I Can Do OMM For That? V O M A

I Can Do OMM For That?
APRIL 5, 2014
 Go over common issues
 Review anatomy
 Review mechanism
 Give time efficient ways to use techniques
 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
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
Normal Anatomic Variants
 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%
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
 Cervical rib
 Muscles variant
 Trauma/ Injury
Cervical Rib
 X-ray
 Ultrasound
 CT angiogram/venogram
 Physical exam findings
Worse with over head motions, trauma to area,
obiesity, computer work
Modified Adson
Roos: checking pulse
Costoclavicular manuver
Hyperabduction-extension test
Direct pressure over outlet: symptoms
 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
 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
 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
 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
Respiratory Diaphragm
and salts
Emulsified fats (Chyle)
cellular immunity
B-Lymphocytes humoral immunity
Left Lymphatic Duct
(Thoracic Duct)
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
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
 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
I Want YOU to Do OMM!