Transcript Osteopathy 101: Our Manipulation Techniques

Osteopathy 101: Our
Manipulation Techniques
Jon P. Burdzy, D.O.
Board Certified in Family Medicine and
Neuromusculoskeletal Medicine
Assistant Clincial Professor of Medicine, KCUMBS
First Lesson in Osteopathy
Other Possible Titles
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Osteopathy and You – Perfect Together
OMT in a Nutshell
Hippity Hoppity Osteopathy
Crackety Poppity Osteopathy
“To think implies action of the brain.”
– At Still, The Philosophy and Mechanical Principles of Osteopathy, p. 41
“Motion is not life. Motion is a manifestation of
life.”
Roland Becker, Life in Motion, p. 62
“To find health should be the object of the
doctor. Anyone can find disease.”
-At Still, Philosophy of Osteopathy, p.2
Tenets of Osteopathic Medicine
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The body is a unit.
2.
The body possesses self-regulatory mechanisms.
3.
Structure and function are reciprocally inter-related.
4.
Rational Therapy is based upon the understanding of
body unity, self-regulatory mechanisms, and the interrelationship of structure and function.
Tenets of Osteopathic Medicine
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First, do no harm. A thoughtful diagnosis should be made before exposing the patient
to any potentially harmful procedure.
Look beyond the disease for the cause. Treatment should center on the cause, with
effect addressed only when it benefits the patient in some tangible way.
The practice of medicine should be based on sound medical principles. Only therapies
proven clinically beneficial in improving patient outcome should be recommended.
The body is subject to mechanical laws. The science of physics applies to humans. Even
a slight alteration in the body’s precision can result in disorders that overcome natural
defenses.
The body has the potential to make all substances necessary to insure its health. No
medical approach can exceed the efficacy of the body’s natural defense systems if those
defenses are functioning properly. Therefore, teaching the patient to care for his own
health and to prevent disease is part of a physician’s responsibility.
The nervous system controls, influences, and/or integrates all bodily functions.
Osteopathy embraces all known areas of practice.
Excerpted from A Historical Perspective on the Philosophy of Osteopathic Medicine, by Robert E. Suter, D.O., based on the
writing of A.T. Still.
“First, there is the material body; second the
spiritual being; third, a being of mind which is
far superior to all vital motions and material
forms, whose duty is to wisely manage this
great engine of life”
-AT Still, the Philosophy and Mechanical Principles of Osteopathy, pp. 16-17
“You begin with anatomy, and you end with
anatomy, a knowledge of anatomy is all you
want or need”
– At Still, The Philosophy and Mechanical Principles of Osteopathy, p. 16
Somatic Dysfunction
Somatic dysfunction: Impaired or altered
function of related components of the
somatic (body framework) system:
skeletal, arthrodial and myofascial
structures, and their related vascular,
lymphatic, and neural elements.
Somatic dysfunction is treatable using
osteopathic manipulative treatment.
The positional and motion aspects of
somatic dysfunction are best described
using at least one of three parameters:
1). The position of a body part as
determined by palpation and referenced
to its adjacent defined structure,
2). The directions in which motion is
freer, and 3). The directions in which
motion is restricted.
TART
T.A.R.T.
A mnemonic for four diagnostic criteria of
somatic dysfunction:
-tissue texture abnormality
-asymmetry
-restriction of motion
-tenderness
“It may be that by measurement we can
discover a variation one-hundredth of an inch
from the normal, which, though infinitely small,
is nevertheless abnormal”
-At Still, The Philosophy and Mechanical Principles of Osteopathy, p.33
Barrier Concept
(this is how somatic dysfunction looks on paper)
Direct Technique
Direct method (D/DIR), an
osteopathic treatment strategy by
which the restrictive barrier is engaged
and a final activating force is applied to
correct somatic dysfunction.
(we move through the restrictive barrier to release the tissue)
I ndirect Technique
Indirect method (I/IND), a
manipulative technique where the
restrictive barrier is disengaged and the
dysfunctional body part is moved away
from the restrictive barrier until tissue
tension is equal in one or all planes and
directions.
