OSTEOPATHIC PRINCIPLES AND PRACTICE

MANIPULATION IN 2021Walter B. Flesner III, D.O.Medical Director, ICPR, Cape Coral Florida. Past President, Florida Osteopathic Medical Association 1996-1997. Jon Burdzy, D.O. President FOMA District XI.October 14th, 2021, 3:30-4:30 PM

Osteopathic Philosophy and Osteopathic Manipulative Medicine

§ One of seven core competencies taught in Osteopathic Medical Schools, how the musculoskeletal system interacts with circulatory, neurologic, gastrointestinal, endocrine systems.

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§ Visionary-Pioneer: Andrew Taylor Still, M.D., D.O.;1828-1917. 1st Osteopathic Physician.

Structure, Function, and Dysfunction

§ Somatic dysfunction is impaired function of fundamentally normal anatomy.

§ Somatic dysfunction may occur as functional impediment due to altered soft tissue (muscle, ligament, fascial) tensions, articular motion restrictions, or any combination of these components.

§ Articular dysfunction of typical spinal segments (adjacent vertebrae possessing zygopophyseal joints and intervertebral discs) may occur as group dysfunctions composed of three or more consecutive vertebral segments or as dysfunctions composed of two adjacent segments.

Dysfunction-continued

§ Response of axial musculoskeletal system to force of gravity is usually asymmetric. Most individuals have unequal leg length with resultant pelvic unleveling. § Therefore most everyone is predisposed to compensatory group

and segmental spinal dysfunction and stresses from activities of daily work and activities, trauma- micro & macro. It is understandable that musculoskeletal problems are so widespread.

§ Somatic dysfunction- both group and segmental dysfunctions occur in response to sidebending forces (except trauma/acceleration-deceleration, i.e. MVA’s).

Clinical Example§ Patient presents with dysaesthesia of palmar surface of right

hand consistent with presumptive diagnosis of carpal tunnel syndrome.

§ Upper extremity complaints often are linked to upper thoracic somatic dysfunction. Although involved somatosensory innervation of the median nerve should result in paravertebral findings from C6 to T1, findings are more typically encountered in upper thoracic region.

§ Sympathetic innervation of the upper extremity arises from T1 to T4. Autonomic nerves contain afferent as well as efferent neurons, therefore sympathetic afferent neurons from the right upper extremity are capable of facilitation in the upper thoracic region lateralizing to the right.

Example –continued.

§ Facilitation can result from spinal dysfunction or spinal segmental dysfunction with facilitation can result from postural accommodation to pelvic unleveling.

§ Spinal segmental facilitation has been shown to result in segmentally related soft tissue edema, adding edema to the carpal tunnel.

Somatic Dysfunction defined as:

§ Impaired or altered function of related components of the somatic “body framework” system: skeletal, arthrodial, and myofascial structures and related vascular, lymphatic, and neural elements.

§ The positional and motion aspects of somatic dysfunction are best described using:

§§ 1) The position of a body part as determined by palpation and

referenced to its adjacent defined structure.

§ 2) The directions in which motion between two adjacent structures is freer.

§ 3) The directions in which motion is restricted. Somatic dysfunction may be primary or secondary.

Acute vs. Chronic Somatic Dysfunction§ Acute somatic dysfunction: immediate or short term

impairment or altered function of related components of the body framework (somatic) system, characterized in early stages by vasodilation, edema, tenderness, and tissue contraction.

§ Diagnosed by history and palpatory assessment of tenderness, asymmetry of motion, restriction of motion in relation to relative position, and tissue texture change (T-A-R-T).

§ Chronic somatic dysfunction: Impairment or altered function of related components of the somatic characterized by tenderness, itching, fibrosis, paresthesias, tissue contraction indentified by TART.

Primary vs. Secondary Somatic Dysfunction§ Primary somatic dysfunction: Maintains total pattern of

dysfunction, initial or first somatic dysfunction to appear temporarily.

§ Secondary somatic dysfunction: Arises from either mechanical or neurophysiologic response subsequent to or as a consequence of other etiologies.

§ Examples: Sacral dysfunction resulting from unequal leg length or may be of neural reflex origin as a viscerosomatic(sympathetic/parasympathetic afferent/efferent reflex innervation) or somatosomatic reflex. Secondary somatic dysfunction responds to OMT but will recur unless primary condition is identified and treated. Primary somatic dysfunction is completely reversible when correctly diagnosed and specifically treated with Osteopathic Manipulative treatment (OMT) such as acute iliopspoas syndrome.

Diagnosis: Physical/Objective Diagnosis of Somatic Dysfunction is Accomplished by Palpation

TART: T-A-R-T is the mnemonic for 4 diagnostic criteria for somatic dysfunction.

TART

§ 1. Tissue texture abnormality (edema vs. fibrosis). § 2. Asymmetry of position. § 3. Restriction of motion. § 4. Tenderness.

