiritual aspects of wellness.

• Recognizes that the body is capable of self-regulation, self-

healing, and health maintenance.

• Identifies that structure affects function, and the musculoskeletal

system is regarded as the “conductor” that organizes and

coordinates the different systems to act in concert with each

other to optimize wellness in the total being.

1. The body is a unit; the person is a unit of body, mind, and

spirit.

2. The body is capable of self-regulation, self-healing, and

health maintenance.

3. Structure and function are reciprocally interrelated.

4. Rational treatment is based upon an understanding of the

basic principles of body unity, self-regulation, and the

interrelationship of structure and function.

• Osteopathic manipulative treatment involves the use of a

practitioner’s hands to diagnose, treat, and prevent illness or

injury.

• Muscles and joints are mobilized using gentle techniques,

including stretching, light pressure, and resistance.

• When appropriate, OMT can complement or even serve as an

alternative to drugs or surgery, providing an added dimension

to traditional medical care.

1. Myofascial Techniques

2. Muscle Energy Techniques

3. Counterstrain Techniques

4. Facilitated Positional Release

5. High-Velocity, Low-Amplitude Thrusting

6. Craniosacral Therapy

7. Articulatory Techniques

• An advanced application of OMT is demonstrated in end of life

care and comfort care.

• Osteopathic medicine partners very well with geriatric care

because both approaches value the interrelationship of mind,

body, and spirit in efforts to relieve suffering, restore dignity,

and enhance quality of life.

• Research studies have shown the effectiveness of OMT in

geriatric care, and more studies are currently underway.

• Along the geriatric pathway, not all of the osteopathic

manipulative techniques are appropriate for symptom

management.

• A specialized subset of manipulative techniques has been found

to be effective in treating symptoms, such as:

Pain Anorexia

Dyspnea Insomnia

Nausea/Vomiting Fatigue

Among many other symptoms…

• JK is 60 YO F with metastatic breast cancer, never treated per patients choice. Lifelong sensitivity to any medication and chose alternative treatment for cancer. Questions Buddhist beliefs related to suffering. Now at EOL, pt has fungating breast wound on L, contracting L pectoral muscles, enlarging R mass causing neuropathic pain, lung and brain metastases.

• Physical Assessment

• Rib dysfunction

• Myofascial dysfunction

• Nerve impingement

• Active problems

• Pain: L mass, open wound and muscle contractions R mass, neuropathic pain, impingement

• Dyspnea: Secondary to lung mets and restricted rib cage

• True opioid allergy with anaphylaxis, highly sensitive to benzodiazepine and antipsychotics at very low doses

• Pharmacological Management:

• Lorazepam 0.2 mg po q 12 hr prn (sleep, headache)

• Fentanyl 200 mcg stick, use 15 seconds

• Last day of life used Phenobarbital suppository x 1

• Osteopathic Treatment: • More acute patients short, frequent treatment

• Myofascial release chest wall, thoracic inlet, abdominal diaphragm

• Myofascial unwinding, single and two operator

• Pedal pump for lymphatic flow

Outcome: Improved comfort, improved respiration, improved sleep

• Can be direct or indirect

• Goal is to restore functional balance and to improve lymphatic

flow

• Indications – gentle, acutely ill patients, patients with limited

movement

• Contraindications – Infection, fracture, advanced cancer (risk of

metastatic spread), visceral rupture

• Procedure:

• Palpate restriction – muscle tension, tenderness, decreased

range of motion

• Choose direct (traction) or indirect (compression)

• Add other forces (operator)

• Enhancers (patient)

• Release – “melt”

• LL 64 YO F with two primary cancers: lung and ovarian cancer.

Pain in R arm, shoulder, upper back. Methadone 10 mg BID

plus morphine prn, using approximately 80 mg morphine daily

in breakthrough dosing.

• Physical assessment:

• Limited ROM R UE, limited scapular movement

• Point tenderness at T3 in paraspinal muscles

• Rib dysfunction

• Active problems:

• Pain: Bone (femur), ribs, R UE/back pain

• Anorexia: Due to fatigue and disease progression

• Dyspnea: Fatigues easily

• Goals of care: “Avoiding” getting things done.

