Somatic Dysfunction in Osteopathic Family Medicine

SOMATIC DYSFUNCTION IN OSTEOPATHIC FAMILY MEDICINE WRITTEN UNDER THE AUSPICES OF THE AMERICAN COLLEGE OF OSTEOPATHIC FAMILY PHYSICIANS

Editor

Kenneth

Nelson, DO, FAAO, FACOFP

E.

Pr ofessor, Departments of Osteopathic Manipulative Medicine, Family Medicine, and Biochemistry Chicago College of Osteopathic Medicine Midwestern University, Downers Grove, Illinois Associate Editor

Thomas Glonek, PhD Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University, Downers Grove, Illinois Chicago Osteopathic Family Practice Michael Reese Hospital, Chicago, Illinois

aco

fp

AmcriGIn College of 0

s

teo pat h j

c

Family Physicians

•

,.

Lippincott Williams & Wilkins a

Wolters Kluwer business

Philadelphia· Baltimore· New York· london Buenos. Aires· Hong Kong' Sydney' Tokyo

Acquisitions Editor: Nancy Anas�asi Duffy Managing Editor: Kellv Horvath Manager: Linkins Editor: Julie I\lontalbano Terry Mall.on Compositor: International Typesetting and Composition Printer: R.R. Donnelley & Sons-Crawfordsville Copyright © 2007 Lippincott Williams & Wilkins Il!ustrations © 2007 American College of Osteopathic Family Physicians Camden Street MD 21201

530 Walnut Street Philadelphia, PA 19106 All rights reserved. This book is protected repmdmed in any form or :my means, storage and system withollt

copyright. No part of this book may be photocopying, utilized by any mfor permission [com copyright

(as a mailer product liah:lll negligence, or pllblisher is not wise) for any injury resulting from any material contained herein. This publication contains information relating to general principles of medical care that should not be construed as specific instructions for individual patients. Manufacturers' product infor­ mation and package inserts should be reviewed for current information, including conprecautions. dosages,

the United

America

Library of Congress Cataloging-in-Publication Data Somatic dysfunction in osteopathic family medicine / sponsored by the American College of Osteopathic Family Medicine; editor, Kenneth E. Nelson; associate editor, Glonek. cm. bibliogra phicli references. "5-3 3: 978-1-40) ISBN 1-4051-0475-9 1. Osteopathic medicine. 2. Manipulation (Therapeutics) I. Nelson, Kenneth E., DO. II. Glonek, Thomas. III. American College of Osteopathic Family Medicine. [DNLM: 1. Manipulation: Osteopathic. 2. Family Practice. .1. Patient-Centered Ph}'sician-P:n F(elations. S693 20071 2007

2006019403 The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the first arrangements additional

638-3030 or fdX (301) 223-2300.

of this to (301)

our cusromer

departmefll International customers shou

il

Visit Lippincott Williams & Wilkins on the Internet: http://t/JUJUJL . WWcom. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am ro EST. 600 09 567 8

11)

Dedicated to Andre V. Gibaldi, DO, FACOFP, family physician, educator, colleague, mentor, and friend.

Preface

As osteopathic medicine has grown and taken its rightful place in the mainstream of medical practice, the isolated environment in which we once taught our students and residents has given way to open-staffed hospitals. Consequently, our clinical edilcators are now as apt to be allopathic as they are to be osteopathic physicians. At this same time, and in part because of this progress, there has developed a need to demonstrate what we have that is distinctly osteopathic. The American Osteopathic Association has mandated that our residents demonstrate seven core competencies; the first of those competencies is osteopathic philosophy and osteo­ pathic manipulative medicine. Thus, there has arisen a need for a clinically oriented text that addresses the dis­ tinctive aspects of osteopathic medicine. In an attempt to fill that need, this text presents a contemporary understanding of the fundamentals of osteopathic philos­ ophy and the applied diagnosis and treatment of somatic dysfunction throughout the practice of family medicine. It is not intended to be a review of general med­ ical practice. There are many such texts. Nor is it intended to be a manual of osteo­ pathic manipulative treatment (OMT) procedures, although many examples of applicable procedures are provided throughout the book. Again , many excellent and more complete procedure manuals are available. Rather, this text provides medical students, residents, and physicians in practice with a description of how their patients may be empowered to take an active part in the establishment and maintenance of health; how the diagnosis and treatment of somatic dysfunction fosters a holistic, patient-oriented approach to health care; how somatic dysfunc­ tion affects the patient's health status; and the clinical logic for the use of OM T in the care of those patients with examples of possible procedural choices. All too often individuals consider OMT as an appropriate treatment only for musculoskeletal pain. Although this is one area in which the modality is effective, it is but a single application. Early osteopaths employed OMT to treat patients

with all manner of medical conditions. These pioneers were frequently criticized for their practices, for inappropriately treating cholecystitis or a myocardial infarc­ tion with OMT. This, of course, was not the case. Rather, these clinicians were treating the patient, attempting to alleviate the effects of somatic dysfunction upon the individual's overall ability to respond to the illness. They were addressing the effects of somatic dysfunction upon their patients mechanically as well as the effect it exerted upon circula tion and neurophysiology. Following in that original tradition, this text is focused upon the advantages of the diagnosis and treatment of somatic dysfunction in all types of patients, of all ages, with all manner of clinical conditions. The specific conditions discussed are used as exam­ ples of the clinical approach to broad categories of illness, and the reader is encouraged to generalize. After ail, there is consistency in the ways somatic dysfunction affects an individual mechanically and physiologically, whether the infirmity is gastrointestinal or upper respiratory. The answer to how I would "osteopathically" treat a patient with hypertension is ... the same way I would treat a patient with diabetes. The focus is upon the patient, in the context of his or her given illness, but still (pun intended) upon v

Preface

vi

the patient. Recognition of the inherent reliability of human anatomy and the univer­ sality of the presence and effects of somatic dysfunction fosters this approach. This

one of the most difficult medicine. Certainly, the speci

clmicians who affecting the context

and treated approprialc!Y, individual. Such a patient

i

paradigm,

significantly less frustrating disease-focused

than is a

especially when the problem

falls into

the broad and otten ambiguous category of functional Illnesses. Ihls is why osteo­ pathic medicine is applied so naturally to the practice of family medicine. This text is divided into four areas: philosophy and principles of patient care, categories of patients encountered, categories of clinical conditions encountered, and practice issues. Within these categories, the chapters that deal with the middle two begin with a discussion of the patient or clinical condition and are followed, in each case, with examples of the OMT procedures that could be applicable. We have attempted

examples from all categorics

selected are

representative of what t

has found

his or her experience.

assuredly must again the reader

procedures chapter have most text-it

procedures that other ell

Further,

intended as an OMl the examples of OMT

that: exam-

ples. They do nO[ represent [he exact procedure to

employed a[ all tlmes for a

given condition. OMT must be individually applied. After all, we are treating the patient, and every patient is a unique individual, as is every physician. Although the dysfunctional areas manipulated can be expected to demonstrate some consis­ tency for a given condition, the procedures that prove most effective for a given condition will differ from patient to patient as well as from clinician to clinician. for further inquiry into osteopathic medicine, we have included chapter references , which, though often pertinent-nclt ies supporting This texi less effort FACOFP, t of OsteopathiC

should not be considered dated.

continues to be

important-because if we do least we can demonstrate that come to light if it were It began as a request Department of Family Medicine cducJtion. Then

series of lectures for

a student and now a contributor to this project, Anette Mnabhi observed that the materials would lend themselves well to a textbook of clinical practice. Thls end product is the result of the clinical experience and much didactic research on the part of the contributing authors, overseen by the members of the American College of Osteopathic Family Practice (ACOFP), Committee for Osteopathic Principles and Practice, and a number of other conscriptees, who acted as peer reviewers. Gratitude must be expressed to the leadership of the ACOFP ,md Mr. Peter Schmelzer, Gratitude

of the ACOFP, for

project.

c\pressed to Patricia Nuccio,

ucational

coordinated resources and throughout this effort. measure must be extended associate

t

without whose broad-based

,

PhD, the

expertence

and long hours of dedicated effort, this book would have never been completed. Respectfully submitted, K. E.

June

Nelson 2005

7,

Contributors L

Zachary J. Comeaux. DO. FAAO Associate Professor Division of Osteopathic Philosophy and Practice West Virginia School of Osteopathic Medicine Lewisburg, West Virginia

David M. Driscoll. DO Assistant Clinical Professor of Medicine Tufts University School of Medicine Boston, Massachusetts Director of Inpatient Services, Department of Internal Medicine Lahey Clinic Peabody, Massachusetts

David B. Fuller. DO Assistant Professor, Department of Family Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Attending Family Physician North Baldwin Infirmary Bay Minette, Alabama

Thomas Glonek. PhD Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Chicago Osteopathic Family Practice Michael Reese Hospital Chicago, Illinois

Ann l. Habenicht. DO. FAAO. FACOFP Professor, Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Senior Staff, Department of Family Medicine Palos Community Hospital Palos Heights, Illinois

vii

viii

Contributors

Kurt Heinking. DO Associate Professor and Chairman Manipulative Medicine Medicine Downers

Jan Lei

DO

Adjunct Clinical instructor Department of Osteopathic Manipulative Medicine Midwestern University Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Douglas Community and Fami

Adjunct Assistall Dartmouth Hanover, Osteopathic Manchester Jorgensen Manchester, Maine

Raymond T. Jorgensen. MS. CPC President and Co-Founding Partner Priority Management Group, Inc. Pawtucket, Rhode Island

NMM/OMM Department of Surgery Medicine and Biosciences Idwin Infirmary

James Laub. MS. DO. MPH. FACPM Attending Physician Family Practice and Osteopathic Manipulative Medicine Grandview Medical Center Dayton, Ohio

Andrew Lovy. DO. FACN Past Chairman,

Psychiatry

Chicago

ic Medicine

Midwestern Downers Psychiatric Northeast

Council

Kirksville, Missouri

John McPartland. DO. MS Associate Professor Unitec School of Health Auckland, New Zealand

Contributors

Anette Karin Schilling Mnabhi, RN, M S N , DO Adjunct Clinical Faculty Department of Osteopathic Manipulative Medicine Midwestern University Downers Grove, Illinois Staff, Department of Family Medicine Rush Copley Medical Center Aurora, Illinois

Kenneth E. Nelson, DO, FAAO, FACOFP Professor, Departments of Osteopathic Manipulative Medicine, Family Medicine, and Biochemistry Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Nils Olson, DO, FACOFP Adjunct Professor of Family Medicine University of Des Moines College of Osteopathic Medicine Des Moines, Iowa Attending Physician, Department of Family Medicine Marshfield Clinic/Mercer Center Mercer, Wisconsin Midwestern University College of Osteopathic Medicine Chicago, Illinois Affiliate Staff, Howard Young Medical Center Woodruff, Wisconsin

Dean Raffaelli, DO Clinical Assistant Professor Departments of Family Medicine and Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Downers Grove, Illinois Midwestern University Attending Physician, Chicago Osteopathic Family Practice Michael Reese Hospital Chicago, Illinois

Thomas M. Richards, DO, FAAO, CIME Department of Neuromusculoskeletal Medicine Marshfield Clinic/Lakeland Center Minocqua, Wisconsin Community Preceptor Kansas City University of Medicine and Biosciences Kansas City, Missouri Attending Physician Primary Care Department Howard Young Medical Center Woodruff, Wisconsin

ix

x

Contributors

Joey Rottman, DO, FACOOG Associate Professor and Director of Clinical Clerkship Department of Obstetrics and Gynecology University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine Stratford, New Jersey Professor, Department of Obstetrics and Gynecology Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Associate Professor, Department of Obstetrics and Gynecology Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Nicette Sergueef, DO (France) Adjunct Assistant Professor Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Sandra L. Sleszynski. DO. AOBI'JMM Adjunct Clinical Assistant Professor Department of Osteopathic Manipulative Medicine Chicago College of Osteopathic Medicine Downers Grove, Illinois

Charles J. Smutny III. DO. FAAO Assistant Professor, Clinical Osteopathic Medicine New York College of Osteopathic Medicine Old Westbury, New York NMM Residency Director North Shore LIJ at Plainview Plainview, New York

Frank C. Walton, Sr.. DO, FAAO Adjunct Associate Professor, Department of Family Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Program Director NMM-OMM Residency Westview Osteopathic Hospital Indianapolis, Indiana

Alice J. Zal. DO. FACOFP Adjunct Faculty, Department of Family Medicine Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Private Practice, Family Medicine Geriatrics Family Practice Staff Mercy Suburban Hospital/Montgomery Hospital Norristown, Pennsylvania

Reviewers

Joseph D. Allgeier, DO Program Director and Director of Medical Education Florida Hospital East Orlando Orlando, Florida

Richard K. Book, DO Active Medical Staff, Family Medicine Arkansas Valley Regional Medical Center La Junta, Colorado

Jeffrey S. Brault, DO Assistant Professor of Physical Medicine and Rehabilitation Mayo Clinic Rochester, Minnesota

Janet M. Burns, DO Assistant Professor of Osteopathic Manipulative Medicine Ohio University College of Osteopathic Medicine Athens, Ohio

Boyd Buser, DO, FACOFP Professor of OMM University of New England College of Osteopathic Medicine Biddeford, Maine

Sarah Cates Osteopathic Medical Student, 4th year Virginia College of Osteopathic Medicine Virginia Polytechnic Institute and State University Blacksburg, Virginia

Robert S. Dolansky, Jr. , DO Director of Medical Education St. Luke's Hospital, Allentown Campus Allentown, Pennsylvania

Mary E. Franz, DO, FACOFP Private Practice, Family Medicine Topeka, Kansas

Dan C. Galloway, DO, FACOFP Private Practice, Family Medicine Seasons Health Center Crown Point, Indiana

xi

xii

Reviewers

Ann L. Habenicht, DO, FAAO, FACOFP Professor, Department of Osteopathic M anipulative Medicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois Senior Staff, Department of Family M edicine Palos Community Hospital Palos Heights, Illinois

Patrick J. Hanford, DO, FACOFP Private Practice, Kings Park Urgent Care Center Lubbock, Texas

Wilbur T. Hill, DO, FACOFP Private Practice, Family M edicine (Retired) Liberty, Missouri

Howard H. Hunt, DO, FACOFP Professor of Family Medicine (Retired) West Virginia School of Osteopathic M edicine Lewisburg, West Virginia

Douglas J. Jorgensen, DO, MS, CPC Adjunct Assistant Professor of Community and Family Medicine Dartmouth Medical School Hanover, New Hampshire Osteopathic Manipulation and Pain Management Jorgensen Consulting, LLC Manchester, Maine

John N. Kasimos, DO, FCAP, FASCP, FAOCP Chair and Professor of Pathology Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

Brian Loveless, DO Private Practice, Family Medicine Chino Valley Medical Center Chino, California

Barbara Peterson, DLitt Adjunct Associate Professor, Department of Internal M edicine Chicago College of Osteopathic Medicine Midwestern University Downers Grove, Illinois

T homas M. Richards, DO, FAAO, CIME Department of Neuromusculoskeletal Medicine M arshfield Clinic/Lakeland Center Minocqua, Wisconsin Community Preceptor Kansas City University of Medicine and Biosciences

Reviewers

xiii

Kansas City, Missouri Attending Physician Primary Care Department Howard Young Medical Center Woodruff , Wisconsin

J. Jerry Rodos, DO, DSc, FAANP Clinical Professor, Department of Behavioral Medicine Chicago College of Osteopathic M edicine Midwestern University Downers Grove , Illinois

Steven F. Rubin, DO, FACOFP dist Adjunct Clinical Professor, Departments of Osteopathic Manipulative Medicine and Family Medicine University of M edicine and Dentistry of New Jersey, School of Osteopathic Medicine Stratford, New Jersey Private Practice, Family Medicine Fair Lawn, New Jersey

George T. Sawabini, DO, FACOFP Private Practice , Family M edicine Farmington Village, Michigan

Frank R. Serrecchia. DO, RDH Adjunct Assistant Professor, Department of Osteopathic M anipulative Medicine Chicago College of Osteopathic Medicine M idwestern University Downers Grove, Illinois

William H. Stager, DO, FACOFP Clinical Assistant Professor of Family Medicine and Osteopathic M anipulative Medicine NOVA Southeastern University College of Osteopathic Medicine Fort Lauderdale, Florida

Marline A. Wager, DO Professor of Family Medicine West Virginia School of Osteopathic M edicine Lewisburg, West Virginia

Earle Noble Wagner, DO, FACOFP Private Practice. Family Medicine Cheltenham, Pennsylvania

Elaine M. Wallace, DO, MSc Chair and Professor of Osteopathic Principles and Practice NOVA Southeastern University College of Osteopathic Medicine Fort Lauderdale, Florida

xiii

Anthony M. Will. DO Assistant Clinical Professor, Pre-clinical Division Arizona College of Osteopathic Medicine Midwestern University Glendale, Arizona

Alice J. Zal. DO. FACOFP Adjunct Faculty, Department of Family Medicine Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Private Practice, Family Medicine Geriatrics Family Practice Staff Mercy Suburban Hospital/Montgomery Hospital Norristown, Pennsylvania

Contents

Preface

v vii

Contributo r s

xi

Reviewers

xxiii

List of Abbreviations

SECTION I 1

Philosophy and Principles of Patient Care 1

Patient Empowerment, J. L. Laub

2

Osteopathic Distinctiveness, K. E. Nelson

3

Diagnosing Somatic Dysfunction, K. E. Nelson Standing Structural Examination Supine Structural Examination Palpation for Tissue Texture Abnormality, Layer Palpation Regional and Segmental Examination of the Cervical Spine Examination of the Occiput (CO on (1) Examination of the Atlas (C1 on (2) Segmental Examination of the Cervical Spine (C2 on C3 to C7 on T1) Evaluation of the Upper Thoracic Region (T1 T4) : Using the Head and Cervical Region as a Lever Evaluation of the Upper Thoracic Region (T1-T4): Using the Thumbs to Assess Motion Evaluation of the Lower Thoracic Region (T5-T12): Using the Shoulders as a Lever Regional and Segmental Examination of the Lumbar Spine Motion Test for Sacroiliac Articular Dysfunction Standing Flexion Test Seated Flexion Test

22 23 25 25

The Manipulative Prescription, K. E. Nelson

27

6 12 17 17 18 19 19 20 20

-

4

21 21 21

xv

xvi

Contents 5

Viscerosomatic and Somatovisceral Reflexes, K. E. Nelson

Red Reflex Skin Drag Beal's Compression Test Inhibitory Pressure Treatment of Chapman's Reflexes Soft Tissue/Range of Motion, Patient on Side, a Stimulatory Procedure Soft Tissue/Range of Motion, Patient Prone Rib Raising to Stimulate Sympathetic Activity 6

Psychoneuroimmunology, J. L. Iwata

33 49 49 50 50 51 51 52 53 56

SECTION II Patient Populations 7

The Psychiatric Patient, A. Lovy

8

The Pediatric Patient, N. Sergueef and K. E. Nelson

Lumbopelvic Release Thoracic Release Cranial Membranous Release Sphenobasilar Release Occipital Release Occipitomastoid Release Frontal Release 9

The Female Patient, K. E. Nelson and J. Rottman

Structural Examination of the Obstetric Patient Sacrum, Inhibitory Pressure Lumbar Paravertebral Muscles (Soft Tissue) Psoas Release (Indirect) Psoas (Muscle Energy) Anterior Sacrum (Muscle Energy) Anterior Sacrum Leg Pull (HVLA) Posterior Sacrum Leg Pull (HVLA) Piriformis Muscle (Muscle Energy) Posterior Innominate Dysfunction (Muscle Energy) Anterior Innominate Dysfunction (Muscle Energy) Symphysis Pubis Superior or Inferior Shear (Muscle Energy) Ischial Tuberosity Spread (Myofascial Release) Sacrum Diagnosis and Treatment (Cranial) 10

The Surgical Patient, J. M. Krettek

Compression of the Fourth Ventricle, CV-4 (Cranial) Cervical (Soft Tissue/Articulation) Thoracic, Patient on Side (Soft Tissue) Lumbar Paravertebral Muscles (Soft Tissue)

73

73 87 98 98 99 99 101 101 102 105 112 113 114 115 116 117 118 119 119 121 121 122 123 124 127 132 133 134 134

Contents

11

12

xvii

Rib Raising

135

R ib Balancing

135

Pedal Pump (Dalrymple's Pump)

136

Pectoral Traction to Enhance Motion of the Diaphragm

136

Wound or Scar Release (Indirect)

137

The Athlete, K. P. Heinking

139

Anterior Lateral lVIalleolus (Muscle Energy)

151

Indirect Hamstring Release (Myofascial Release)

152

Knee (Indirect Myofascial Release)

153

Anterior Innominate Dysfunction (Muscle Energy)

154

Plantar Fascitis (Counterstrain)

155

Epigastric Thrust (HVLA)

156

Biceps, Long Head (Counterstrain)

157

The Geriatric Patient, K. E. Nelson, A . L. Habenicht, and 1\1. Sergueef

159

Cervical Treatment (C2-(7), Patient Supine (Still Technique)

171

Cervical Treatment (C2-(7) , Patient Seated (Still Technique)

13

172

Thoracic Dysfunction (Still Technique)

173

Lumbar Dysfunction (Still Technique)

174

Sacrum (Facilitated Positional Release)

175

Simple Cervical Isometrics (Exercise)

176

Cervical Isometrics (Exercise)

177

Simple Calf Strengthening to Stabilize Gait ( Exercise)

178

Calf Strengthening to Stabilize Gait ( Exercise)

