1. Osteopathic EPEC
Education for Osteopathic Physicians on End-of-Life Care
Based 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 Association
AOA: 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 disability
cancer, metastasis
heart disease,stroke, COPD, neuropathy
neurodegenerative conditions/failure to thrive:
e.g., Alzheimer or Vascular Dementia and Parkinson Disease
impair mobility
cause musculoskeletal dysfunction

4. Goal of OMT: Normalization
The body is:
Being assaulted by disease
Suffering medication side effects
Going through a closing down process
The mind
The 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 barriers
Depression
Anything that can be addressed?
Family Issues
Relationship resolution
Personal Issues
Context and meaning of one’s life
Personal faith
Hope
The patient
The family

6. Compassionate Touch = OMT
biomechanically
alters physiology
Addresses emotions

7. Compassionate Touch = OMT
Compassionate touch has its own healing quality
People’s emotional barriers often soften when compassionate touch is involved
OMT is designed to biomechanically alter physiology

8. MIND / BODY/ SPIRIT Set goals: curative versus palliative Body
assaulted by disease
suffering from medical side effects
going through closing down process
i.e., end-of-life phase ?

9. Body/mind/spirit approach Principles
Select your goal
Extension of life
Quality of life (Palliation)
Diagnosis:
Cause as little pain as possible
Treatment:
First, do no harm
Treat one problem
Allow the body to adjust

10. Treat one body part Allow body to adjust Re-assess Re-treat
OMT
Treat one body part
Allow body to adjust
Re-assess
Re-treat

11. Treatment Type Decisions
Global disease
Area of greatest restriction (AGR)
Best method when problem is complex,
e.g., chronic LBP
Best demonstrates OMM
Best for hardest cases
Local disease
Treat the local somatic dysfunction
Commonly works!

12. Two Approaches Global diagnosis
Sequencing area of treatment by area of greatest restriction (AGR)
Best method when the problem is complex
E.g., chronic low back pain
Best demonstrates osteopathic theory and philosophy
Best for hardest cases
Local diagnosis
Easier method when you know the problem is local
E.g., sprained ankle
Most commonly used
Does not completely demonstrate osteopathic theory and philosophy
Often works

13. Two Approaches Which to choose? Dependent on: Time
What the real problem is
Your level of mastery
Where the patient is in the end of life process
Why you need both of these skills
Global probably has the highest success rate
Local approach can be done in less time to address
specific problems

14. Global Approach
Examine the body for the area of greatest restriction (AGR)
Treat the AGR
Reexamine other areas of restriction to see if they have changed (or start
the whole process over)
Treat successive areas of
greatest 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 forces
distributed through a
tensegrity 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
Cranium
Dural attachments
Neck
Fascia and muscle attachments, innervation of superficial low back muscles
Thoracic and ribs
Fascia and muscle attachments, abdominal muscles, diaphragm
Upper extremity
Scapular and latissimus dorsi attachments
Lumbars
Local problem
Pelvis and sacrum
Lower extremity
Fascial and muscle attachments to ilia and sacrum

20. Examination for AGR
Based on the third principle of physiologic spinal motion
When motion is induced in one plane, movement in the other two planes is decreased.
We will induce motion in one plane
This will restrict motion into the other two planes
Then we will induce motion into the other two plane
If you induce motion into a second plane, it also restricts motion in the other two planes
This 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 solutions
You can always go back to the global approach
Weakness: forming the habit of relying only on the local approach
The local approach is more reductionist, and therefore doesn’t always treat the cause of the problem

22. Local approach
Focused exam on a problem region and it’s autonomic connections
Analyze:
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 patient
Counterstrain - Still
MFR Muscle Energy
HVLA

23. Model of Dx and Tx Depends upon the patient!
Options for frail and/or elderly:
Counterstrain
Myofascial release technique (MFR)
Craniosacral technique (Still)
Muscle energy technique
requires patient effort
High velocity low intensity - HVLA
VERY cautiously, rarely best

24. Common problems at the End of Life
Pain
Dyspnea, secretions
Disorders of the CNS
Gastrointestinal symptoms
Fluid retention
Disorders of skin and mucous membranes

25. Dyspnea
Thoracic-sympathetic connection: improve cardio-vascular and respiratory systems
Upper thoracics normalization:
indirect MFR
Musculoskeletal system
Coughing, loss of muscle mass
Rib dysfunction
Mechanical structures
Diaphragm

26. Dyspnea Treatment Cervical treatment OA decompression
C 3/4/5: Phrenic nerve
OA, AA: Vagus
Rib dysfunction
Diaphragm
Doming it
Indirect treatment
Thoracic sympathetic connection

27. Dyspnea Autonomics Cervical Treatment: OA decompression
C 3/4/5 – phrenic nerve
OA, AA – vagus nerve
Ligamentum nuchae – MFR
Suboccipital release: slight compression/traction; let gravity do the work
CV- 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 cooperation
Release enhancing maneuvers
Slight compression, traction, or torque
Follow 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 neutral
Retest for resolution of TART criteria for somatic dysfunction.

30. Ligamentum Nuchae

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 release
Enhance the release with use of traction, compression, or by initiating micro-motion and following the progressive tissue relaxation as it occurs
The 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 neutral
Retest for TART resolution.

33. C3-7 Segmental Technique

34. Segmental Release

35. Gastrointestinal problems
N/V, diarrhea, ileus cause autonomic effects; attempt to “damp down”
General Treatment
upper thoracics
vagus nerve (OA, AA)
T 5-9
Diarrhea and constipation
Thoracic and lumbar – sympathetics
Sacral – autonomics
Abdominal treatment
Nausea caused by CMTRZ will require meds

36. Gastrointestinal Problems Treatments
Occipitomastoid decompression
Vagus Nerve OA, AA
Thoracic and Lumbar sympathetic connections
Sacral autonomic connections
Abdominal treatment
Inhibition
Facilitation

37. General Autonomic Reset
CV IV
Lumbosacral decompression

38. Extremities Evaluation of limitation of motion
Flexion
Extension
Adduction
Abduction
Rotation
Shoulders: bursitis, adhesive capsulitis, or disuse syndromes.

39. Edema fluid Lymphatic Pump Mobilization of the patient
Can be done easily at the bedside
Mobilization of the patient
To the extent possible
May actually help reduce overall pain

40. Additional Principles
Give patients hope
But not false promises
Help them to have a sense of at least some control over their pain
If you’re using the global osteopathic approach:
Explain to patients why you may not treat the area of greatest complaint
Do at least something with the area of greatest complaint
A number of patients do not wish to take more medicine, but they do want to feel better
Some have difficulty tolerating medication
You may have to talk them into more medication

41. The Last Days: The Actively Dying Patient
Pain is addressed by medication
Some pain is poorly addressed by medication
Rib pain with inspiration
General autonomic treatment