Osteopathic Manipulative Medicine/Treatment Models

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Chapter 2: Treatment Models[edit | edit source]


Objectives:

  1. Identify the major treatment techniques utilized in osteopathic manipulative treatment
  2. Describe the mechanism of the major treatment techniques
  3. Discuss the absolute and relative contraindications of each treatment model
  4. Understand the physiology of facilitated segments, somatic dysfunction, and neuromusculoskeletal receptors.

Osteopathic Treatment Techniques:[edit | edit source]

To know Osteopathy one must live it in practice, this is the proving ground it is not a theory but an art based in an oral - – James S Jealous DO


Osteopathic Manipulative Treatment table


Osteopathic manipulative treatment (OMT), historically also known as Osteopathy, is a manual treatment modality that serves as an adjunctive therapy to medical management. The goals of using OMT are to relieve or reduce pain, increase range of motion, improve physiologic functioning, increase circulation (of blood, venous and lymphatic flow), and to restore homeostatic balance of autonomic neural transmission.

Osteopathic treatment techniques can be classified as active/passive and as direct/indirect:

  • Direct technique: movement into the restrictive barrier
  • Indirect technique: movement into the ease of motion
  • Active technique: patient is actively involved in the treatment
  • Passive technique: physician performs treatment without patient input


The classes of techniques which we will consider from the 2017 Glossary of Osteopathic Terminology from the Educational Council on Osteopathic Principles (ECOP) :