(we move tissues away from the barrier until they release)
“An intelligent head will soon learn that a soft
hand and a gentle move is the head and hand
that gets the desired result”
– At Still, Autobiography of AT Still, P. 191
Contraindications and Precautions for
Manipulative Techniques
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Acute Trauma
Congenital or Acquired Malformations
Friable, acutely inflamed or infected tissues
Hemarthrosis
Hypermobility
Nearby thrombosis, aneurysm or dissection
Primary joint, metabolic or cancerous bone
disease
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-from Seffinger, Evidence Based Manual Medicine, A Problem-Oriented Approach, p . 61
Contraindications and Precautions for
Manipulative Techniques
Patient hesitation
or
lack of consent!!!
Direct Techniques
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HVLA
Muscle Energy
Articulatory
Soft tissue
Myofascial Release
HVLA
A rapid,therapeutic force of brief duration that
travels a short distance within the anatomic
range of motion of a joint,and that engages
the restrictive barrier in one or more planes of
motion to elicit release of restriction.
• Kirksville Crunch, Texas Twist, Etc.
“Use force enough to remove all obstructions;
be careful that you do not bruise any of the
delicate parts….”
– AT Still, Autobiography of AT Still, p. 191
“I put my elbow in his back and pulled him
backwards over it with force”
– AT Still, Autobiography of AT Still, p. 113
Cervical HVLA
Since 1925, there have been approximately 275 cases of adverse events
reported with cervical spine manipulation. It has been suggested by some
that there is an under-reporting of adverse events . A conservative estimate
of the number of cervical spine manipulations per year is approximately 33
million and may be as high as 193 million in the US and Canada. The
estimated risk of adverse outcome following cervical spine manipulation
ranges from 1 in 400,000 to 1 in 3.85 million The estimated risk of major
impairment following cervical spine manipulation is 6.39 per 10 million
manipulations.
NSAIDs are the most commonly prescribed medications for neck pain.
Approximately 13 million Americans use NSAIDs regularly. 81% of GI bleeds
related to NSAID use occur without prior symptoms. Research in the United
Kingdom has shown NSAIDs will cause 12,000 emergency admissions and
2,500 deaths per year due to GI tract complications. The annual cost of GI
tract complications in the US is estimated at $3.9 billion, with up to 103,000
hospitalizations and at least 16,500 deaths per year. This makes GI toxicity
from NSAIDs the 15th most common cause of death in the United States.
Cervical HVLA
A study done in 1999 reviewing 367 cases of VBA reported from 19661993 showed 115 cases related to cervical spine manipulation; 167
were spontaneous, 58 from trivial trauma and 37 from major trauma.
It has been proposed that thrust techniques that use a
combination of hyperextension, rotation and traction of the
upper cervical spine will place the patient at greatest risk of
injuring the vertebral artery.
Cervical HVLA
Conclusion
Osteopathic manipulative treatment of the cervical spine, including but not limited
to High Velocity/Low Amplitude treatment, is effective for neck pain and is safe,
especially in comparison to other common treatments. Because of the very small
risk of adverse outcomes, trainees should be provided with sufficient information
so they are advised of the potential risks. There is a need for research to
distinguish the risk of VBA associated with manipulation done by provider type
and to determine the nature of the relationship between different types of
manipulative treatment and VBA.
Therefore, it is the position of the American Osteopathic Association that all
modalities of osteopathic manipulative treatment of the cervical spine, including
High Velocity/Low Amplitude, should continue to be taught at all levels of
education, and that osteopathic physicians should continue to offer this form of
treatment to their patients.
Muscle Energy
Patient voluntarily moves the body as
specifically directed by the osteopathic
practitioner. This directed patient action is
from a precisely controlled position against a
defined resistance by the practitioner.
Articulatory
A low velocity/moderate to high amplitude
technique where a joint is carried through its
full motion with the therapeutic goal of
increased range of movement. The activating
force is either a repetitive springing motion or
repetitive concentric movement of the joint
through the restrictive barrier.
Soft Tissue
A direct technique that usually involves lateral
stretching, linear stretching, deep pressure,
traction and/or separation of muscle origin
and insertion while monitoring tissue
response and motion changes by palpation.
Myofascial Release
• Direct MFR, a myofascial tissue restrictive
barrier is engaged for the myofascial tissues
and the tissue is loaded with a constant force
until tissue release occurs.
Indirect Techniques
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Functional
Strain-counterstrain
Myofascial Release
Balanced ligamentous tension
Most cranial techniques
Myofascial Release
Functional Techniques
An indirect treatment approach that involves
finding the dynamic balance point and one of the
following: applying an indirect guiding force,
holding the position or adding compression to
exaggerate position and allow for spontaneous
readjustment. The osteopathic practitioner
guides the manipulative procedure while the
dysfunctional area is being palpated in order to
obtain a continuous feedback of the physiologic
response to induced motion. The osteopathic
practitioner guides the dysfunctional part so as to
create a decreasing sense of tissue resistance.