178

Gluteal Strengthening to Stabilize Gait (Exerc ise)

179

The Patient at the End of Life, A. J. Zal

181

Anterior Thoracic Tender Points Tl-T 6 (Counterstrain)

189

Anterior T horacic Tender Points Tl-T12 (Counterstrain)

189

Posterior Thoracic Tender Points Tl-T4 (Counterstrain)

191

Posterior Thoracic Tender Points T5-T12 (Counterstrain)

192

Posterior Thoracic Tender Points,Alternative Procedure T9-T 12 (Counterstrain) Anterior Lumbar Tender Points (Counterstrain)

192 193

Posterior Lumbar Tender Points (Counterstrain)

194

Lateral Tender Points for Lateral L3, Lateral L4, and UP5L

195

Lateral Recumbent Treatment of the LP5L Tender Point

195

SECTION III

Clinical Conditions 14

197

The Patient with Otitis Media, D. B. Fuller,

197

Posterior Chapman's Reflexes from Otitis Media

201

Galbraith's Procedure

201

xviii

Contents

Traction on the Pinna Cranial Vault Hold for Spheno-occipital Synchondrosis Torsion Temporal Bone Dysfunction (Cranial) Pterygoid Fossa Decongestion, Sphenopalatine Ganglion Procedure 15

206

208 214 216 216

The Patient with a n Upper Respiratory Infection,

K. E. Nelson Upper Thoracic Spine (Muscle Energy) Diagnosis of Elevated First and Second Ribs First Rib (HVLA) Second Rib (HVLA) Acromioclavicular, Anterior Clavicle (HVLA) Acromioclavicular, Posterior Clavicle (HVLA) Cervical (Soft Tissue/Articulation) Cervical (Indirect Balancing) Cervical Posterior (HVLA) Atlas Posterior (Muscle Energy) Atlas Anterior (HVLA) Occiput Posterior (Muscle Energy) Occiput Anterior (Muscle Energy) Occipitoatlantal (Myofascial Release , Direct) Trigeminal Nerve Procedure of Bailey Facial Effleurage Submandibular Percussion Anterior Neck Soft Tissue, Lymphatic Procedure Thoracic Lymphatic Pump 17

203 204

The Patient with Temporomandibular Joint Pain and Dysfunction, J. McPartland EVA Procedure (Cranial) Jaw Lock Open Lock Correction Jaw Lock Closed Lock Correction

16

202

218 224 225 226 227 228 228 230 230 231 232 233 234 235 236 237 239 239 239 240

The Patient with a Lower Respiratory Tract Infection, Z. J. Comeaux Observation and Palpation Rib Raising Rotation and Rib Raising Rib Articulation, Seated Paraspinal Muscle Stretch: Lateral Recumbent Occipitoatlantal Release Cervical Paraspinal Muscle Release Cervical Articulatory Release Cervical Articulatory Release, Oscillatory Release Diaphragmatic Release Diaphragmatic Release Alternative (Doming the Diaphragm)

243 248 249 250 250 251 251 252 252 253 253 254

Contents

18

xix

The Patient with Hypertension, D. M. Driscoll

262

Local Scan of the Cervical Area ( Functional Diagnosis)

272

Segmental Definition of Cervical Somatic Dysfunction (Functional Diagnosis and Treatment)

273

Segmental Definition of Thoracic Somatic Dysfunction (Functional Diagnosis and Treatment)

19

20

274

The Patient with Congestive Heart Failure, K. E. Nelson

279

Cervical (Facilitated Positional Release)

285

Thoracic Inlet (Myofascial Release)

286

Scapulothoracic (Myofascial Release)

287

Lymphatic Pump (Oscillatory Modification)

288

T horacoabdominal Diaphragm Release

288

The Patient with Gastrointestinal Problems, K. E. Nelson and A. L. Habenicht

291

Patient Supine for Flexed or Extended Thoracic Somatic Dysfunction, HVLA

21

301

Transabdominal Stimulation

302

The Patient with Thyroid Disease, D. J. Jorgensen

304

Upper Thoracic on Side, Extended: HVLA and Articulatory Treatment

317

Upper Thoracic on Side, Flexed: HVLA and Articulatory Treatment Diagnosis of Elevated First and Second Ribs

319

First Rib,Facilitated Positional Release

320

First Rib, HVLA

321

Second Rib, HVLA

321

22 The Patient with Parkinson's Disease, C. J. Smutny,III Cervical (Soft Tissue)

23

3 18

324 331

Cervical (Muscle Energy)

331

Inhalation Second to Sixth Ribs (Muscle Energy)

333

Inhalation Seventh to Tenth Ribs (Muscle Energy)

334

Exhalation First and Second Ribs (Muscle Energy)

335

Exhalation T hird to Fifth Ribs (Muscle Energy)

336

Exhalation Sixth to Tenth Ribs (Muscle Energy)

337

Thoracic Cage Balancing (Indirect)

338

Cross Pisiform or "Texas Twist" (HVLA)

339

Psoas Release (Balanced Ligamentous Tension)

340

The Patient with Larson's Syndrome: Functional Vasomotor Hemiparesthesia Syndrome, F. C. Walton, Sr.

342

Spinous Process T hrust (HVLA)

351

Fixed Point, Rotation (HVLA)

352

Reverse Rib (HVLA)

353

Contents

Ribs Posterior (Elevated) Tender Points, Patient Seated (Counterstrain)

356

Ribs Anterior (Depressed) Tender Points, Patient Seated (Counterstrain)

24

The Patient with Fibromyalgia/Chronic Fatigue Syndrome, A. K. Schilling Mnabhi

25

357

360

Piriformis Muscle Tender Point (Counterstrain)

375

Hamstring Release ( Myofascial Release)

376

Knee (Myofascial Release)

377

Tibiofibular Balancing (Indirect)

378

Plantar Fascial Tender Point «(ounterstrain)

379

The Patient with Chronic Pain, Headache, T. Richards

383

Knee in the Back, Upper T horacic Type II Extended Dysfunction (HVLA)

395

Knee in the Back, Upper T horacic Type II Flexed Dysfunction (HVLA)

26

396

Reverse Rib (HVLA)

397

Elevated First and Second Ribs, Patient Prone (HVLA)

398

(1 Posterior (Counterstrain)

399

Sutherland's Occipitoatlantal Decompression (Cranial)

400

Occipital Condylar Decompression (Cranial)

401

Frontal Lift (Cranial)

402

Parietal Lift (Cranial)

404

The Patient with Back Pain: Short Leg Syndrome and Postural Balance, K. E. Nelson and A. K. Schilling Mnabhi

27

426

Posterior Sacrum, Trunk Rotation (HVLA)

427

Lumbar Walk-Around (HVLA or Muscle Energy)

428

Psoas Spasm (Muscle Energy)

429

Psoas Stretch, Standing (Exercise)

430

Psoas Stretch, Prone (Exercise)

432

The Patient with Back Pain: Postural Decompensation in the Sagittal Plane, N. A. Olson

28

408

Constant Rest Position

434

Lumbosacral Release (Direct Myofascial Release)

447

Pelvic Tilt (Exercise)

448

Psoas and Quadriceps Stretch Kneeling (Exercise)

449

Dry-Land Swim (Exercise)

450

The Patient with Scoliosis, K. E. Nelson

452

Lazy-Person Exercise (Mobilization)

461

Group Curve Mobilization (Articulation, HVLA, or Muscle Energy)

461

Back Extension Exercises (Stabilization)

463

Torso Curls Exercises (Stabilization)

463

Reverse Torso Curls Exercises (Stabilization)

464

Contents

xxi

SECTION IV

Practice Issues 29

The Office, D. Raffaelli

30 Progress Notes and Coding, D. J. Jorgensen, R. T. Jorgensen, and K. E. Nelson 31

466 466

470

The Standardized Medical Record, S. L. Sleszynski and T. Glonek

490

Appendix

513

Index

519

List of Abbreviations

A-A,atlantoaxial (joint) AACOM,American Association of Colleges of Osteopathic Medicine AAFP,American Academy of Family Physicians AAO,American Academy of Osteopathy ABG,arterial blood gas ACL, anterior cruciate ligament ACOFP,American College of Osteopathic Family Physicians ACTH, adrenocorticotropic hormone, corticotropin ADLs,activities of daily living AEA,anandamide,arachidonylethanolamine 2-AG,2-arachidonylglycerol AIDS,acquired immune deficiency syndrome ALT,alanine amino transferase AMA, American Medical Association ANA,antinuclear antibody (panel) ANS,autonomic nervous system AOA, American Osteopathic Association AP curve, anteroposterior curve ART, articulatory treatment ASIS,anterior superior iliac spine AST, aspartate transaminase AVM, arteriovenous malformation BA, body areas BLT, balanced ligamentous tension/ligamentous articular strain BIVII, body mass index BMT, balanced membranous tension BPH, benign prosthetic hypertrophy BTS,British Thoracic Society C2, 3, etc. , cervical vertebral segments CAE,certified association executive CAM,complementary and alternative medicines CAP, Clinical Assessment Program

xxiii

xxiv

List of Abbreviations

CAP, community acquired pneumonia CBC, complete blood count CC, chief CCK, receptor

CCR5, chemok

Control and Prevention

CDC, Centers

CDROM, compact disk read-only memory CF IDS, chronic fatigue and immune dysfunction syndrome CF S, chronic fatigue syndrome CHF, congestive heart failure CME, continuing medical education CMS, Center

Standards

c NOS, constitutive C NS, central CI\I X, cranial transferase

COMT, catechol

COPD, chronic obstructive pulmonary disease CPC, Certified Professional Coder CPM, continuous passive motion CPT, current procedural terminolog y CR, cranial, cranial osteopathy (see also OCF ) CRH,

ng hormone Ise

CS, counterstrai CSF, cerebrospi CT, cervica CT, computed tomography CV-4, compression of the fourth ventricle DAs, dopamine agonists DASH, dietary approaches to stop hypertension DBP, diastolic blood pressure DBS, deep DECIDA acid

technetium-99m diisopropyl scintigraphy

DIR, direct DIT, diiodotyrosi DJD, degenerative joint disease DNR, do not resuscitate

List of Abbreviations

DO, Doctor of Osteopathy, Doctor of Osteopathic Medicine DSM-IV- TR, Diagnostic and Statistical Manual of Mental Disorders: 4th Text Revision

DVD, digital video disk E&M, evaluation and management EEG, electroencephalogram EENT, eyes, ears, nose, throat EKG, electrocardiogram EMG, electromyogram ErvlR, electronic medical record EMS, electrical muscle stimulation ENT, ears, nose, throat EPF, expanded-problem-focused eSOAp, ESR, erythrocyte sedimentation rate EV-4, expansion of the fourth ventricle FACOFp, Physicians FAAO, Fellow of the American Academy of Osteopathy

FM, fibromyalgia FPR, facilitated positional release GAS, general adaptive syndrome GERD, gastroesophageal reflux disease GH, growth hormone GHAA, Group Health Association of America GI, gastrointestinal GMS, general mUlti-system (examination) GVA, general visceral afferent neuron H&P, history and physical HCFA, Health Care Financing Administration HCPCS, HCFA's Common Procedural Coding System (pronounced "hickpicks") HDL, high density lipoprotein HEENT, head, eyes, ears, nose, throat HIDA, hepato nuclear medicine biliary tract scans HIPAA, Health Insurance Portability and Accountability Act HIV, human immunodeficiency virus HLA, human leukocyte antigen

xxv

xxvi

List of Abbreviations

HPA, hypothalamic-pituitary adrenal (axis) HPI, history of present illness HS CRp, high sensitivity C-reactive protein HVLA, high-velocity, low-amplitude ICD-9CM, International Classification of Disease, Ninth Clinical Modification ICHD-2, International Classification of Headache Disorders, 2nd ed. ID, internal derangement IDET, intradiscal electrothermal therapy IGE, immunoglobulin-E IL-1, -6, and so on, interleukin ILA, inferior lateral angle (sacrum) I ND, indirect (treatment) I NR, integrated neuromuscular release IT, Information Technologies (Department) JNC 7, Seventh Report of the Joint National Committee on High Blood Pressure KO H, potassium (kalium) hydroxide L1, 2, etc., lumbar vertebral segments LAS, ligamentous articular strain/balanced ligamentous tension LBORC, Louisa Burns Osteopathic Research Committee LC-NE, locus ceruleus-norepinephrine axis L HR H, leuteinizing hormone releasing hormone MA, Medical Assistant MAO-B, monoamine oxidase B MD, doctor of medicine MD M, medical decision-making ME, myalgic encephalopathy ME, muscle energy MFR, myofascial release MIT, monoiodotyrosine MODE MS, Musculoskeletal Outcomes Data Evaluation and Management System MPD, myofascial pain dysfunction MRI, magnetic resonance imaging MSA, mUltiple system atrophy NAD H, nicotinamide adenine dinucleotide (reduced form) NC, noncontributory

List of Abbreviations

NK, natural killer (cells) NO, nitric NOS, NO nflammatory drugs

NSAID, OA, occi OCF,

cranial field

OIVlM, osteopathic manipulative medicine OMT, osteopathic manipulative treatment OP T!, osteopathic post-graduate training institutions OS, organ systems OTH, other treatments used (region)

PAG, periaq PAH,

hypertension

PAN,

nociceptors

P C, personal PCP, phencyclidine P D, P arkinson's disease PET, positron emission tomography P F SH, past family, medical, and social history PhD, doctor of philosophy PI, pelvic index P IPIDA,

PTSD,

acetanilido-iminodiacetic

disorder

PPD, (tuberculin) purified protein derivative PSIS, posterior superior iliac spines PSP, progressive supranuclear palsy P SS, pelvic side shift PT, physical therapy PT U, RA, rheumatoid RAI U,

uptake

ROM, range REM, rapid RF, rheumatoid factor RICEM (principle), rest, ice, compress, elevate, medicate

xxvii

xxviii

List of Abbreviations

RN, registered nurse ROS, review RP R, rapid SARS, severe

ratory syndrome

SBP, systol synchondrosis

SBS,

SF36, Rand 36-ltem Health Survey SI, sacroiliac (joint) SNS, sympathetic nervous system SOAP, subjective, objective, assessment, plan SOQ, Specialized Osteopathic Questionnaire SOS, Sing

(SOAP note form)

SPEeT, sing

ission computed

SS, SSRI, selective

reuptake inhibitor

ST, soft tissue STDA, soft-tissue, deep articulation SP, substance P T1, 2, etc., thoracic vertebral segments T3, triiodothyronine T4, thyroxine asymmetry, range

TART, tissue

lectrical nerve stimulation

TENS, tra

hormone

TRH, thyrotropi

attack

TIA, transient

TMJ, temporomandibular joint T NF, tumor necrosis factor TRH, thyrotropin-releasing hormone TSH, thyroid-stimulating hormone UPDRS, Unified P arkinson's Disease Rating Scale VIP, vasoactive intestinal polypeptide WHO, World

Ith

ization

tenderness

SECTION

I

Philosophy and Principles of Patient Care

CHAPTER

1

Patient Empowerment James L. Laub

INTRODUCTION After y ears working in a variety of hospitals and clinics in the military, facilities where medical doctors and doctors of osteopathic medicine worked side by side, occa­ sionally a patient newly assigned to the installation would ask when first checking in to the medical facility, "Do you have any DOs on the staff?" I thought I knew why, so I never-nor did any of the other staff members-ask why the patient requested an osteopathic physician. One day in my clinic, I had an allopathic medical student shadowing me for the afternoon. The patient, who had more than 20 years of mil­ itary service and whom I had seen on several previous visits, struck up a short con­ versation with the student while I was finishing the note in the chart. In the con­ versation, he mentioned that he always preferred osteopathic physicians and sought them out at every opportunity. When the student asked why, his answer surprised me a bit: "Because they listen better." Mine was a neuromusculoskeletal medicine clinic. More than 90% of the treatment I gave was OMT (osteopathic manipulative treatment). My patients were all referred from their primary care physician. This patient was assigned at a nearby military installation and drove 50 miles to see me for his chronic myofascial pain, which was showing marked

improvement. But his number one reason for seeking my counsel as a physician apparently was that my osteopathic colleagues and I were known to him to be good listeners. Moreover, I believe he was saying that his osteopathic physicia�

2

Section I • Philosophy and Principles of Patient Care

was listen i ng at the level needed to under sta n d

him and t hereby showed respect for

his persp ecti ves con cerning his health care. Respect i ng patien ts' perspe ctives makes them part of the treatment team an d

establishes the basis for empowering them active ly to seek solutions to their own medical issues. The empowere d pa tient is not just the s ufferer ; the empowered patient is

a

collegial m em ber o f the team seeki ng the m ost e ffect ive t h erapeutic

pl an . As with any form of parti cipati ve management, the p atie nt is a stakehol der in the success of the t h erapeut i c plan, not the su bject of it. This starts with good liste n ing , but it is necessary to do more than JUSt good l isteni ng to ma k e patient e mpowerment wo r k. Heal ing occurs from wi th in; the first step to a ssisting patients to get past the bar riers to th ei r own hea l ing power is for them to develo p a pe r­

sonal commitment to th e t h e rapeut ic plan for their own rec overy. The most effec­

tive way to secure th a t commitment is to ensure th a t patien ts are partn e rs in the

p l an's dev elopm ent. T h eir partnersh ip in the process is most e asily don e t hrough a patient-cent er ed medical practice. The next few paragraphs e xp l or e and contrast the patient-centered m e di cal practice model with what is perhaps the more famil­ iar physician-centered mode l. Later on the ch a pter addresses how the patient­

centered model is the cornerstone of effective patient e mpowerment . T he physician -cente red model is a parent-child transacti on I in which the patient is expected to be passive and dependent on the doctor's advice in an uneq u al rela­

tion shi p. Teaching is designed to keep information simple to facilitate retention. The

health profess ional holds valued medical information and conveys it to the pati ent,

who is expected to absorb it uncrit i cally. The chief issue in the physician-cente red model is the pa tient who is unable to understand or to retain the information or who lacks the motivation to comply. The model assum es that a ra tional argument is suf­

ficient to pers u a de pati ents they need to change their behavior to accommodate the health message. In this relationsh i p, t he p rim ary reason for failure is the bad, non­ compliant patient who just wouldn't do what the doctor said. Also, in this re lat i on­ s hip, a patie nt who ga t h ers outside information ch allenges th e verac ity of the h ea lth pro fessional and is often admonished or criticized for doing so. The re fore, the energy to improve t h is system is expended in ge tting patients to com p ly. Metrics (e.g., we ight, laboratory va lues, blood pressure) are used for j udgm ent.

The p atie n t-center e d model is an ad u lt -adult transaction I in which tbe patient part i cip ates as an equal pa r tner with the p ro fe ssional to make informed judgments

and devel op a pe rsonal therape u t i c plan. This model see ks to e li c i t and satis fy

patients' expressed needs as a first step toward taking greate r control over their own heal th . Patients'

involvement in decision ma ki ng is the key part of the educa­

tional process itself. Use of the p atien t-centere d m odel deve lop s our patients' understanding and encour ages se lf-r e liance , with access to information necessary

to exercise control over their own body. The energy to improve this system is spent e ncouraging pati ents to share and refl ec t upon theif e xi st ing understandi ng as a basis for future l earning. Metrics are used for self-evaluation.

P at i ents have th e c apa b i l i ty to monitor the p e rfor m a nce of their body conti n ­

uou sly. When t h ey assess s omet h ing and find it awry, t h ey attempt to make

a

de te rm i nat i on as t o what may be the probl em from their k now le dge, abi lity, and

e x pe rience ( diagnosis) . They go on to decide what to do about it, aga in from

their knowledge, abili t y, and experience (treatment). And finally, they watc h f or

t he ir e xp ec te d outcome (follow-up). Patients seek counsel wh en t h e pro bl em is ou tsi de of their knowledge, a bi lity, or experience to diagnose or treat or when there is no improvement at follow-up. I s u bmit that doctors of osteopath ic m edicine go through the same process with patients. And if treat m ent fails, clinician s do the

Chapter 1

• Patient Empowerment

3

same thing: seek the counsel of a specialist and call it a referral. True primary care medicine occurs before the patients even are present. Osteopathic physician s show patients a desire to understand by consulting patients as they would a referring physician. It is necessary to respect the fact that patients have exceeded their level of expertise and exchange information collegially, discuss courses of action, what outcomes to expect, and when they should occur. In addition, when patients gather information on their condition from outside sources, they are providing more data to draw upon. No one's knowledge is infinite, and when a colleague shares knowl­ edge, it has the potential to contribute to better decision making. An inquiring patient is not challenging the physician's veracity but participating in an effort to achieve a suc cessful therapeutic dec i sion from the team. And that participation also enfranchises the patient as a stakeholder in the success of the therapeutic plan. Not long after osteopathic physicians attained full practice rights, the search was on to find out what makes them distinct. Apparently with full practice rights comes the loss of the osteopathic equivalent of the H oly Grail. In an excellent 1993 article,

].