  1. Soft tissue (ST)
  2. Myofascial release (often used interchangeably with soft tissue; MFR)
  3. Counterstrain (CS)
  4. Muscle energy (ME)
  5. High-velocity low-amplitude (HVLA)
  6. Lymphatic techniques
  7. Osteopathic cranial manipulative medicine (OCMM)
  8. Balanced ligamentous tension (Ligamentous articular strain) (BLT/LAS)
  9. Facilitated positional release (FPR)
  10. Still technique
Technique Direct or indirect Active or passive Mechanism of action Absolute contraindications Relative contraindications
Soft tissue
Direct
Passive
  • Deep pressure, kneading, stretching, direct inhibition and/or traction; separation of muscle origins and insertion while monitoring tissue response and motion changes by palpation
  • Manual stretching of the skin, fascia, and the muscle tissues
  • Treatment directly over fracture or dislocation
  • Patient refusal
  • Lack of somatic dysfunction
  • Vascular compromise
  • Malignancy or infection
  • Severe osteoporosis or osteopenia
  • Acutely injured muscles, tendons, or ligaments
  • Patient tolerance
Myofascial release (MFR)
Direct or indirect
Passive
  • Light, moderate or heavy force which engages fascia versus deeper tissue with constant pressure; piezoelectric changes relax and release restricted tissues (direct)
  • Guiding fascia along the path of least resistance until free movement is achieved (indirect)
  • Treatment directly over fracture or dislocation
  • Patient refusal
  • Lack of somatic dysfunction
  • Vascular compromise
  • Malignancy or infection
  • Severe osteoporosis or osteopenia
  • Acutely injured muscles, tendons, or ligaments
  • Patient tolerance
Counterstrain (CS)
Indirect
Passive
  • First described by Lawrence Jones, DO
  • Positions tenderpoint in position of significantly decreased or eliminated pain for 90 seconds
  • Somatic dysfunction is due to a neuromuscular dysfunction involving muscle spindle receptors and inappropriate proprioception (sense motion/position)
  • Tenderpoints involving a hypertonic muscle (common in upper and lower extremity somatic dysfunctions), can be found anywhere along the length of the muscle
  • Severe illness in which strict positional restrictions preclude treatment
  • Traumatized tissue that would be negatively affected by repositioning
  • Vascular or neurologic syndromes, such as basilar insufficiency or neuroforaminal compromise (where treatment position may exacerbate the condition)
  • Any disease that predisposes increased pain with repositioning
  • Patients that cannot voluntarily relax
  • Patients that cannot follow or understand verbal instruction
Muscle energy (ME)
Direct
Active
  • First described by Fred Mitchell Sr., DO
  • Post isometric relaxation: During the patient’s contraction towards the ease, increased pressure is placed on the Golgi tendon organ proprioceptors within the muscle tendon leading to reflex inhibition and subsequent muscle lengthening (patient pushes into their ease); chronic somatic dysfunctions
  • Reciprocal inhibition: Utilizes the agonist/antagonist relationship of inverse relaxation with contraction towards the barrier (patient pushes into their barrier); utilized for acute somatic dysfunctions
  • Respiratory assistance: Utilizes patient respirations to move through a restrictive barrier
  • Joint mobilization: Use of muscular attachments and physician hands as fulcrums to mobilize joints with limited mobility
  • Techniques are repeated 3-5 times for 3-5 seconds each; each time the physician is moving further into the restrictive barrier.
  • Fracture/dislocation
  • Moderate to severe joint instability
  • Patient that cannot follow or understand verbal instruction
  • Moderate to severe muscle strains
  • Severe osteoporosis or osteopenia
  • Severe illness with cardio-pulmonary compromise (ICU, post-surgical)
High-velocity low-amplitude (HVLA)
Direct
Passive
  • A quick thrust with very minimal distance through a restrictive barrier, which may generate a "pop" or "click"
  • This articular "pop" has been theorized to be a vacuum phenomenon or change in synovial fluid to a gaseous state. This sound does not indicate a successful HVLA treatment.
  • Often termed as a "mobilization", "impulse", or "adjustment"
  • Joint instability
  • Severe osteoporosis
  • Osteoarthritic joint with ankylosis
  • Severe discogenic spondylosis with ankylosis
  • Severe herniated nucleus pulposus with radiculopathy at area of treatment.
  • Metastatic disease in local area
  • Infection in the local area
  • Joint replacement in the area receiving a thrust
  • Vertebrobasilar insufficiency
  • Congenital abnormalities: Down’s syndrome, Chiari malformation
  • Rheumatoid arthritis of the cervical spine
  • Osteoarthritis with moderate motion loss
  • Osteopenia
  • Mild to moderate sprain/strain
  • Rheumatoid disease outside the spine
  • Minimal disc bulge/herniation
  • Atypical joint facet morphology
  • Some hypermobile patients
Lymphatic (an extension of MFR)
Direct
Passive
  • Mechanical compression via physician’s force leads to mobilization of lymphatic fluid
  • Necrotizing Fasciitis
  • Acute hepatitis
  • Mononucleosis
  • Malignancy
  • Deep venous thrombosis
  • Severe heart failure
Osteopathic cranial manipulative medicine (OCMM)
Direct or indirect
Passive
  • First described by William Sutherland, DO
  • Engages the PRM to improve ANS function
  • Mobilizes soma to reduce dysfunction
  • Five principles of the PRM:
  1. Inherent motility of the brain and spinal cord
  2. Fluctuation of cerebrospinal fluid
  3. Mobility of membranes
  4. Articular mobility of the cranial bones
  5. Involuntary mobility of the sacrum between the ilia
  • Intracranial hemorrhage
  • Acute skull fracture
  • Increased intracranial pressure
  • Space-occupying lesion
  • Coagulopathies
  • Seizure disorders
Balanced Ligamentous Tension (BLT) &Ligamentous Articular Strain (LAS)
Direct or indirect
Passive
  1. Disengagement: compression or traction of tissues allows the most motion to occur without resistance
  2. Exaggeration: moving the joint toward the original position of injury (indirect) or barrier (direct)
  3. Balance: balancing the tension until a release is felt results in an ebb and flow
  • LAS has been said to describe the dysfunction, while BLT describes the process or goal of treatment.
  • Geographic distinction between the terms has led to the use of two terms for this technique:
    • LAS is used more in Texas and the south
    • BLT is used more in the northeast
  • Treatment directly over fracture or dislocation
  • Serious vascular compromise
  • Local malignancy or infection
  • Patient refusal
  • Lack of somatic dysfunction
  • Fracture or dislocation
  • Vascular compromise
  • Malignancy or infection
  • Severe osteoporosis
  • Acutely injured muscles
  • Patient tolerance
Facilitated Positional Release (FPR)
Indirect
Passive
  • First described by Stanley Schiowitz, DO
  • First, flatten the spinal curvature of the vertabrae being treated, or in the extremities, adding compression towards the joint being treated.
  • Place the dysfunction into its ease of position, and then adding an "activating force" into the dysfunction (typically using gentle compression) and holding this position for 3-5 seconds.
  • The physician may choose to add a very rapid articulatory springing force into the dysfunction in very small distances:
    • This was not included in Dr. Schiowitz original descriptions, however, it was later described by him as a "secret ingredient" during his Heilig Symposium presentations at PCOM (2007)
  • This treatment causes muscle spindle fibers return to normal length decreasing tension in muscle activity fibers
  • Moderate-to-severe joint instability
  • Severe vertebral herniated nucleus pulposus with radiculopathy at area of treatment
  • Intervertebral foraminal stenosis
  • Severe spains and strains
  • Congenital abnormalities: Down’s syndrome, Chiari malformation
  • Vertebrobasilar insufficiency
  • Fracture or dislocation
  • Vascular compromise
  • Malignancy or infection
  • Severe osteoporosis
  • Acutely injured muscles
  • Patient tolerance
Still Technique
*Indirect, then Direct
Passive
  • Initially described by Richard L. Van Buskirk, DO, PhD, FAAO in The Still Technique Manual (2000)
  • Indirect positioning toward the ease of somatic dysfunction in which pressure is applied, followed by another part of the body being used as a long-levered force vector to move the segment through the least resistant path, toward the barrier causing relaxation of hypertonic musculature
  • Moderate-to-severe joint instability
  • Severe vertebral herniated nucleus pulposus with radiculopathy at area of treatment
  • Intervertebral foraminal stenosis
  • Severe spains and strains
  • Vertebrobasilar insufficiency
  • Fracture or dislocation
  • Vascular compromise
  • Malignancy or infection
  • Severe osteoporosis
  • Acutely injured muscles
  • Patient tolerance


