Download Osteopathic Manipulative Treatment as Consideration

5/19/2016
William H. Devine, DO
Clinical Professor MWU/AZCOM
C‐ NMM OMM, C‐FM OMT
Fellow Osteopathic Research
MWU OPT Post Graduate Program Director OPP
MWU Program Director and DME of NMM OMM Residency
LEARNING OBJECTIVES: Lecture and BRIEF OMT
lab/workshop one should be able to:
• Understand basic Philosophy and physiology
of OMT methods shown today
• Have an appreciation for Osteopathic
functional anatomic and physiological
considerations of HEENT in health & disease.
• Formulate a simple OMT Tx Plan for Common
HEENT Conditions by application of OP & P.
• Review a number of OMT techniques specific
to HEENT, and new OMT Lab Tx’s
• Be exposed to Clinical Counterstain OMT and
Chapman’s Reflexes.
• Have an ability to code and bill for OMT as a
medical procedure with 25-modifier for $$.
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Special Thanks to:
• Michael Kuchera, DO, FAAO and Harmon L. Myers, DO
– For their kind permissions and contributions to this lecture and for their contributions to Osteopathic education, research and clinical applications of Strain Counterstrain OMT and Chapman’s Reflex OMT.
Old but “New” for Today’s Medical Care
• Osteopathic Principles and Practice is with or without OMT…. But OMT can be helpful.
• We apply functional anatomy to applied physiology, not just treat symptoms as part of our Osteopathic Philosophy in order to Diagnose
• We ask “WHY” as DOs as part of treament.
• With OMT we can address the Autonomic Nervous System (ANS), the Biood Microcirculatory system, and the Lymphatic Circualtion System.
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Osteopathic Philosophy
Basic Osteopathic Principles:
• The body is a functional unit
• Structure & functional are reciprocally
related
• The body has the ability to self regulate
• Treatment results from the rational
application of the above principles
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Five (5) Models Many Approaches
Techniques Galore
The four (4) osteopathic tenets
Osteopathic health care MODELS (5)
Postural - Biomechanical
Neurological –
Autonomic
Biopsychosocial
Metabolic - Hormonal
Respiratory
- Circulatory
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Postural-Biomechanical Model
The Postural-Biomechanical Model considers the patient
from the perspective of an “engineer,” looking at the individual’s
tensegrity properties and specifics of structural-mechanical alignment and
function.
Alterations of postural mechanisms, motion and connective tissue
compliance are associated with somatic dysfunction and these components
are considered to be primary causes that may lead to secondary vascular,
lymphatic, neurological, metabolic, and homeostatic consequences as
well as pain, loss of motion, tissue dysfunction and other symptoms.
Treatment in this model:
• Remove key somatic dysfunction
• Restore structural integrity and function
• Techniques include Travell Trigger Points, Jones
Counterstrain, Mitchell Muscle Energy – OMT is a first-line
consideration!
Neurological-Autonomic Model
The Neurological-Autonomic Model requires an
understanding of the structure-function of central & peripheral neurological
processes. DOs consider the influence of nociception & afferent drive,
spinal facilitation, sympathetic-parasympathetic interactions (as well as
their activity as separate and distinctive systems); proprioceptive influences
on gait and posture, neural influences affecting the neuroendocrine-immune
network, impact of neurological pathologies on somatic & visceral tissues,
and of neural trophism. Important in this model are somatic & visceral
(autonomic) system inter-relationships & multiple reflex combinations.
As a treatment, OMT is used therapeutically to:
• ⇓ nociceptive/afferent drive from somatic & visceral sources
• Optimize neural integrative/regulatory homeostatic functions
(neurological structural, vascular, metabolic & behavioral functions)
• Approaches include: Chapmans reflexes; part of 3:3:3 OCSD
• Very helpful in differential diagnosis & in enhancing
homeostasis
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Respiratory‐Circulatory Model
The Respiratory-Circulatory Model focuses upon
respiratory & circulatory homeostasis for returning and maintaining
cellular level health; maximizing extra and intracellular environments
through unimpeded delivery of oxygen and nutrients and the removal of
cellular waste products (lymph/CSF); and playing a major role in local
and systemic immune responses.
In this model, the impact of myofascial and segmental somatic
dysfunction is interpreted relative to effects on central mechanisms
(including neurological and primary respiratory mechanisms) to
peripheral functions (the flow or circulation of any body fluid).