F. Peppin lists six potential activities for osteopathic distinction.2 After discrediting

each , he suggests that touch is a better candidate. Peppin includes a statement from an osteopathic physician who claims "true" osteopathic medicine no longer exists in the United States and a statement from another who suggests it is not any one of his six factors but the collection together that makes osteopathic medicine distinct, an osteopathic collage.2 While pursuing this search is beyond the scope of this chapter, one irrefutable item does bind all osteopathic physicians the letters "DO" after one's name. Fewer than 5% of physicians in the United States have an osteopathic profes­ sional degree. As with any minority, the actions of one frequently speak for many. The action of a medical physician usually only speaks to how the patient population regards that one individual. But the action of an osteopathic physician frequently speaks to how the patient population regards osteopathic physicians collectively. Thus, doctors of osteopathic medicine entrust part of their reputation to each other and should do their best for one another. Patient empowerment is not anything that's u niquely osteopathic. Patients

will

hold the empowering allopathic physician in high regard, also. But the empower­ ing osteopathic physician may well engender a positive reflection on our entire profession. I always felt a sense of pride when a family transferred into our

mili­

tary installation and requested to see a DO. It told me one or more of my osteo­ pathic colleagues had left them with an identifiably positive experience. The pride continued along with

a

profound sense of responsibility when tbe staff chose to

send that family to me to continue their care in that sa m e identifiably positive way. Regardless of the chosen specialty it is necessary to continue the legacy, listen well, ,

practice patient-centered medicine, and empower patients. The material in this chapter comes from a collection of concepts that I have taken and tested in the laboratory of life. Certainly, the concept of empowerment is not new and is easily traceable in both the clinical and management literature over 50 years.3,4 I received my original exposure to participative management con­ ce pt s in the mid-1970s as a graduate student at the University of Utah. Especially significant to me were the writings of Douglas McGregor5

and Abraham

Maslow,6 along with the lectures and writings of F rederic k Hertzberg.7,8 There

I also had the good fortune to take

a

course in social psychology from Martin

Chemers. Since at the time I was a military officer, I could easily take a collage of

academic concepts and test them fro m my positions as a manage r and leader. From

this empirical immersion, my use of and confidence in empowerment evolved. Later, when I embarked on my quest to study osteopathic

m edicine,

I discovered

4

Section I • Philosophy and Principles of Patient Care

I had learned some tools to describe what some of my clinician mentors had dis­

covered apparently by trial and error. Empowerment, whether in a clinic or at a worksite, has a demonstrated history of success. Thomas Gorclon4 has an excellent

description of his experiences in tl-le preface of Making the

Patient Your Partner,

including his exposure to the clinical work of Carl Rogers in clinical psychology

in the 1950s. I recommend the book by Go r don and Edwards4 to any clinician who wants to learn more in this area.

Later, after my osteopathic internship, I reentered the military and was exposed

to the work of W. Edwards Deming9 in quality management. I now was reener­ gized to expand the empowerment concepts from my management background

into my clinic. r learned from both coworkers and patients; my appreciation for the value of empowerment continued to evolve. In preparing for this chapter, I came across the work of Carl E. Schneider,lo The Practice of Autonomy, in which he discusses the development of autonomy as Thus, the use of empowerment concepts

a

sociological movement in our society.

in a population whose desire for autono­

my is on the rise is a terrific combination for success. Additionally, I recently came upon the work of Daniel Fisherll and his use of empowerment as the basis for suc­ cess with schizophrenic patients. At least on the surface, empowerment appears to be just a portion of a larger sociological movement. And I, as a subject in this movement, have merely read, listened, tried, and learned. If anyone feels I've encroached u pon his or her intellectual property, I humbly beg forgiveness. Where I believe this treatise fits

in osteopathic literature is perhaps in the

revered stature the osteopathic profession gives to physicians who have engen­ dered empowerment in the practice of osteopathic medicine. Despite the profes­ sion's inability heretofore to codify what those revered osteopathic physicians do,

the profession subjectively embraces them. Reverence begets emulation , and emu­ lation begets a culture (treat tile person, not the disease).

HOW TO BE ON A TEAM WI TH AN EM POWERED PATIEN T Teams can take one of three basic forms. The first is the synergistic team. The syn­ ergistic team exploits t he ideas and participation from each of its members and seeks to reach a set of conclusions that is superior to what any individual on the

team could do alone. The second is the leader-follower team. The leader-follower team designates one member as the expert who autonomously selects the set of conclusions for the team. The third is the antagonistic team. The antagonistic team is one in which internal conflict, personal interest, and politicking usually attempt a compromise set of conclusions that often are inferior to what many of the mem­ bers could have accomplished individually.

If we wish to be part of a synergistic team as we empower our patients, here are

t\VO basic rules: There is no room for ego in clinical encounters. This is easier to understand in concept than to accomplish in fact. Ego challenges cause a visceral reaction. That reaction has to be recognized for what it is and discarded at the same emotional level it enters, before the physician can continue witb the patient interaction. Empowering the patient does not abrogate the responsibility of the clinician. No two combinations of patient and illness are the same. Each will require a unique interplay among the decision team members. Each will demand a con­ tribution from the clinician at some level given the situation.

Chapter 1

• Patient Empowerment

5

References 1. Berne E. Whar Do You Say Afrer You Say Hello? New York: G r ove , 1972. 2. Peppin JE The osteopathic distincrion: fact or fancy) J Med Humanir 1993;14(4):203-222. 3. Siegal B, August Y. Help Me to H ea l . Carlsbad, CA: Hay House, 2003. 4. Gordon T, Edwards WS. Making the Parient Your Parrner. Wesrporr, CT: A u b urn House, 1995. 5. McGregor D. The Human S ide of Enterprise. 25rh Anniversary Printing. New York: McGraw Hill, 1985. 6. Ma sl o w A. Motivarion and Personality. 2nd ed. New York: Harper & Row, 1970. 7. Hertzberg F. Work and the Narure of Man. London: Harper Collins, 1966. 8. Hertzberg F. Motivation ro Work. Somers er, NJ: Transaction, 1993. 9. Deming WE. The New Economics for Industry, Government, Educa tion. 2nd ed. Cambridge, MA: MIT, 2000. 10. Schneider CEo The Practice of Autonomy. New York: Oxford U n i ver s ity Press, 1998. 11. Fisher D. Narional Empowerment Center. Available at http://www.power2u.org. Accessed Februa ry 20, 2005.

Osteopathic Distinctiveness Kenneth E. Nelson

IN TRODUCTION Osteopathic medicine is a success. With the new millennium, this nineteenth cen­ tury medical reactionary movement is well established within the mainstream of contemporary medicine. Success, however, has come with a price. Mainstream acceptance has resulted in the assimilation of the allopathic model of practice by osteopathic physicians to the detriment of their reactionary heritage. The osteopathic profession is being challenged to demonstrate its unique quali­ ties and thereby justify its existence as an independent institution within American health care. To do so, osteopathic distinctiveness must be identified, measured, and validated. The responsibility to prove osteopathic distinctiveness ultimately belongs to the osteopathic academic community, basic scientists and clinicians alike. Since contemporary osteopathic medicine has become mainstream, it is logical to look to its origin to identif y its distinctiveness. The philosophy of osteopathic medicine is based on four key principles:1 1. The body is a unit; the person is a unit of body, mind, and spirit.

2. T he body is capable of self-regulation, self-healing, and health maintenance. 3. Structure and function are reciprocally interrelated. 4. Rational treatment is based upon an understanding of the principles of body

unity, self-regulation, and the interrelationship of structure and fun ction. 6

(I)

..... .. I') (

Chapter 2 • Osteopathic Distinctiveness --�.

(a)

FIGURE 2. 1

-.... . .. (b)

-

.... . .. (c)

--

7

--

A schematic representing cause-and-effect logic.

These individual principles, however, are not necessarily unique to osteopathic medicine, and they are extremely difficult to quantify. Consistent with principle 1, contemporary osteopathic physicians claim to be holistic. This is an admirable trait, but it is not distinctly osteopathic. Holism has been all but usurped by contemporary alternative medicine, and increasing num­ bers of practitioners are approaching their patients in this manner. Consistent with principle 2, contemporary osteopathic physicians claim to be patient oriented (as opposed to disease oriented). Although allopathic medicine focuses upon the diagnosis and treatment of disease , the practice of medicine is acknowledged to be highly personaJ.2 With the progressive understanding of the role of the immune system, much of the contemporary treatment of disease is focused on assisting the patient's ability to respond to the illness. An apparent difference (consistent with principle 3) is the diagnosis and treatment of dysfunction in the musculoskeletal system. Yet many doctors of osteopathic medicine do not use osteopathic manipulation, and a number of medical doctors, most notably in physical medicine and rehabilitation, employ manual therapy. Principle 4 appears to identify the distinction by combining the first three prin­ ciples to form a system for clinical practice. If osteopathic medicine is distinctive and the understanding of somatic dysfunction in the context of the patient's level of wellbeing occupies a pivotal position in that distinctiveness, then it is the appre­ ciation of the significance of dysfunction of the neuromusculoskeletal system that offers osteopathic physicians a uniquely holistic system of clinical logic. HOLISTIC LOGIC

The logic of Western science, and consequently Western medicine, is Aristotelian (Fig. 2.1). It seeks to understand systems by reducing them to the sequential rela­ tionship of their smallest parts (alamos). Therefore , in Figure 2.1, the sequence could represent an individual (I) who gets caught in the rain (a), which lowers his resistance (b) . He is exposed to a virus (c), which causes him to catch a cold (n. Comparatively, holistic logic may at first appear to be an oxymoron. Holism is an acceptance of the totality and indivisibility of a system. It is nonlinear. It is exemplified by the Taoist philosophy of ancient China. Such a nonlinear system might be illustrated (Fig. 2.2) as the determination of a resultant vector. As multi­ ple forces act upon the individual (I), the resultant vector or outcome (I') is the development of disease or the maintenance of health.

I) ( '(I)Y ' (c)

(a)

'(b) FIGURE 2.2

A schematic representing holistic logic.

8

Section I • Philosophy and Principles of Patient Care

STRUCTURE, FUNCTION, AND DYSFUNC TION The third principle, describing the relationship between structure and function, gives rise to the recognition of somatic dy sfunction. The diagnosis and treatment of somat­ ic d ysfunction d ifferentiate osteopathic med icine from allopathic medicine. Somatic d ysfunction is impaired function of fundamentally normal anatomy. It is not pathol­ ogy. Rather, it is thought to predispose to and, once established , maintain pathology. The mechanics of somatic dysfunction have been described .I,3-S Somatic d ysfunc­ tion may occur as functional impediment due to altered soft tissue (muscular, liga­ mentous, fascial) tensions, articular motion restriction, or any combination of these components. Articular dysfunction of typical spinal segments (adjacent vertebrae possessing zygapophyseal joints and intervertebral discs) may occur as group dys­ functions composed of three or more consecutive segments , or as segmental dysfunc­ tions composed of two adjacent segments. Articular dysfunction of atypical spinal segments and appendicular joints is determined by their unique anatomy. The response of the axial musculoskeletal system to the force of gravity is nearly always asymmetric. Most ind ividuals have unequal leg length, with resultant pelvic unleveling.3 Therefore, everyone is pred isposed to compensatory group and seg­ mental spinal dysfunction.s Add to this the asymmetry imposed by dominance (left- and right-handedness), stresses from activities of daily living, and trauma (micro and macro), and it is understandable that musculoskeletal problems are so widespread. Somatic dysfunction, both group and segmental dysfunctions, occur in response to sid e-bend ing forces.4 The physiology of somatic dysfunction has been extensively studied.6-9 The greater bod y of scientific literature has been reviewed and compared to the pro­ posed mechanisms of somatic dysfunction.10,11 Van Buskirk12 offers a nociceptively rooted model for spinal somatic d ysfunc­ tion as follows: 1. A peripheral focus of irritation results in activation of nociceptive neurons.

These may be somatosensory or general visceral afferent neurons. 2. These primary afferent neurons synapse in the dorsal horn of the spinal cord

with internuncial neurons. 3. Ongoing afferent stimulation of insufficient intensity to reach firing potential results in the establishment of a state of irritability (facilitation) of the inter­ nuncial neurons. 4. Additional afferent activity from any source results in a segmenral response to

significantly less stimulus than would normally be required. 5. Such activity from internuncial neurons, which synapse with ventral horn motor

neurons, results in segmentally related myospasticity. Stimulation of internuncial neurons, which synapse in the intermediolateral cell column of the thoracic and upper lumbar cord, will produce a segmentally related sympathetic response (somatic and/or visceral). The same response to stimulation applies to the parasympathetic efferent system. Moreover, internuncial neurons travel up and down the spinal cord for several segmenrs and further synapse with the spinothal­ amic tract. These neurons are, thus, capable of initiating a broad response.

SPINAL SOMATIC DYSFUNC TION AS A FOCAL POIN T FOR HOLISM A focus of irritation producing spinal facilitation can affect structures in segmentally related derma tomes, myotomes, sclerotomes, and viscerotomes . If the peripheral focus of irritation is the result of vertebral articular dysfunction, the paravertebral

Chapter 2 • Osteopathic Distinctiveness

9

myospasticiry and sensitivity found with spinal dysfunction resul t. If a peripheral somatic focus of irritation (dysfunction or pathology) produces a ventral horn motor response, the result is a somatosomatic reflex. If the somatic focus of irritation pro­ duces a response in the intermediolateral cell column or a parasympathetic nucleus, the result may be a somatovisceral or a (sympathetic) somatosomatic reflex. In a sim­ ilar fashion, general visceral afferent activity is capable of producing viscerosomatic

and viscerovisceral reflexes. As such, the spinal cord links seemingly unrelated systems and structures in a manner that fosters a clinical system of logic, rendering it more inclusive or holistic.

Clinical Example A pai:ient presents with d ysesthesia of the palmar surface of the right hand consis­

tent with a d iagnosis of carpal tunnel syndrome of uncertain etiology. Upper extremity complaints have been specifically linked to upper thoracic somatic dysfunction.13 Although the involved somatosensory innervation, the med ian nerve, should result in somatosomatic reflex findings paravertebrally from C6 to TI, such findings are more typically encountered in the upper thoracic region. The

sympathetic innervation of the upper extremity arises from

TI to T4. Autonomic

nerves contain afferent as well as efferent neurons. Therefore, "sympathetic affer­ ent" neurons from the right upper extremity are capable of producing facilitation in the upper thoraCic region lateralizing to the right. Facilitation, lateralizing to the right in the upper thoracic region, may be the result of primary spinal d ysfunction. Spinal segmental dysfunction with facilitation also can result from postural accommodation to pelvic unleveling or from environ­ mental stresses with resultant sym ptoms referable to the right hand. Viscerosomatic andlor somatovisceral mechanisms m ay also be present. The h igh thoracic region receives general visceral afferent input from m yocardium, lungs, and esophagus.14 Pathology in any of these organs is capable of producing nigh thoracic facilitation. Facilitation of upper thoracic spinal segments can result in a reflex visceral response. Tachycardia through the sympathetic innervation of the sinoatrial node of the heart is an example. Further, somatic dysfunction of minor intensiry may be am plified through cen­ tral facilitation by emotional stress. Spinal segmental facilitation has been shown to result in segmentally related soft tissue edema. IS Edema of the contents of the carpal tunnel can compress the median nerve. Thus, the upper thoracic spina I segmental facilitation, of whatever etiology, can produce or maintain carpal tunnel syndrome. As such, the symptom s of carpal tunnel syndrome may be the result of organic pathology of the wrist. They may be a manifestation of a somatosomatic reflex from upper thoracic somatic dysfunction, either primary or as postural accommo­ dation, or they may be a reflex from visceral pathology. Finally, th e entire situa­ tion may be increased

by the patient'S mental status.

Conversely, carpal tunnel syndrome may result in spinal facilitation

with sec­

ondary (reflex mediated) spinal somatic d ysfunction and untold effect upon seg­ mentally related viscera.

DISCUSSION From this description of the mechanics and physiology of spinal somatic d ysfunc­ tion, it can be seen how seemingly unrelated structures are linked through the axial central nervous system. A logical argument can be mad e as to how one might

10

Section I • Philosophy and Principles of Patient Care

alleviate a tachyarrhythmia by treating carpal tunnel syndrome or how a proton pump inhibitor might be employed to decrease the inflammation of reflux esophagitis (viscerosomatic reflex T3, right), thereby reducing the median nerve compression of a right-sided carpal tunnel syndrome. These are, of course, hypothetical proposals, presented merely to illustrate how the appreciation of somatic dysfunction Jeads to the development of a distinctive form of clinical logic that is unique to osteopathic medicine. The basic science is sound, but much more should be done in the areas of functional anatomy, biochemistry, and physiology. The preceding discussion deals superficially with only the mechanics and neurophysiology of somatic dysfunction. No mention is made of the effect of somatic dysfunction upon circulation, the immune system, and homeostasis. From the perspective of clinical research, such complex problems are best pur­ sued as outcome studies, for which massive amounts of data are necessary. The development of such a database is predicated upon effective data gathering. The American Osteopathic Association (AOA) requires that a musculoskeletal exami­ nation be incorporated into the medical record. In the hospital, this is typically recorded in the admitting history and physical examination. It is, therefore, imper­ ative that this portion of the medical record be completed with particular diligence. The American Academy of Osteopathy (AAO) has developed and validated a series of outpatient osteopathic SOAP (subjective, objective, assessment, plan) note forms for outpatient use (see Chapter 31).16--18 The Des Moines College of Osteopathic Medicine and Surgery is developing an Internet-mediated central database for purposes of electronically gathering information pertaining to the practice of osteopathic medicine. The validity of the degree of osteopathic physi­ cians rests to a significant extent upon the results of this future research and con­ sequently upon the efficacy with which they participate in these projects.

References 1. Ward RC, ed. Fo un dations for Osteo pa th i c Medicine. 2nd ed. Philadelphia: Li pp incott Williams & Wilkins, 2002. 2. Fauci AS, ed. Harrison's Principles of Internal Medicine. 14rh ed. New Yo rk: McGraw Hill, 1998;1. 3. Schwab WA. Principles of Manipulative Treatment: The Low Back Pr o b lem. 1965 Yearbook. Vol 2. Indianapolis: American Aca de my of Osteo pa t h y, 1965;95. 4. Fryette HH. P rinc i pl es of Ost eopat h ic Technique. J nd ia napoli s: American Academy of Osteopat hy, 1954, 1980. 5. Nelson KE. The management of low back pain: S ho r r leg syndrome/postural balance . AAO J 1999;9(1 ):33-39. 6. Beal MC, ed. Lo u isa Burns, DO, Mem o ria l. 1994 Yearbook. Indianapolis: American Academy of Os teopathy, 1994. 7. Beal MC, ed. Selected papers of John Stedman Denslow, DO. 1994 Yearbook. Indianapolis: American Academy of Os teo pa t hy, 1994. 8. P e terson B, ed. Tile Collected Pape rs of Irvin M. Korr. Indianapolis: American Academy of Osteoparhy, 1979. 9. King HH, ed. The CoUected Papers of Irvin M. Korr. Vol. 2. Indianapolis: American Academy of Osteopathy, 1997. 10. Patters on MM, Howell IN, eds. The Ce n tra l Connection: Somarovisceral and Viscerosomaric I n ter a c rion . 1989 inrernational symposium. Athens, OH: University Classics, 1992. 11. Will ar d FH, Pa tter so n MM, eds. Nociceprion and the Neuroendocrine-Immune Connection. Athens, OH: University Classics, 1994. 12. Van Buskirk RL. Nociceprive reflexes and the somatic d ys f uncrio n: a m od el . J Am Osteopath Assoc 1990;90:792-794, 797-809 [review].

Chapter 2 • Osteopathic Distinctiveness

11

13. Larson NJ. Osteopathic manipulation for synd romes of the brachial plexus. J Am Osteopath Assoc 1972;72:378-.384. 14. Van Buskirk RL, Nelson KE. Osteopathic family practice: An application of the primary care model. In: Ward RC, ed. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia: Lippincort Williams & Wilkins, 2002;292.

15. Ramey K et al. MRI assessment of changes in swelling of wrist structures following OMT in patient s with ca rpal tunnel syndrorne. AAO J 1999;9:25-3l. 16. Nelson KE, Glonek T. Computer/outcomes: Hardcopy SOAP note preliminaty report: Family physician. Fam Physician 1999;3:8-10. 17. Sleszynski SL, Glonek T, Kuchera WA. Standardized medical record: A new outpatient osteo­ pathic SOAP nOfe form: Validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc J 999;99:516-529. 18. Sleszynski SL, Glonek T, Kuchera WA. Outpatient osteopathic single organ system muscu­ loskeletal exam form: Tra i n in g a nd certification. J Am Osteopath Assoc 2004;104:76-81.

Diagnosing Somatic Dysfunction Kenneth E. Nelson

INTRODUCTION Somatic dysfunction is a distinctly o steopathic diagnosis. It is unique in contempo­ rary medicine in that it is considered to be central to the practice

of osteopathic

medicine, yet it is not o rganic pathology. It is functional impairment. Somatic dysfunction is present to a greater or lesser d egree in all individuals. It should be part of the approach to the care of any patient to identify the relative importance of somatic dysfunction in the overall clinical presentation and to address it appropriately. Osteopathic manipulative treatment (OMT) is the defin­ itive treatment of somatic dysfunction. The e ffective use

of

OMT is predicated

upon the effective diagnosis of somatic dysfunction.

