1. OMT for LBP Samuel A. Yoakum, DO

2. Disclosures none

3. Outline Background Definitions Diagnosis Techniques Billing

4. Definitions Manual manipulation/therapy Hands-on manipulation, mobilization or massage techniques involving articulations and/or soft tissue movements in order to modulate pain, augment range of motion, facilitate movement, and improve function.

5. Manual therapy ● Acupressure ● Bodywork ● Bowen technique ● Chiropractic ● Craniosacral therapy ● Indian head massage ● Lomilomi ● Manual lymphatic drainage ● Massage therapy ● Naprapathy ● Osteopathic medicine ● Physical therapy ● Rolfing structural integration ● Shiatsu ● Thai massage ● Tui na ● Watsu

6. Osteopathic Medicine Definitions: Osteopathy = Osteopathic medicine Osteopathic manipulative medicine = OMM Osteopathic manipulative treatment/techniques = OMT Doctor of Osteopathy = DO According to the World Osteopathic Health Organization, Osteopathy is a “…system of healthcare which relies on manual contact for diagnosis and treatment. It respects the relationship of body, mind and spirit in health and disease; it lays emphasis on the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.”

7. Tenets of Osteopathy ●The body is a unit o Understanding this concept allows the treatment of patients as a functional whole. ●Structure and Function are interrelated o Still’s philosophy: “Disease is the result of anatomical abnormalities followed by physiologic discord” ●The body possesses self-regulatory and self-healing mechanisms ●Rational treatment is based on applying these principles

8. Diagnosis Somatic Dysfunction ●Tissue Texture Changes o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed, atrophied, rigid, moist, dry ●Asymmetry o ‘Inspection’ ●Restriction of motion = a deeper look at A/PROM o Named for FREEDOM Of MOTION o Restricted motion is the BARRIER ●tenderness o Tenderpoints vs. Triggerpoints

9. Tissue Texture Changes ●Acute o Edematous o Erythematous o Boggy o Slick, sweaty ●Chronic o Flat o Cool o Leathery, low tone o Flaccid, ropy, fibrotic

10. Asymmetry ● Group curvature ● Single segment disfunction ● Compare Side-to-side ●Mastoid ●Acromion ●Lower ribs ●Iliac crests ●Greater trochanters ●Lateral femoral condyles ●Lateral malleoli

11. Restriction of motion ● Orthopedic o Very Loose ● Rheumatologic o Very Restricted ● Somatic Dysfunction o Free in one direction + restricted in the other

12. The Barrier Concept ●BARRIER stops motion ●FREEDOM Of MOTION is opposite the barrier ●Barriers o Anatomical o Physiological o Restrictive

13. Anatomical & Physiological Barriers

14. Restrictive Barrier

15. Osteopathic Manipulative Techniques ●Direct Techniques o Engage (go into) the dysfunctional barrier o Goal is moving through the barrier to restore normal motion ●Indirect Techniques o Disengage (go away from) the barrier o Using the path of least resistance ●Combined Techniques o Begin indirect, then go direct

16. OMT ●Soft tissue mobilization / Articulatory Techniques o Direct ●Myofascial Release (MFR) o Direct or Indirect ●Muscle Energy (contract-relax) o Direct ●Jones Counterstrain & FPR o Indirect ●High Velocity Low Amplitude (HVLA) o Direct ●Craniosacral o Direct or Indirect

17. Common PT Crossover ●Contract-Relax o Muscle Energy ●Joint Mobilizations = “Mobs” = direct technique with a range of force and velocity (Grade I-V) o Deep articulation

18. Key: Know What You Are Treating ●Soft tissue – skin, adipose, superficial fascia ●Deep Fascia – layers, lines, planes, strain patterns ●Muscle – follow the fibers ●Joint – vertebral segments, articulations, syndesmoses

19. High Velocity, low amplitude ●Confronting restricted motion of segments and articulations “head on” ●Requires skill for safety and appropriate application ●The barrier is engaged, isolated in multiple planes to minute specificity ●Final thrust in nearly ALL cases should be quick (high velocity) but short (low amplitude) ●“shotgun” techniques are discouraged

20. Soft Tissue Mobilization ●Soft tissue tensions affect function of the soft tissues and the joints to which they attach. ●Allows treatment to other parts of the body to be more effective. ●Gently and directly applying pressure as to separate the origin and insertion of muscle fibers from each other. ●Deep articulation, in contrast, is the repeated engagement of the barrier or endpoint of joint motion in order to increase mobility and ROM.

21. Myofascial Release (MFR) ●MFR is an umbrella term encompassing several types of osteopathic manipulative techniques (OMT) that stretch and release muscle and fascia restrictions. ●MFR first involves palpating a restriction in the fascia/soft tissue. ●Direct MFR = practitioner engages the restrictive barrier and holds until a release is felt in the tissue. ●Indirect MFR = practitioner moves the myofascial structures away from the restrictive barrier.

22. Counterstrain Used to treat Tenderpoints ●Tenderpoints are small tense edematous areas of tenderness typically located near tendon attachments, ligaments, or in the belly of some muscles. ●Tenderpoints, unlike trigger points, do not radiate pain when compressed.

23. Counterstrain ● Jones Counterstrain = passive indirect technique o Muscle being treated is positioned at a point of balance or ease, away from the restrictive barrier. o “Fold and hold” for 90 sec ●This is a neurosensory approach to the treatment of tenderpoints. o Mimicking the original strain position -> reducing aberrant afferent flow from the muscle spindle -> relaxes the muscle “spasm” associated with a tenderpoint

24. Facilitated Positional Release (FPR) ●Indirect technique ●Place tissue in neutral position to diminish tissue/joint tension in all planes ●Add activating force (compression or distraction) ●Takes 3-4 seconds to induce a release ●Good for superficial muscles or deep intervertebral muscles

25. Muscle Energy ●Muscle energy, also known as “contract-relax,” is a direct technique used to improve range of motion. ●This is a form of OMT in which the patient actively uses his/her muscles against the practitioner’s resistance. o Physician engages a barrier and holds o Patient is instructed to contract the muscle against your holding force (Activating force) o Relax o Engage a new barrier o Repeat

26. Still Technique ●A combination of indirect technique, moving to direct technique following the release ●The patient is completely passive ●The lever is placed in a position of ease ●Holding force (compression/distraction) is applied ●The joint, or body part is then taken through a range of motion while attempting to hold the activating force as long as possible ●The range of motion is taken to (and through if reasonably possible) the barrier

27. References