4/23/2019 AKOMA OMT Workshop Crystal Martin, DO May 2, 2019 Objectives • Discus and learn an osteopathic approach to common medical problems • Describe underlying structure and function of why OMT works for various clinical problems • Apply osteopathic treatment principles to patients in a variety of settings and clinical situations • Demonstrate OMT for common clinical problems • Otitis media • Back pain • Supplemental material will be provided on provided on: headache, ankle sprains and post-op ileus Otitis media • Otitis media is the most common medical condition for which care is provided in children under 5 years of age. 1
4/23/2019 Horizontal Eustachian Tubes Notice that the Eustachian tube is much more vertical in adults allowing for better drainage Lymphatic Treatments • Always open the thoracic inlet first! • Next free up any obstructions • Finally lymphatic pumps can be considered Galbreath Technique • Galbreath Maneuver first described in 1929 by William Otis Galbreath, DO • A simple mandibular manipulation, the Eustachian tube is made to open and close in a "pumping action" that allows the ear to drain accumulated fluid more effectively 2
4/23/2019 Acute Low Back Pain • In 1990, the direct medical care costs for low back pain exceeded $24 billion • When disability compensation and lost productivity are included the total annual costs in the United States increases to approximately $100 billion • The overall incidence of LBP has been reported to be 60 to 80 percent in industrialized countries Mechanical Vs. Non-Mechanical • Mechanical represents 90% of disorders and dysfunction of muscles, ligaments and connective tissue • Non-mechanical can include serious and/or life threatening medical and surgical disorders which require urgent evaluation and intervention Non-Mechanical Back Pain • Spinal Tumor • Spinal infection • Vertebral fractures – trauma, osteoporosis • Primary cancers with bony metastasis • Kidney dysfunction • Ureteral obstruction • Prostate or Bladder irritation • Viscerosomatic reflex 3
4/23/2019 Non-Mechanical Back Pain • Cauda Equina • Pressure on spinal cord from space occupying lesion, disc, tumor, boney elements, spinal stenosis • Bowel and/or bladder dysfunction • Perianal or saddle anesthesia • Lower extremity neurologic deficits • Surgical emergency • Ruptured/dissecting abdominal aortic aneurysm • Severe, sharp or tearing acute back pain • Surgical emergency Mechanical Back Pain • Thoracic and Lumbar Spine Somatic dysfunction • Short Leg/Sacral Base Unleveling Syndrome • Gravitational Strain/Postural Decompensation • Herniated or Degenerative Disc Disease (DDD) • Degenerative Joint Disease (DJD) • Myofascial pain syndromes • Ligamentous Strains and Sprains These are the patients • Spondylolysis & Spondylolisthesis who benefit from • Spinal Stenosis OMT! ‘ RED FLAGS’ Suggestive of Serious Spinal Pathology • Age <20 or >50 Remember that you are first and foremost a physician. These are patient’s you need to work up! • Trauma OMT may be considered as an adjunct therapy. • ESR>25 • Constant and progressive non-mechanical pain • Hx: Ca, HIV, systemic steroids, drug abuse • Weight loss with undefined illness • Persisting severe restriction with flexion • Deformity, x-ray with vertebral destruction or collapse • Progressive neurologic deficit 4
4/23/2019 Soft Tissue • Kneading • Inhibition • Stretching A great way to prepare for other techniques. A Quick Review of Fryette’s Diagnosis Type I Dysfunctions Type II Dysfunctions • Sidebending and rotation occur • Sidebending and rotation occur in OPPOSITE directions in the SAME direction • There is no sagittal component • There is a FLEXION / EXTENSION (dysfunctions are NEUTRAL) component • Usually a group • Usually a single segment • Typically less painful and may • Typically more painful. be compensatory from a Type II dysfunction. Balanced Ligamentous Technique (BLT) • Can be done seated of supine • Taking structures into a position of ease • Respiratory phase of ease can also be used to help with the activating force. • Position is held until a release occur 5