"Somatic Dysfunction Defined A. Somatic dysfunction: 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. Somatic dysfunction is treatable using OMT 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 palpa­ tion and referenced to its adjacent defined structure, (2) the directions in which motion between two adjacent structures is freer, and (3) the directions in which motion is restricted. Somatic dysfunction may be primary or secondary. 12

Chapter 3 • Diagnosing Somatic Dysfunction

13

B. Acute somatic dysfunction: Immediate or short-term impairment or altered func­ tion of related components of the somatic (body-framework) system; characterized in early stages by vasodilation, edema, tenderness, pain, and tissue contraction; diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion, and tissue texture change (TART). C. Chronic somatic dysfunction: Impairment or altered function of related compo­ nents of the somatic (body framework) system, characterized by tenderness, itching, fibrosis, parestheslas, tissue contraction; identified by TART. D. Primary somatic dysfunction: 1. The somatic dysfunction that maintains a total pattern of dysfunction. 2. The initial or first somatic dysfunction to appear temporally. E. Secondary somatic dysfunction: Somatic dysfunction arising either from mechan­ ical or neurophysiologic response subsequent to or as a consequence of other etiologies." A T Still'

Secondary somatic dysfunction may be mechanical, as is seen with sacral dys­ function resulting from unequal leg length, or it may be of neural reflex origin, as a

viscerosomatic or somatosomatic reflex.

Because somatic dysfunction is functional impairment and not organic pathology, primary somatic dysfunerion is completely reversible when correctly diagnosed and specifically treated wit h OMT. Secondary somatic dysfunction also responds to OMT, but it will recur unless the primary condition is identified and treated. Somatic dysfunction that is a reflex response to visceral pathology (viscerosomatic reflex) typically does not respond to

OMT until the underlying visceral pathology is treated.

Somatic dysfunction independently is responsible for a great deal of discomfort that cannot be attributed to organic cause. Because it manifests through the nerv­ ous and vascular systems as well as the musculoskeletal system, it can result in a broad array of symptoms. Somatic dysfunction also contributes to the effect of organic pathology. Somatic dysfunction of the thoracic spine, ribs, and diaphragm results in decreased thoracic compliance, increasing the severity of existent congestive heart failure. It also exerts deleterious eHeer upon viscera receiving innervation from the same spinal segment (somatovisceral reflex).

DIAGNOSIS The physical diagnosis of somatic dysfunction is accomplished by palpation. TART, a mnemonic for the four diagnostic criteria of somatic dysfunction, stands for the following: Tissue texture abnormality Asymmetry of position Restriction of motion Tenderness The presence of any one of these is justification for the diagnosis of somatic dysfunction. Palpation for tissue texture abnormality is probably the most efficient screen for somatic dysfunction.

The qualitative aspects of tissue texture abnormality, as indi­

cated in the definitions given previously, are used to differentiate acute from chronic

14

Section I • Philosophy and Principles of Patient Care

somatic dysfunction. T he degree of tissue texture abnormality indicates the severity of the somatic dysfunction. Mechanical somatic dysfunction typically demonstrates asymmetry of position and restriction of motion. Asymmetry of position is stressed in the diagnostic par­ adigm of muscle energy. Restriction of motion is stressed in the diagnostic para­ digm of articular dysfunction . Tenderness must not be confused with pain. Pain is the subjective awareness of nociceptor activity. Tenderness is pain elicited upon palpation. As such, tenderness is an objective physical finding. Tenderness is often elicited as an involuntary pain response, a muscular twitch or facial wince, to diagnostic palpation, and may be employed to confirm the diagnosis of somatic dysfunction following the observa­ tion of tissue texture abnormality. Like tissue texture abnormality, tenderness is indicative of the severity of somatic dysfunction. Although the site of the patient's pain may demonstrate tenderness, it is fairly common for significant findings of somatic dysfunction to be adjacent to or distant from the site of pain. Commonly, the motion restriction of somatic dysfunction places compensatory stress upon adjacent structures, with resultant pain in those adjacent structures. The pain, however, may be distant from the etiologic dysfunction, presumably because of shared innervation (often sympathetic). This innervation results in a trigger point at the location of the responsible dysfunction which when palpat e d reproduces the distant pain. Tissue texture abnormality and tenderness in the absence of the findings of mechan­ ical somatic dysfunction, particularly restriction of motion, are indicative of somatic dysfunction of reflex origin, that is, viscerosomatic or somatosomatic reflexes.

PROCEDURES In diagnosis of somatic dysfunction, it is appropriate to begin, when possible , with an overall assessment of the patient's weight-bearing mechanics. A

d ec i sion can

then be made as to what extent postural mechanics contribute to the condition being evaluated. This is followed by regional assessment of the problem area . It is here that screening for tissue texture abnormality offers an effective method for quickly identifying areas requiring more definitive examination. Once discrete somatic dysfunction is recognized, it is necessary to precisely identify asymmetry of position and all components of motion restriction (flexion and extension, side bending left and right, rotation left and r ight translation ante­ ,

rior and posterior and left and right, with additional motions as appropriate for assessing appendicular dysfunction). To accomplish this, it is useful to be aware of common mechanical patterns of dysfunction. S pin al somatic dysfunction is defined as type I (neutral, principle 1 of spinal physiologic motion) and type II (nonneutral, principle 2 of spinal physiologic motion).1.2 These mechanics are found between typical vertebrae, t h at is, vertebrae possessing zygapopbyseal joints and separated by intervertebral discs: the entire spine from C2 upon C3 to L5 upon 51, although the cervical spine demonstrates regionally atypical type I mechanics. In type I mechanics, a group of three or more vertebrae demonstrate

a

coupled

relationship between side bending and rotation. Under neurral circumstances (absence of spinal flexion or extension engaging the zygapophyseal articulations) when side-bending forces are applied to a group of typical vertebrae, rotation of the entire group will occur toward the side of the produced convexity. Side bending

Chapter 3 • Diag nosing Somatic Dysfunction

15

and rota tion of the entire group are coupled in opposite directions. In the cervical region, the entire group will demons t ra te coupled side bending and rotation in the same direction. The levels of transitional mechanics within and between group curves are important. The vertebrae of maximum rotation, also where rotational mechanics change direction, is designated the apex of the curve. The conjuncture of two curves, or crossover point, is where side-bending mechanics change direction. Anterior-posterior (AP) spinal mechanics are affected by type I mechanics. The presence of a g roup curve increases the existing spinal k yphosi s or lordosis. Therefore,

a

thoracic type I curve will demonstrate increased kyphosis, and a lum­

bar curve will demonstrate increased lordosis. At a crossover point, the existing AP curve is decreased.

Although type II (nonneutral) somatic dysfunction may affect any two adjacent typical vertebrae, it is often found at the transitional points of group mechanics. Fryette2 noted that type II dysfunction most commonl y occurs when forces decrease the existing AP curve. The preexisting AP flattening at the crossover point therefore makes this area most vulnerable for the development of ty p e 2 mechanics. Because t h e AP curve is fla ttened at the crossover point between two type I curves, the physician would expect to find type II e x tens i on dysfunctions in the

tho r a ci c region and type II flexion dysfunction in the lumbar r egion The rotational relationship between individual vertebrae changes direction between the apical segment of a group curve and the vertebrae immediately above it. For this reason, the upper half of a group curve behaves as a series of ty p e 1I dysfunctions. Because a group curve produces an increase in the norm a l AP curve, t y p e II flexion mechanics might be expected above the apex of a type I thoracic curve and t y pe II extension mechanics above the apex of a type I lumbar curve. Atypical spinal segments, occiput on Cl, CIon C2, and the sacrum between the ilia, demonstrate dysfunctional mechanics as dic t a ted by their unique anatomy. The occiput on Cl and the sacrum between the ilia become dysfunctional with restriction of side bending and rotation coupled in opposite dire ct i o ns CIon C2 becomes dy s fu nc tional with restriction of r o t a tion The identification of spinal somatic dysfunction should lead the physician to inquire about segmentally related viscera, thereby identifying the contribution of viscerosomatic and somatovisceral reflexes to the clinical picture. Somatic dysfunc­ tion that is the result of a viscerosomatic reflex is pr i marily of diagnostic value. It is definitively treated by treating the causa t ive visceral pathology. Viscerosomatic reflexes are addressed in Chapter 5. Somatic dysf u nc ti on of areas other than the spine occurs as restricted motion that is dictated by the anatomy of the structures involved. It is common for artic­ ular motion restriction to invo lve the minor motions of the affected area. Rib dysf unc tion is often secondary to dysfunction of the respective thoracic spinal segments. Primary rib dy sf unc tio n occurs as restriction of inspiratory or expiratory excursion. When examining for appendicular dy s fu nc tion, one should begin by examining the region of complaint, followed by a thorough examination of the areas proxi­ mal and distal to the complaint. However, the examination is not complete until related spinal segments have been examined.3 Fi n ally, once the mechanical p a ttern of the somatic dysfunction has been diag­ nosed, the physician must further decide what is causing it. Is the dysfunction an articular restriction? Is the dysfun c t ion the result of tight muscles or altered fascial tension? It is certain that very few dysfunctions are purely articular, muscular, or fascial in origin. However, more times tha n no t the p hysici a n will feel that one .

.

.

,

16

Section I • Philosophy and Principles of Patient Care

component contributes significantly. Making this decision will help the physician to choose the type of OMT that can best treat the dysfunction.

Examining the Patient The diagnostic assessment of any patient begins from the focal point of the chief complaint. This allows the physician to prioritize the physical examination. That is not to say that one will necessarily skip parts of the examination, but the physi­ cian may emphasize some aspect in one patient and examine the same region less extensively in another. The physician must learn to do this because it is necessary to understand the significance of that component of the physical examination in the context of the patient'S condition. It would arguably be logical to perform a more extensive neurological examination upon a patient with a recent onset of seizures than an individual with me lena. The evaluation of the musculoskeletal system for somatic dysfunction as part of the complete physical examination should be performed upon every patient. However, it can be modified to conform to the diagnostic requirements of each patient. To determine how to do this, it is appropriate that the physician answer the following questions: •

Does the somatic dysfunction have a mechanical effect upon the patient? Restriction of the thoracic cage and diaphragm, while detrimental to anyone, will be particularly deleterious to a patient with chronic obstructive pulmonary disease or congestive heart failure. Similarly, does the patient have a pain com­ plaint that is the result of or is compounded by somatic dysfunction? Physicians o ften become so focused upon the patient's serious illness that they overlook simple problems that contribute greatly to the patient'S discomfort.

•

Is there facilitation of sympathetic (thoracolumbar) or parasympathetic (high

cervical or sacral) componenrs of the spinal cord? (See Chapter 5.) If so, how does it affect the patient? Sympathetic stimulation of the gastrointestinal tract decreases peristalsis, which predisposes the patient to constipation or the devel­ opmenr of an ileus. Parasympathetic stimulation increases peristalsis that can produce diarrhea and colic. •

How does venous and/or lymphatic stasis affect the patient? Impaired circula­ tion interferes with the body's natural defenses and with its ability to mount an effective healing process and retards the efficacy of medications. The diagnosis of somatic dysfunction is best approached in an organized fash­

ion. The examination may have to be modified as dictated by the physical status of the patient. Some patients cannot stand, sit, or even move freely in bed. If physi­ cians keep in mind these questions, they will identify methods of modifying the physical examination to accommodate even the sickest of patients. The only rea­ son not to perform an examination for somatic dysfunction is an emergency that necessitates

immediate attention.

Begin with an overall screen of the patient's general body pattern.

If the patient

can stand, assess postural balance. Look for unequal leg length and pelvic and pec­ toral girdle unleveling. Identify type I spinal mechanics and look at regional mechanics, such as thoracic cage excursion , that will affect the clinical presenta­ tion. If the patient cannot stand, ileoileal mechanics and thoracic cage excursion can be assessed while the patient is supine . Examine areas where one would expect to find sympathetic and parasympathetic viscerosomatic reflexes associated with the patient'S medical problems. Having identified the overall body pattern, specif­ ically diagnose localized, segmental, dysfunction that is relevant to the presenta­ tion of the patient.

Chapter 3 • Diagnosing Somatic Dysfunction

17

The following exercises are intended to demonstrate a systematic approach to d iagnosis of the spine. The discussion is limited to the diagnosis of the spine. The appropriate osteopathic texts offer descriptions of appendicular, thoracic cage, and cranial diagnosis. •

Standing structural examination

•

Supine structural.examination Regional and segmental examination

• •

Palpation for tissue texture ahnormality; layer palpation •

Cervical spine

•

Thoracic spine

•

Lumbar spine Sacrum and pelvis

•

Standing Structural Examination

The purpose of the examination is to learn as much as possi ble about the patient's general body mechanics so that findings of local somatic dysfunctio n can be placed in context. Standing behind the patient, observe for the symmetry of each of these structures (Figure

3.1).

•

Mastoid processes

•

Should er (acromion)

•

Inferior angle of scapula

•

Iliac crests Posterior superior iliac spine (PSIS)

• •

Greater trochanter of femur

TEST FOR PELVIC SIDE SHIFT (PSS)

From behind, observe the standing patient to see whether the pelvis is deviated toward one side or appears centered. Place one hand on the patient's shoulder. Place your other hand on the patient's opposite hip. Gently push the hip and pelvis medially. Switch your hands to the patient's opposite shoulder and hip and repeat the process. Compare the symmetry of motion between both sides. The pelvic side shift test is positive on the side toward which the pelvis more easily moves. OBSERVATION FOR LATERAL CURVES

From behind, observe the standing patient as the patient bends forvvard at the waist. Look for paravertebral prominence resulting from spinal rotation that occurs as one component of the type I mechanics of lateral spinal curves. In the thoracic region, the scapula will appear more posterior on the side toward which the spine is rotated. OBSERVATION OF THE AP CURVES

From the side, inspect lumbar, thoracic, and cervical AP curves for increased and flattened areas. Determine whether any such areas correspond to the observed lateral curves. Supine Structural Examination

Although the supine examination does not yield as much information about the postural mechanics of the patient as the standing examination, if this is the only position that the patient can be examined in , it is useful to do so. Assess pelvic, ileoileal, and thoracic cage mechanics by sliding your hands under the patient and palpating for paravertebral tissue texture abnormality. Screen lumbar and thoracic spinal mechanics and loo k for viscerosomatic reflexe s. Examine the cervical region as described later in the chapter.

18

Section I • Philosophy and Principles of Patient Care

Spinal Curvature Anterior / Posterior Cervical LordOSIS: ThoracIc KypnOSIS: Lumbar Lorccsls:

Latentl

(Scoliosis)

o

.�one

o

Functional

o Mild

FIGURE 3.1

I

N

o

o o o

a o o

o o o

Exam Position

Sitting

0

Standing

0

Prone/Supine

0

NO Exam

0

The recording format for the standing structural examination from the standardized osteopathic SOAP note. (See Chapter 31.)

Palpation for Tissue Texture Abnormality, Layer Palpation

Use layer palpation to gain significant information about tissue texture abnormal­ ity in each of the procedure descriptions that follow. Screen each region looking for tissue texture abnormality. When such abnormality is identified, perform a thorough segmental examination. Place your palpating hand on the skin and make light contact. Palpate for tem­ perature and texture. Next, evaluate the subcutaneous tissue. Use more palpatqry pressure. Sense how thick this area feels. The tissue texture abnormalities found in association with viscerosomatic reflexes cause distinctive changes in subcutaneous tissues that closely mirror the severity of the reflex. Introduce movement in various directions and notice the directions of loosest and tightest movement. This assesses superficial fascial tension in the region. To palpate the deep fascial layer, increase palpating pressure until you sense the deeper underlying structures. The deep fascia is generally described as a smooth,

Chapter 3 • Diagnosing Somatic Dysfunction

19

firm, and continuous layer. Identify areas of thickening involving the fascia that surrounds the regional musculature. Pa lpate through the deep fascia, concentrating on the underlying muscle. Identify individual muscle fibers. Attempt to palpate the direction in which the

muscle fibers run. Pay attention to areas of increased musculature tension. Regional and Segmental Examination of the Cervical Spine (Fig.

3.2)

EXAMINATION OF THE CERVI CAL REGION

Patient position supine. Physician position: seated at the head of the examination table. This position is not always easily accomplished in the hospital setting. Palpate for tis­ sue texture abnormality and tenderness. After you have appropriately screened the cer­ vical region, with the patient remaining supine, examine the specific segments where you have identified TART findings Examination of the Occiput (CO on C1)

The major motions of this articulation are flexion and extension. The minor motions are rotation and side bending. The most commonly used test for motion is the lateral trans­ lation test Grasp the patient's head, placing your fingertips in contact with the occipi­ toatlantal (OA) junction. Identify OA side bending by introducing lateral translation to the left and right. Greater ease of lateral translation in one direction is indicative of side bending in the opposite direction. Once you have identified the side bending, you can extrapolate rotational mechanics because OA rotation and side bending are coupled in opposite directions. That is, side bending to the left of the occiput upon the atlas is associated with rotation to the right, and side bending right is associated with rotation to the left. Next, introduce OA flexion and extension and observe the symmetry of these motions. This test, along with the location of tissue texture change (and tenderness), is used to Identify anterior or posterior occiput dysfunction. If the occiput translates with greater ease to the right it indicates that the occiput is sidebent to the left side, and consequently rotated to the right upon the atlas. If the right

FIGURE 3.2

The supine position may be used for both the regional and segmental examination of the entire cervical spine.

20

Section I • Philosophy and Principles of Patient Care

OA joint will not move forward when extension is introduced and the nght OA joint has pal­ pable tissue texture change and is tender, the diagnosis is posterior occiput on the right If the OCCiput translates more freely to the nght it indicates that the occiput is sidebent to the left side and rotated to the right on the atlas. If the left OA joint will not move to the posterior when flexion is introduced and the left OA joint has palpable tissue texture change and is tender, the diagnosis is anterior occiput on the left Examination of the At l as ( C1 on C2)

The major motion of this articulation is rotation. This articulation is the exception that makes the rule. Atlantoaxial dysfunction involves restriction of the major motion of rota­ tion with little or no minor motion restriction. With the patient supine, flex the ceNical spine. This greatly reduces freedom of rota­ tion from C2 through (7, significantly limiting available rotation to the atlas upon (2. While palpating over the lateral masses of the atlas, rotate the head to the right and then to the left obseNing for rotational asymmetry. You may use the nose or chin as a gauge to compare available rotation. Identify the direction of greatest rotation. The dys­ function, posterior on the side toward which rotation occurs most freely or anterior on the side toward which rotation is restricted, is indicated by the side where palpable tis­ sue texture abnormality and tenderness are found. Segmental Examination of the Cervical Spine (C2 on C3 to C7 on T1)

Palpate the cervical paraspinal tissues from (2 to (7. Look for asymmetric tissue texture abnormality and tenderness and focus motion assessment on these areas. (2 to (7 demon­ strates type II (nonneutral) and regionally unique type I (neutral) dysfunctional mechaniCS. To test for rotation, hold the head and neck in your hands and place your fingertips posterior to the transverse processes of the cervical segment being examined. Rotate the vertebra to the right and to the left. Observe for restriction of rotation in either direc­ tion. Rotation is named for the direction of freer motion. Example (5 rotates more freely to the right, or left rotation is restricted. (5 is rotated right To test for side bending, employ a lateral translation test Place your fingertips over the lateral edge of the transverse processes of the cervical vertebra being tested. Translate the vertebra to the left and to the right. Translation to the left results in side bending to the right and vice versa. Side bending is also named for the direction of freer motion. Example: (5 translates more freely to the left; it is, therefore, side bent to the right. Using the informa­ tion gained from the rotational test, (5 is rotated right and side bent right. To test for forward bending (flexion) and backward bending (extension), introduce flex­ ion and extension between the vertebrae being examined. Decide whether flexion or extension demonstrates the freer motion. To confirm your findings, attempt to rotate the vertebrae being examined after introducing flexion and again after introducing extension. This is application of principle 3 of spinal physiologic motion. I In the example, (5 upon (6 is rotated and sidebent to the right (restricted rotation and side bending to the left) If a type II dysfunction is present, rotation will be more restricted in the dysfunctional compo­ nent of flexion and extension. That is, if (5 is flexed (restricted extension), rotation will be more restricted to the left in extension than in flexion. This dysfunction, named for the unrestricted components of motion, is recorded as (5 sidebent and rotated right flexed. REGIONAL AN D SEGMENTAL EXAMIN ATION OF THE THORACIC SPINE

Begin by palpating the paravertebral soft tissues. After identifying segmental tissue tex­ ture abnormality, assess for motion restriction. This is most easily accomplished from behind the seated patient. Move the patient through a complete range of motion (flexion, extension, side bending, and rotation)

Chapter 3 • Diagnosing Somatic Dysfunction Evaluation of the Upper Thoracic Region

21

(Tl-T4) Using the Head and Cervical

Region as a Lever Patient position seated. Physician position standing behind patient. Place your active hand on the patient's head and your monitoring hand on the appro­ priate thoracic segment

Flexion and Extension With your monitoring hand, place the pad of your middle finger in the interspinous space below the segment you wish to evaluate. Allow the index and ring fingers to con­ tact the interspinous spaces above and below. With your active hand, introduce forward bending from above downward until motion is sensed at the spinal level being exam­ ined. Note how far and how easily the spinous processes separate. Then introduce back­ ward bending until motion is sensed at this segment. Note how close and how easily the spinous processes approximate.

Side Bending and Rotation Place your thumb and index finger over the spinous process of the segment you wish to evaluate. Side-bend left and right from above down to the segment being examined. This process may be repeated for rotation. Note asymmetry and quality of motion. Evaluation of the Upper Thoracic Region

(Tl-T4) Using the Thumbs

to Assess Motion Patient position seated. Physician position: standing behind patient. The thumbs of both hands should contact the transverse processes of the thoracic segment being examined. This procedure is effectively used to assess rotation, flexion, and extension. It is less effective in assessing side bending.

Rotation Place your thumbs over the transverse processes of the segment to be tested. Allow your fingers to rest over the patient's shoulder area. Motion is introduced by applying pres­ sure anteriorly, alternately through your thumbs. Introduce rotation left and right. Note any restriction of motion. Assess quality and quantity of motion.

