Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 $$. 1 5/19/2016 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. 2 5/19/2016 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 3 5/19/2016 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 4 5/19/2016 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 5 5/19/2016 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 6 5/19/2016 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 7 5/19/2016 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 8 5/19/2016 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) 9 5/19/2016 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 10 5/19/2016 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 11 5/19/2016 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 12 5/19/2016 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 13 5/19/2016 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) 14 5/19/2016 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. 15 5/19/2016 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 16 5/19/2016 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 17 5/19/2016 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 18 5/19/2016 & TONGUE RETINA & THYROID Retina & Thyroid 19 5/19/2016 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 20 5/19/2016 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 21 5/19/2016 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 22 5/19/2016 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 23 5/19/2016 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 24 5/19/2016 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 25 5/19/2016 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 26 5/19/2016 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? 27 5/19/2016 SINUSES MIDDLE EAR SINUSES PHARYNX-TONSILS BRONCHUS LARYNX UPPER LUNG LOWER LUNG Middle Ear Sinuses, Pharynx Larynx Nasal Sinuses Bronchus Lung 28 5/19/2016 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) 29 5/19/2016 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 30 5/19/2016 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 31 5/19/2016 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. 32 5/19/2016 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. 33 5/19/2016 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 34 5/19/2016 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. 35 5/19/2016 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) 36 5/19/2016 Balance Diaphragm to Breathing: Take indirect, enhance w breath, Take direct, enhance w breath, Return to midline, synch both sides with breath. Retest. Omohyoidius 37 5/19/2016 SCLM 38 5/19/2016 SCLM TENDERPOINTS‐ TWO DIVISIONS Suboccipitals • • • • • Affect Vagus nerve balance Affect Vision Affect Sinus Congestion Affect Neurovascular cephalgia threshold Affect occulogyric reflex‐ balance 39 5/19/2016 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 40 5/19/2016 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 41 5/19/2016 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 42 5/19/2016 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 43 5/19/2016 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 44 5/19/2016 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 45 5/19/2016 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 46 5/19/2016 Galbreath Maneuver: Mandibular Pump for Eustachian Tube Anterior C1 Tender Point‐ SCS 47 5/19/2016 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. 48 5/19/2016 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 49 5/19/2016 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 50 5/19/2016 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 51 5/19/2016 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 52