Download Osteopathic Approach to Treatment of the Obstetrical

3/12/2012
Osteopathic Approach to Treatment of:
1. Obstetrical Patient
2. Geriatric Patient
Stuart Williams D.O.
Chairman & Associate Professor
Osteopathic Manipulative Medicine
Objectives
Review the Structural and Functional changes that take
place during gestation.
Discuss and practice OMT techniques helpful for obstetrical
patients with:
Edema
Low Back Pain
References
Foundations of Osteopathic Medicine, 3rd Ed, 2011,
Anthony Chila D.O., P 961-973.
Somatic Dysfunction in Osteopathic Family Medicine,
Nelson, Glonek, 2007, P 108-125.
Osteopathic Considerations in Systemic Disease, Revised
2nd Ed, Kuchera & Kuchera, P 149-158.
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Common Complaints
• Edema (esp LE swelling)
• LBP
Differential for LE Swelling
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Varicosities
Passive vascular congestion
Preeclampsia
Lymphedema
Thrombophlebitis
DVT
Cellulitis
UTI
Somatic Dysfunction
Differential Dx for LBP in Pregnancy
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Spinal facet
Leg‐length inequality
Overweight
Trauma
Scoliosis
Somatic dysfunction
Spondylolisthesis
Congenital
Multiple gestations
Discogenic
Ligamentous laxity
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Differential Dx cont.
• Viscerogenic
– Urinary tract
– Bowel function
– Endometriosis
– Pelvic Infection
– Labor
Vascular
compression of gr v.
venous plexopathy
thrombosis
placental location
Changes in Pregnancy
• Center of Gravity
– Affects both:
• Posture – lordosis tips sacrum forward LBP
• Gait
• Both Joint motion restrictions and hypermobility
• Pressure from expanding uterus – Decreases venous and lymphatic drainage esp from dependent areas (LE) Edema
Somatic Dysfunction in Pregnancy
• Compensated m/s imbalances while nonpregnant may decompensate during gestation Somatic Dysfunction
• A scoliosis that may not have bothered a patient may become more uncomfortable
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Physical Examination
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Observation
Palpation
ROM
Muscle Imbalances
DTRs
Posture
Degree of lumbar lordosis
Contraindications to OMT in Pregnancy
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Undiagnosed vaginal bleeding
Ectopic pregnancy
Placental abruption
Untreated DVT
Elevated maternal BP
Preterm labor
Unstable maternal VS
Fetal distress
• “Only one report has been published concerning complications of direct manipulation in the pregnant patient.”
Foundations of Osteopathic Medicine, 3rd Ed, 2011.
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Edema (both OB and Geriatric)
• Goal: efficient and effective venous and lymphatic drainage • Areas of Restriction to address:
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Craniocervical Junction
Thoracic Inlet
Thoraco‐abdomenal Diaphragm
Pelvic Diaphragm
• Methods to augment the flow of fluids: 3rd space, lymph
Pelvic Diaphragm
Ischiorectal Fossa Release and Dome Pelvic Diaphragm
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Distention of the pelvic diaphragm must be in phase with the continual movements of the thoracic diaphragm and also with the transient changes in intrapelvic pressure
This aids in free flow of fluids within the vascular and lymphatic channels of the pelvic region
Pages 56‐58 in the Kimberly Manuel
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Ischiorectal Fossa Release and Dome Pelvic Diaphragm
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Lymphatic flow depends on elasticity of the pelvic floor
The pelvic floor must compensate for respiratory pressures and the transient increase of pressure caused from coughing, sneezing, hiccups, pregnancy etc
A rigid pelvic floor leads to dysfunction
Pelvic Region Ischiorectal Fossa Release, Supine
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The patient lies supine with the hips and knees flexed. The physician sits at the side of the table opposite the side of the dysfunction to be treated. The physician places the thumb of the hand closest to the table medial to the ischial tuberosity (arrow, Figs. 16.80 and 16.81) on the dysfunctional side. The physician exerts gentle pressure cephalad (arrow, Fig. 16.81) into the ischiorectal fossa until resistance is met and then applies a lateral force (curved arrow, Fig. 16.82). The physician can attempt to feel a fluid ebb and flow with a resultant release or add a release‐enhancing mechanism by instructing the patient to inhale and exhale deeply. With each exhalation, the physician exerts increased cephalad pressure on the pelvic diaphragm until no further cephalad and lateral excursion is possible. This technique is repeated on the opposite side of the pelvis as needed
16.80 16.81) Fig. 16.82). 6
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Plantar Fascia
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Interosseous Membrane
Interosseous Membrane
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Fibular Head and Interosseous Membrane
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Technique: Supine Direct Ligamentous Articular Release
Findings: – Posterior and lateral knee pain or unstable ankle with chronic spraining of the ankle. The latter is a result of an unstable ankle mortise with the fibula displaced at the knee. Pt is supine and Physician
is seated facing the side of the table at the level
of the affected knee
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Fibular Head and Interosseous Membrane
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Treatment.