Flexion and Extension Place your thumbs and hands in the same position. Instruct the patient to flex the neck (you should feel flexion localize all the way down to the vertebral segment you are testing). Assess rotation in the manner already described with the patient's neck in flexion. Instruct the patient to extend the neck. Assess rotation in the same manner. Rotation will be more restricted when attempted in the dysfunctional component of flexion and extension. Example T2 rotates freely to the right upon T3. Rotation to the left is restricted. When T2 is rotated to the left, the right transverse process appears more prominent underneath your thumb; therefore, T2 is rotated right. With the neck positioned in flex­ Ion, T2 has increased rotation to the left (motion still restricted but improved) With the neck extended, T2 has decreased rotation to the left. Flexion results in increased rota­ tion. Extension results in decreased rotation. T2 is therefore rotated right and flexed. Evaluation of the Lower Thoracic Region

(T5-T12): Using the Shoulders

as a Lever Patient position seated. Physician position: standing behind the patient to the left side. Drape your left forearm (the active hand) across the patient's posterior cervicothoracic junction, so that your left elbow touches the anterior surface of the patient's left shoulder

22

Section I • Philosophy and Principles of Patient Care

and your left hand rests comfortably across the right shoulder. Place the thumb and index finger of your right (monitoring) hand on the spinous process of the thoracic segment to be examined. Side Bending and Rotation

Introduce side bending to the left by using a downward motion through your left arm while monitoring the segment Move to the patient's right side (switch hand and arm positions) and introduce right side bending. Assess the difference in side bending at that segment Return to your original assessment position at the patient's left side. Introduce rota­ tion by applying a posterior motion through your left elbow. Repeat this procedure from the right side and assess the difference in rotation at that segment. Once you become accustomed to this procedure, a combined side bending and rotation movement that is much more efficient can be employed. Flexion and Extension

Assess flexion and extension by placing the fingers of your monitoring hand over the lower thoracic interspinous spaces. Instruct the patient to cross the arms over the chest. Use your active hand to hold on to the patient's crossed arms. Introduce forward and backward bending from below upward by rocking the patient forward and backward on the ischial tuberosities. REGIONAL AND SEGMENTAL EXAMINATION OF THE LUMBAR SPINE

Begin by palpating the paravertebral soft tissues. After identifying segmental tissue tex­ ture abnormality, assess for motion restriction. This may also be accomplished with the patient seated, using the method described for the low thoracic region already described, or the patient may be examined in the supine position Patient position: prone. Physician position: stand at the patient's side. Place the pads of your thumbs over the transverse processes of a single segment Wrap the rest of your hands around the lumbar paraspinal area. Rotation

Use one hand to rotate the vertebra by directing an anterior force through your thumb over one transverse process This will rotate the vertebra to the opposite side. Repeat the process in the other direction, and compare one side with the opposite side and with the segments above and below. Side Bending

Assess side bending with your hands in the same position. Use both hands to laterally translate the vertebra to the left and right. Translating the vertebra to the right intro­ duces side bending to the left, and translating the vertebra to the left introduces side bending to the right Flexion and Extension

Assess flexion and extension by directing an anterior force over the spinous process with your thumb. Then allow the segment to spring back to its original position. An extended segment will easily move anteriorly and will not spring back properly. The opposite is true for a flexed segment. Flexion and Extension (Patient on Side)

The patient lies on the side facing you with the knees bent Place the fingers of your mon­ itoring hand over the interspinous spaces of the vertebrae being tested. Cradle the patient's legs below the knees uSing your active hand. Assess fi€xion and extension by introducing these motions through the patient's hips and pelvis up into the lumbar spine.

Chapter 3 • Diagnosing Somatic Dysfunction

23

EXAMINATION OF THE SACRUM AND PELVIS Sacropelvic articular dysfunction occurs commonly as sacroiliac dysfunction. lIeoileal and global lumbosacropelvic (torsion) mechanics are given significant consideration in the muscle energy approach to pelvic dysfunction. Additionally, pubic symphysis articular dysfunction is occasionally encountered. This discussion focuses upon sacroiliac dysfunc­ tion. Diagnosis of sacroiliac dysfunction is a two-step process. First, determine the mechanical pattern of the dysfunction. Second, deter mine the side of the dysfunctional sacroiliac articulation. Motion Test for Sacroiliac Articular Dysfunction (Figure 3.3) Patient position prone. Physician position standing at the patient's side near hip level. Place the pads of the index and middle fingers of your monitoring hand so that one contacts the posterior superior iliac spine and the other rests in the superior portion of the sulcus of the sacroiliac joint Place the heel of your active hand in contact with the sacral inferior lateral angle (ILA) on the side opposite the monitoring fingers. With your active hand, apply downward (anterior) pressure on the apex and ILA of the sacrum, pro­ duce motion , and note freedom or restriction. With your monitoring hand, appreciate posterior motion of the base of the sacrum (reduction in depth of the sulcus) or absence thereof. Assess both quantity and quality of available motion. Repeat this process, exam­ ining the opposite sacroiliac loint, and compare the two sides. Somatic dysfunction can be named in terms of position and in terms of motion restric­ tion. Because anatomic structures vary in their size, shape, and symmetry in the normal pop­ ulation, diagnosis by defining motion restriction is considered to be the superior method. Pressure over the left ILA of the sacrum with the active hand produces right rotation about the left oblique axis. Conversely, pressure over the right ILA produces left rotation about the right oblique axis. When you palpate these motions, you will commonly note that one rotational pattern occurs with greater ease than the other. It is not readily possible to produce left rotation about the left oblique axis or right rotation about the right oblique axis since this would require directing a posterior force to the anterior surface of the sacrum.

FIGURE 3.3

Hand placement for sacroiliac motion assessment.

24

Section I • Philosophy and Principles of Patient Care Example: Pressure over the left ILA results in unrest ricted motion, while pressure over

the right ILA is met by significant resistance. Since the unrestricted sacrum can rotate both right and left about either oblique axis and decreased rotation left about the right oblique axis is identified, it is possible to extrapolate that the sacrum is rotated right on the right oblique axis. This motion pattern is consistent with the a rticular dysfunctions of either an anterior sacrum left or a posterior sacrum right The mechanical pattern of sacral motion having been identified, the next step is to identify the side of the dysfunc­ tional sacroiliac a rticulation. The dysfunctional side can be determined by performing the sacral flexion tests (discussed later) Additional Findings to Assist in Diagnosing an Anterior Sacrum (Upper Pole) Somatic Dysfunction Look for a deeper sacral sulcus, tissue texture abnormality, tenderness, an d decreased posterior motion at the upper pole. Also look for increased gluteal muscle tension on the somatic dysfunction side (the same side as the deep sulcus) Additional Findings to Assist in Diagnosing a Posterior Sacrum (Lower Pole) Somatic Dysfunction Look for tende rness of the lower pole and piriformis muscle tension, all on the somat­ ic dysfunction side (side opposite to the deep sulcus, if present). The deep sulcus

FIGURE 3.4

The standing flexion test.

Chapter 3 • Diagnosing Somatic Dysfunction

25

should become less deep when movement is initiated, that is, not be stuck in a deep position. Standing Flexion Test (Figure

3.4)

Stand behind the standing patient. Place your thumbs over the PSIS. Ask the patient to bend forward. The standing flexion test is positive on the side where the thumb moves further superiorly. This occurs because in the standing position the sacrum rests in a rel­ atively flexed position. With further flexion of the lumbar spine, the sacrum moves with­ out also moving the innominate bones. However, if sacroiliac Joint restriction exists, motion of the sacrum will move the innominate bone (hip bone) on the side of the restriction. The innominate will thus move with the sacrum, and the PSIS will shift supe­ riorly on the restricted side. This innominate motion will cause the PSIS monitoring thumb to rise superiorly, indicating a positive standing flexion test on that side. Although usually indicative of sacroiliac joint dysfunction, a positive standing flexion test could also indicate dysfunction anywhere in the ipsilateral pelvis or lower extremity. Seated Flexion Test (Fig.

3.5)

This test is performed in a manner similar to the standing flexion test. The patient is preferably seated with the feet flat on the floor and asked to bend forward at the waist. The physician monitors for PSIS motion with the thumbs. The seated flexion test is pos­ itive on the side where the thumb rises more superiorly. This test is more specific for

FIGURE 3.5

The seated flexion test.

26

S e ction I • Philosophy a n d P r i n c i p l e s of P a t i e nt C a r e

sacro i l i ac J o i n t dysf u n ct i o n t h a n t h e sta n d i n g f l e x i o n test beca use t h e i n f l u e nce of l ower extrem ity dysfu nct i o n i s effectively removed by s i tt i n g d own .

Refe rences 1. E C O P. Glossary o f oste o pa t hi c term i n o l ogy. In: Wa rd RC, ed . F o u n d a t i o n s fo r Osteopa t h i c Medic i n e . 2 n d e d . P h i l a d e l p h i a : L i p p i n c o t t W i l l i a m s & W i l k i ns , 2 0 0 2 ; 1 229-1 2 5 3 . 2 . Fryette H H . Principles of Osteop a t h ic Tech n i q u e . I n d i a n a p o l i s : A m e rica n A c a d e m y o f Osteo p a t h y, 1 9 5 4 , 1 9 8 0 . 3 . S t r a c h a n W F. A p p l ied a n a r o my o f t h e pelvis a n d lower e x t re m i t i es J A m Osteo p a t h Assoc. 1 94 0 ;4 0 : 5 9-6 0 . .

The Manipulative Prescription Kenneth E. Nelson

"One must not be

a

blacksmith only, and only able to hit large bones and muscles with

a heavy hammer, but one must be able to use the most delicate instruments of the sil­ versmith in adjusting the deranged, displaced bones, nerves, muscles and remove all obstructions, and thereby set the machinery of life moving

To do this is to be an

osteopath"

A T Still I

As defined by

Stedman's Medical Dictionary, a prescription is "a written for­

mula for the preparation and administration of any remedy."2

When writing a prescription, you must determine wh i c h therapy, how much,

how often. An example is ampicillin 500 mg every 6 hours. The same questions must be answered when deciding upon a prescription osteopathic manipulative treatment

(OMT).

for

OMT is a therapeutic inter ve n ti o n. It is the definitive treatment for somatic dys­ function and is employed to treat primary somatic dysfunction. It is also used to address the effect of somatic d y s f u n c t i on upon a patient'S recuperative abilities from concomitant disease processes. Because it is a therapeutic modality, its dosage must be determined and prescribed. This is defined by the diagnosis of the somatic dysfunction withi n the context of the individual patient. 27

28

Section I • Philosophy and Principles of Patient Care

DIAGNOSIS Before one ca n determine what therapy is to be used, a diagnosis must be ma de.

A

d iag no s is is a logical c o ncl usio n based upon information obtaine d from the chief S his to ry and the p h ysic al examination. The diagnosis of primary somatic dysfunction is often, a ltho ugh not always , associated with musculoskeletal pain. Somatic dysf unct io n may contribute to the patient'S illness, as in the effect of motion restriction of the thoracic cage upon the p atient with pneumonia. Consequently, somatic d y sfunction shoul d be appropri­ c o m pl ai n t, the p atient

'

,

ately treated, even in the absence of musculoskeletal complaint.

The diagnosis of somatic dysfunction is based upon the i dentification of one or m ore of the p hys ica l fi n ding s described as TART: tissue te x tur e abno rm a l it y, asym­

metry of position, restriction of motion, and ten de r n ess. Of these, tenderness a n d tissue texture abnormality may be sought out when screening an area for significant dysfunction. Once a d y s func tion al area has been identified, one mu st specifically define (diagnose) the mechanics of the dysfunc­ tion. (See Chapter 3.) Define the Barrier T he ph y sici a n examines the patient and precisely identifies asymmetry of position and restriction of motion. Motion restriction is pa rt icu la rl y i m po r ta n t because the most common go al of OMT is restoration of free movement. The mechanical pattern of the motion restriction determines the mechanics of the t her ape u tic intervention.

Determine Why the Barrier Is Present Once the physician has diag no se d the mechanical pattern of the so m a ti c d y s fu nc

­

tion, it is necessary to ide ntif y what is causing the d ys f unc tion Is it the result of .

articular restriction? Is it due to ti g ht muscles or altere d fascial tension? Making this decision will help to determine what ty pe of OMT will be selected to treat the dysf unc t ion .

TREATING THE PATIENT If it is determined that the barrier is the result of articular dysfunction, the proce­ dure s h o u l d be d i rec te d at affecting articular mechanics. Such proce du res inclu de high-velocity, lo w a mplitu de (HVLA) thrust and low-velocity, moderate- to high­ am p l it u de articulation proce dures. If the barrier is the result of soft tissue tension, a procedure that is inte n de d to affect soft tissue is c ho s e n (muscle energy, soft tissue s tret ching , myofascial -

release).

If the dysfunction is best addressed by attempting to re duce neural reflex activity, counterstrain and facilitate d positional release may prove to be the procedures of choice.

So matic dys fu nctio n that is the result of viscerosomatic re fle x activity is specifi­ c ally treated by treating the underlying visceral pathology. Treatment of the visceral pathology may be facilitated (but not replaced) b y man ip ul at ing the somatic compo­ nent (somatovisceral reflex). Procedures chosen under these circumstances shoul d produce somatic relaxation with minimal stimulation. Once the visceral component

29

Chapter 4 • The Manipulative Prescription

has been effectively treate d, residual somatic dys funct i o n may be treated using the

logic described earlier and that discussed in the following pa ra grapbs

.

Patient Tolerance The physician at this point is almost ready to choose the procedure. There is, how­ e ver, one more decision-making point to consider: How much can tbe patient tol­ erare ? Obviously, a healthy 27 year old has greater tolerance than a health),

90 year old. A lso, a healthy 27 year old can tolerate more than tbe same individual

with pneumonia. Patient tole rance dictates the level of aggressiveness of the procedure chose n . A somewhat artificial continuum of procedures can be created based upon the rel­ · arive aggressiveness of the procedu res.

High-velocity, low-amplitude (HVLA), most aggressive Articulation (ART) Soft tissue (ST) Direct fascial release (DlR)

Muscle energy (ME)

Counterstrain (CS)

Facilitated positional release (FPR)

Indirect fascial release (lND)

Indirect cr
The physician should also consider that besid es the aggressiveness of a procedure type, the time re quired for application can affect tolerance. The longer a procedure rakes, the more l i ke ly the patient cannot tolerate it. As a rule, the more agg ressive the procedur e, the less time required for its application. Consideration of the diagnosis of the mechanical pattern of the dys fu nction the ,

anatomic component (articular, muscular, fascial) responsi bl e for rhe dysfunction, and patient tolerance will identify the most appropriate procedure for the p a ti ent

.

RESPONSE How much O M T is enougb? Treat the patient until

a

res ponse occurs.

What kind of response should the physician look for? Relaxation of the soft tis­

sues in the area being treated is a good response, often re fer red to as a release. Increased muscle spasm during the application of a procedure indicates that the patient S tolerance has been exceeded an d th at a less aggressive procedure should '

be selected or that treatment should be stopped and attempted again at a later time. Altered autonomic tone is also an indication of a response. Peripheral vasodi­ lation resulti ng in increased skin te mperature or redness and increased pe rspiration indicates that it is time to stop. Increase d heart or respiratory rate also indicates that one has reached the patient's level of tolerance. If the patient feels t bat the

i nterven t ion is too uncomfortable, the physician should stop and choose anorher approach or wait and try again later. The overall health status of the patient affects tolerance to whateve r procedure is chosen. The sicker the patient, the lower one can expect the tolerance to be.

Cons e q u e n tl y,

a

smaller dose of OMT will be necessary to obtain the o ptimal ther­

apeutic response without exceeding the patient's tolerance. Individuals at the extremes of age (infants, children, and geriarric patients) gen­

erally require lower doses of OMT to obtain

a

t her a pe u tic response

.

30

Section I • P h i l os o p h y and Pr i nc i p l e s of Pa tient Care

How o ften should the patient be treated? This is not an easy question. It depends upon the patient's response to the initial intervention. It also depends upon whether one is treating primary somatic dysf unction or addressing the con­ tribution of somatic dysfunction to coexistent illness.

Primary Somatic Dysfunction When treating primary somatic dysfunction that is typically associated with mus­ culoskeletal complaints, such as headache and low back pain, the physician can base a decision upon the following sequence of responses. The dose of the initial treatment is estimated as described earlier, in the discussion of tolerance. After the initial intervention, the patient frequently re ports immediate symptom reduction. This relief is occasionall y followed by a brief intensification of the original com­ plaint and may be treated with appropriate analgesia. Such a rebound reaction should not last more than 24 hours. If it does, the intensity of the second OMT intervention should be appropriately reduced. As the rebound reaction subsides, a period of resolution typically follows, and the chief complaint is significantly reduced or absent. This period of resolution may last a few hours, or it may be per­ manent. Ideally the patient should be reevaluated 48 ho urs after the initial treat­ ment. By this time, the rebound reaction should have subsided, and residual somatic dysfunction can be specifically diagnosed and treated. Symptom resolu­ tion should last progressively longer following each application of manipulative treatment, and treatment intervals should be adjusted accordingly. Failure of this resolution period to increase indicates than an incomplete diag­ nosis has been made. Contributing causes must be thoroughly explored, identified, and treated.

Contributory Somatic Dysfunction Somatic dysfunction encountered in patients with established disease processes, whether acute or chronic, contributes to the coexistent illness. The effect upon the patient may be mechanical (i.e., thoracic cage compliance in obstructive pul­ monary disease or congestive heart failure), or it may be somatovisceral. The desired response to treatment is related to the status of the respective disease processes. The same principles as described earlier apply; however, the circum­ stances are more complex. The very sick patient will respond significantly to very little intervention. The duration of the response may be short, however, necessitat­ ing repetition of treatment in as little as 4 to 6 hours. The hospitalized patient is more likely to be aged or very young and will conse­ quently respond differently, as discussed earlier. Geriatric patients respond slowly and may require more time between treatments. (See Chapter 12.) Infants and children respond rapidly and may be treated again after shorter intervals. (See Chapter 8.) The determination of what kind of OMT, how much, and how often is nor as easy as prescribing ampicillin. The physician can base decisions upon the parame­ ters l i sted earlier, but each consecutive intervention must be individualized to the patient'S response to the previous treatment. The dose also must continually be adjusted to the patient'S tolerance.

TREATMENT OF TRAUMA PATIENTS

OMT is used s pecifically to treat somatic dysfunction. In most cases, its use is intend­ ed to increase available motion. It is, therefore, inappr opriate to mani pulate areas of the musculoskeletal system that are structurally unstable. With this caution in mind,

Chapter 4 • The Manipulative Prescription

31

the physician should recognize that trauma patients still can benefit greatly from appropriately applied OMT. Because trauma often results in torn soft tissue and fractures, extreme care must be taken not to apply force through such areas. This said, areas adjacent to trau­ matic instability frequently demonstrate somatic

dysfunction. Appropriate treat­ in

ment results in less physical stress and increased circulation (tissue perfusion) the area of instability, decreasing the patient'S discomfort.

However, because the condition is the result of exogenous force, it is initially very difficult to estimate the patient'S tolerance. A simple approach to this dilemma is to decide how much one believes the patient will tolerate and apply about one­ half that dose. Subsequent treatments may then be adjusted as outlined earlier. This is an area where the use of indirect procedures (counterstrain, facilitated positional release, myofascial release, and cranial) can produce impressive results.

Recording in the Progress Note (See Chapter 31) As noted earlier, in most cases (exceptions to this include lymphatic procedures), OMT is specifically employed to treat somatic dysfunction. As such, the physical

findi n gs that justify the diagnosis of somatic dysfunction must be recorded in the objective portion of the SOAP note, and the anatomically specific diagnosis of

somatic dysfunction must be recorded in the assessment portion of the SOAP note.3-7 OMT is a procedure. The prescription must be charted in the

plan portion of

the SOAP note. The OMT prescription consists of the following steps:

1. Select procedure type or types. Indicate the anatomic region to be treated.

2.

3. Indicate frequency of treatment.

Examples of prescriptions follow: Muscle energy, cervicothoracic, daily Pedal fascial pump lymphatic mobilization every 8 hours

Rib raising, thoracic cage, every 6 hours

CONCLUSION A prescription for a therapeutic intervention is determined by the condition to be treated and the requirements and limiting factors of the patient receiving the treat­ ment. A prescription identifies the therapy to be

u se

d and the quantity and fre­ ,

quency of its use. All of these criteria apply whether the therapeutic intervention is ampicillin or OMT. Use of any therapeutic intervention must be properly recorded in the medical record.

References 1. St il l AT. The Aurobiography of A. T. Still. Chapter 24. Kirksville, MO: Author, 1908:290. 2. Williams RH, Stedman TL, eds. Stedman's Medical Dictionary. 25th ed. Baltimore: Williams & Wilkins, 1990. 3. Nelson KE, Glonek T. Computer/outcomes: Hardcopy SOAP note preliminary report. Fam Physician 1999;3:8-10.

32

Section I • P h ilosophy an d Prin ci ples of Patient Care

4. Sleszynski SL, Glonek T, Kuchera WA. Sr andar d i zed medical record: A new outpatient osteo­ pathic SOAP note form: Validation of a standardized office form against physician's progress notes. J Am Osteopath Assoc 1999;99:516-529.