Physiology & Mechanism of Action:


There are three joint capsule receptors that are affected by OMT:

  1. Proprioceptors are receptors which sense motion and position of the body
  2. Mechanoreceptors are receptors excited by mechanical pressures or distortions such as those responding to touch and muscular contractions
  3. Nociceptors are peripheral nerve organs or mechanisms for the appreciation and transmission of painful or injurious stimuli

These neurologic receptors have dysfunctional physiology when affected by pathologic disease states and somatic dysfunction. This altered neurologic functioning within a specific region or vertebral segment is known as "facilitation" or a "facilitated segment".

Facilitated segments exist in a state whereby the maintenance of a pool of neurons is at full or partial sub-threshold excitation. Facilitation occurs when a segment of the nervous system has been subject to injury via trauma or chronic disease, causing the segment to become hyperactive and hypersensitive. Strain on facilitated segments are often compensated for by the body until mechanical failure and/or injury occurs. This may manifest as various somatic dysfunctions throughout the body and spine. Single vertebral dysfunctions often form initially, with group spinal dysfunctions occurring as a result of compensation and adaptation of the soma. Nociceptive input, also known as pain, can lead to increased muscle tension and chronic irritation as well as gradual compensatory structural changes (i.e. facilitated segments). This is usually in response to physical tissue damage or toxic stimuli and can be induced either mechanically or chemically.

Two mechanisms of muscular physiology that are affected by OMT include muscle spindle fibers and Golgi tendon organs:

Muscle spindle fibers are stretch receptors are very sensitive to changes in length. The three subclasses of muscle spindle fibers are dynamic nuclear bag fibers (bag 1), static nuclear bag fibers (bag 2), and nuclear chain fibers. When stretched sufficiently, they will induce reflex contraction of the muscle, as a protective mechanism to prevent further tissue injury. Muscle spindle fibers monitor stretch and rates of change. In somatic dysfunction, the muscle spindle fibers are facilitated and functioning with imbalanced physiology, thus causing TART (Tenderness, asymmetry, restricted range of motion, abnormal tissue texture changes) findings that become evident upon osteopathic examination.
Muscle spindle fibers
Golgi tendon organs is a proprioceptive sensory receptor that senses changes in muscle tension. It lies near the origin and insertion of all muscle tissue. They are safeguards of anatomic integrity and joint structure; they serve as a “relief reflex” which produces marked reduction of muscular activity when there is a severe stretch. Sufficient impulses from Golgi tendon organs will result in inhibition of the muscle it occupies and its muscular synergists (and facilitate antagonists).
Golgi tendon organs

Review Questions:[edit | edit source]


1. A patient presents with significantly hypertonic paraspinal muscles. Which treatment technique is the most appropriate initial treatment on this patient?

A. Counterstrain
B. Muscle energy
C. HVLA
D. Myofascial release/Soft tissue
E. Lymphatic techniques

Questions 2-5: Match the following descriptions with the listed treatment technique.

2. Myofascial release/Soft tissue
3. Counterstrain
4. Muscle energy
5. HVLA

A. Passive, direct
B. Passive, indirect
C. Active, direct
D. Active, indirect
E. Can be either direct or indirect

Questions 6-10: Match the mechanism with the treatment technique.

6. Post-isometric muscle energy
7. Counterstrain
8. HVLA
9. Reciprocal inhibition muscle energy
10. Myofascial release/Soft tissue

A. Deep pressure, kneading, stretching, inhibition and/or traction of the skin, fascia, and muscle tissues with separation of muscle origins and insertion while monitoring tissue response and motion changes by palpation
B. Positioning of a tenderpoint to a position of significantly decreased or eliminated pain (typically for 90 seconds)
C. Increased stretch is sensed by the Golgi tendon organ proprioceptors within the muscle tendon leading to reflex inhibition and subsequent muscle lengthening
D. Utilization of agonist/antagonist muscle relationships of inverse relaxation with contraction used primarily in the treatment of acute somatic dysfunctions
E. Quick thrust with very minimal distance through a restrictive barrier, which may generate a "pop" or "click"

11. Which of the following correctly describes a direct and active technique?
A. A technique in which the patient is taken to the barrier of the somatic dysfunction and the patient performs an action, against resistance, as directed by the physician.
B. A technique in which the patient is taken into the ease of motion and the patient performs an action, against resistance, as directed by the physician.
C. A technique in which the patient is taken into the barrier of the somatic dysfunction and the physician performs all of the action without assistance from the patient.
D. A technique in which the patient is taken into the ease of motion and the physician performs all of the action without assistance from the patient.

Answers to Review Questions[edit | edit source]

  1. D
  2. E
  3. B
  4. C
  5. A
  6. C
  7. B
  8. E
  9. D
  10. A
  11. A