Presentation on theme: "Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association and supported."— Presentation transcript:
1 Osteopathic EPECEducation for Osteopathic Physicians on End-of-Life CareBased on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use.American Osteopathic AssociationAOA: Treating Our Family and Yours
2 Module 13: Osteopathic Manipulative Technique in End-of-Life Care
3 OMT Applications at End of Life Generalized pain and disabilitycancer, metastasisheart disease,stroke, COPD, neuropathyneurodegenerative conditions/failure to thrive:e.g., Alzheimer or Vascular Dementia and Parkinson Diseaseimpair mobilitycause musculoskeletal dysfunction
4 Goal of OMT: Normalization The body is:Being assaulted by diseaseSuffering medication side effectsGoing through a closing down processThe mindThe spirit
5 Psychosocial and Spiritual Issues Near the End of Life Talking with a non-family member may assist in eliminating past emotional baggage and barriersDepressionAnything that can be addressed?Family IssuesRelationship resolutionPersonal IssuesContext and meaning of one’s lifePersonal faithHopeThe patientThe family
7 Compassionate Touch = OMT Compassionate touch has its own healing qualityPeople’s emotional barriers often soften when compassionate touch is involvedOMT is designed to biomechanically alter physiology
8 MIND / BODY/ SPIRIT Set goals: curative versus palliative Body assaulted by diseasesuffering from medical side effectsgoing through closing down processi.e., end-of-life phase ?
9 Body/mind/spirit approach Principles Select your goalExtension of lifeQuality of life (Palliation)Diagnosis:Cause as little pain as possibleTreatment:First, do no harmTreat one problemAllow the body to adjust
10 Treat one body part Allow body to adjust Re-assess Re-treat OMTTreat one body partAllow body to adjustRe-assessRe-treat
11 Treatment Type Decisions Global diseaseArea of greatest restriction (AGR)Best method when problem is complex,e.g., chronic LBPBest demonstrates OMMBest for hardest casesLocal diseaseTreat the local somatic dysfunctionCommonly works!
12 Two Approaches Global diagnosis Sequencing area of treatment by area of greatest restriction (AGR)Best method when the problem is complexE.g., chronic low back painBest demonstrates osteopathic theory and philosophyBest for hardest casesLocal diagnosisEasier method when you know the problem is localE.g., sprained ankleMost commonly usedDoes not completely demonstrate osteopathic theory and philosophyOften works
13 Two Approaches Which to choose? Dependent on: Time What the real problem isYour level of masteryWhere the patient is in the end of life processWhy you need both of these skillsGlobal probably has the highest success rateLocal approach can be done in less time to addressspecific problems
14 Global ApproachExamine the body for the area of greatest restriction (AGR)Treat the AGRReexamine other areas of restriction to see if they have changed (or startthe whole process over)Treat successive areas ofgreatest restriction (AGRs)
15 Q: Why go global? A: Chasing pain often leads to failure Consider the case of two people carrying a heavy load; one drops most of his load. Which one complains the most?THINK: The painful SI joint is frequently on the side opposite the pain.(Analogy for the classic presentation of sacroiliac joint dysfunction. That is, the side exhibiting most pain is often the side opposite the dysfunction!)
16 Global Diagnostic Principle The AGR may be and frequently is in a different body region than the site of the chief complaint.In those cases, the area of pain is where the body is compensating, not where the problem is originating.
17 . . . with forces distributed through a tensegrity system The body is a unit…. . . with forcesdistributed through atensegrity system
18 Global Treatment Principle Sequence is vital…You have the right numbers…But having the right numbers won’t always open the lock!
19 Distant dysfunction mechanisms manifesting as low back pain CraniumDural attachmentsNeckFascia and muscle attachments, innervation of superficial low back musclesThoracic and ribsFascia and muscle attachments, abdominal muscles, diaphragmUpper extremityScapular and latissimus dorsi attachmentsLumbarsLocal problemPelvis and sacrumLower extremityFascial and muscle attachments to ilia and sacrum
20 Examination for AGRBased on the third principle of physiologic spinal motionWhen motion is induced in one plane, movement in the other two planes is decreased.We will induce motion in one planeThis will restrict motion into the other two planesThen we will induce motion into the other two planeIf you induce motion into a second plane, it also restricts motion in the other two planesThis will achieve what is called a physiologic lock.A normal joint will still have joint play, a small ability to move.A restricted joint will not have the ability to spring.