5. S l esz ynsk i SL, Glonek T, Kuchera WA. Outpatient osteopathic single organ system muscu­ loskeletal exam form: Training and certification. J Am Osteopath Assoc 2004;104:76-81. 6. Sleszynski S, Glonek T, Kuchera WA. Outpatient osteopathic single organ system muscu­ loskeletal exam form series: Validation of the outpatient osteopathic SOS musculoskeletal exam form, a new standardized medical record. J Am Osteoparh Assoc 2004;104:423-438.

7. Licciardone Je, Nelson KE, Glonek T, et al. Osteopathic manipulative treatment of somatic dysfunction among patients in [he family practice: A retrospective analysis. J Am Osteopath Assoc 2005;105 :53 7-544.

Viscerosomatic and Somatovisceral Reflexes Kenneth E. Nelson J

INTRODUCTION Osteopathy began in the latter half of the nineteenth century as a holistic approach to medical practice. Fundamental to the earliest osteopathic theory and extending to the prese nt is the concept that dysfunction of the musculoskeletal system affects the health and well being of the remainder of the body. This impact may occur in a directly mechanical fashion. From the earl i es t years of the profession, however,

it was reco gni zed that visceral pathology was reflected along the spine as somatic dysfunction. Additionally, it was recognized that the effect of spinal somatic dys­

function upon t he nervous system also applied to segmentally related viscera. This was

proposed to occur through what were or igi n ally known as spinal centers. I) developed throug h clinical e m p i r i c i s m were ba sed upon the

These principles,

,

scientific knowledge of the day. The autonomic nervous system, as described by

Claude Bernard ) was known to consist of both efferent and afferent neurons. The ,

somatic distribution of sensation and/or referred pain from visceral disease had

been thoroughly described. 4-7 Louisa Burns,

possibly the best known of early osteopathic investigators, dedi­

cated much of her career to the study of viscerosomatic and somatovisceral reflexes

effect of osteopathic mani pu lative treatment (OMT) upon these reflexes.8-IO 1907, her studies on a ni mals and human subjects led her to conclude that (1) "A very important, if not the only, pat h way of viscera-sensory impulses enters the

and of the

As early as

33

34

Section I • Phi l osophy and Principles of P a t i ent Care

spinal cord through its posterior roots." (2) "Somatovisceral reflexes are less circum­ scribed and less direct than are viscerosomatic reflexes." (3) "Since abnormal condi­ tions of the viscera follow ... pressure upon somato-sensory nerves as is sufficient to lessen conscious sensation, and since section of the somato-sensory nerve is fol­ lowed by a bnormal conditions of the viscera, it is inferred that normal visceral activ­ ity d epends in part upon the st imulation derived from the somato-sensory nerves."

(4) "The possibility of recognition of abnormal viscerosomatic reflexes as an aid in

d iagnosis is in ferr ed

.

"8

THE PHYSIOLOGY OF VISCEROSOMATIC A N D SOMATOVISCERAL REFLEXES Following upon Burns's p i oneer i ng studies, John Stedman Denslow11 and Irvin M. Korr12 identified the physiology of spinal segmental facilitation and demonstrated its association with somatic dysfunction. The facilitated spinal segment was shown to occur not just as a result of simple spinal somatic dysfunction but also as the result of segmentally related visceral pathology. Furthermore, it was shown in

some instances to be demonstrably present prior to the overt presentation of a cl in­ ical com plainr.i.J This physiology has been clearly demonstrated to be involved in viscerosomatic and somatovisceral reflex relationships.14 Van Buskirk 15 proposed a nociceptively initiated model for sp inal somatic dysfunct ion that offers a descrip­ t ion of the physiology of viscerosomatic and somatovisceral reflexes. Thus, reflex­ i vely mediated spinal somatic dysfunction is thought to occur as follows: 1. A peri pheral focus of irritat ion, in the case of a v iscerosomatic reflex f rom the

inflammation associated with visceral pathology, activates general v isceral afferent neurons. In the case of a somatovisceral reflex, primary somatic dys­ function results in the activation of somatosensory nociceptive neurons.

2. These p rimary afferent neurons enter the s p ina l cord and synapse in the dor­ sal horn w ith internuncial neurons. 3. O n goi n g afferent stimulation from the focus of irr itat ion, be it visceral or

somatic, results in establishment of a state of irritability (facilitat ion) of the internunc ial n eurons of that spinal segment. 4. Additional afferent activity from any source results in a spinal segmental

response to less stimulus than would be normally required. In the case of

a

v is­

cerosomatic reflex, this results in tenderness that is p roportionate to the degree of visceral pathology, when the area of the associated dermatome or myotome is palpated. If the amount of afferent activity from the offending

organ is sufficient to cause spontaneous internuncial f iring with the activation of ascending spinal pathways, referred pain results.

5. S u ch activity from internunc i al neurons, which synapse with ventral horn

motor neurons, results in segmentally related myospasticity, as seen in primary somatic dysfunct ion and viscerosomatic reflexes. Activity from internuncial

neurons that synapse with nemons in the intermed iolateral cell column of the thoracic and upper lumbar cord results in segmentally related somatosomatic, somatovisceral and viscerovisceral reflex sympathicotonia. Similar physiology is thought to occur in the parasympathetically mediated reflexes, although in this instance it is less clearly identified.

6. The degree of segmental irr itability that is directly proport ionate to the sever­ ity of the v isceral pathology, and the anatomic relationsh ip between the involved organ and the paravertebral soft tissues that makes the location of the reflex changes consistent from in dividual to individual, together allow

Chapter 5 • Viscerosomatic and Somatovisceral Reflexes

35

viscerosomatic reflexes to be of d ia gnostic value. OMT reduces the fac i l it a ted state and t h e re by provides a the r a p eu ti c somatov i s cera l r e sult.

Viscerosomatic Reflexes Somati c dy sfu ncti on is present , by d e fini tion , whe n any of the criteria (tissu e tex­ tur e ch a n ge, asymmetry of functional position, restriction of motion, or tend er­ ness) are id ent ified by palp a t io n. Visceroso matic reflexes are the somatic reflection of visceral pathology. As such, t h e y are so ma ti c dys functi on that is se condary to the seg m en tally related v isce r a l inflammation and are mediated throu gh the ge n e r a l visceral a fferent ne urons of th e a uto nom i c n er vo u s sy s tem. B e ca use the y are reflexive in or i gin and not p rim a r y me ch a n ica l som ati c d y sf u n cti on, th ey ma y nor cl e a rly mani fest a sy mmetry of functional position or restriction of motion. Any motion restrictio n is commonly ge ner a liz ed and may be wi thout asymmetry. Rather rhan manifesting a d i st incti ve restrictive barrier, viscerosomatic reflex somatic dy sfunct i on often demonstrates a mbi gu ity of the ba r r i er. Howe ver, because tenderness, ti ssue texture c h a n ge, and gen e r a l i ze d motion restriction are present and can be i d e n tified by pal pati on, viscerosoma tic reflexes ind i c a te somat­ ic d y sf u n cti on and ma y be classified a ccord i n g to the a pp ropri ate 739 codes li sted in the ICD-9CM.16

The ana tom i c reli a b i l i ty of autonomic innervation of the viscera m a k e s th e se g ­ m e n ta l par a ve r te b ral location of organ-specific reflexes predictable and conse­ que n tl y of d iagnos ti c value. The intensity of the p al p a t ory find ings d irect l y mirrors the se verity of t he causative viscera l p a tho logy, off e r ing a d diti o n a l c l i nica l insight for t he clinician with d i scern i ng touch. Visceral neoplasia is an exception to this p r incip le . B ecaus e neop las m s are ty pica l ly without innervation, they do not pro­ vide ge ne r al visceral affe rent i n p u t to the spi nal cord. Any a ffe r e nt neural activity occurs because of t he effect o f the rumor upon sur roun d i ng tiss u e s . Ch a p man's reflexes prov i d e another m ethod of recogn i z ing viscerosoma tic effects.17-19 These are small (2-3 mm) nodular masses, p a l p abl e in soft tissue, that d emon strat e sharp pinpoint non radiat ing tenderness. As viscerosomatic r e flexes, they are t ypicall y found i n l ocat ions that are se gmenta ll y related to viscera l i n nerva tion . Chapm a n's refl e xes are t h o ug ht to be the effect of d y sfunct ion o f the sy mp at he t i c nervous system upon se gme nta ll y r e l ated ly mph atic vasculature.19 They are com­ mon l y loc a ted p os ter i o r l y in the tissues adjacent to the spin e and anteriorly often in se g me n tall y related areas. Traditionally, the ante rior points ha ve been e mployed diag­ nosticall y, while the posteri or points are treated by a pply ing slow circu lar pre ssu re. Diagnosis of Viscerosomatic Reflexes

Viscerosomatic reflexes are i d entified, as are all other manifestations of s o m atic

d y sfu nctio n , by pa lp a t ion. They are similar in the ir c l i n i cal ma nifestation to pri ­ mary somatic dysf unction . They may, a s d e s cr ibed earlier, p r esent with ambiguity of end feel of the restri ctive barrier. Beal20 recom m e nds that special p a l patory

atte ntio n be d irected towa r d the costotransverse area in the th o ra c i c spine and sug­ gests that visce rosomat ic reflexes may be d i fferenti ated from p rima ry soma tic dys­ function by t he invo l vement of two or more ad j a c ent sp i n a l segments. The i nitia l response may be limited to two adjacent seg me nt s, but as the d uration or se v er ity of the u nderl ying c o n d i t i o n increases, the response will s pre ad to a d j ac e nt seg­ m e n ts via ioternuncial connections.21 Localized skin and su bcu tane o u s tissue tex­ ture c h ang es a ls o p r o v i d e indications as to the se ve rity a n d acuity or chro n i ci ty of the underlying visce ral pathology.

36

Section I • P h ilos o p h y and P r i n ciples of Patient Ca re

Cor re sp o n d i n g tissue texture c ha nge of musc l e is most a pparen t in t h e d eep par­ avertebral musculature, multifidi and rotatores, because of their li mite d s eg me n t a l

inn e r v a tio n as co mp a re d to t he more su p erficia l par a ve r te b ra l musculature. The s p i na l lev e l of the d eep muscular involvement consequent l y most c l ose l y corre­ s pon d s to t h e sp i na l l e v e l of reflex s eg m e nt a l somatic dy sfu n c t ion. Signs of ac u te visceroso m a tic reflex a ct i vi ty similar to th os e of acute primary s om a tic d ysfun ct i o n can be apprec i ate d by pa l p a ting se qu ent i ally from superficial to deep tissues. The e xamin ation s hould begi n w i t h the l ighte st of touch and pr ogress t hr o ugh i nc r e a singl y gr e a te r pal p a to ry pressure. Increased skin temp e rat ure wi l l be pre sent as a result of v a sod i lat io n Red re fl e x , a visual obs er vation , is a prolonged v asomo to r reaction to tactile stimulation that results in d e rm atom a l ly re l a ted c uta n eous e r yth e m a. The acute sudomotor reaction results in increased swe at ing This increases ski n d rag, the p erc e p tion of res i sta nc e as t h e examiner s lid e s the hand over the pati ent'S skin. Cutaneous and su bcu tane o u s tissue texture change , a result of increased in terstitia l fluid, p r oduc e s ski n th i ck en in g a n d subtle su bc u ta ne ous ed ema that once ap pre ciated , may be quantified (mild, mod e ra te, severe ) to p r ov i de invalu­ able d iagnos tic information as to the severity and acuity of the re flex The segmen­ t a l ly related deep paraver te bral musculature will demonstrate active s p a sm The signs of chronic viscerosomatic reflex a ctivi ty, as migh t be ant iCIp a ted , include local vasospasm with resultant decreased skin temperature a n d red uced sud omotor activity w it h decreased skin d ra g beca u s e of decreased sw e at i n g. S l ig h tl y deeper pal p a ti on reveals the sens a tio n o f subcutaneous fi b rosis , while with even d eeper pressure the deep pa r a ve rtebr a l muscles feel hard and tense and exhibit hyper s e n si t i vity to pa lp a ti o n . Testing for passive motion of the s p i na l segments involved is p e rfor med in a fa shi o n similar to motion testi ng for primary sp i na l somatic dysfunction. (See C ha p ter 3.) D iffe re n t ia tion between p rimary sp in a l somatic dysfunction and that of vi s c e rosoma ti c origin is often diffic ult As noted earlier, rather t h a n manifesting a d is ti n c ti v e restrictive barrier, such as that demonstrable with primary spina l somatic d ys fu n c tion , viscerosoma t i c reflex som atic dy sfu nc t i on often d emo n­ s t r a tes am b igu it y o f the rest r ic t i ve barrier. Any motion restr ic t ion is comm only g ene ral ized a nd may be without a symm e try. Visc ero soma tic reflex dysfunc t ion and mec hanic al s p ina l somatic dys f un cti o n however, are often c l i n i ca l l y encountered in a c h i c k e n egg re lati ons h i p a t the same v e r te bra l l e veJ,21 making the di fferent i a t i o n between t he two difficult or i m p o ssi ­ ble. When t he pa tient has esta b l i she d viscera l pa thology and c o nco m i t a n t m e chan­ i cal d ys fu nc ti on it is i mp ossi bl e (and unn e ce ssar y ) to discern whether pr imar y s p in a l dysfu nction re su l ted in the d evelopment of v i sc er a l pa t h o l ogy thr o ug h somatovisceral effects or longs ta n d ing visceral pathology p r od uc ed mechanical s p in a l dysfunc tion . Paraspi na l v i sc e r o somat i c ref l ex e s when i d en tifi e d , may be further conf i rm ed by searching for C h ap m a n s poin t s. As stated earlier, these are found pair ed , a nt e ri or ly and poste r ior iy. They are in sp ec ifica l l y ma pped loc a tions ( Figs . 5.1 and 5.2) and ar e palpa b l e as disc r e t e gangliform mass e s that a re firm but not hard. They are quite sma l l , 2 to 3 mm in d iam ete r, and very te n d e r, and t hey l i e upon deep fasc ia or p e r i osteum. They wil l move sligh t l y w i th palpatory pr e ssure but rema in a ttached to the de e p tissues. They may be fou nd alone or in groups, a nd wh e n they a re the r es ult of chronic disease processes , they a re of greater mag ni tud e and tend to coa l e sc e. Som atic dysfunc t i on that is the result of a viscerosomatic reflex is pr ima r il y of d iagnos tic val ue. It is de fin it ive l y trea ted by tre at i n g the causat ive visceral pathology. The i n sepa rab l e relationship between vi sceroso matic reflexes and som a tovisceral .

­

.

.

.

.

,

-

,

,

'

­

Chapter 5 • V i scero s o m atic a nd S o m a t o v i scera l Ref l e x e s

Liver

37

and gall

bladder (Right) Adrenals (bilat) Kidney (bil a t) Appendix (Right) Urinary bladder (Midline

and bilat)

Uterus (bilat) Ovaries and

FIGURE 5.1

The anterior Chapman's tender points.

reactions thar are the result of spi n a l facil itation, however, means that for e v ery

so m at ic dysfunction due ro visceral pathology there is a segmenta l l y related response that will in turn affect segmentally related viscera. As such, although therapies should be employed that are specifically directed at the visceral pathology, as discussed later,

OMT may be used as ad ju nct ive treatment through its effect upon somatovisceral physiology. The Location of Viscerosomatic Reflexes

As Burns� suggested, viscerosomatic reflexes offer

a

signifi cant contribution to the

phys i c a l d iagnosis of visceral pathology. For physical findings to have diagnostic value, h ow e v e r they must be co ns istently reliable. Head4 extensively mapped ,

referred pain based in parr upo n increased tenderness to palpation. Following the

earlier works on referred pain, Potte n ger 7 provided one of the first thorough descriptions of the somatic manifestations of visceral disease. Much of the early osteopathic literature on viscerosomatic reflexes consists of anecdotal case studies.

38

Section I • Ph i l os o p h y and Pr i ncip l e s of Pa tient Care

}

0

Tons i l (bilat) Middle ear (bilat) @ B ron C hi Pharynx (bilat) (bllat) Esophag u s Larynx lung er (bilat) . Heart (bilat)----.""""'"-.
S .i nuses

_____.

�

i

.

{

__

Spleen (Left) O vanes . (b'I I at) �"l"'==:::t:::-::.., Te t e Adrenal glands (bilat)-ii--+-Kidneys (bilat)--'--T---::; Bladder and urethra (bilat) Fallopian tUbes

Prostate

{Liver

}.

(Right) Gall bladder Pancreas (Rioht) Duodenum (bilat)

s s}

) �!���:

}

Jejunum

(bilat)

Pyloris(Right) Ileum (bilat)

{Colon

Appendix (Right) (bi l at) Rectum (bilat) Hemorrhoids emorrhoids* (bilat)

J

( b i lat)

Seminal vesicles Fallopian tUbes*(bilat)

.

}

W

Vagina and clitoris (bilat) Vagina and clitoris*(bilat).l''!--�-\E'" Vagina*(bilat)

"

* De n otes an anterior point atypically found in a posterior location.

FIGURE 5.2

The posterior Chapman's tender points.

Consequently, the exact location of reported reflex findings varies slightly from

author to author. Beapo reviewed this literature and provided probably the most thorough overview of the recorded locations of viscerosomatic reflexes to date.

Because viscerosomatic reflexes are mediated through general visceral afferent neurons traveling with the autonomic nerves that supply the target area or organ they represent, they are classified as sy mpathetic and parasympathetic. Viscerosomatic reflexes classified as sympathetic are found from the first thoracic segment through the mid lumbar region. As

a

rule, organs above the rflOracoab­

dominal diaphragm manifest their sympathetic viscerosomatic reflexes in the par­ avertebral soft tissues at or above the level of T5, while organs below the diaphragm manifest their sy mpathetic viscerosomatic reflexes at or below the level of TS. The parasympathetic viscerosomatic reflexes a re found in association with the vagus, cranial nerve X, with manifestation in t h e high cervical region.

Parasympathetic viscerosomatic reflexes are also found in association with the pelvic splanchnic nerves, the second, third, and fourth sacral segments, with

man­

ifestation in the pelvic region. Certain exceptions are discussed as they are descri bed later in the cha pter.

Cha pter 5 • V i sceroso m a t i c a n d S o m atoviscera l Refl exes

39

Tiss ue texture c h a nges o f vi scerosomatic r e f l e x o r i g i n a re pred icta b l y b i l a tera l or a s y m m e trica l , a s w e l l as being predicta b l e as to t h e s p i n a l segm ental level where they a re fo u n d . Mid l i n e organs, such a s the pancrea s , p ro d u ce b i l a tera l tissue tex­ t u re cha nge. P a i red orga ns, such a s the l u ngs, prod uce b i lateral reflex fi n d i ngs when a genera l i zed d isease process , s u c h as p u l m o n a r y fibrosis, a ffec ts both s id e s , w h i l e a n a s y m metrical d i sease process w i l l p rod u c e a n i p s i l a teral r e flex res p o n s e . R ight l o w e r l o b e p n e u m o n i a therefore w o u l d be expected to res u lt i n a right- s i d e d pa ra verte bral refl e x . Asym metrica l l y p l aced orga n s res u l t i n a s y m metrica l i p s i l a t­ era l reflexes. Conseq u e n t l y, the myocard i a l refl e x t e n d s to be left-s i d ed , wh i Ie the reflex fro m l i ver d i sease w i l l be right-s i d e d . T h e fo l l o w i ng l i s t i ng of v isceroso m a t i c reflex loca t i o n s (Ta b l e 5 . 1 ) is c o mp i l ed

from s i tes l isted by m u l t i p l e s o u rces .4,7, 1 7,20, 2 2- 2 4

Pa raverte bra l Vi sce roso matic Reflexes System or Organ

Sympathetic

Head and neck

T 1 -T5

Upper respi ratory tract

T l -T5

Pa rasympathetic

Trigemina l : f i n a l common pathway, temporal is m u scles, occiput, C 1 , C 2 .

