1. Integrating Osteopathic Manipulative Treatment into Clinical Care
Helen Luce DO
Marguerite Elliott DO, MS
Mark Robinson DO
University of Wisconsin
Department of Family Medicine
May 3, 2008

2. Welcome & Introductions
Presenters
Helen Luce DO
Marguerite Elliott DO, MS
Mark Robinson DO
Purpose of seminar
Overview of osteopathic philosophy, the use of OMT in specific clinical scenarios, and guidelines for the allopathic precepting physician.

3. Objectives
Describe 3 clinical situations in which OMT can be performed to augment other medical therapy and improve patients’ health.
Participate in OMT through observation or performance of 2 specific treatments.
Discuss precepting methods for allopathic physicians who supervise osteopathic residents performing OMT.

4. Overview Osteopathic medicine Osteopathic philosophy
OMT (Osteopathic Manipulative Treatment)
Overview of some common techniques

5. Definition Osteopathic Medicine
A system of diagnosis and treatment that recognizes the role of the musculoskeletal system in the healthy functioning of the human body.
-From the AMA Encyclopedia of Medicine

6. Osteopathic Philosophy
Four basic principles
Body functions as a unit – body, mind, spirit
Structure and function are interrelated
Body is capable of self-regulation, self-healing, and health maintenance
Rational treatment is based on understanding these principles

7. Somatic Dysfunction
Impaired or altered function of related components of somatic system (body framework)
Skeletal and myofascial structures
Related vascular, lymphatic, & neural elements

8. Palpatory Diagnosis T: Tissue texture abnormalities A: Asymmetry
R: Restriction of motion
T: Tenderness

9. Barrier Concepts Anatomic Barrier Physiologic Barrier
Restrictive Barrier
Anatomic Physiologic Restrictive Physiologic Anatomic
Barrier Barrier Barrier Barrier Barrier

10. Direct and Indirect Techniques
Technique that engages the most restrictive barrier
Indirect
Technique that engages the least restrictive barrier

11. Forces Applied in OMT Extrinsic Supplied by physician Intrinsic
Supplied by patient

12. OMT Includes many different techniques
Requires additional training ( hrs during med school)
Requires ongoing practice and continuing education

13. Safety of OMT Low rate of complications (1 in 1 million)
Careful patient and modality selection
Most common complications
Vertebrovascular accidents
Cauda Equina syndrome
Modality most associated with complications is HVLA

14. Contraindications Case-by-case basis
Fracture, dislocation, tumor, infection, and osteomyelitis are contraindications for OMT directly over that site
Conditions to consider carefully:
Down Syndrome, RA, pregnancy, strains & sprains, acute herniated disc, acute inflammatory situations, anatomic instability, hypermobility, joint prosthesis, and severe manifestations of visceral disorders

15. Common Techniques HVLA Muscle Energy Soft Tissue Counterstrain
Facilitated Positional Release
Lymphatic
Visceral
Myofascial Release
Cranial
Techniques of Still
Balanced Ligamentous Tension & Ligamentous Articular Strain
Articulatory

16. Soft Tissue Techniques
Direct technique
“Involves lateral stretching, linear stretching, deep pressure, traction, and/or separation of muscle origin and insertion while monitoring tissue response and motion changes by palpation”
Indications
↓muscle spasm; stretch and ↑elasticity; improve circulation; ↑ venous and lymphatic drainage; promote patient relaxation
Absolute contraindications: none

17. Myofascial Release Techniques
Direct, indirect, or combination of both
“Designed to stretch and reflexly release patterned soft tissue and joint-related restrictions”
Indications
↓ muscle and fascial tension; stretch and ↑ elasticity in tight tissues; improve circulation to specific region; ↑ venous and lymphatic drainage
Absolute contraindications: none

18. Muscle Energy Techniques
Direct technique
“system of diagnosis and treatment in which the patient voluntarily moves the body as specifically directed by the physician; from a precisely controlled position, against a defined resistance by the physician”
Indications
1º = Somatic dysfunction of myofascial or articular origin
2º = Improve circulation, balance neuromuscular relationships, and ↑ tone in hypotonic/weak muscles
Absolute contraindications
Fracture, dislocation, or joint instability at treatment site
Patient unable to understand instructions or uncooperative

19. HVLA Direct technique Indications Absolute contraindications
“Uses high-velocity/low-amplitude forces; also called mobilization with impulse treatment”
Indications
Somatic dysfunction of articular origin
Absolute contraindications
Joint instability; severe osteoporosis; bony metastasis, osteomyelitis, other infection, or joint replacement in the treatment area; osteoarthritic joint with ankylosis; severe herniated disc with radiculopathy; congenital anomalies; Down syndrome (esp. c-spine); RA of c-spine; achondroplastic dwarfism (c-spine)

20. Balanced Ligamentous & Ligamentous Articular Strain Techniques
Indirect technique
Indications
Somatic dysfunctions of articular or myofascial basis; areas of lymphatic congestion or local edema
Absolute contraindications: none

21. Visceral Techniques Direct, indirect, or combined Indications
“system of diagnosis and treatment directed to the viscera to improve physiologic function; typically the viscera are moved toward their fascial attachments to a point of fascial balance”
Indications
Multiple, depending on specific organ dysfunctions
Cardiac, pulmonary, GI, GU, gyn, etc.
Absolute contraindications: none

22. Lymphatic Techniques Technique classification Indications
Techniques removing restrictions to lymphatic flow vs. those promoting lymphatic flow
Indications
Lymphatic congestion (postsurgical edema), mild to moderate CHF, URI/LRI, other infections, asthma, COPD, pain due to lymphatic congestion & swelling
Absolute contraindications
Fracture, dislocation, or osteoporosis; acute hepatitis; malignancy; organ friability (inf. Mono); acute indurated lymph node

23. Interactive Clinical Scenarios (small groups)
Headaches
Post-op ileus
Pneumonia
GERD
Asthma
Sinusitis
Hiccups
Otitis media
Constipation
Back pain in pregnancy
Edema in pregnancy
Dysmenorrhea
Carpal Tunnel Syndrome
Others…

24. Summary Osteopathic Medicine and Osteopathic Philosophy
Review of common OMT techniques
Examples of using OMT in specific clinical situations
Guidelines for allopathic preceptors

25. Resources
Nicholas, A and Nicholas, E. Atlas of Osteopathic Techniques. Philadelphia: Lippincott Williams & Wilkins, 2008.
Ward, R (ed). Foundations for Osteopathic Medicine. Philadelphia: Lippincott Williams & Wilkins, 2003.
Greenman, P. Principles of Manual Medicine. Philadelphia: Lippincott Williams & Wilkins, 2003.
Nelson, K and Glonek, T (ed). Somatic Dysfunction in Osteopathic Family Medicine. Philadelphia: Lippincott Williams & Wilkins, 2006.

26. Questions?