Treatment objectives:
– Maximize respiratory mechanics (and other inherent motions)
– Minimize circulatory obstructions (flow of body fluids for nutrient,
drainage, or immune functions)
– Approaches include: Zink’s; Part of the 3:3:3 Approach;
Sutherland’s Primary Respiratory Mechanism Approach
Bioenergic‐Metabolic Model
The Bioenergic-Metabolic Model places the focus on metabolic &
energy conserving aspects of the homeostatic adaptive response. The DO
recognizes the need for proper nutrition to “power” & sustain normal biochemical
processes underlying cellular activities that are needed for systemic &
neuromuscular functions and proper healing. In this model, aspects of the
posture & respiration are considered—but from the perspective of efficacy. The
OCMM approach is considered from the perspective of its role in neuroendocrinemetabolic regulation or overall vitality.
Treatment objectives:
– Maintain overall balance between energy production & expenditure
– Emphasize pt education, diet, ergonomics, energy conservation
– Maximize biomechanical function (“Ergonomics” - such as gait and
activities of daily living as the mainstays of somatic energy conservation)
– Nutrition & metabolic/neurohormonal functional efficiency
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Biopsychosocial Model
The Biopsychosocial Model encourages recognition of unique
impact
by mental, emotional, spiritual, psychological, body image,
socioeconomical, cultural & environmental influences on health & healthcare.
(Body unity tenet central.) These determine lifestyle choices & compliance to
treatment approaches & are involved in both placebo & nocebo responses.
Somatic clues including neuromuscular tension – e.g. palpable @ linea alba or
CRI vitality. Coupled the patient’s history as a complete individual in context
with environment, helps to determine when this is the 1st (or 1o) model to employ
or adjunctive to optimize other osteopathic care models.
Objectives:
• Address fears & questions (understandably) with empathy
• Tailor patient & family education (on health, disease and lifestyle
choices, mental outlook and preventive care);
• Advise to take personal responsibility in the process of finding
optimal health within their complete environment. Empowerment
We Treat w/Functional Anatomy and Physiology:
• Multiple Reflex Connections in HEENT Sx:
• Cough & hoarseness can be from stimulated
pulmonary & pleural tissue
• Increased nasal & pharyngeal secretions can
come from stimuli in Lung or Upper GI tract
• Vertigo can come from dysfunction of
– Temporal bone related structures
– Cervical vertigo from C. spondylosis, Inertial
injury (whiplash), Som. Dysf. & Disk Dz
– As well as usual Inner Ear issues, eg otoliths
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Balance ANS: SNS to HEENT:
• T1-T4 chain ganglia
• Cervical chain ganglia:
– Superior (C2)
– Middle (C4-5)
– Inferior/Stellate (C8-T1)
• SNS plexus –usu follow artery to target
tissue
• Cranial Nerves: Trigeminal, Deep Petrosal
• Viscero-Somatic Reflexes:
– Viscero-Visceral Reflex (pharynx to T1-T4 sp
cord to other EENT viscera-ear related cough)
– Viscero-Somatic Reflex (T1-T4 sp cord
segmt. to somatic structures innervated by
T1-T4)
• Chapman Neuro-Lymphatic Reflexes
Increased SNS leads to:
HEENT, C & Upper T spine
• Vasoconstriction (decreased O2 & nutrients)
• Venous Congestion (toxicity)
• Lymphatic Congestion:
– Diminished Immunity
– Inflammation/swelling
– Accumulation of particulates
• Inability to effectively concentrate
medications for Tx
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Increased SNS leads to
HEENT Problems‐
Thick tenacious Mucus
Dryness/Cracking mucous membranes
Secondary bacterial infections
Dilation of the pupil (mydriasis)
Protrusion of globe in exophthalic in
Grave’s Dz
• Increased Thyroid gland secretion
• Sxs: photophobia, sl. Vertigo, tinnitus,
sense of difficulty swallowing, need to
cough, sweating, fatigue, palpitations,
tachycardia, insomnia
•
•
•
•
•
Balance ANS: PNS to HEENT:
• CN III, VII, IX, X
•
•
•
•
Ciliary ganglia to contract pupil (CN III)
Otic ganglia
Geniculate ganglia
Sphenopalatine ganglia to
– “Waterworks of the Face” tears, mucus (thin),
saliva (CN VII)
– Superficial Petrosal N.
