OMT & Sports Injuries - FSACOFP
Transcript of OMT & Sports Injuries - FSACOFP
"OMT & Sports Injuries"
Disclosure
• The Presenter Has No Financial Relationships With Commercial Interests That Would Constitute A Conflict Of Interest Concerning This Presentation.
Outline
• Review Of The Basics Including:
1. The Tenets Of Osteopathic Medicine
2. Basic Terminology
3. Basic Documentation
• Discuss The Basic Sciences Of Two Common Sports Related Injuries
• 10 Min Break
• Lab
• Closing Remarks
The Basics
The Basics: The Tenets of Osteopathic Medicine
• The Body Is A Unit; The Person Is A Unit Of Body, Mind, And Spirit.
• The Body Is Capable Of Self-Regulation, Self-Healing, And Health Maintenance.
• Structure And Function Are Reciprocally Interrelated.
• Rational Treatment Is Based Upon An Understanding Of The Basic Principles Of Body Unity, Self-Regulation, And The Interrelationship Of Structure And Function.
The Basics: Terminology
• Somatic Dysfunction: Impaired Or Altered Function Of Related Components Of The Somatic (Body Framework) System Including The Skeletal, Arthrodial, And Myofascial Structures With The Related Vascular, Lymphatic, And Neural Elements.
• Diagnosed By Observing T-A-R-T Or S-T-A-R In Regions During Physical Examination.
–Fred Mitchell Sr
“Not every injury/problem/lesion is necessarily a Somatic Dysfunction; “Implicit in the term
‘somatic dysfunction’ is the notion that manipulation is appropriate, effective, and
sufficient treatment for it.”
The Basics: Terminology
The Basics: Examples
• Applying For Nmm +1 Residency While Still In ACGME Psychiatry Residency: "How Would You Treat Schizophrenia With OMT?"
• While Doing Neurology Rotation In PGY I Year: "How Would Cracking This Person's Neck Help His Migraine?"
• In A Patient's Chart: • Incorrect: ”Piriformis Syndrome Treated With OMT.” • Correct: “Piriformis Tender Point Treated With OMT.
After Treatment, Patient Noticed A Decrease In Sx Of Piriformis Syndrome Suggesting A Link Between The Above-Listed Dysfunction And Patient's Pain.
The Basics: Documentation - 1
The Basics: Documentation - 2
The Basics: Summary
• Omm/Nmm Is A Treatment For Somatic Dysfunction. It Is Used To Facilitate The Body's Intrinsic Ability To Heal Itself.
• There Is Often Overlap Between Somatic Dysfunction And Illness/Injury.
Injury 1: Concussion
Some Physics
What is the expected outcome and why?
Force
Some Physics
Force
Some Physics
The Brainstem Is Relatively Fixed Meaning Shearing Or Tearing Is Possible
Some Physics
• Reticular Formation: Regulation Of Arousal And Of Consciousness • Pons:
1. Base (Upper): Arousal And Modulation Of The The Sleep–Wake Cycle, Pain Sensation
2. Tegmentum (Lower): Nuclei For CN 6 & 7
Concussion Facts - 1
• Professional Football Players Who Have Had Concussions Are 1.5–3 Times More Likely To Develop Depression Than Their Non-Concussed Team Mates.
• Results Of Brain Imaging And Neuropsychiatric Testing In Retired Players Are Similar To Those Of Patients Who Have Had A Traumatic Brain Injury.
• Previously Concussed Brains Show Excess Cerebral Tau Protein And Plaques And Tangles.
Concussion Facts - 2
• Patients Who Have Had A Concussion Are More Likely To Have Additional Concussions.
• Even After A Patient Has Fully Healed, Subsequent Concussions Will Be More Severe Because Of A Cumulative Effect .
• A Concussed Patient Who Receives An Additional Head Injury Within Days Of The First Is Vulnerable To The “Second Impact Syndrome.”
• Destructive And Potentially Fatal Cerebral Edema. • Affects Children And Teenagers More Frequently And More
Severely Than Adults. • Fatal In Almost 50% Of Cases.
Treatment
• Removal From Sports!!
• Brain And Physical Rest With Titration Of Exertion. • Encourage Patient To Have Some Activity As Being
Bed Bound Or Home Bound Can Worsen Sx. • Explain To Patients That Pushing Themselves
Beyond Their Limits Will Worsen Sx.
• Monitor Progress With Concussion Specific Testing Like SCAT-3 Or Concussion Vital Signs.