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Flex the hip and the knee to 90 deg.
Slightly externally rotate the femur
With the cephalad arm, bend elbow to 90 deg and prop it on the table making a pedastal out of your forearm and thumb. With the pad of the thumb push the posterior superior portion of the fibular head inferiorly toward the pt’s foot. The distal hand inverts and slightly medially rotates the foot. A release occurs when the fibular head moves inferiorly and anteriorly and slides back into the socket. Interosseous Membrane Somatic Dysfunction
• Diagnostic findings:
– Tissue texture changes anywhere between fibula and tibia
– One or both ends of the fibula restricted
– Ankle function may be impaired
– Tenderness at proximal tibiofibular joint, distal tibiofibular joint and/or ankle
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Popliteal Fascia
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Direct MFR: Popliteal Fascia
• Technique: supine, direct, MFR
• Findings: Pain behind the knee or baker’s cyst.
• Physician: Seated at the side of the table inferior to the patient’s knee, facing the head of the table. Direct MFR: Popliteal Fascia
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Procedure:
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With the patient’s leg relaxed place your fingertips just above the popliteal fossa.
Fingers of both hands are bent with the fingernails of the two hands facing each other and thenar eminences about 3” apart to form a “plow” shape. Press anteriorly just superior to popiliteal fossa.
Draw the fingers inferiorly until resistance is felt, then hold until the release occurs.
Soft Tissue
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Pubic Decompression
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PUBIC COMPRESSION/ DECOMPRESSION
Compression of Pubic Symphysis
pubic bones are forced toward each other at the pubic symphysis
Characteristic Findings
tender over symphysis bilaterally.
lack of apparent asymmetry.
restriction of motion at pubic ring.
ASIS springing affected bilaterally
Note: Pubic shears are usually associated with pubic compression. It’s a good idea to
decompress the pubic bones prior to treating a shear.
PUBIC DECOMPRESSIONMUSCLE ENERGY
1. Pt. supine on table, knees and thighs flexed.
2. Feet flat on table 10-12 inches apart.
3. Grasp both knees. “Try to pull your knees apart.” (abductor muscles pull laterally on
innominate compressing the symphysis further to prepare it to relax.)
4. Repeat.
5. Heel of one hand in knee, posterior distal humerus in other knee.
6. Knees 10 to 12 inches apart. “Try to pull your knees together.”
7. Repeat . (av. 3 times)
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Innominate Rotations
INNOMINATE ROTATION
Innominate: 3 fused bones
ilium
ischium
pubis
Articulations:
innominates
femur at acetabulum
sacrum at SI joint
pubic bones articulate with each other at symphysis.
Do lateralizing tests 1st to determine side of somatic dysfunction:
ASIS compression test, standing flexion, seated flexion.
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ANTERIOR INNOMINATE ROTATION
Def: one innominate will rotate anteriorly compared to the other.