• Thyroid from sup. & inf. larnygeal n (CN X)
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Passive Congestion: secondary to “tight fascia”
• Venous:
– ~90% venous blood exits head via IJV via
Jugular Foramen through the Occip-Mastoid
(OM) Suture
– Bony Compression or Fascial Restriction
here can lead to headache, anxiety, “head
fullness”
• Lymphatic:
– Supra-clavicular fullness
– Nodes: pre & post-auricular, tonsilar,
submaxillary, submental, and post. cervical
chain
– Thoracic duct (L) & Lymphatic duct (R)
Passive Congestion:
• Boggy edematous toxic sore tissueresult in decreased Homeostasis (state
of Health)
• Angle of Anterior Chamber of Eyeglaucoma from improper circulation of
sclera, cornea, iris
• Endolymph of Inner Ear-sluggish
reabsorption with hydrops & fibrosis of
endolymphatic duct as in Meniere’s Dz
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9/12 CNs are influenced by the position of the Temporal Bones:
• CN III, IV, VI: dural strains in Cavernous sinus
• CN V: dural strain Meckel’s cave & compression petrous
– tingling in cheek, HA eye brow & sinuses
Trigeminal neuralgia
• CN VII: congestion at Facial Canal
– metallic taste, altered salivation, facial
droop
– Bell’s Palsy
• CN VIII: r/o Acoutic Neuroma
– Vertigo, tinnitus, hearing loss
• CN IX, X, XI
entrapped at Jugular foramen
– Nausea, altered swallowing,
– Torticollis; Hypertonic SCM, Trapezius
Temporal Bone Sxs:
Consider:
• Tinnitus:
– External Rotation: low pitch roaring
– Internal Rotation: high pitch ringing tinnitus
• Vertigo:
– Restricted motion of either can cause
• Blockage Sensation:
– Eustachian Tube Dysfunction
• Otalgia:
– TMJ Dysfunction
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Other CN Dysfunction:
• CN I:
compression cribiform plate ethmoid-base of Nose
– altered or loss of smell
• CN II:
dural strains affecting sphenoid & orbits
– visual change esp focus
• CN XII:
compression hypoglossal canal in occipital bone
– difficulty swallowing or speaking
Somato‐Visceral Connections:
• Trigger Pts in various muscles can mimic HEENT
Sxs:
• Eye Pain or other Eye Sxs:
– SCM, Trapezius, Splenius cervicis, Occipitalis,
Orbicularis oculi mm
• Eustachian Tube Dysf:
– Medial pterygoid m
• Ear Pain: TMJ:
– Medial & Lat. pterygoids, Masseter, Temporalis mm
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Historical Perspective:
• Pioneers:
–
–
–
–
–
TJ Ruddy, DO, MD
HA Richardson, DO
Perrin T. Wilson, DO
A Hollis Wolf, DO
W Hadley Hoyt, III, DO
• Concept of “Resistive Duction”:
– TJ Ruddy, DO, MD
– He applied to Eyes-can be used elsewhere too
– Forerunner to Muscle Energy Concept-
• Eye Clock Exercise
Osteopathic Eye Clock Exercises:
•
•
Richardson, HA, Increasing the Strength of the Eyes and the Eye Muscles without
the Aid of Glasses, Kansas city KS, The Eyesight and Health Association 1925.
Recent resurgence in interest & study: see Paul Dart, MD, Cranial Academy 2011
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OMT Approaches:
•
•
•
•
•
Myofascial Release-direct & indirect
Muscle Energy
Strain Counterstrain
Still Technique-indirect-compress-direct-neutral
Visceral Techniques:
– Balance Autonomics (SNS & PNS)
– Chapman’s Neurolymphatic-Reflex Points
– Lymphatics incl. Effleurage
• Cranial Osteopathy:
–
–
–
–
–
even if you can’t feel the CRI!
BMT/BLT- ½ way point. in all planes-compress & hold
V Spread
Venous Sinus Release
Temporal Bone Rocking
CV4 (Compression of 4th Ventricle)
Usual Osteopathic Treatment:
• For HEENT Facilitated Structures:
– C2 esp for Ear Sx
– C3-C5 “keep the diaphragm alive” phrenic n
– SCM, Levator Scapula, Trapezius, Scalenes
– T1-T4
– Tx of Choice (ME, HVLA, MFR, SCS, Still)
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Common OMT to Regions
• Still Technique– Thoracic Inlet: Necklace Technique
– MFR Ant C Muscles & Fascia w Hyoid Bone
• BMT/BLT– Abdominal Diaphragm Release,
– OA, C1-C2
• Resistive Duction: (Ruddy) ME to Eye
Still Technique: An Overview:
Dx: Determine which direction the dysf. joint or tissue, moves easiest in 1‐3 planes of motion.
