OMT for LBP

Samuel A. Yoakum, DO

Disclosures

none

Outline

BackgroundDefinitionsDiagnosisTechniquesBilling

Definitions

Manual manipulation/therapyHands-on manipulation, mobilization or massage techniques involving articulations and/or soft tissue movements in order to modulate pain, augment range of motion, facilitate movement, and improve function.

Manual therapy

● Acupressure● Bodywork● Bowen technique● Chiropractic● Craniosacral therapy● Indian head massage● Lomilomi● Manual lymphatic drainage● Massage therapy● Naprapathy● Osteopathic medicine● Physical therapy● Rolfing structural integration● Shiatsu● Thai massage● Tui na● Watsu

Osteopathic Medicine

Definitions:

•Osteopathy = Osteopathic medicine

•Osteopathic manipulative medicine = OMM

•Osteopathic manipulative treatment/techniques = OMT

•Doctor of Osteopathy = DO

According to the World Osteopathic Health Organization, Osteopathy is a“…system of healthcare which relies on manual contact for diagnosis and treatment. It respects the relationship of body, mind and spirit in health and disease; it lays emphasis on the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.”

Tenets of Osteopathy

● The body is a unito Understanding this concept allows the treatment of patients as

a functional whole.

● Structure and Function are interrelatedo Still’s philosophy: “Disease is the result of anatomical

abnormalities followed by physiologic discord”

● The body possesses self-regulatory and self-healing mechanisms

● Rational treatment is based on applying these principles

Diagnosis

Somatic Dysfunction● Tissue Texture Changes

o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed, atrophied, rigid, moist, dry

● Asymmetryo ‘Inspection’

● Restriction of motion = a deeper look at A/PROMo Named for FREEDOM Of MOTION

o Restricted motion is the BARRIER

● tendernesso Tenderpoints vs. Triggerpoints

Tissue Texture Changes

● Acuteo Edematous

o Erythematous

o Boggy

o Slick, sweaty

● Chronico Flat

o Cool

o Leathery, low tone

o Flaccid, ropy, fibrotic

Asymmetry

● Group curvature● Single segment disfunction● Compare Side-to-side

● Mastoid

● Acromion

● Lower ribs

● Iliac crests

● Greater trochanters

● Lateral femoral condyles

● Lateral malleoli

Restriction of motion

● Orthopedic o Very Loose

● Rheumatologic o Very Restricted

● Somatic Dysfunction o Free in one direction + restricted in the other

The Barrier Concept

● BARRIER stops motion

● FREEDOM Of MOTION is opposite the barrier

● Barriers

o Anatomical

o Physiological

o Restrictive

Anatomical & Physiological Barriers

Restrictive Barrier

Osteopathic Manipulative Techniques

● Direct Techniqueso Engage (go into) the dysfunctional barrier

o Goal is moving through the barrier to restore normal motion

● Indirect Techniqueso Disengage (go away from) the barrier

o Using the path of least resistance

● Combined Techniqueso Begin indirect, then go direct

OMT

● Soft tissue mobilization / Articulatory Techniqueso Direct

● Myofascial Release (MFR)o Direct or Indirect

● Muscle Energy (contract-relax)o Direct

● Jones Counterstrain & FPRo Indirect

● High Velocity Low Amplitude (HVLA)o Direct

● Craniosacralo Direct or Indirect

Common PT Crossover

● Contract-Relax o Muscle Energy

● Joint Mobilizations = “Mobs” = direct technique with a range of force and velocity (Grade I-V)o Deep articulation

Key: Know What You Are Treating

● Soft tissue – skin, adipose, superficial fascia

● Deep Fascia – layers, lines, planes, strain patterns

● Muscle – follow the fibers

● Joint – vertebral segments, articulations, syndesmoses

High Velocity, low amplitude

● Confronting restricted motion of segments and articulations “head on”

● Requires skill for safety and appropriate application

● The barrier is engaged, isolated in multiple planes to minute specificity

● Final thrust in nearly ALL cases should be quick (high velocity) but short (low amplitude)

● “shotgun” techniques are discouraged

Soft Tissue Mobilization

● Soft tissue tensions affect function of the soft tissues and the joints to which they attach.

● Allows treatment to other parts of the body to be more effective.

● Gently and directly applying pressure as to separate the origin and insertion of muscle fibers from each other.

● Deep articulation, in contrast, is the repeated engagement of the barrier or endpoint of joint motion in order to increase mobility and ROM.

Myofascial Release (MFR)

● MFR is an umbrella term encompassing several types of osteopathic manipulative techniques (OMT) that stretch and release muscle and fascia restrictions.

● MFR first involves palpating a restriction in the fascia/soft tissue.

● Direct MFR = practitioner engages the restrictive barrier and holds until a release is felt in the tissue.

● Indirect MFR = practitioner moves the myofascial structures away from the restrictive barrier.

Counterstrain

Used to treat Tenderpoints● Tenderpoints are small tense edematous areas of

tenderness typically located near tendon attachments, ligaments, or in the belly of some muscles.

● Tenderpoints, unlike trigger points, do not radiate pain when compressed.

Counterstrain

● Jones Counterstrain = passive indirect techniqueo Muscle being treated is positioned at a point of balance or

ease, away from the restrictive barrier.o “Fold and hold” for 90 sec

● This is a neurosensory approach to the treatment of tenderpoints.o Mimicking the original strain position -> reducing

aberrant afferent flow from the muscle spindle -> relaxes the muscle “spasm” associated with a tenderpoint

Facilitated Positional Release (FPR)

● Indirect technique● Place tissue in neutral position to diminish tissue/joint

tension in all planes● Add activating force (compression or distraction)● Takes 3-4 seconds to induce a release● Good for superficial muscles or deep intervertebral

muscles

Muscle Energy

● Muscle energy, also known as “contract-relax,” is a direct technique used to improve range of motion.

● This is a form of OMT in which the patient actively uses his/her muscles against the practitioner’s resistance.o Physician engages a barrier and holdso Patient is instructed to contract the muscle against

your holding force (Activating force)o Relaxo Engage a new barriero Repeat

Still Technique

● A combination of indirect technique, moving to direct technique following the release

● The patient is completely passive● The lever is placed in a position of ease● Holding force (compression/distraction) is applied● The joint, or body part is then taken through a range of

motion while attempting to hold the activating force as long as possible

● The range of motion is taken to (and through if reasonably possible) the barrier

References