• MMSE Not Appropriate
• Reassure
Injury 2: The Unhappy Triad
The Unhappy Triad
Mechanism Of Injury - 1
ACL
Force
Mechanism of Injury - 2
• When The Heel Is Planted In The Ground And The Knee Twisted, The Medially Directed Force Causes A Gapping Of The Medial Compartment Ultimately Causing Tearing Of:
• Acl Resulting In A Positive Anterior Draw And Lachman Test
• Mcl Resulting In A Positive Valgus Stress Test • Medial Meniscus Resulting In A Positive
Mcmurray Test
Treatmement
• R-I-C-E At First
• Surgery For ACL And Meniscus If Necessary
• PRP Beneficial
Lab Session
PINS - 1
• Examine For S-T-A-R (Sensitivity, Tissue Texture Changes, Asymmetry, Restriction Of Motion)
• Use Patient’s Complaint As Guide
• A “Primary Sensitive” Point Is Located. If A Significant One Is Not Found, Then The Physician Widens The Search To Contiguous Areas.
• Another Point, Designated As The “Endpoint” Is Located Distal Or Proximal To The Primary Point. If The Primary Point Is At The Origin Of A Muscle, The Endpoint May Be At The Insertion
PINS - 2
• The Physician Establishes A Muscular, Fascial, And/Or Neurological Pathway Between The Primary Sensitive Point And The Endpoint. The Primary-To-Endpoint Line May Be Curved, Straight, Or Zigzag. The Direction Of Treatment May Be From Distal To Proximal, Or Proximal To Distal.
• Both The Primary Point And The Endpoint Are Pressed Simultaneously Using A Few Ounces Of Pressure By A Finger Pad On Each Hand.
PINS - 3
• The Physician Should Also Determine The Soft Tissue Response To Pressure.
• After A Change In S-T-A-R Is Observed, Another Finger Is Used To Locate A “Secondary Point.” If The Index Finger Is On The Primary Point, Then The Middle Finger Can Be Used To Palpate An Arc To Look For A Secondary Point. The Patient Is Asked To Compare The Initial Primary Point To The Secondary Point.
• Note: The Endpoint Finger Never Changes!
PINS - 4
• If The Secondary Point Is More Sensitive Than The Primary Point, It Becomes The New Primary Point.
• If The Secondary Point And Primary Point Are Equally Sensitive, Maintain Inhibition Of The Primary Point Until Another Change Is Felt And Look For Secondary Point Again.
• If There Is No Secondary Point Found, Maintain Inhibition Of The Primary Point Until Another Change Is Felt And Look For Secondary Point Again.
• Repeat Until Primary Point And End Point Are Approx 2 Cm Apart.
• Re-Evaluate Patient.
Directing The Tide - 1
• Used To Alter The Pattern, Rate, Direction, And Amplitude Of CSF Fluctuation.
• Used To Improve Motion At Cranial Articulations
• Remove Restrictions On The Mechanism
Directing The Tide - 2
• Cradle Patient’s Head Crossing Fingers Beneath Neck, Mcp At Mastoid Processes, Thenar Eminences At Mastoid Portions.
• Observe
• Roll Hands, “Wait For Water In Glass To Be Completely Emptied”
• Roll Hands In Opposite Direction, “Wait For Water In Glass To Be Completely Emptied”
• When The Fluid Begins To Move On Its Own, Switch From Directing To Catching, Continue Until A Still Point Is Reached
• Wait For PRM To Establish New Pattern
• Leave It Alone
Directing The Tide - 3
• Contraindications Include Recent Skull Fracture, Acute Hemorrhage, Elevated ICP, Cerebral Edema
Compression Of The Fourth Ventricle
• Fingers Overlapped Under Patient’s Neck
• Thenar Eminences Of Both Hands Under Supraocciput At Lateral Angle
• Make Sure Contacts Are Not On Temporal Bones Or Above Nuchal Line On Occipital Scam
• Once Contact Established, Bring Thinner Eminences Together Until You Feel A Change
• Hold Until Still Point
• Procedure Is Finished When Patient Has Deep Inspiration, Pinker Cheeks, Forehead Moisture, Recognition Of Improved Physiology
Torque Unwinding
Fibular Head Dysfunction
• A Posterior Fibular Head Somatic Dysfunction Is Defined As Increased Posterior With Decreased Anterior Slide; Often Accompanied By Foot Inversion, Forefoot Adduction, And Lower Leg Internal Rotation.
• Increased Anterior Slide With Decreased Posterior Slide Signifies Anterior Slide Dysfunction; Accompanied By Foot Eversion, Forefoot Abduction, And Lower Leg External Rotation
Muscle Energy For Posterior Fibular Head
• Flex Knee And Hip To 90 Degrees Each.