Strain-Counterstrain
Somatic dysfunction, diagnosed by (an)
associated myofascial tenderpoint(s), is
treated by using a passive position, resulting
in spontaneous tissue release and at least
70 percent decrease in tenderness.
Myofascial Release
Indirect MFR, the dysfunctional tissues are
guided along the path of least resistance until
free movement is achieved.
Cranial
A system of diagnosis and treatment by an
osteopathic practitioner using the primary
respiratory mechanism and balanced
membranous tension.
Balanced Ligamentous Tension
According to Sutherland’s model, all the joints
in the body are balanced ligamentous articular
mechanisms. The ligaments provide
proprioceptive information that guides the
muscle response for positioning the joint and
the ligaments themselves guide the motion of
the articular components.
Combined Direct and Indirect
• Still Technique
• Myofascial Release
Still Technique
1. Determine where the tissue moves most easily.
2. Move the tissue into the direction of ease until it releases.
3. Introduce a vector of force of about 5 lbs. Into affected tissue.
4. Use the force vector as a lever maintaining compression, carry tissue in the
opposite direction through the restrictive barrier.
5. Remove force vector and compression and return tissue to neutral.
6. Retest and repeat if necessary.
From Foundations of Osteopathic Medicine, 2nd. Edition, p. 1094
Myofascial Release
Affected tissue may be manipulated
directly through the barrier
Other Types
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Fulford Percussion Hammer
Lymphatic Techniques
Biodynamic
Visceral
PINS
Percussion Vibratory (Fulford)
A manipulative technique involving the
specific application of mechanical vibratory
force to treat somatic dysfunction.
Biodynamic
• The therapeutic powers of the Dynamic
Stillness, the Breath of Life, the tidal potency,
fluids and other Natural Laws at work
supporting and generating life.
Visceral
A system of diagnosis and treatment directed
to the viscera to improve physiologic function.
Typically, the viscera are moved toward their
fascial attachments to a point of fascial
balance.
Lymphatic Technique
PINS
Progressive inhibition of neuromuscular
structures (PINS), A system of diagnosis and
treatment in which the osteopathic
practitioner locates two related points and
sequentially applies inhibitory pressure along
a series of related points.
BIBLIOGRAPHY
Foundations of Osteopathic Medicine, 2nd Edition, Lippincott Williams and
Wilkins, 2003
Seffinger, Hruby, Evidence Based Manual Medicine, A Problem Oriented
Approach, Saunders, 2007
Autobiography of AT Still
At Still, Philosophy of Osteopathy
AT Still, The Philosophy and Mechanical Principles of Osteopathy
Becker, Life in Motion, Eastland Press
Becker, Stillness of Life, Eastland Press
Web Resources
academyofosteopathy.org
do-online.org
eastlandpress.com
cranialacademy.com
Billing and Coding
• OMT CPT codes [inpatient & outpatient] 98925 1-2
body regions 98926 3-4 body regions 98927 5-6 body
regions 98928 7-8 body regions 98929 9-10 body
regions
• Body region codes: head, sacral, rib cage area, cervical,
pelvis, abdomen, thoracic, lower extremities, visceral
region, lumbar, upper extremities
• ICD Codes -739.0 Head region 739.1 Cervical region
739.2 Thoracic region 739.3 Lumbar region 739.4
Sacral region 739.5 Pelvic region 739.6 Lower
extremities 739.7 Upper extremities 739.8 Rib cage
739.9 Abdomen and other
.25 Modifier
• In General
– First give a code for the complaint (e.g. low back pain
– Then code the somatic dysfunction (739 codes)
– Attach the .25 modifier (for separate, distinctly identifiable
services from other services or procedures rendered
during the same visit) to the ICD code
– Then bill the appropriate CPT
From Philosophy of Osteopathy, Chapter IV,
Ear Wax and its Uses
“I asked myself to try and get a reason of why
nature had made and placed in a person’s head
so much fine machinery just to make a little ear
war. If nothing is made in vain, what is that
bitter stuff made for ? It is always there, and
more being made all the time . . I consider
earwax one of the most important questions
before the minds of our physiologists.”
“All through life I have been ever been ready to
buy a better plow ”
-AT Still, Autobiography of AT Still, p.187