Cardiac Myocard i a l

T 1 -T5 left

Coronary a rtery

( 3-C 5 (sympa thet ic7)

Occ i p u t , C 1 , C 2

Pulmonary T 1 -T4

Occi put, ( 1 , C 2

B ronchomotor reflex

T 1 -B

Occiput, ( 1 , C 2

Asthma reflex

T2 left

Occiput, C 1 , C 2

Bronch ial m ucosa reflex l u n g

T2-B

Occiput, ( 1 , C 2

Parenchyma reflex

B-T4

Occi p u t , ( 1 , C 2

Parietal p l e u ra

T 1 -T1 2

Occi put, ( 1 , C 2

Esophagus

B-T6 r i g h t

Occiput, ( 1 , ( 2

Stomach

T5-T1 0 left

Occiput, C 1 , ( 2

Duodenum

T6-T8 right

Occi put, C 1 , C 2

Small intestine

T8-T 1 0 b i lateral

Occiput, C 1 , ( 2

Appendix a n d cecum

T9-T 1 2 right

Occiput, ( 1 , C 2

Ascending colon

T l 1 -L 1 right

Occ i p ut, C 1 , ( 2

Descending colon, rectu m

L 1 -L3 l eft

S2-S4

Pancreas

T5-T9 right or bi lateral

Occi put, ( 1 , C 2 Occi put, ( 1 , C 2

Lung

U p per GI

Lower G I

Liver, gallbladder

T5-T 1 0 right

Phrenic nerve somatoso matic reflex

C 3-C 5 right

Spleen

Tl-T9 left

(Continued )

40

Section I • P h i los o p h y an d Pri n c i ples o f Pat ient C a re

TA B L E 5 . 1

(Co n t . )

Paraverteb ral Viscerosomatic Reflexes System

or

Organ

Sym pathetic

Pa rasym pathetic

U r i nary tract K i d ney

T9-L 1 ipsilateral

Occiput, C 1 , C2

Proxi m a l ureter

T 1 1 -L3 ipsilateral

Occiput, C 1 , C 2

Distal u reter

T 1 1 -L3 i ps i l a teral

52-54

B ladder

T 1 1 -L3 b i l ateral

5 2 -54

Urethra

T l l -L2 b i l a teral

Genital tract Fal lopian t u bes

T1 O-L2 b i l ateral

52-54

S e m i n a l vesicles External genitalia

T 1 2 bilateral

Prostate

T1 0-L2 bilateral

Ovaries and testes

T1 0-T 1 1 i psi lateral

Uterus

T9-L2 bi lateral

Ad renal glands

T8-T l 0 i p s i lateral

52-54

52-54

Gr, gastroi ntestinal

Viscerosomatic Reflexes from th e Head, Eyes, Ears, Nose, and Throat

The sy m p a thetic i n nerva t i o n of the hea d a n d neck e m a n a tes from the u pper tho­ racic s p i n e , T h u s , T l -T 5 d y s fu nction can be fo u n d i n response to p a t h o l ogy o f the str u c t u res o f t h e hea d a n d nec k . 2 2 U p per Res p i ratory Tract

The fi n a l common p a t hwa y fo r sympa thetic a n d p a r a sympathetic i n nerva tion of t h e u p per respi ratory tract i s the trige m i n a l nerve. I n n e r v a te d by t h e trige m i n a l n e rve, t h e m u sc les o f m a st i c a t i o n , pa rtic u l a rl y the tem pora l is m u sc l e s , serv.e as a som a ti c c o m p o n e n t fo r a n upper respira tory tract viscerosomatic reflex t h a t m a y be consid ered both sym pa thetic a n d pa rasympa thetic . An a d d itiona l u p p e r resp i ­ r a t o r y tract v i scerosom a tic refJ e x s i te i s occ i p u t t o C2, T h i s rep resents a re flex between the trigemina l n erve a nd upper cervica l nerves tha r i n ne r v a te the posterior neck m u s c l e s . 25 The Chapman p o i n t s 1 7 assoc i a ted with the u p pe r res p i ratory tract are fo u n d bil a te ra l l y. T h e y i nc l u d e t h e fo l l ow i n g : Nasa l s i n u s e s . Th e a nterior poi nts l i e 7 to 9 e m l a tera l to t h e ste r n u m o n the u .pper e d ge of the seco n d r i b s . Pharynx , The a n terior p o i n ts lie u p o n the first ri bs 3 to 4 cm med i a l to w h ere the r i bs emerge from beneath the c l a vicles, Laryn x . The a n terior p o i nts l i e u pon the second ri bs, S to 7 em l a teral to the s ter­ nocosta l j u nc t i o n . The posterior poi nts a re fo u n d in the same l oc a t i o n fo r the

Cha pter 5 • Visce ro s o m a t i c a nd S o m atovisce ra l Ref l exes

41

n a s a l s i n u se s , p h a ry n x , and l a ry nx , upon C 2 m i dw a y between the s p i n o u s p r ocess a n d t h e t i p o f t h e tra n s v e r s e p rocess . To n s i l s . T h e a n te r i o r p o i n ts a re between t h e fi rst a n d s e c o n d r i b s a d j a c e n t to the s tern u m , and t h e poste r i o r p o i n ts lie u p on Cl m i d w a y b e tween t h e s p i n o u s p rocess a n d t h e tip of t h e tra n s v e rs e p r o c e s s . M i d d l e e a r. T h e a n te r i o r p o i n ts l i e u pon t h e s u perior a n te r i or a spect o f t h e c l a v i ­ c l es j u st l a tera l t o w h e r e they cross the first r i bs , a nd t h e poste r i o r poi n ts l i e u p on t h e poste r i o r a spect o f t i p s of tra n s verse processes o f C l . E y e . T h e a n terior p o i n ts l i e u p o n the a n te r i o r a s pect o f t h e h u m e r u s a t t h e l e v e l o f t h e s u rg i c a l n e c k , a n d t h e p o s t e r i o r p o i n t s l i e u pon t he s q u a m o u s p o r t i o n o f t h e occ i p i ta l b o n e b e l o w t h e s u pe r i o r n u c h a l l i n e . Viscetosomatic Reflexes from the Heart

There is genera l agree m e n t t h a t the myoca rd i a l sympa thetic viscerosomatic reflexes a re

fo u n d fro m Tl to T5, w i th gre a t e r l e ft - s i d e d t h a n r i g h t - s i d e d i n c i ­ d en c e . 7. 1 7.20,22-24 La rson26 s u b d i v i d ed t h i s reg i o n , n o t i n g a h ig h e r i n c i d ence o f a s s o ­ c i a te d ca rd i a c a rr h y t hm i a w hen t h e v i s c e r o s o m a t i c r e f l ex w a s o bserved a t t h e T2 l e ve l . R e f l e x fi n d i ngs a t t h e T5 leve l , h e s u ggested , were m o r e l i kely a s s o c i a t e d w i t h poste r i o r w a l l m y o c a r d i a l i n fa rc t i o n s . Lucia n i ,6 re v i e w i ng t h e e a r l y l i tera t u re o n refe rred p a in i n a ss o c i a t i o n w i t h hea rt d i s e a s e , d e s c r i bed a n a re a of c u ta n e o u s h y p ersensitivity i n d er m a tomes C 3 to C 4 . Larson i d e n t i fi e d r e f l e x p a ra verte bra l t i s s u e texture cha nge a t C3 to C 5 t h a t w a s a tt r i b u ted t o coronary a rtery d i sease a n d myoca r d i a l i sch e m i a .26 T h e p a r a s y m p a t h e t i c v i scero s o m a t i c r e fl e x from the heart i s the v a ga l refl e x , occi p u t, C l , C 2 . 23,24 T hese h i g h cervica l fi n d i n gs a re , howe v e r, nonspec i fi c f o r t h e h e a r t b e c a u s e t h e v a g u s i n nerva tes s o m a n y v i sceral s t r u c t u res, a n d the u p p e r res­ p i ratory t r igem i na l refl e x d e sc r i bed earl i e r i s a ls o fo u n d at t h i s l e v e l . T h e C h a p m a n p o i nts 1 7 a s s oc i a te d w i t h the heart a r e b i l a tera l . T h e a n teri o r myoca rd i a l p o i nts a re i n t h e i n terc o s t a l space b e tween t h e s e c o n d a n d t h ird r i b s a t t h e sternocos ta l j u nction . T h e poste r i o r p o i n ts u e fo u n d i n t h e s p a c e between t he t r a n sve rse p rocesses o f T2 a n d T3 m i d w a y between the s p i n o u s p rocess a n d the ti p of the tra n s verse proce s s . Viscerosomatic Reflexes from the Lower Respiratory Tract

The v i scerosomatic reflex fro m l u n g is genera l l y agreed u po n as being bilatera l from Tl to T4,1·1 7,22-24 a l th o u gh Bea l 's review i d e n t i fi e d a broa d e r a rea of i n v o l veme n t

from T 2 to TS . 20 T h e u p per thora c ic p u l mo n a ry reflex h a s been further s u b d i vided

i n to

a

bronchom otor reflex a r e a , Tl to T3 (with T2 l eft referred to a s the asthma

refle x ) , a bron c h i a l m ucos a reflex area, T2 to T3 , a nd a l u n g pa renchyma reflex area,

T3 to T4 . 23 Beca u s e t h e pa rieta l p l e u ra rece i v e somatic i n nerva t i o n , i n fl a m ma t i o n

i n v o l ving t h e p l e u ra m a y b e fo u n d anywhere between T l a n d T 1 2 , left- o r right­

sided depend i n g upon the l o c a t i o n a n d exte n t of p l e u ra l i n v lovem e n t. 7

As stated e a r l i e r, ge n e ra l p u l mo n a ry i n v o l ve m e n t w i l l re s u l t i n b i l a te r a l p a r a v e r ­ te b r a l re f l ex fi n d i n g s , w h il e l a tera lized p a t h o logy p r o d u c e s i p s il a tera l t i s s u e t e x ­ t u re c h a ng e . O ne w o u l d a n ticipate t h a t t h e p a r a s y m p a t h e t ic v iscero s o m a t i c r e f l e x f r o m t h e l u ngs wo u l d m a n i fest a s the v a g a l reflex, occ i p u t, C l , C2.24 T h e b i l a te r a l C h a p man p o i n ts 1 7 a ssoc i a ted w i t h t h e l u n gs i n c l u d e t h e fo l l o w i n g : Bronc h i . T h e a n terior p o i n t s a re in the i nterc osta l s p a c e between t he s e c o n d a n d t h i rd r i bs a t t h e s te r n ocosta l j u ncti o n , a n d the p o s te r i o r p o i n ts a r e o n T2 m i d ­ w a y between t h e s p i n o u s process a n d t h e t i p o f t h e t r a n s v e r s e p roce s s .

42

Section I • P h i l o s o p h y a n d P r i n c i p l es of P a t i e nt Ca re

U pper l u ng . The a n terior p o i n ts a re in the i n tercosta l s pa c e between the t h i r d a n d

fo u rth r i b s a t t h e sternocosta l j u nc t i o n , a n d the posterior p o ints a re fo u n d i n t h e s p a c e betwee n t h e tra n sverse processes o f T 3 a n d T4 , m i d w a y between t he s p i n o u s p r o c e s s a n d the tip o f the t r a n sverse proces s . L o wer l u n g . T h e a n ter i o r p o i n ts a r e i n t h e i n te rcosta l s p a c e betw e e n t h e fo u rt h a nd fi fth r i bs at the sternocosta l j u n c t i o n , and the poste r i o r p o i n t s a re fo u n d in t h e s p a c e between t h e t r a n s v e r s e processes of T4 a nd T5, m i d w a y between t h e s p i n o u s process a n d t h e tip o f the tra n sverse p ro c ess . Viscerosoma tic Reflexes from the Gastrointestinal Tra ct

B ec a u se t h e g u t d e v e l op s a s a m i d l i n e s t r u c t u re t h a t e x t e n d s a l o n g t h e e n t i re l e n g t h o f t h e e m br y o , t h e g a stro i ntes t i n a l t r a c t r ec e i ves s y m p a t h e t i c i n n e r v a t i o n fro m a l m o s t t h e e n t i re l e n g t h o f t h e t h o r a co l u m b a r s p i n a l c o r d . T h e rost ra l ­ to - c a u d a l g a str o i n t e s t i n a l s y m p a t he tic v i s c er o s o m a t i c refl exe s progress seq u e n ti a l l y a l o n g t h e th o r ac o l u m b a r p a r a v e r te b r a l s o ft t i s s u e s . A l t h o u g h i t s h o u l d be expected th a t a m i d l i n e s t r u c t u re w o u l d m a n i fe s t b i l a tera l p a r a v e r te b r a l reflexes, t h e r o t a t i o n t h a t o c c u r s a s the e m b ryo l o g i c g u t d e v e l op s ca u se s c e r ta i n re flexes to be p r e d o m i n a n tl y l e f t - s i d e d ( s t o m a c h ) , w h i le others ( c ec u m a n d a p pe n d i x ) a r e right-s i d e d . The v a g u s p r o v i d e s t h e p a ra s y m p a thetic i n n erva t i o n o f t h e g a s t ro i n testi n a l tract p r ox i m a l t o t h e m i d tra nsverse c o l o n , a nd c o n s e q u e n t l y, m o s t o f t h e g u t ­

d em o n s t r a tes a p a ra sy m p a t h e t i c v i scer o s o m a tic reflex a t t h e l ev e l o f t h e occ i p u t, C l , C2. The d ista l h a l f of the transverse c o l o n to the r ec t u m receives its p a r a s y m ­ p a t h e t i c s u p p l y from t h e pelvi c s pl a n c h n i c n e rves, 52 to 54 , a n d c onse q u e n t l y 4 d e m o n s tr a tes s a c r o p e l v i c viscer o s o m a tic refl e x a c ti v i ty. 2 3 . 2 U p p e r G a st r o i ntesti n a l Vi sce roso m a t i c Refl exes

T h e esoph a g u s h a s v e r y l i ttle s y m p a t h e ti c i n nerva t i o n . Its r e p o rted refl e xes a r e v a r i a b l e : T3 r i g h t,23 T5 to T6 r i g h t .22 T h e s t o m a c h h a s b e e n ge n e r a l l y a g reed u po n to m a n i fes t a s a l e ft-s i d e d r e fl e x fro m T5 to a s low a s T I O . 7,2o,22,23 T h e d u o d e n u m reflex ten d s t o b e ri g ht - s i d e d fro m T 6 t o T 8 . 23 A d i s t i n c t ive a l t e r n a tin g pattern o f p a r a v e r te b r a l fi n d i n gs e m e rg e s. I t c a n b e c o n s i d e re d i n d ic a t i v e of u p per gastroin­ testi n a l p a t h o logy: h i g h c e r v i c a l v a g a l re f l e x a cco m p a n i e d by T3 r i g h t , T5 t o T 7

l e ft , a n d T6 to T 8 r i g h t . This o ffe rs a s s i s t a nce w i t h d i ffe re n t i a t i n g a n u p per gas­ troi nte s t i n a l d is o r d e r fro m p o s s i b l e c a r d i a c or p u l mo n a r y e t i o l ogy. The C ha p m a n p o i n ts l 7 a s s o c i a te d w i t h the u p pe r ga s tr o i n t e s t i n a l tract inc l u d e t h e fol l o w i n g :

E s o p h a g u s . The a n te r i o r p o i n ts a r e in t h e space betwee n t h e sec o n d a n d t h i r d r i b s a t t h e sternocosta l j u n c t i o n , a n d t h e poste r i o r p o i n ts a re fo u n d u p o n T2, m i d ­ w a y between t h e s p i n o u s p rocess a n d t h e t i p o f t h e tra nsverse process . Sto m a c h . The a n t erio r p o i n ts a re i n the spaces betwee n the fi fth to seventh ri bs, fro m the m i d m a mm i l l a ry line o n the left to the stern u m . The poste r i o r poi n ts a re fou nd i n the spaces between the tr a n sv e rse p rocesses of T5 to T7, m i d w a y between t h e spi n o u s processes a nd the tips of the tra nsverse processes o n the left. Pyl o r i s . The a n te r i o r p o i n ts a re on the front o f t he stern u m from t h e ster­ n o m a n u br i a l j u n c tion i n fe r i o r l y to t h e x i p h o i d process . T h e poster i o r po i n t i s fo u n d o n the t e n t h ri b a t t h e costotra ns verse j u n c t i o n o n t h e ri g h t . D u o d en u m . T h e a n te r i or p o i n ts l i e b i l a te r a l l y in the spaces between the e i g h t h a n d n i n t h r i bs n e a r t h e costoc h o n d ra l j u n c ti o n s , a n d t h e p o st e r i or p o i n ts a re fo u n d b i l a t e r a l l y in the s p a c e between the tra n sverse p rocesses o f T8 a n d T9 m i d w a y be tween t h e s p i no u s processes a n d the t i ps o f t h e tra nsverse p rocesses .

Chapter 5 • Viscerosomatic a n d Somatovisceral Ref l exes

43

Lower G a st rointesti nal Viscerosomatic Reflexes

The p a r a sy m pa thetic re flex a s far as t h e m i d tra ns verse col on c on t i n u e s to be the vaga l re flex, occ i p u t , C I , C2. The s y m pa t hetic v isce rosomati c reflex fro m t h e sma l l i n test i n e is T8 to T I O, b i lateraJ 2 2 (pos s i b l y right grea te r t h a n l e ft n ) . The b i l a tera l C ha p m a n p o i n t s 1 7 asso c i a te d w i th the sm a l l i n t es t i n e i n c l u d e the fo l l o w i n g : J ej u n u m . T h e a n te r i o r poi n ts a re i n t h e s p a ce be twee n t h e n i n th a n d t e n t h r i b s nea r the costoc h on d ra l j u n cti o n s , and the poste r i o r p o i nts a r e fou nd i n the space between t h e tra nsverse p rocesses o f T9 a n d T I O , m i d wa y between t h e s p in o u s processes a n d t h e ti ps of t h e tra nsverse processes . I l e u m . The a n te r i o r p o i n ts a r e i n t h e space between the te n t h a n d e l eventh r i bs nea r the costoc h o n d ra l j u ncti o ns , and t h e posterior p o i n t s a r e fo u n d in t h e space b e t w e e n t h e t r a n sverse processes o f T I O a n d T I l , m i d w a y between the s p inous processes a nd t h e tj p s of t h e t ra n s v e rse p rocess e s . Viscerosomat ic Reflexes for t h e Rema i n d e r of the Gast roi n test i n a l Tract

The verm i form appen d i x a n d cec u m res ult in reflex t i s s u e text u re c h a n ge fr om T9 co T 1 2 on the r i g h r . 20.23,24 The a s c e n d i ng co lon res u l ts i n reflex t i s s u e tex t u re c h a ng e fro m T I l t o L 1 on the r i g h t 20 22 24 At the l e v e l o f t h e mid tra n s v e r s e c o l o n , the p a r a s y m p a t h e t i c v i sc e roso m a ti c reflex s h i fts f r o m vaga l c o p e l v i c s p l a n c h n i c , 52 to 54 , res u l ti n g i n s a c r o p e l v i c t i s s u e te x t u re c h a ng e a n d te n d ern e s s , Pa t h o l ogy a f fe c t i n g t h e d e s c e n d i n g c o l o n t o t h e rec t u m re s u l ts i n reflex t i s s u e text u r e changes from L I r o L 3 o n t h e l e ft Y-24 The Ch a p m an p o i n ts ' 7 for the a ppen d i x a re r i ght- s id e d , The a n terior po i n t is nea r t h e t i p of t h e twe l fth r i b on the right upon its s u perior edge, a n d the posterior poi n t i s fou n d i n t h e space between the t i p s of th e t r a nsve rse p rocesses of T I l a n d T I 2 o n the f i g h t . T h e b i l a te r a l C h a p m a n p o i n ts l 7 associated with t h e la rge intesti n e i n cl u d e t h e c o l o n , C h a pma n 's d e s c r i p ti o n o f t h e refl e x p o i n t s a ss o c i a te d w i th t h e c o l o n n ecess i t a tes fu rther d i s c u s s i o n . T h e p o s t e r i o r p o i n ts represe n t i n g t h e e n t ire c o l o n a re fo u n d b i l a tera l l y i n a t r i a ng u l a r are a , from t h e t r a n s v e r se p roce s s o f L 2 to the tra nsve rse p rocess of L4 a n d e x te n d i ng l a tera l l y to the ili a c c r e s t . The a n te­ r i o r p o i n t s o f the colon lie b i l a te ra l l y on t h e l a te r a l a s p ects of the t h i g h s i n the tensor fa s c i a l a ta and the a n t e r i o r p o r t i o n o f the i l i o t i b i a l t r a c t . The c ol o n i c s u b ­ d i v i s i o n s , cec u m to s i gmoid , h o w e ver, are in d i v i d u a l l y represented w i t h i n t h e a n te r i o r p o i n ts , beg i n n i ng w i t h t h e cec u m o v e r t h e r i g h t g r e a ter tro c h a nter a nd progre s s i n g CO the r i g h t ha l f of t h e t r a n s v e rse c o l o n , pr o x i m a l to t h e r i g ht k n e e . T h e a nteri o r p o i n ts for t h e l e f t ha l f o f t h e transve rse co l o n a r e fo u n d u p o n the l e ft i l i o ti b i a l t ra ct d i s t a l l y, beg i n n i ng p r o x i m a l t o the l e ft k n ee a n d a s c e n d i n g the la tera l thigh to t h e l eft grea ter troc h a n te r, w here the a n te r i o r p o i n t s for the s i g­ mo i d c o l o n are fo u n d . The a n te r i o r co l o n ic points are a s fol l o w s : .

,

-

Cecu m . T h e a nt e r i o r po i n ts a re l o c ate d l a tera l l y u pon the u p per f i ft h o f t h e right

thigh, a n terio r ly o n the te nsor fascia l a ta . Asce n d i ng co l o n . The a n terior p o i nts are loca ted latera l l y upon t h e m i d d le three­ fi fths o f t h e right thigh, on the a n terior a s pect o f the i l i o t i b i a l tract. R i g h t h a l f of the tran sverse colon . The ante r i o r p o i n ts a re p ro x i ma l to t h e right knee, l a te ra l l y u pon the a n t e r i o r a s p ect of th e i l i o t i bia l tract. Left ha l f o f t h e tra n s v e rs e c o l on. The a n terior p o i n ts are prox i m a l to the l e ft k n ee, l a tera l l y u po n the a nteri o r a spect of the i l i o t i b i a l tra c t .

44

Section I • Ph i l os o p h y and P r i nc i p l es of P a t i ent Care

Descen d i ng c o l o n . The a n te r i o r p o i n ts a re located l a tera l l y upon t h e m i d d l e three­ fift h s o f t h e l eft thigh, on t h e a n terior a s pect o f t h e i l i o t i bia l tract. Sig m o i d c o l o n . T h e a n ter i o r p o i n ts a re l oca te d l a t e r a l l y u p o n the u p pe r fifth o f t h e left th i g h , anterio r l y o n t h e tensor fa s c i a l a t a . A d ditiona l l o w e r g a s tro i n te st i n a l b i l a te r a l C h a p m a n 's p o i n ts t h a t h a v e been d e scri b e d : Rectu m . The a n te r i or p o i n ts are located on t he prox i m a l i n n er t h ighs over t h e l esser trocha n ters b i l a te r a l l y, a n d the p o s te r i o r p o i n t s are fo u n d on the s a c r u m , c l o se to t h e i l i u m at the l o w e r e n d of the sacroi l ia c a r t i c u l a t i o n . Hemorrh o i d s . T h e a n terior p o i n ts a re loca ted i m m ed i a te l y a b o v e isch i a l tu bero s i ­ t i e s , a nd the p o s terior p o i nts a re fo u n d o n t h e s a c r u m , c l o se to t h e i l i u m a t t he lower e n d of the sacroi l i a c a rt i c u l a t i o n .