• The Physician Stabilizes The Patient’s Bent Knee And Holds The Fibular Head Between Thumb And Index Finger With One Hand And Holds The Foot With The Other.
• The Physician Engages The Barrier By Everting And Dorsiflexing The Patient’s Foot And Externally Rotating The Lower Leg.
• The Patient Will Push Toward The Fibular Head Freedom By Pushing His Foot Medially Against Isometric Resistance For 3 To 5 Seconds.
• The Patient Is Instructed To Relax For 3 To 5 Seconds, And Then The Physician Repositions The Patient Into The New Barriers.
• The Procedure Is Repeated Until Normal Range Of Motion Is Accomplished Or Approximated.
Muscle Energy For Anterior Fibular Head Dysfunction
• Flex Knee And Hip To 90 Degrees Each.
• The Physician Stabilizes The Patient’s Bent Knee And Holds The Fibular Head Between Thumb And Index Finger With One Hand And Holds The Foot With The Other.
• The Physician Engages The Barrier By Inverting The Patient’s Foot And Internally Rotating The Lower Leg.
• The Patient Will Push Toward The Fibular Head Freedom By Pushing His Foot Laterally Against Isometric Resistance For 3 To 5 Seconds.
• The Patient Is Instructed To Relax For 3 To 5 Seconds, And Then The Physician Repositions The Patient Into The New Barriers.
• The Procedure Is Repeated Until Normal Range Of Motion Is Accomplished Or Approximated.
Summary
Osteopathy Is Not Just High Velocity...
Summary
• The Body Is An Interconnected Unit.
• Somatic Dysfunction Is Effectively Treated By Omt
• Correcting Somatic Dysfunction Can Greatly Improve Symptoms The Patient Has As The Result Of Traumatic Injury Such As Injury To The Head Or Knee
REFERENCES• CDC.Heads Up Animation Of A Concussion Video. Retrieved From Http://Www.Cdc.Gov/Headsup/Basics/Concussion_Whatis.Html
• CDC.Heads Up Video: What Is A Concussion. Retrieved From Http://Www.Cdc.Gov/Headsup/Basics/Concussion_Symptoms.Html
• Digiovanna, E. L. (2004). Chapter 4: Somatic Dysfunction. An Osteopathic Approach To Diagnosis And Treatment, 3Rd Edition (3Rd Ed., Pp. 16-24) Lippincott Williams & Wilkins.
• Dowling, D. J. (2004). Chapter 23: Inhibition And Progressive Inhibition Of Neuromusculoskeletal Structures (Pins) Techniques. An Osteopathic Approach To Diagnosis And Treatment (3Rd Ed., Pp. 118-123) Lippincott Williams & Wilkins.
• Dowling, D. J. (2004). Chapter 31: Pins Techniques For The Cervical Spine. An Osteopathic Approach To Diagnosis And Treatment, 3Rd Edition (3Rd Ed., Pp. 158) Lippincott Williams & Wilkins.
• Dowling, D. J. (2014). Chapter 97: Muscle Energy Of The Lower Extremity . An Osteopathic Approach To Diagnosis And Treatment (3Rd Ed., Pp. 509-511) Lippincott Williams & Wilkins.
• Feibish, G. (2006). The Knee Joint: Anatomy, Physiology And Examination.
• Kaufman, D. M., & Milstein, M. J. (2013). Chapter 22: Traumatic Brain Injuries, Minor Head Trauma. Kaufman’s Clinical Neurology For Psychiatrists (7Th Ed., Pp. 532-535) Saunders, Elsevier Inc.
• Ropper, A. H., Samuels, M. A., & Klein, J. P. (2014). Chapter 35. Craniocerebral Trauma. Adams & Victor's Principles Of Neurology (10Th Ed. ). New York, Ny: The Mcgraw-Hill Companies.
• Sleszynsk, S. L., Glonek, T., Zanetti, C. A., Ching, L. M., Dudley, G. J., Lund, G. C., . . . Cole, D. Outpatient Osteopathic Single Organ System Musculoskeletal Form Series Usage Guide Retrieved From Http://Files.Academyofosteopathy.Org/Lborc/Soapnotes/Soapnotessosms-Usageguide.Pdf
• Split-Shift.Jpj. Retrieved From Http://Www.Kimberlydurban.Com/Blog/Wp-Content/Uploads/2011/03/Split-Shift.Jpg
• Burruano, M. P.Management And Fluctuation Of Csf. Unpublished Manuscript.