Download Osteopathic Medicine

OMT for LBP
Samuel A. Yoakum, DO, MS, FAAPMR
Tennessee Orthopaedic Clinics: TOC Spine
Knoxville, TN
Disclosures
none
Outline
Background
Definitions
Diagnosis
Techniques
Manual therapy
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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
Osteopathic Medicine
Definitions:
•Osteopathy = Osteopathic medicine
•Osteopathic manipulative medicine = OMM
•Osteopathic manipulative treatment/techniques = OMT
•Doctor of Osteopathic Medicine = 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.”
Osteopathic Medicine
Andrew Taylor Still
• Founded Osteopathy 1870’s
• Previously trained as an MD
• Lost entire family to meningitis
• Devoted to the study of
anatomy and physiology
• Early Hipster
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
Diagnosis
Somatic Dysfunction
● Tissue Texture Changes
o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed,
atrophied, rigid, moist, dry
● Asymmetry
o Macro and Micro
● Restriction of motion = a deeper look at ROM
o Named for FREEDOM Of MOTION
o Restricted motion is the BARRIER
● tenderness
o Tenderpoints vs. Triggerpoints
Tissue Texture Changes
● Acute
● Chronic
o Edematous
o Flat
o Erythematous
o Cool
o Boggy
o Leathery, low tone
o Slick, sweaty
o Flaccid, ropy, fibrotic
Asymmetry
● Group curvature
● Single segment disfunction
● Compare Side-to-side
● Mastoid
● Acromion
● Lower ribs
● Iliac crests
● Greater trochanters
● Lateral femoral condyles
● Lateral malleoli
Restriction of motion
Alignment vs Restriction
- everyone has some asymmetries
- sometimes it points to dysfunction
- sometimes it is normal
Symmetry is less of a goal than improving
restriction
The Barrier Concept
● BARRIER stops motion
● FREEDOM Of MOTION is opposite the barrier
● Barriers
o Anatomical
o Physiological
o Restrictive
Anatomical & Physiological Barriers
So what is wrong?
Assessment and Diagnosis
- Observe gait
- Structural exam: standing, seated
- Axial spine exam
- Extremities
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Tenderness and Tissue Texture change are homing
beacons
Asymmetry sets the stage
Restriction of motion answers the question
Common LBP Problems
Diagnosis
- Soft tissue injury
- Myofascial strain / tenderpoints
- Muscular: iliopsoas, QL, paraspinals,
hamstrings, piriformis, gluts, multifidi
- Malrotated Sacrum and/or Ilium
- Lumbar Segmental restriction
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
Know how you are treating
● 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
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
Soft Tissue Mobilization
High Yield Targets:
Lumbar paraspinals, T-L junction, flank
● Allows treatment to other parts of the body to be
more effective.
● Gently and directly applying pressure through the soft
tissue layers: skin, fascia, adipose, muscle.
● Deep articulation, in contrast, engages joint motion
Myofascial Release (MFR)
High Yield Targets:
Fascial restrictions
TL junction, iliolumbar ligament, sacral
● 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.
Counterstrain
High Yield Targets:
Tenderpoints
Iliolumbar ligament, piriformis, hamstring
lumbar and sacral TP
What is a tenderpoint?
● Tenderpoints are small tense edematous areas of
tenderness typically located near tendon attachments,
ligaments, or in the belly of some muscles.
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.
If you can put it into a position of comfort, you can
probably treat it with counterstrain
Facilitated Positional Release (FPR)
High Yield Targets:
SI-joint fascia, piriformis, lumbosacral junction
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Indirect technique
Set up is similar to counterstrain
Add activating force (compression or distraction)
Takes 3-4 seconds to induce a release
Great techniques for spine and joint
dysfunctions
Muscle Energy
High Yield Targets:
Iliopsoas, hamstring, quad, piriformis
anterior/posterior ilium, sacral torsion
lumbar segmental dysfunction
● Muscle energy ~ “contract-relax”
● Direct technique
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Barrier engaged
Patient contracts against holding force
Relax, muscle lengthens
Engage a new barrier
Repeat
High Velocity,
low amplitude
High Yield Targets:
Anterior/Posterior sacrum or Ilium
Lumbar segmental dysfunction
● Confronts restricted articulations “head on”
● Don’t try it if you don’t know how
● Barrier is engaged, fine-tuned 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
● Don’t do it if you don’t know how