Move joint/tissues in direction of ease of motion, Slightly exaggerate until tissue palpably relaxes
Add slight compression (FORCE VECTOR) into the dysfunctional joint/tissue from your point of contact enough to maintain the localization. Maintaining compression, carry the tissue from direction of ease to direct barrier.
Return to neutral. Retest.
Van Buskirk, RL, The Still Manual Technique Manual: Applications of a
Rediscovered Technique of Andrew Taylor Still, MD, 2nd ed, 2006.
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Necklace Technique: Thoracic Inlet
Myofascial Release of the Cervical Thoracic Fascia:
• Pt. seated, operator from behind places hands gently but firmly
over the shawl of the shoulders. Stretch your hands out as much
as you can and let them sink into the fascia to take in as much
proprioceptive information as you can.
• Diagnosis if fascia prefers to rotate CW or CCW.
• Take it to its most indirect relaxed position
• Add myofascial enhancers of the release:
-Have Pt. turn head L or R-which relaxes the fascia more?
-Have Pt. look L or R-which relaxes the fascia more?
-Have Pt. reach down with arm on ipsilateral side
• Have Pt. inhale, then enhance release of stretch on the exhale
(when fascia is most relaxed)
• Take fascia to its tightest most direct barrier & reverse above.
• Retest-Goals:
– Balanced CTJ transverse diaphragm in synch with pt.’s breathing
– Open Lymphatic drainage at Thoracic Inlet
Typical OMM Plan:
• Sympathetic Nervous System (SNS):
– Dorsal Inhibition: Cervical chain ganglia
(superior, middle, inferior)
– Chapman Reflexes: eye, ear, nose/sinus,
throat, thyroid/bronchus
– SNS Chain ganglia: Rib Raising w indirect
MFR T1-T4
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SNS: VSR Cervicals & T1-4:
DORSAL INHIBITION: “The Holding Technique”
• Sitting above your supine patient or standing in
front of your seated patient, place both of your
hands, palms up, on post. upper T then C spine
of the patient, spanning their spinal column and
both sides of their adjacent paraspinal muscles
(primarily Erector spinae).
• With enough tension to engage the soft tissue,
approximate your fingers and the
thenar/hypothenar eminences of your hand. This
engages your intrinsic hand muscles (intraossei &
lumbricals) and may take some practice to build
up their strength. Maintain (hold) the tension
until the paraspinals are softened and the
facilitation is broken.
Chapman’s points:
Neuro‐lymphatic reflexes
• Frank Chapman, DO & his student Charles
Owens, DO
• Migrate in Embryol Development- “ganglion
formed”structures.
• A-P Map of viscerally related reflexes 1928
• SNS derived TTAs in discrete locations
• Location:
– Ant. Chapm. Pts-helpful for Dx (and Tx) d/t
tender
– Post. Chapm. Pts.-use to Tx initially +/-tender
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Chapman’s Reflex Points:
Neuro‐lymphatic reflexes
• Tx:
– Seated, supine or LR
– Monitor post. while Tx anterior point 1st
– Rapid rotary stimulation CW & CCW 20-30
sec.
– Recheck If residual Chapman ant. point,
Tx it again.
HEENT Chapman’s Points: SNS Neuro‐Lymphatic Reflexes
A. Middle Ear
E. Eye (Retina, Conjunctiva)

E
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& TONGUE
RETINA
& THYROID
Retina
& Thyroid
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CHAPMAN POINTS
HEENT:
ANT
POST
EYE
Ant-lat Humerus
Post Mastoid Process
EAR
Sup Clavicle (MCL)
Inion (Gr Occ
Protruberance)
NOSE/SINUS
1st ICS (MCL)
Post-lat OA
THROAT
1st ICS (lat to sternum)
Post-lat AA
THYROID
BRONCHUS
2nd ICS (lat to sternum) Post-lat vertebra
between T1-T2
SNS:
Rib Raising with Indirect MFR SNS Chain Ganglia:
• Load the fascia
INDIRECT in 3
planes over the
rib heads.
• Deep to the rib
heads are the SNS
chain ganglia.