21 Problem-based Local Approach Based on the knowledge that certain problems have local solutionsYou can always go back to the global approachWeakness: forming the habit of relying only on the local approachThe local approach is more reductionist, and therefore doesn’t always treat the cause of the problem
22 Local approachFocused exam on a problem region and it’s autonomic connectionsAnalyze:is there a biomechanical problem?is there a problem with fluid flow?are there autonomic imbalances that you can treat to improve the patient’s condition?Choose:a model of diagnosis and treatment to treat, depending on the condition of the patientCounterstrain - StillMFR Muscle EnergyHVLA
23 Model of Dx and Tx Depends upon the patient! Options for frail and/or elderly:CounterstrainMyofascial release technique (MFR)Craniosacral technique (Still)Muscle energy techniquerequires patient effortHigh velocity low intensity - HVLAVERY cautiously, rarely best
24 Common problems at the End of Life PainDyspnea, secretionsDisorders of the CNSGastrointestinal symptomsFluid retentionDisorders of skin and mucous membranes
25 DyspneaThoracic-sympathetic connection: improve cardio-vascular and respiratory systemsUpper thoracics normalization:indirect MFRMusculoskeletal systemCoughing, loss of muscle massRib dysfunctionMechanical structuresDiaphragm
26 Dyspnea Treatment Cervical treatment OA decompression C 3/4/5: Phrenic nerveOA, AA: VagusRib dysfunctionDiaphragmDoming itIndirect treatmentThoracic sympathetic connection
27 Dyspnea Autonomics Cervical Treatment: OA decompression C 3/4/5 – phrenic nerveOA, AA – vagus nerveLigamentum nuchae – MFRSuboccipital release: slight compression/traction; let gravity do the workCV- VI: “reset” button for autonomics
28 Ligamentum Nuchae Regional Technique A useful technique for balancing more than two segments, or to address the general connective tissue for the posterior neck.Sit at the head of your supine patient.Cradle the patient’s occiput in the palm of one hand.Use your other hand to grasp the posterior neck. Your thenar/hypothenar eminences are on one side, your fingerpads at the contralateral articular pillars.Use motion testing to determine and place the patient in the position of ease, as determined by decreased tissue tension, for the connective tissue: F/E, S, and R
29 Ligamentum Nuchae Regional Technique You may use the following activating forces:Respiratory cooperationRelease enhancing maneuversSlight compression, traction, or torqueFollow the changing tissue tension in the direction of its relaxation, taking the tissue toward the decreased tension.When the tissue stops relaxing, slowly return the patient to neutralRetest for resolution of TART criteria for somatic dysfunction.
31 Suboccipital Release Sit at the head of your supine patient Place your finger pads against the inferior occiput so that your fingertips are approximately at the atlas.Your palms are underneath the occiput, but it is initially suspended above them.Allow the weight of the patient’s head to create the releaseEnhance the release with use of traction, compression, or by initiating micro-motion and following the progressive tissue relaxation as it occursThe occiput gently settles into your palms as the release occurs.Retest the area for TART resolution.
32 C3-7 Segmental Technique Sit at the head of your supine patient.Diagnose the key dysfunction (e.g., C4 ESRRR).Contact the articular pillars of the dysfunctional segment with the pads of your long fingers.Induce F/E, then S, then R to match the direction in which the vertebra is already drawn by the tissue (go indirect). Use translation to achieve sidebending.To enhance the release, you may use activating forces.Continue until the desired tissue response is obtained, then slowly return to neutralRetest for TART resolution.
37 General Autonomic Reset CV IVLumbosacral decompression
38 Extremities Evaluation of limitation of motion FlexionExtensionAdductionAbductionRotationShoulders: bursitis, adhesive capsulitis, or disuse syndromes.
39 Edema fluid Lymphatic Pump Mobilization of the patient Can be done easily at the bedsideMobilization of the patientTo the extent possibleMay actually help reduce overall pain
40 Additional Principles Give patients hopeBut not false promisesHelp them to have a sense of at least some control over their painIf you’re using the global osteopathic approach:Explain to patients why you may not treat the area of greatest complaintDo at least something with the area of greatest complaintA number of patients do not wish to take more medicine, but they do want to feel betterSome have difficulty tolerating medicationYou may have to talk them into more medication
41 The Last Days: The Actively Dying Patient Pain is addressed by medicationSome pain is poorly addressed by medicationRib pain with inspirationGeneral autonomic treatment