• Pharmacologic management:

• Increase methadone to 15 mg BID

• Osteopathic management:

• Rib raising

• Sternum balance

• Abdominal diaphragmatic release

• Psychosocial management: POLST/AD

Outcome: Improved ROM, improved pain, improved

peace of mind

• Goal to stimulate sympathetic chain ganglia

• Seated or Supine

• Procedure:

• Patient Seated

• Physician stands in front, places hands at rib angles

• 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

Foundations for Osteopathic Medicine, p. 1065

Outline of Osteopathic Manipulative Procedures, The Kimberly Manual, p. 61

• Goal

• Procedure

• Have patient inhale and then exhale

• Thumbs gently carry the costal margin slightly lateral and superior

• Thumbs can simultaneously resist the drop of the diaphragm during the

inhalation phase of respiration.

Foundations for Osteopathic Medicine, p. 1066

• Review the history and discuss advantages of

Counterstrain treament

• Identify the conventional Counterstrain tenderpoints.

• Discuss steps of the Counterstrain treatment model.

You are a caregiver and come

across an elderly individual

who has had to sit for long

periods of time.

The gentleman reports of pain

in his left buttocks and low

back

Photo Walt Disney Productions

• You immediately reply “I know Counterstrain! This

appears to be a piriformis spasm secondary continued

sitting with your hip externally rotated.”

Photo Walt Disney Productions

• Counterstrain began as an unexpected discovery in 1955

• Lawrence H Jones DO, FAAO theory for the mechanism of action is that the initial injury produces a sudden “panic” of lengthening of the antagonist muscle that was originally strained

• Jones treated the tender point associated with the asymptomatic antagonist muscle by shortening the muscle.

• Consequently, the muscle strained and painful muscle is placed back into a stretched position

• Thus, the mechanism produces a “counter to the strain”

Lawrence Jones DO

“I did it because it worked.”

Photos, Jones Strain Counterstrain

• Cervical Spine

• Thoracic spine

• Ribs

• Upper Extremity

• Lumbar Spine

• Pelvis/Sacrum

• Lower Extremity

• Convenient doesn’t require a table

• Gentle for those frail patients who cannot tolerate

manipulation

• Specific symptom relief

• Response may be rapid

• Articular specificity may be decreased

• Some dysfunctions may be treated, but not all

• Patients must be passive

• If it hurts, don’t do it

• Fractures in area used to treat somatic dysfunction

• Torn ligaments

• All other contraindications for not using

counterstrain are relative

• Note severe OP where positioning the patient for

treatment may risk a fracture is contraindicated

although this is typically not an issue due to the

position for treatment is usually within the patients

ROM and there for shouldn’t cause problem

• Jones’ mapping

• Anatomic correlations

• Pain or increased sensitivity may signal strain

• Additional Considerations • Muscle origins / insertions

• Mid-belly of a muscle

• Neural referred pain

http://fitnessmen.blogspot.com/2011/01/ronny-rockel.html

• Diagnosis by tender-point

• Assess regionally, treat the worst tenderpoint first

• Treatment completed through passive

positioning

• Neuromuscular resetting is key

• Time element is essential

Jones

• Tender points

• Anterior articular pillars

• Posterior: spinous processes /posterior articular pillars

Tender point photos from Pocket

Manual of OMT, LWW 2006

• Start with complete / thorough history

• Identify most significant or relevant tender point, sometimes indicated by palpable nodular edema or muscle tension

• Survey of adjacent tender points.

• Label this “10“ (not to be confused with pain scale)

Tender points over

the spinous process

or laterally

From Beatty The Pocket Manual of OMT 2nd Ed.

LWW 2011

• Identify and scale tender point as 10

• Passive positioning to “2” or less is target for treatment

• Monitor location, do not remove finger

• Hold for 90 seconds, ribs 120 seconds

• Passive return to neutral position

• Retest, retreat as needed

• Limit treatment to 6 tenderpoints per visit

http://www.goingtomedschool.com/2011/08/09/what-is-osteopathic-medicine/

From www.i.ehow.com http://www.drbambach.de/osteopathie/counterstrain.htm

• Inspect the anatomy

• Inquire “How did this tissue get in trouble?” Muscle?,

Tendon? Ligament?