• Helps to decrease
SNS tone
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RIB RAISING
W INDIRECT MFR
of the SNS CHAIN GANGLIA C, T1-T4:
• Patient supine (or seated) Physician above table (or facing the
patient).
• Place the fingertips of both hands under the upper back or neck of
the patient on the spinous processes of the spine. Slowly slide your
fingertips laterally pulling the paraspinal muscles (Erector spinae)
laterally. This will put you onto the costo-transverse articulations,
where the rib meets the vertebra. The SNS chain ganglia are just
deep to these structures.
• Palpate along the SNS chain. Place the finger pads of your index &
middle fingers under the worst segments on each hand at these
positions.
• Motion test the myofascial tissue under the finger pad in all 3
planes of motion. Ask, what position does the tissue prefer
(sup/inf, medial/lateral, CW/CCW)?
• Stack each preferred motion INDIRECTLY and hold until it softens.
Then move your hands up the chain to the next dysfunctional SNS
ganglion.
Parasympathetic Nervous System (PNS):
• PNS/Cranial (Sutherland):
– Sub-occipital Release
– V spread to OM Suture
– Temporal Rocking
• Counterstrain Cranial (SCS)
– MULTIPLE new techniques for today
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Treatment : PNS
• OA, AA-Suboccipital Release
• Jugular foramen in OM Suture• “V Spread” Cranial, or Counterstrain OM Txs
• Temporal Bone Restriction- Dural Stretch by
Temporal Rocking or Counterstrain
Reflexes & Headaches
V
V V
V
V
V V
X
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Cranial Nerve V
Eyes / Cornea
Sinuses
Upper Teeth / TMJ
Masseter Muscles
Pterygoid Muscles
Suture/Dura SD above TC
Cranial Nerve X
Heart
Lungs
Stomach
Lower teeth
Suture/Dura SD below TC
Manual Treatment: Posterior intermittent headaches
MTrP
Entrapment?
P1C?
P2C?
C2
Articular Dysfunction?
OM Suture?
2nd Cervical Nerve
Nociceptive input??
Organs with CNX
Visceral afferents
(lungs, heart, GI, etc)
Dural input from Post.
Cranial Fossa
C2; P1C; P2C
Occipitomastoid Suture
Entrapped??
Trapezius MTrP
Semispinalis capitis
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Eyes
SCM (sternal)
Splenius Cervicis
Occipitalis
Orbicularis Oris
Trapezius
Ears
Masseter (deep)
SCM (clavicular)
Medial pterygoid
Eustachian tube
Medial pterygoid
Nose/Sinus
Orbicularis oculi
Lateral pterygoid
Masseter
SCM (sternal)
Throat
Medial pterygoid
Digastric
Sternocleidomastoid Related HEENT Conditions
Eustachian Tube Dysfunction
Otitis Media
Rhinosinusitis
Common Cold & Upper Respiratory Infection
Cranial Nerve Dysfunction incl: Facial (Bell’s) Palsy
Recall Prior: Meniere’s; Asthma; etc
Integration
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Sympathetics:
T1 4; Chapmans; C2 3 SCG
Parasympathetics:
CN III, VII, IX, X; OM suture; sphenopalatine
ganglion; C2
Lymphatics:
Thoracic inlet; TAP diaphragm & C3 5; PRM;
Cervical soft tissues
Myofascial Trigger Points:
Multiple points (especially SCM and pterygoids)
Integration
SCM related
Imbalance – Ataxia
Eye manifestations
Headache
Teachey EENT experience
Pterygoid related
Ear pressure
Recurrent otitis media
Sinus pain & dysfunction
Masseter related
Tooth pain
TMJ pain
Integration
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Affect ANS in eye
excessive lacrimation
vascular engorgement of conjunctiva
ptosis due to 2o TrP in orbicularis oculi
view “strongly contrasting vertical lines”
Affect ANS to nose
unilateral maxillary sinus congestion
Coryza
SCM responds well to occipitomastoid release
(CN XI) and Counterstrain to A7C-A8C
Palpatory findings of SD in SCM:
• Boggy, edematous muscle
• Tender tight muscle
• Muscle harbors latent or active MTrPs
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Sympathetics:
T1 4; Chapmans; C2 3 SCG
Parasympathetics:
CN III, VII, IX, X; OM suture; sphenopalatine
ganglion; C2
Lymphatics:
Thoracic inlet; TAP diaphragm & C3 5; PRM;
Cervical soft tissues
Myofascial Trigger Points:
Multiple points (especially SCM and pterygoids)
Integration
What is the Importance of OA-C2?
