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!
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