§ The presence of any of these findings is justification for diagnosis of somatic dysfunction. Palpation for tissue texture abnormality is most efficient screen . Degree of tissue texture abnormality (vasodilation, edema, vs. fibrosis) indicates the severity of somatic dysfunction as well as delineates acute vs. chronic.

Diagnosis: Somatic Dysfunction-Continued§ Mechanical somatic dysfunction demonstrates asymmetry of

motion stressed in paradigm of muscle energy OMT techniques and restriction of motion stressed in paradigm of articular dysfunction OMT techniques.

§§ Tenderness should not be confused with pain. Pain is patient

subjective; tenderness is discomfort elicited on palpation by physician , objective finding- involuntary: muscle twitch or facial wince. Tenderness may be used to confirm tissue texture abnormality.

§ Motion restriction places compensatory stress upon adjacent structures with resultant pain- which may be adjacent or distant, such as intervertebral cervical muscle spasms causing adjacent cervical facet pain or distant upper extremity cervical radiculopathy.

Exam- Continued§ Tissue texture abnormality and tenderness in absence of findings of

mechanical restriction of motion is indicative of secondary somatic dysfunction of reflex origin: § X-ray, CT, MRI, EMG, Ultrasound to diagnose and find pain generator such as

facet disease, spinal cord or nerve root impingement for appropriate referral to Interventionalist or Surgeon.

§ Cervical exam: Supine § Thoracic exam: Sitting § Lumbosacal exam: Prone best, if not possible sitting okay. § Standing structural exam: Inspection- Check for pelvic side shift,

observation for lateral-rotational curves, i.e. scoliosis, observation of AP curves; loss of lordosis cervical and lumbar vs. flattened spine, loss of kyphosis thoracic vs. increased- buffalo hump.

§ Palpation- for tissue texture abnormality layered-superficial vs. deep. § Segmental-Regional Exam: ROM- Flexion-extension, Left and right side

bending , left and right rotation, restricted regionally vs. segmental. § Practice, Repetition, Experience- will improve diagnostic skills.

Osteopathic Manipulative Treatment:-Many Different Types and Techniques-Varies with Patient Type, Age, Etc. § High Velocity-Low Amplitude (HVLA)-localizing your forces are

essential for proper safe treatment. Quick, fast, little movement if localized properly- Physician do no harm. Avoid neck extension.

§ Articulation. § Soft tissue. § Direct fascial release/ Myofascial release. § Muscle energy. § Counterstrain. § Fascilitated positional release. § Indirect fascial release. § Indirect cranial/Craniosacral. § Practice, Repetition, Experience- will improve your OMT skills.

American Academy of Osteopathy offers CME Certification courses in Osteopathic Manipulation to M.D’s, Nurse Practitioners, Physical therapists, as well as D.O.s.

OMM/OMT ICD-10 CODES

M99.00- Head region. M99.01-Cervical region.M99.02- Thoracic region. M99.03-Lumbar region.M99.04- Sacral region. M99.05-Pelvic region. M99.06- Lower extremity. M99.07-Upper Extremity.M99.08- Rib cage. M99.09- Abdomen and other.

§ Use primary diagnoses with -25 modifier.

Resources§ “Somatic Dysfunction in Osteopathic Family Medicine, 2007” by

my mentor Kenneth Nelson, D.O., FAAO, FACOP from Chicago College of Osteopathic Medicine is an excellent text for Osteopathic techniques. The ACOFP bases its OMT board questions and practicum on this text.

§ Also, Dr. Frank Walton’s textbook. 1st and 2nd editions.§ Robert Kappler, DO, “A Comparison of Osteopathic Spinal

Manipulation with Standard Care for Patients with Low Back Pain, NEJM 1999;341:1426-1431.§ demonstrated evidence based efficacy of osteopathic manipulation in

the treatment of low back pain. § University of North Texas Health Science Center in Fort Worth,

Texas is the National Center for Research in Osteopathic Manipulative Medicine.

§ Journal of the American Osteopathic Association (JAOA) and Osteopathic Family Physician News are published monthly and feature original articles featuring Osteopathic research and treatment.

Resources§ Alexander S. Nicholas, D.O, FAAQ, and Evan A. Nicholas, D.O.,

Atlas of Osteopathic Techniques, LWW, 2015.§ Part 1: Principles.§ Part 2: Techniques.

§ Phillip Greenman, DO, FAAO, Principles of Manual Medicine, LWW, 1996

§ Robert Savarese, DO, OMT Review, 3rd Edition, 2003§ Andrew Taylor Still

§ The Philosophy and Mechanical Principles of Osteopathy§ Philosophy of Osteopathy§ Autobiography

OMT Hand on Skills Lab

Walter B. Flesner III, D.O.Jon Burdzy, D.O.

Any Questions? Thank you!