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SINUSES
MIDDLE EAR
SINUSES
PHARYNX-TONSILS
BRONCHUS
LARYNX
UPPER LUNG
LOWER LUNG
Middle Ear
Sinuses, Pharynx
Larynx
Nasal Sinuses
Bronchus
Lung
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Terminal lymphatic
drainage site
= supraclavicular
Lymph nodes
anterior vs posterior (generality)
enlargement due to activation of
germinal centers & proliferation of
plasma cells
Treatment opens drainage
path
avoid OMT over nodes
Chapman’s Points
Thoracic Spine Dx/Tx
Thoracic Inlet Release
Rib Raising
Auricular Drainage
Mandibular Drainage
(Galbreath)
Thoracic/Splenic Pump
OCF (esp temporals, C0 &
occipitomastoid suture)
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CHAPMAN’S REFLEXES
Diagnose BEFORE
use of OMT!
Finding a tissue
texture change at
which site would
suggest an
otitis media?
D
A
B
E
C
O
T
I
T M
I E
S D
I
A
Stretches contralateral
medial pterygoid muscle:
Opens eustachian tube
Helps TMJ Tracking
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Stretch to side move
1.
2.
Treat Facilitated Segment(s)
Release Thoracic Inlet
•
3.
4.
5.
6.
7.
8.
9.
Cervico thoracic junction/1st Rib
Anterior Cervical Arches
Anterior/Posterior Cervical Chain
Galbreath Technique
Auricular Chain
Frontal Nasal Release
Trigeminal Stimulation
Facial effleurage
•
Frontozygomatic, maxillary, & mandibular
Nicholas Atlas
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Sympathetics
Cell bodies: T1-4
Multiple cervical
sympathetic ganglia
(note ganglia sites relative
to cervical vertebra)
But C2 also has Direct
Connection to Vagus
(Parasympathetic)
SUB-OCCIPITAL RELEASE:
Using hands or forearms as a lever, place tips of flexed fingers
on lower occiput & lean back w direct MFR of suboccipital muscle
& fascia. As tissue softens, advance & repeat till reach Foramen magnum
(opisthion) & observe deep relaxation of patient.
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Occipital Mastoid Suture and Temporals
TMJ DYSFUNCTION AND PAIN
OCCIPITO‐MASTOID SCS TENDERPOINT
LOCATION OF THE TENDER POINT: Over the occipito‐mastoid suture on a small vertical ridge of bone2‐3 cm posterior and cephalad from the tip of the mastoid process.
ANATOMICAL CORRELATION: As stated above.
DIRECTION TO PRESS ON THE TENDER POINT: Press in an anterior medial direction over the tender point location. TREATMENT POSITION: With the patient supine and you sitting at the head of the table, place your palms flat on the sides of the head with your ring finger and small finger around the undersurface of the mastoid processes. Apply a mild to moderate compression with both palms. Then twist one side in a clockwise or counterclockwise direction around a transverse axis as if to unscrew a jar cap. Apply counter rotation to the opposite side. :Twist both ways to find the direction of greatest ease and patient preference and hold in that direction.
CLINICAL CORRELATIONS: Frontal headache, Pain behind the eye, Periorbital pain, Ear ache, Tinnitus, Vertigo and TMJ pain.
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BELL’S PALSY –Stylomastoid Foraminal
Inflammation of VII Facial CN
• OMT Attention to:
– Temporal bones
– Compression of Occipitomastoid sutures
– C2, OA
– T1‐T4
– Posterior digastric muscle
– SCLM
– Lymphatics at anterior and posterior chains
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Dural Tube Stretch
Suboccipital Release, Supine
Decompression Ethmoid‐Vomer:
• Indications: chronic sinusitis, “sinus HA,”
Hx trauma to eye, nose or face.
• Place thumb & index fingers between
eyebrows (glabella) & just below bridge of
nose.
• Hold one, move one.
• Test motion in all 3 planes (sup/inf,
med/lat, CW/CCW).
• Use Still technique or BLT with further
compression to find new point of balance.
• Retest.
