I Can Do OMM For That? SAUNORA PROM, DO, C-NMM/OMM, CAQSM VOMA APRIL 5, 2014 Objectives  Go over common issues  Review anatomy  Review mechanism  Give time efficient ways to use techniques Topics  Pregnancy  OB, FM, husbands  Thoracic Outlet Syndrome  Ortho, Neuro, FM, ER, friends of “desk jockeys,” spouses  Pneumonia  Hospitalists, FM Low Back Pain in Pregnancy  Very common, 60-80% of pregnant women during course of pregnancy  Multiple musculoskeletal changes  Weight gain, 25-35 lbs  Laxity of ligaments   SI Iliolumbar Musculoskeletal Changes of Pregnancy Musculoskeletal Changes of Pregnancy  Increased lumbar lordosis, thoracic kyphosis  Poor rib/diaphragm motion  Increased motion of SI/pelvis  Restriction of thoracic outlet OMM in Pregnancy  Usually needs less force  Try to be efficient with time  Start with problem area, then work out  F/U typically follows regular OB schedule.  Always assess the piriformis  Most techniques are tolerated well. Few modifications for pregnancy  Some techniques work better then others Piriformis Normal Anatomic Variants Piriformis  Origin: Pelvic surface of sacrum (Anterior)  Insertion: Greater trochanter of femur  Action: External rotation, abduction  Stabilizes hip joint Pelvic Floor OMM schedule  Ideally begin in first trimester  Follows typical OB schedule  Monthly: first visit – 28 wks.  Bi-weekly: 28-36 wks.  Weekly: 36 wks - delivery  Unless more frequent visits are needed OMM in pregnancy  Leg pull  Pelvic floor MFR  Rib raising  Piriformis counterstrain  HVLA thoracic spine, lumbar spine, cervical  Thoracic outlet MFR Some Tips ● Aim for patient comfort ● Be creative with techniques ● Less force is usually needed with HVLA ● Remember seated techniques ● SI belts ● Worst case scenario: Remind the patient that they will deliver soon, hopefully Thoracic Outlet Syndrome  Common complaint  Can be similar to radicular pain  Numbness  Tingling  Cervical pain  Multiple etiologies of thoracic outlet syndrome  Neurogenic TOS: 1: 1,000,000    Disputed TOS: 95% Venous TOS: 3% Arterial TOS: 1% Anatomy Anatomical Triangles  Spaces or areas that can cause TOS symptoms  Scalene triangle anterior, middle scalenes and 1st rib  Brachial Plexus and Subclavian artery   Costoclavicular space space between 1st rib and clavicle  Brachial plexus, subclavian artery, SUBCLAVIAN VEIN   Pectoralis Minor space Pectoralis minor and the chest wall  Brachial plexus, subclavian artery and vein  Pathogenesis  Cervical rib  Muscles variant  Trauma/ Injury Cervical Rib  Diagnosis  EMG  X-ray  Ultrasound  CT angiogram/venogram  Physical exam findings Diagnosis • H&P: – • • • • • • Worse with over head motions, trauma to area, obiesity, computer work Adson's Modified Adson Roos: checking pulse Costoclavicular manuver Hyperabduction-extension test Direct pressure over outlet: symptoms Spurlings  Performed with the patient seated.  A compressive force is applied to the patient’s head if the patient experiences pain the problem is more likely due to nerve root compression rather than thoracic outlet syndrome. Adson Test  Performed on the symptomatic arm.  While palpating the radial artery, the arm is abducted and the patient turns their head toward the affected side and extends the neck, then takes a deep breath.  A positive test is when pulse diminishes, disappears, or if the patient’s symptoms are reproduced.  If the test is negative it can be repeated with the head turned to the other side for confirmation.  If the Adson test is positive and there is no radiographic evidence of an abnormality, consider evaluation of the scalenes. Roos Test  The patient repeatedly clenches and unclenches the fists while keeping the arms abducted and externally rotated (palms forward and upward); the elbows are braced slightly back of the frontal plane.  The test is positive when the symptoms are reproduced with the maneuver.  A positive Roos test is very suggestive of the diagnosis of Thoracic Outlet Syndrome. Roos Test OMM for Thoracic Outlet Syndrome  Scalene  Pectoralis minor  Upper extremity  Thoracic Outlet  First rib  T1-4  C6-7 Hospitalized Patient  Community Acquired Pneumonia (CAP) is relatively common, 5-6 per 1000  Pneumonia and Influenza was 8th most common reason of death in US in 2005  2010- 1.1million people hospitalized with pneumonia  Average length of stay (LOS) in the hospital: 5.2 days OMM in Patients with Pneumonia  Can reduce the LOS  Improve patient satisfaction  Decrease the frequency of respiratory failure  Decrease the amount of IV antibiotics Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia  2010- Noll, D et al.  387 pts., > 50 y.o., hospitalized with pneumonia.  Multicenter trial  3 treatment arms: conventional care only (CCO), light touch (LT), OMM  2 x / day treatment  Length of stay, time until clinical stability and a symptomatic and functional recovery score Results  Decreased LOS: OMT: 3.5 (3.2-4.0), CCO: 4.5 (3.9- 4.9), LT: 3.9 (3.5-4.8)  Decreased IV abx duration, death and respiratory failure were less * Statistically significant difference in OMT group vs CCO but not to LT group. OMM Techniques  Thoracolumbar soft tissue  Rib raising  Doming of the diaphragm myofascial release  Cervical spine soft tissue  Suboccipital decompression  Thoracic inlet myofascial release  Thoracic lymphatic pump  Pedal lymphatic pump  Inpatient or outpatient Why Treat These Areas?  Rib raising/ Thoracolumbar fascia  Improved rib motion  Sympathethic  Improved diaphragm function  Diaphragm  Main driver of lymphatics  Improved respiration  OA  Parasympathetics  Lymphatic pumps  Improved lymph motion/drainage Sympathetics Parasympathetics Respiratory Diaphragm Lymph Proteins and salts Emulsified fats (Chyle) Lymphocytes Defense T-Lymphocytes cellular immunity B-Lymphocytes humoral immunity Left Lymphatic Duct (Thoracic Duct) The trunk, left side of head and neck, left arm, thorax, lower extremities 36-45 cm in length Enters venous system between left subclavian and the left brachiocephalic vein Right Lymphatic Duct Right head and neck, right arm and right chest(heart and right lung) Terminates into right subclavian vein One way valves under sympathetic tone Thoracic duct and other larger lymph vessels have smooth muscle cells and are under sympathetic control Sympathetic Chain Ganglia Hospital OMM Tips  Begin OMM early in visit  Do two things at once  Position hospital bed for comfort  Be aware of lines  Use indirect techniques References  UpToDate.com  Noll DR, Dengenhardt BF, et al; Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia. Osteopath Med Pri Care 2010 March 19  Nicholas AS, Nicholas, EA; Atlas of Osteopathic Techniques, 2nd; LWW  Kuchera, M, Osteopathic Considerations in Systemic Dysfunctions I Want YOU to Do OMM! THANK YOU!