- tight quadriceps
Diagnostic Findings: ex: Right Anteriorly Rotated Innominate
ASIS more inferior on R
PSIS more superior on R
Right sulcus shallow
Right sacrotuberous ligament loose
Right medial malleolus may be inferior
AP compression test restricted on R
+ standing flexion test on R
+ sitting flexion test on R
ANTERIOR INNOMINATE ROTATION SUPINE
MUSCLE ENERGY
Ex: Right Anterior Innominate:
1. Pt. supine & D.O. on side of dysfunction.
2. Flex lower extremity on side of dysfunction at knee and hip.( no abduction as in shear
and flare).
3. Put shoulder against pt’s leg & cup ASIS with cephalad hand & ischial tuberosity with
caudad hand.
4. Hold tension at all points until innominate rotates posteriorly to restrictive barrier.
5. “Push knee against my chest.”
6. Sense that force is localized at SI joint.
7. Wait 3-5 seconds.
8. Flex hip and rotate innominate posteriorly to new restrictive barrier.
9. Repeat until best motion. (usu. 3 times). Recheck.
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INNOMINATE POSTERIOR
Def: one innominate will rotate posteriorly compared to other.
(remember to lateralize: ASIS compression, Standing and Seated
flexion tests).
Physical Examination:
ASIS superior on involved side.
PSIS more inferior on involved side.
medial malleolus may be superior
AP compression restricted on involved side.
+ standing flexion test on involved side.
+ sitting flexion test on involved side
sacrotuberous ligament tight on involved side.
tender over SI joint.
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INNOMINATE POSTERIOR
SUPINE MUSCLE ENERGY
EX: Left Posterior Innominate
1. Pt. supine & D.O. on side of somatic dysfunction.
2. Pt. on edge of table allowing ischial tuberosity to be off edge.
3. Leg hangs freely.
4. Cephalad hand reaches across & stabilizes opposite ASIS.
5. Tension applied to ant. thigh rotating innominate anterior to new restrictive barrier.
(D.O. leg on outside of pt’s leg).
6. “Pull your knee up to the ceiling.”
7. Sense that contractile force is localized to SI joint.
8. Extend extremity to new restrictive barrier.
9. Repeat until best motion obtained. ( usu.. 3 times.)
10. Recheck.
Sacral Base Anterior
Name: Sacral Base Anterior, Bilateral Sacral Flexion
Lateralization: Does NOT matter.
Spring test: Negative
Landmarks:
Sacral Base:
Sacral Sulcus:
ILA:
STL:
Bilaterally (B/L) Anterior
B/L Deep
B/L Posterior
B/L Tight
Ant +
Deep
Ant+
Deep
Motion:
Sacral Base:
ILA:
B/L +
B/L –
Post - Post-
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LUMBAR REGION‐MUSCLE ENERGY
LUMBAR NEUTRAL
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SEATED‐DIRECT METHOD – MUSCLE ENERGY
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Lumbar neutral, side‐bending left, rotation right
1.Patient straddles the end of the table and the physician stands to the left and behind the patient
2.Patient’s right hand is placed on his/
her left shoulder
3.Physician reaches across the patient’s
chest with his/her left hand, grasps
right shoulder of arm, and leans against the patient’s left shoulder
4.Physician places the pad of his/her
right thumb on the TP of the dysfunctional
segment to monitor motion and provide a fulcrum
5.Physician induces varying increments of left
rotation, right side‐bending, and flexion or extension until
there is full engagement of the restrictive barrier. Keep the
patient upright and balanced
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LUMBAR REGION‐MUSCLE ENERGY
6.Patient is instructed to “bend to the left against me”
7.Patient maintains force for 3‐5 seconds
8.Patient is instructed to relax
9.Physician waits about 2 seconds and then repositions all planes to the new restrictive barrier
10.Repeat 3‐4 times
11.Recheck
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THANK YOU!!!
Questions?
Stuart F. Williams D.O.
Chair and Associate Professor, OMM
Edward Via College of Osteopathic Medicine, Carolinas Campus
Spartanburg, SC 29303
864‐327‐9832 [email protected]
Brian Mulroy D.O.
Year Family Medicine Resident
Spartanburg Regional Medical Center
Member of our PPC/OMM Faculty
3rd
Assisting me with this workshop.
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