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Lymphatic/Fascia
• Stain Counterstain to Head, neck and
upper body
• Still Technique– Thoracic Inlet: Necklace Technique
– MFR Ant C Muscles & Fascia w Hyoid Bone
• BMT/BLT– Abdominal Diaphragm Release,
– OA
• Resistive Duction: ME to Eye
Myofascial Release Ant. Strap Muscles using Hyoid
Bone (can even do trachea for deeper MFR)
• Esp for trouble
swallowing pills etc,
freq. throat clearing
• Take up 3 planes of
motion (sup/inf,
med/lat, CW/CCW)
(indirect or direct)
• Allow to rebalance
• Can apply principle
of the Still
technique (go
indirect, then
direct, then neutral)
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Balance Diaphragm to Breathing:
Take indirect, enhance w breath, Take direct, enhance w breath,
Return to midline, synch both sides with breath. Retest.
Omohyoidius
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SCLM
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SCLM TENDERPOINTS‐ TWO DIVISIONS
Suboccipitals
•
•
•
•
•
Affect Vagus nerve balance
Affect Vision
Affect Sinus Congestion
Affect Neurovascular cephalgia threshold
Affect occulogyric reflex‐ balance
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Posterior Cervical Points
C1 Tender point
• Picture showing point locations...
C1: located low on occiput, approximately 2 cm lateral to muscle mass at back of neck
Posterior Cervical Tender Points
C1 Tender Point
Lateral Tender Points
•C2‐C7: located on spinous process of vertebrae and laterally in paravertebral muscle masses
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Posterior C1(and C2) Tender points
Posterior Cervical Tender Points
C1 Tender Point
• Contact C1 TP on low occiput 2 cm lateral to muscle mass
• BB high cervicals, and introduce caudad pressure on high occiput bone
• **Backward bend before pressure or else you’ll get compression only
Lateral Tender Points
C3 Tender Point
• Contact INFERIOR surface of C2
• Flexion to approximately 45 degrees
• Sidebending and rotation away from the side on which the spinous process is tender • Wait...
Posterior Cervical Tender Points
C1 Tender Point
Lateral Tender Points
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C4 Tender Points
• Inferior portion of C3 spinous process • Seen with TMJ
• Hang head over table
• finger directly over C4 level
• Light compressive force on top of occiput; less than used in C1
Posterior Cervical Tender Points
C1 Tender Point
Lateral Tender Points
C5‐8 Tender Points
Posterior Cervical Tender Points
• Patient supine, support head off end of table
• Extension down to appropriate level
• Monitor TP
• Sidebend and rotate away from the tender point
• Fine tune…wait…
C1 Tender Point
Lateral Tender Points
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Anterior C1 Tender Point
•Also known as
the OA joint TP
•High on
posterior
ascending ramus
Anterior Cervical Tender Points
of mandible
•90º rotation
away
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
Anterior C2-6 Tender Points
Located on Anterior Surface
of tips of the transverse
processes
Anterior Cervical Tender Points
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
•Flexion to TP
•Equal SB away
and Rot away
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Anterior C7 Tender Point
•2 cm lateral to medial end of
clavicle on superior, posterior
surface
•Flexion to C7
•Sidebending toward - Rotation
away (slightly)
Anterior Cervical Tender Points
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
Anterior C1 Tender Point
•Also known as
the OA joint TP
•High on
posterior
ascending ramus
Anterior Cervical Tender Points
of mandible
•90º rotation
away
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
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Anterior C2-6 Tender Points
Located on Anterior Surface
of tips of the transverse
processes
Anterior Cervical Tender Points
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
•Flexion to TP
•Equal SB away
and Rot away
Anterior C7 Tender Point
•2 cm lateral to medial end of
clavicle on superior, posterior
surface
•Flexion to C7
•Sidebending toward - Rotation
away (slightly)
Anterior Cervical Tender Points
•Ant. Cerv TP’s
•Typicals
•AC2-AC6
•Atypicals
• AC1, AC7,
AC8
•Lateral column
points
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Anterior C8 Tender Point
•Medial end of clavicle at sternoclavicular joint
•Flexion to C8
•SB away and Rotate away
Galbreath’s Maneuver: Mandibular Pump to improve
Eustachian Tube drainage
• Hold One, Move One:
• Soft tissue technique using jaw
motion to increase drainage of
middle ear structures and
tonsilar congestion via the
Eustachian tube and
lymphatics-direct MFR
• Gentle ant-inf-medial traction
on the proximal mandible-don’t
dislocate TMJ!