4/23/2019 Muscle Energy • Structures are brought into the “feather’s edge” of the restrictive barrier • Patient tries to return to neutral for 3-5 seconds and physician resists (post-isometric relaxation) then following a 1-2 second pause the new restrictive barrier is engaged. “The Osteopathic Salute“ can be a bit awkward for patients, but it works great for type I dysfunctions! Type II dysfunction are treated by reaching over the patient’s arm Modified MET for Flexed Thoracic SD • This modified technique works best in mid to upper thoracics • The patient’s hand on the side of posterior transverse process is placed on opposite shoulder. physician rotates the patient into the barrier and gently extends. • The patient is instructed to push his elbow into the physician’s hand which activates flexion or rotation for post isometric relaxation MET. Modified MET for Flexed Thoracic SD Can be done seated... Or Supine. 6
4/23/2019 High Velocity, Low Amplitute (HVLA) Shotgun Techniques The Kirksville Crunch • Texas Twist • Lumbar Roll • Chicago Roll Not very comfortable body mechanics… Modified HVLA for Flexed and Neutral Thoracic Somatic Dysfunctions • Works well for flexed and neutral dysfunctions T4-T11 • Patient supine with arms opposite usual Kirksville Crunch • The physician’s thenar eminence is placed on posterior transverse process • The patient must turn head fully toward side of rotation to achieve a lock out for the HVLA thrust. Not all mechanical back pain is from thoracic or lumbar somatic dysfunction • Remember to also check • Ribs • Neck • Sacrum • Pelvis • Leg length The body is a unit! Dysfunction in one area can cause pain in another area of the body. 7
4/23/2019 Research on OMT and Back Pain • OSTEOPATHIC Trial • My current research project at PNWU: The short-term outcomes of OMT in migrant farmworkers with back pain • Measuring quantitative back range of motion (BROM) prior to and following 3 OMT sessions scheduled two weeks apart. • Also measuring baseline Quality of Life, Functional Status, medication use, and pain scale then repeating at final OMT treatment and 4 weeks after final OMT treatment Rib Movement 3 main types of movement Pump handle ● Primarily Ribs 1-5 ○ Bucket handle ● Primarily Ribs 6-10 ○ Caliper ● Primarily Ribs 11-12 ○ Ribs 1-10 have some of all 3 motions, but do have a primary component of motion Which rib is the Key Rib? Remember BITE ● Bottom inhaled, Top exhaled ○ Bottom rib is the key rib in an Inhalation ● Exhalation inhalation dysfunction dysfunction dysfunction It’s holding the rest of the group up bottom rib is “key ○ top rib is “key rib” Top rib is the key rib in an ● rib” exhalation dysfunction It’s holding the rest of the group down ○ 8
4/23/2019 Modified Position for BLT and MET of Ribs • Works best for treating inhaled or exhaled bucket handle ribs • Have patient place his or her elbow on your shoulder. Traction the key rib and bring into position of balance to treat with BLT • You can also treat with MET in this position by using hands to position the key rib at the restrictive barrier and ask the patient to push his or her elbow down into your shoulder. • Fine tune by adjusting the angle at which you have the patient press elbow down. Fitting OMT into your clinical practice • OMT takes time, but you can make up for the time by billing for a procedure when you take time to perform OMT. • Billing is done by number of body areas treated, not how much time you spend. • Effective OMT can easily be done in less than 10 minutes. • Often even in less than 5 minutes • If you don’t have time or skills for OMT, refer your patient to someone who does. Billing for OMT • The diagnosis of somatic dysfunction in the assessment justifies the use of OMT. • Describe specific somatic dysfunctions in the MSK section of your physical exam (Objective) • example: T3 F SRRR, thoracic paraspinal muscle hypertonicity • A somatic dysfunction diagnosis must be present in order to bill for OMT that was performed. • Your note in the Plan should state that OMT was used for somatic Dysfunction identified. • “The procedure (OMT) and the E/M visit may both be billed with the same diagnosis code and during the same encounter, if the decision to perform the procedure was made at the time of the encounter. Modifier -25 is used with the E/M code.” 9
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