1. Somatic Dysfunction in Osteopathic Family Medicine

2. THe patient with Lower Respiratory Tract Infection
Chapter 17
THe patient with Lower Respiratory Tract Infection

3. From: Somatic Dysfunction in Osteopathic Family Medicine
From: Somatic Dysfunction in Osteopathic Family Medicine. Nelson KE, Glonek T, eds. Baltimore, MD: Lippincott, Williams & Wilkins; This presentation is intended to augment the didactic presentation of Chapter 17: The Patient with a Lower Respiratory Tract Infection, by Zachary J. Comeaux, DO. Produced by the Department of Osteopathic Manipulative Medicine, CCOM/MWU, Kurt Heinking DO, FAAO (Chair). Developed by: Samuel Yoakum, OMM fellow. Edited by the ACOFP subcommittee for OMM-OPP Publication and Educational Materials, Kenneth E. Nelson DO, FAAO, FACOFP (Chair) © American College of Osteopathic Family Physicians

4. Introduction
Clearly antibiotics have become the mainstay for reducing morbidity due to pulmonary infections. Supportive care, however, can still play a significant role in recovery. Manipulative treatment is often seen as an alternative to pharmaceuticals, but both are more likely to be effective as complementary treatments.

5. Pneumonia
Although this disease process may be the result of any of a wide spectrum of pathogens… the primary agent, for community acquired pneumonia (CAP), is still Streptococcus pneumoniae. This chapter mostly addresses the treatment of patients with uncomplicated cases of CAP.

6. Respiratory Function
The lungs are usually viewed as organs of O2 exchange, driven by their ability to expand and contract with pressure changes. They also play a large role in the circulatory system, assisting both venous return and lymphatic drainage. Circulatory issues are as important as oxygenation in function and dysfunction of the respiratory system.

7. Osteopathic Correlations in Pneumonia
Classical Considerations:
Still saw the problem as one of vascular stasis to be solved primarily by rib raising.1
Charles Hazzard describes a more general treatment beginning with cervicals and moving on to scalenes, ribs, segments and abdominal release.2
McConnell preferred regional treatment with attention to the thoracoabdominal diaphragm.3

8. Osteopathic Correlations in Pneumonia
Contemporary Considerations:
Kuchera and Kuchera recommend a staged application of OMT to complement conventional medical care aimed at maximizing comfort and the individual’s ability to self-heal.4
Rib raising with paraspinal muscle stretching.
Segmental treatments and myofascial release of accessory respiratory muscle fascias.
Continued rib raising and segmental treatment with addition of lymphatic pump.

9. Treatment: Mechanisms of Action
Neuroreflexive:
Sympathetic – hypertonicity leads to tachypnea, tachycardia and vasoconstriction. Proximity of sympathetic chain ganglia to rib heads allows for external inhibition of this hypertonicity.
Facilitation – segmental dysfunction can lead to viscero-somatic or somato-visceral reflexes.

10. Treatment: Mechanisms of Action
Biomechanical:
Articular – the costovertebral contacts and intervertebral facet joints must have full mobility for full lung expansion to occur.
Myofascial – For optimal respiration distensibility of the horizontal diaphragms; tentorium cerebellae, thoracic inlet, throracoabdominal, pelvic floor and the fascial elements of the accessory muscles of respiration is essential.

11. Treatment: Mechanisms of Action
Vascular :
Lymphatic – primary lymph drainage from the lower body is to the left subclavian vein, dependent primarily upon respiration pressure gradients.
Venous – much venous return relies on activities of daily living, which illness suspends.
Interstitial – tissue edema must be cleared through the vascular system. External pressure may assist in this process.

12. Diagnosis
Specific diagnosis of somatic dysfunction is mandatory for effective OMT. Begin with a global assessment of the thoracic region. Assess for rib and spinal segmental restrictions. Assess other regional influences, including the throracoabdominal diaphragm and pelvic floor.

13. Treatment Considerations
Possible Interventions:
Rib raising.
Rib articulation.
Paraspinal muscle stretch.
Lymphatic pump.
Occipitoatlantal release.
Cervical paraspinal muscle release.
Cervical articulatory release.
Diaphragmatic release.
Oscillatory Release.

14. Treatment Considerations
Rib Raising:
can be accomplished in several positions.
fingertips are used as a fulcrum.
treat all ribs.
increased restriction requires increased focus.
Rib Articulation:
performed seated.
combines translation/sidebending and rotation.
gentle, rhythmic and repetitive.
a good alternative to HVLA treatments.

15. Treatment Considerations
Paraspinal Muscle Stretch:
performed with the patient in the lateral-recumbent.
a simple but effective soft tissue procedure.
Lymphatic Pump:
pedal pump is excellent for the hospital setting.
Thoracic pump is more specific for the lungs.
Occipitoatlantal Release:
normalizes tensions surrounding the vagus.
is a relatively quick technique (one - two minutes).

16. Treatment Considerations
Cervical Paraspinal Muscle Release:
relaxes accessory muscles of respiration.
maximizes phrenic nerve function.
excellent for hospital setting.
Cervical Articulatory Release:
treat dysfunction of the C3-C5 segments to affect the phrenic nerve.
performed with patient seated.
may add oscillation to enhance the procedure.

17. Treatment Considerations
Diaphragmatic Release:
generally performed with patient supine.
may use direct or indirect approach.
performed in all three planes.
highly effective.

18. ANY QUESTIONS OR DISCUSSION?

19. References
Still AT. Research and Practice. Kirksville, MO: Author, Reprinted in Seattle: Eastland Press, 1992;83-89
Hazzard C. Pneumonia. In: The Practice of Applied Therapeutics of Osteopathy
Jordan T, Schuster R, eds. Selected Writings of Carl Philip McConnell, DO. Columbus, OH: Squirrel’s Tail, 1994;90.
Kuchera M, Kuchera W. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus, OH: Greyden, 1994;45.