• Be familiar with conventional tender points

• Determine / evaluate anatomical correlations for

treatment alternatives

http://forums.pelicanparts.com/off-topic-discussions/425070-nasty-injury-olympics.html

Everything that is tender is not necessarily a counterstrain

tender point ◦ Tissue inflammation / destruction

◦ Reflexive tenderness / pain may be possibility

◦ Psychogenically amplified pain intolerance should always be

considered

◦ Correlates to location of structural diagnosis or does it?

◦ Always treat patient, not tender point

http://orthodoc.aaos.org/drrickwalker/about.cfm

A counterstrain tender point acts like a counterstrain

tender point.

◦ If at a sensible location near the area of strain

◦ Correlates with injury

◦ Responds to treatment for counterstrain therapy

http://www.flickr.com/photos/dave_idstewart/4194805602/

• Iliacus

• Sartorius

• Gluteus minimus and medius

• Inguinal ligament

• Adductors

• Pectineus

• Obturator

• Piriformis

• Lateral trochanter

• Gemelli

• Medial hamstring

• Anterior and Posteriour

cruciate ligament

• Medial meniscus

• Lateral meniscus

• Rotated knee

• Knee extenders

• Patellar tendon

• Extension ankle

• Lateral Ankle

• Calcaneus

1 lateral trochanter tp

2 tibial tuberosity

3 patellar tendon tp

4 medial meniscus tp

5 medial ankle tp

6 metatarsal heads

7 fibular head

8 extension ankle tp

9 lateral ankle tp

10 calcaneus tp The Pocket Manual of OMT, p 26

• Jones’ mapping

• Anatomic correlations

• Pain or sensitivity reflects strain

• Consider: • muscle origins and insertions

• mid-belly of a muscle

• neural referred

http://www.t-nation.com/testosterone-magazine-638

Pansky and Allen, 1980, p. 207

The dominant present

hypothesis to help

explain the cause of

somatic dysfunction

in the counterstrain model is

that trauma

or sudden strain causes

proprioceptive

dysregulation.

• Position of ease, 2 or less often corresponds to a position of injury

• Keep monitoring finger in place until retest

• Hold position of ease passively for 90 seconds

• Return patient to resting position passively

• Re-evaluate, retreat with fine tuning or progress to adjacent areas

From www.waybuilder.net

Schuenke, 496

• Position the

gentleman in a

position of ease while

monitoring the tender

point. After 90

seconds you return

him to a neutral

position.

• http://www.jaoa.org/content/108/11/657/F8.expansion

The elderly man then states he feels better. And

you look to the future for new adventures in OMT

Photo Walt Disney Productions

References •DiGiovanna EL, Schiowitz S. (1997). An Osteopathic Approach toDiagnosis and

Treatment, Second Edition. Philadelphia: Lippincott-Raven Publishers.

•Essig-Beatty, D. The Pocket Manual of OMT, Lippincott, Phila. 2011

•Field, D. 2001 Anatomy, Palpation and Surface Markers, 3rd ed., Butterworth

-Heinemann, Oxford

•Jones, L., Jones Strain-CounterStrain,Jones Strain-CounterStrain, Inc.,

Boise ID 1995

•Moore,K. , Dalley, A. 1999, Clinically Oriented Anatomy 4th ed., Lippincott, Williams and Wilkins, Phila

•Netter, F. Atlas of Human Anatomy, Ciba-Geigy, Summit N.J. 1989

•Rennie, P., Counterstrain and Exercise: an integrated approach , 2nd ed

RennieMatrix, Williamson MI, 2004

•Schuenke,M., Anatomy, Atlas of Anatomy, Thieme, New York, NY 2006

(Still looking @ the following to see application possibilities)

http://www.acofp.org/OMT_and_OMM_Resources/OMT_for_

Residents_and_Students/

DO OMT app

Photo Walt Disney Productions