• Pumping action about 30
seconds-10 reps
• Can teach parents: 10 reps x 2
sets both sides 2-3 x/day
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Galbreath Maneuver:
Mandibular Pump for Eustachian Tube
Anterior C1 Tender Point‐ SCS
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Proper Frontal Release
Open sinuses &
decrease sinus
headache (Also
dural HA post-lumbar
puncture & to
balance RTM)
“Not the Best” Frontal Lift: Dural & Sinus Release
• Place Hypothenar eminences gently but
firmly over lateral processes of Frontals
• Interlock fingers & maintain lat. traction
• Gently compress till each side disengages,
then lift ant. till each side releases.
Reseat.
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Sinus Efflurage
& Trigeminal Reflexes:
• Stimulates Trigeminal Centers
– Supra-orbital, Infra-orbital
– Sub-maxillary, Sub-mental
• Stroking moves the lymphatic fluid in
superficial fascia
• Allergic or Infective
• Repetitive strokes
– Thumbs across the frontal, maxillary, from
medial to lateral, ending near the earlobe
– Follow with milking anterior SCM on
each side towards lymphatic
ducts
under Rib 2
Mfr to fascial DYSF of eye:
Orbit & globe:
• Dx: Gently place T, I, M & R fingers around lat
edges of both globes. Test each for CW & CCW
motion. Repeat with fingers around both orbits.
• Tx one side at a time, one plane (globe or orbit)
at a time:
• Still: Take indirect till softens, then direct till
softens then to neutral. Retest.
• BLT: Take to midpoint of available motion &
hold till inherent motion rebalances & pauses.
Retest.
• Restores EOM & fascial balance w improved
fluid drainage
• May also do lymphatic pump-lat to med
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A Final note:
• You (and your residents) have a unique
opportunity as physicians with knowledge of
the Osteopathic principles to apply these:
– Pre-op
– Intra-op
– Post-op
• Balance the fascia, ANS, lymphatic and
blood circulation
• To restore structure & function
• Enhance the Health (homeostasis) of your
patients, and maximize healing –and for $$
You Can and Should be Paid for OMT
• Even if you treat 3‐4 parts of the body‐ Head, Neck and Thoracic Spine, and or Shoulders on only 5 patients a week‐
– You will be able to charge for several minutes more work, about $100+ more per visit.
– (At $100 more X 5 days a week X52 weeks=$2600!
Example‐
E&M Coding: 99213‐25 Office visit Established Patient WITH additional Procedure
Dx: MUSCLE TENSION HEADACHE
CPT: 98926 OMT to 3‐4 Parts of body
ICD‐9 739.0,739.1, 739.2, 739.7+ HA Dx
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Further Information:
• Searching Electronic Databases:
– Pub Med
– OSTMED.DR
• For further Osteopathic studies:
• Learning to Code for Reimbursement of OMT:
• Making a referral to NMM/OMM Specialist:
– www.academyofosteopathy.org
– www.cranialacademy.org
Special Thanks to:
• Michael Kuchera, DO, FAAO
• Harmon L. Myers, DO
– For their kind permissions and contributions to this lecture and to Osteopathic Education
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REFERENCES:
•
•
•
•
•
•
•
•
Kuchera, M and Kuchera, W, Osteopathic Considerations in
HEENT Disorders, Greyden Press, Dayton OH, 2011.
Worden, KA, OMM Applied to EENT Workshop at the Annual
Meeting of American Osteopathic College of Ophthalmology
and Otolaryngology (AOCOO), Tucson, AZ 4hr, May 2011
presenter.
Chila, A, ed, Foundations of Osteopathic Medicine, 3rd ed,
2010.
Worden, KA, OMM & Visceral Disease: How Do We Impact
Medical Conditions with OMT? workshop given AZ Osteopathic
Medical Association Spring Convention, 4/23/2009.
Channell, M and Mason, D, The 5 Minute Osteopathic
Manipulative Medicine Consult, Lippincott Williams &
Wilkins, 2009.
Nelson, KE, and Glonek, T, Somatic Dysfunction in
Osteopathic Family Medicine. ACOFP: Lippincott, Williams &
Wilkins; 2007.
Ward, RC, ed, Foundations of Osteopathic Medicine, 2nd ed,
2003, pp. 931-940.
Kuchera, M and Kuchera, W, Osteopathic Considerations in
Systemic Disease, 2nd ed, 1994.
Now we move on to the OMT Lab Session
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