Viscerosomatic Reflexes from the Pancreas, Liver, Gallbladder, an d Spleen P ancre a s

The symp a t hetic reflex is a m u l t i segmen ta l reaction from T 5 to T9. 7.22.23 The tissue

texture fi nd i ngs have been d escr i bed a s l e ft-sided 7,22 and a s b i l a te ra l Y I n c h ro n i c pa n ­

crea titis, t h e a r e a t e n d s t o become fixed in extensio n . This m a y occ u r a s a d i rect somat­ ic e ffect of the retrope ritoneal location of the pa ncreas a nd the e ffec t of i n fl a mmation a nd the l i beration of p a ncreatic d igesti ve e n z y m e s u po n t h e s u r ro u n d ing tissues. T h e para s y m p a t h e t i c refl ex i s v a g a l , occ i p u t, Cl, C2 . The i n te n s i t y o f this re flex

m a y be mon i to re d fr om d a y to d a y, a s i t t e n d s to mi rror t h e s e v e r i ty o f a c u te pa n c r e a t i t i s . T h e C h a pma n p o i n ts 1 7 a s s oc i a ted w i t h t h e p a ncrea s a re r i g h t -s i d e d . T h e a n te­

r i or point i s loca ted in the space between t h e c o s ta l c a r t i l ages o f t h e seventh a n d

e i g h t h r i bs , a nd t h e p o s te r i o r p o i n t l i e s between the tra n s v e r s e processes of T7 a n d

T 8 , m i d wa y between t h e t i p s o f t h e s p i n o u s p rocesses a n d t h e tra nsverse processes. Liver and G a l l b l a d d e r

T h e s y m p a t hetic re flex i s a r i g h t - s i d e d rea c t i on , p a l p a b l e from a s h i gh a s t h e leve l o f T 5 to T I O . 7,2o,22,23 T h e para s y m p a t h etic refl ex for the l i v e r i s v a ga l , occ i p u t, Cl ,

C 2 . A d d it i o n a l l y, a s o m a to s o m a t i c reflex, med ia ted t h r o u g h the p h re n i c n e r v e , C3

to C 5 , is responsi b l e for r e ferred p a i n to the r i g h t s h o u l d e r a n d m i dcervica l p a r ­ a v e r t e b ral t i s s u e text u re c h a n ge . 7,24 The C h a p m a n p o i n ts ' 7 a s s oc i a te d w i th t h e l i v e r a n d ga l l b l a dd e r a re righ t-s i d e d . T h e a n terior p o i n t s a r e i n the spaces between t h e fifth a n d s e ve n t h r i bs, from t h e m i d m a m m i l l a ry l i ne to t h e stern u m , and the poste r i o r p o i nts a re between the tra n sverse processes o f T5 to T7, midway between the t i p s o f the spi n o u s p rocesses a n d the tra n s verse p rocesses. S p l een

The sy mpa thetic reflex i s a left-sided reaction, p a l p a b l e from t h e level o f T7 to T 9 . 22

The C ha p m a n poi n ts associa ted with the spleen a re left -sided . T h e a n teri o r points

are in the spaces between t h e seventh and eighth r i bs n e a r t h e costoch ond ra l j u nction, a n d the posterior p o i n ts a re located between the tra n sverse p rocesses o f T7 a nd T 8 , m i d w a y between the tips o f t h e s p i n o u s processes a n d t h e transverse processe s . Viscerosomatic Reflexes from the Urinary Tract K i d n ey

The sympa thetic re flex is ipsi l a teral w i t h the s i d e of t h e u r i n a ry tract of i n vo l vement; a p a l p a b l e re action may be present from T9 to L 1 .7,22-24 T he p a r a s y m p a thetic refl e x for the k i d neys i s vaga l , occ i p u t, C l , C 2 .

Chapter 5 • V i sceroso m a t ic a nd S o m atov i sce ra l Ref l e xes

45

T h e C h a p m a n p o i nts l 7 a s soci a te d w i th the k i d ne y s are fo u n d i p si l a te r a l to t h e s i d e o f u r i n a r y t r a c t i n v o l ve m e n t . T h e a n te r i or p o i n ts l i e 1 i n c h a b o v e the u m b i l i ­ c u s , l a tera l l y o n e i t her s i d e o f the m i d l i n e , a n d the p o s te r i or p o i n t s a re between the

t r a nsve rse p r ocesses o f T 1 2 a nd L 1 , m i d way between the ti ps of t h e s p i n o u s processes a n d t he tra n sverse processe s . U rete r

T h e s y m p a t h e t i c r e f l e x is i p s i l a te r a l wi th the s i d e o f t h e u r i n a ry tract of i n v o l ve ­ m e n t; a p a l p a b l e re a c t i o n may be pre s e n t f r o m T 1 1 to L 3 . l,22-24 A s a k i d n ey s t o n e

tra v e rses the u reter, a c o r re s po n d i n g v i s ceros o m a t i c r e f l e x w i l l d e s c e n d a l o n g t h e t h o r a co l u m b a r p a r a v e r te b r a l s o ft t i s s u e s .24

T h e p a r a s y mpa t h e t i c re f l e x fo r t h e prox i m a l u re te r s is vaga l , occ i p u t, C t , C 2 , a n d f o r t h e d i sta l ureters, p e l v i c s p l a n c h n ic, 52 to 54. B l ad d e r

T h e sym p a t h e t i C re f l e x i s b i l a te r a l

p e l v i c s p l a nchnic, 52 to 54.

T I l t o L 3 . 22.24 T h e pa rasympa thetic r e f l e x

IS

T h e C h a p m a n p o i n ts l 7 a ssoci a te d w i th t h e u ri n a r y b l a d d e r a r e b i l a tera l . T h e

a n te r i o r p o i n ts a re loca ted i m m e d i a te l y s u r r o u n d i ng t h e u m b i l i c u s a n d o n t h e p u b i c s y m p h ysis, j u st l a tera l t o t h e m i d l i n e

midway

be tween t h e s u perior a n d i n fe ­

r i o r e d ges o f the p u b i c b o n e s . The p o s te r i o r p o i nts a r e l o c a t e d u p o n t h e s u pe r i o r e d ge o f t h e transve rse p rocess o f L2 . U rethra

The s y m p a t h e tic reflex i s b i l a tera l T I l to L 2 . 22

The C h a p m a n po i n ts l 7 a s s oc i a te d w i t h t h e u re t h ra a re b i l a te ra l . The a n te r i o r

p o i n ts a re o n t h e s u pe r i or a s p e c t o f t h e p u b ic symphy s i s , a n d the poste r i o r p o i n ts

a re on the s u p e r i o r edge of the tra n sv erse process of L2.

Viscerosomatic Reflexes from the Reproductive Organs F a l l opi a n Tu b e s ( a n d S e m i n a l Ves ic l e s )

The sy m p a thetic re fl e x fr o m t h e fa l l o p i a n tu b e s i s i p s i l a tera l to the side of p a t h o l ogy fr o m T l O to L 2 . 2i,24 The p a r a s y m p a t he t i c refl e x i s p e l vic s p l a nc h n i c ,

52-5 4, 23,24

The Cha p m a n p o i n ts l 7 a s s o c i a ted w i th the fa l l o p i a n tu bes a nd sem i n a l v es i c l e s are b i l a te r a l . T h e a n te r i o r p o i nts a re p a r a d o x i c a l l y l oc a t ed posterio rly, m i d w a y

between t h e a c e ta b u l u m a n d sc i a t i c notch, a n d the p o s te r i o r p o i n t s a r e b e t w e e n

t h e poste r i or s u p e r i o r i l i a c s p i n e of the i l i u m a n d the tra n s verse p r o c e s s of L5 o n t h e i l i o l u m ba r l i ga m e n t. ( O w e n s ' t e x t rea d s " s p i n o u s p roce s s , " n o t t r a n s v e rse process, but the i l l ustra t i o n i s m o st con s i s te n t with the d e scri p t i on g i v e n h e r e ) .

G e n i t a l O rg a n s

T h e s y m p a t h e t i c reflex i s b i l a te r a l a t T 1 2 .22 Cha p m a n p o i n t s l 7 a re i d e n tified b i latera l l y for the fe m a l e geni ta l i a ( c l i to r i s and vagi na ) , T h e a n te r i or poi nts a re loca ted b i l a tera l l y o n the d i sta l med ia l t h igh, 7 to 1 5 cm

on

the u pp e r i n ner a spect o f the posterio r t h i g h , a n d the posterior poi nts are

located b i l a te ra l l y between t h e posterior s u p e r i o r i l i a c spine of t h e i l i u m and t h e t r a nsverse p rocess of L5 o n t he i l i ol u m ba r l ig a m e n t . ( O w e n s ' text r e a d s " s p i n o u s p rocess , " n o t tra nsve rse process, b u t t h e i l l ustra tion i s m o s t c o n s i s t e n t w i t h t h e d e s c r i pti o n g i v e n h e re , ) Prostate

T h e s y m pa th e t i c reflex is b i l a tera l fro m 1' 1 0 to L 2 . 7,21,23 The p a r a s y m p a thetic reflex is fro m t h e pe l v ic spl a n c h n i c nerves, 52-5 4 , l,22,23

46

Sect i o n I • P h i l os o p h y a n d P r i n c i p l e s of P a t i e n t C a r e

B i la tera l Cha p m a n p o ints 1 7 a r e i d e ntified f o r t h e prostate. T h e a n t e r i o r p o ints a re l o c a te d b i l a tera l l y on the l a tera l a s p e c t of th e t h i g h s in a si m i l a r d i stri b u t i o n to tha t of the c o l o n , fro m t h e troch a nter d o w n w a r d o n t h e o u te r a spect o f t h e fe m u r t o w i t h i n 2 i nches of t h e knee j oi n t l a te r a l l y, a n d t h e posteri o r poi n ts a re loca ted b i l a te r a l l y betwee n the p osterior s u pe r i o r i li a c s p i n e of t ile i l i u m and the transve rse process of L5 on the iliol u m b a r l i ga m e n t . ( O w e n s ' text reads " sp i no u s process , " n o t t r a n s verse p rocess, b u t t h e i l l u stra t i o n i s m o s t c o n s i s t e n t w i t h t h e d escrip t i o n g i v e n here . ) Ova r i e s ( a n d Testes)

The sympa thetic reflex is i p s i la tera l w i th the side o f gona d a l i n vo lvemen t from TIO to T I L 2 2 ,2 4 The C h a p m a n points 1 7 i d e ntified for t h e ova r i e s a re b i l a te ra l . The a n te r i o r poi n ts are loc a ted u p o n the a n te r i o r s u rface of the p u b ic bone, f r o m the p u b i c t u bercle infe r i o rly t o t h e origin o f t h e a d d uctor m u sc l e s . T h e poster i or poi n ts a re loca ted i n the spaces between T9 a nd T I l . U te r u s

T h e s ym p a t hetic refl e x i s bil a tera l fro m T9 to L2 . 20. 2 2-2 4 T h e p a r a s y m pa th e t i c reflex is fro m the p e l v i c s p l a n c h nic nerves, S2 -S4 . 2 3,2 4 The C h a p m a n poi n ts 1 7 i d e n t i fi e d for the u te ru s a re bila tera l . The a n terior p o i n ts a r e o n t h e med ia l m a r g i n s of the o b turator fora m i n a , a n d t h e posterior p o i n ts a r e l oc a te d b i l a terally b e tween the posterior s u perior i l i a c spine of the il i u m a n d the tra nsverse process o f L 5 o n the i l i o l u m b a r l iga m e nt . ( O wens' text reads " sp i n o u s process , " n o t transverse process, b u t t h e i ll u stra t i o n i s m o s t con s i sten t w i t h t h e d e scription g i v e n here . ) Viscerosoma tic Reflexes from Endocrine Gla n ds Pa n c re a s

See pag e 44 . Ad r e n a l G l a n d s

T h e s y m pa t h e t i c reflex i s i p s i l a tera l w i th t h e s id e of t h e a d r e n a l i n v o l vement from T8 to T I O . 2 2 T h e C h a p m a n p o ints 1 7 identified for t h e a d re n a l g l a n d s a re b i l a tera l . T h e a me­ r i o r points are l o c a t e d 5 to 7 cm a bove a n d 2 to 3 c m on e i t h e r side of the u m b i l i ­ c u s , a n d t h e p o s te ri o r poi nts a re l oca ted b i l a te r a l l y i n t h e i n tertra nsverse spaces be tween T I l a n d T12, m idwa y between t h e tips of the s p i n o u s p rocesses a nd tra nsverse processes .

T R E ATM E NT CO N S I D E RATI O N S Somatic dysfunction that i s the reflex resu lt o f p r i m a ry v iscera l p a t h o l ogy, a v i scero­ soma tic reflex, is trea ted b y employing the med ical treatment speci fica l l y ind icated for the u nderlying pathology respo nsi ble for the reflex . This is not d e ba ta b l e . T h e sp i n a l segm enta l facilitation t h a t is t h e res u l t of t h e v iscerosomatic reflex c a n , however, prod uce a s o m a toviscer a l reflex d e mo n strating l o wered t h re s h o l d s for a utonomic neu rona l firing. Susta i ned hy peractivity of sympa thetic pathways h a s been demon­ stra ted to be delete r i o u s to target tissues, resu l t i ng i n s u c h c l i n ical con d iti ons as pep­ tic u lcer d isease, pancreatitis, n e u roge n ic p u l monary e d e m a , and fa ta l a r r h yth m i a s fo l l o w ing myoc a r d i a l i n fa rction . 14 S u stai n ed parasympa thetic activity wi l l res u lt i n bradyc a r d i a a n d gastroi ntest i n a l hyperacti v i ty. If pa ncrea titis, as a n exam p l e, resu lts

C h a pter 5 • Visce roso m a t i c a n d S o m atovisce r a l R e f l exes

47

i n a v i sceroso m a tic re flex w i t h segmenta l fac i l i tation from T5 to T 9 , the fac i l i tation w i l l i n t u r n expose the pa ncreas to sustai ned s y m p a thetic hyperactiv i ty. T h u s , it has been a rgued t h a t m a n i p u la tive trea tment may be d i rected a t the somatic dysfu nction to decrease the facil ita ted state, even i f i t i s o f v iscerosomatic reflex origi n, w i th resu l t­ a n t beneficia l e ffect upon the s i te of p a t h o l ogy. 1 2 . 1 4,20 Ea r l y osteo path ic research d i ffere n t i a ted between s ti m u l a tory a nd i n h i bi tory m a n i p u l a t i v e treatment and its s o m a to v iscera l i mp a c t . 8 When tre a t i ng the s o m a tic c o m p o n e n t of a v isceros o m a t i c re flex to induce a s o m a tovi scera l effect, i n h i b i tory press u re proced u res, a s descri bed at the end of this c h a p ter, are most o ften the tre a t m e n t o f c h o i c e . C h a p m a n 's points a re treated by a pp l y i ng i n h i bitory pressure i n a s l o w c i rc u l a r fa s h i o n for 1 0 to 3 0 s e c o n d s unti l any a s s oc i a te d tissue texture c h a nge reso l ve s . St i m u l a tory proced u res u t i l i z i ng a rticu la tory ra nge of m o t i o n a n d s o ft- t i s s u e stretc h i ng a re a p p r o p r i a te w h e n tre a t i n g co ngested sta tes, s u c h a s p ne u m o n i a , o r hypoactive co n d i ti o n s , s u c h a s constip a t i o n . Somatosensory i n p u t, w i t h res u l t a n t s t im u l a ti o n o f i ntern u n c i a l n e ur on s t h a t s y n a pse i n t h e i n termed i o l a te r a l ce ll c o l ­ u m n o f t h e t h ora c i c a n d u pp e r l u m b a r c ord , w i l l p r o d u c e a segmenta l l y rela ted s y m pathe tic res p o n s e . S i m i l a rl y, h i g h-cer v i c a l or sacra l s t i m u l a ti o n w i l l res u l t in a p a ra s y m p a t he t i c respo n s e . The a n a to m i c a re a s o f c o n s id era t i o n , w h e n u s i ng m a ni p u l a ti o n to e ffec t a s o m a tovi scera l r e s p o n s e , a re essen t i a l ly t h e same a s those n o t e d e a r l i e r as l o c i for visce roso matic reflexes . As Bu rns note d , however, t hey are " less circu mscri b e d a n d less d irect t h a n a re v i sceroso m a t ic reflex e s . " 8 As s u c h , t h e a re a s l isted herea fte r a re t h e p l a ces to b e g i n look i n g for the s o u rce of s o m a t o v i scera l i m p a c t . Also, p a r t i c u ­ l a r s y m p a thetic refl exes may e m a n a te from a m u c h b r o a d e r a re a t h a n t h e viscero­ somatic reflexes d e sc r i bed here i n . Visceroso ma tic refl exes a re often i d e n ti fied i n s p i n a l segme n t s t h a t a l s o d e m o n ­ stra te mec h a n i c a l s o m a t i c dysfu n c ti o n . T h e s a me n e u r o p h ys i o l og y t h a t i s res p o n ­ s i b l e fo r t h e pa ra verte bra l response to v iscera l pa thol ogy i n t h e visceros o m a t i c r e f l e x exp l a i n s t h e e ffec t of s o m a ti c d ysfu n c t i o n u p o n a segmenta l l y re lated v i s c u s t h r o u g h a s o m a to v i scera l refl e x . T h e l e v e l o f s p i n a l mecha n i c a l s o m a tic d y s fu nc­ t i o n i s m a i n ta i n e d in a faci l i ta te d s t a te b y the mecha n i c a l d y s fu n c t i o n and c a n a ffect segmenta l l y re l a ted v i scera as a s o m a tovisce r a l refl e x . T h e t r e a t m e n t o f s o m a t i c d ys f u n c t i o n a s i t re l a tes to system ic v i scera l d i s e a s e ca n be a pprec i a ted once i t i s d e c i d e d w h a t e ffec t the s o m a t i c d ysfu n c t i o n h a s u p o n t h e s ta t u s of t h e p a ti e n t . The e ffect o f som a t i c d ysfunction m a y be mec h a n i c a l a nd/or the res u l t of somatoviscera l reflex a c ti v i ty. C o n s i d era tion o f the soma toviscer a l e ffec t of s o m a tic d ys fu n c tion s h o u l d p r o m p t the p h y s ic i a n t o a s k t h e fo l lo w i n g q u e s t i o n s : •

•

Is there fac i l i tation o f s y mpathetic ( t horaco l u m b a r ) or pa rasympa thetic ( h igh cer­ vica l or sacra l ) components of the s p i n a l cord ? If so, how does i t a ffect the patient? W h at sympa thetic somatoviscera l m ec h a n is m s are p rese n t ? S p i n a l fac i l itation, with res u l ta n t i ncreased sympathetic tone, i ncreases vascular tone, w hich decreases ti ssue perfu s i o n and n u trient and oxygen s u p p l y to tissues a nd thereby i n c reases a ny need fo r anaerobic glycolys i s . It relaxes the ga l l bl a d d e r and b i l i a ry d ucts a n d d ecreases t h e g l a nd u l a r secretions a n d perista l s i s , prod ucing constipa tion or i l e u s . Sympa thetic stimula tion of t h e gastroi n testin a l tract decreases perista lsis, w hi c h

•

pred is poses t h e p a t i e n t t o consti p a tion or the deve l o p m e n t o f a n i le u s . Wha t p a r a s y m p a t h e t i c s o m a tov iscer a l m ec h a n i s m s a re prese n t ? S p i n a l fa c i l i ta­ t i o n , w i t h res u l t a n t i ncreased p a r a s y m p a t hetic tone, i ncre a s e s the secre t i o n of the d igestive enzymes a my l a s e and l i pase. It ca u ses contraction of t h e ga l l bl a d d e r

48

Secti o n I • P h i l os o p h y a n d P r i n c i p l e s of Pa t i e n t Ca re

a n d b i l iary d ucts and i n creased gl a n d u l a r secreti o n s and peri sta l s i s , producing d ia rr h e a and c o l i c . T h e c o n s i d e r a t i o n of soma toviscera l m ec h a n is m s a s t h e y rela te to t h e i n d i v i d ­ u a l orga n systems a n d specific d is e a s e processes are d i scussed i n l a te r c h a pters .

The M ec h a n i ca l Effect of Somatic Dysf u n ction C o n s i d era tio n of the m e ch a nic a l effect o f s o m a t i c d y sfu n c ti o n s h o u ld c a u s e t h e p hys i ci a n to s e e k a n swers to t he foll o w i ng q u estio n s : •

•

•

D o e s t h e p a t i e n t h a ve a p a i n compla i n t t h a t i s t h e res u l t o f, o r i s c o m p o u n d e d by, s o m a t i c dysfu n c t i o n ? P h y s i c i a n s o ften become so foc u sed u p o n t h e p a t i e nt 's p r i m a ry i l l ness th a t t h e y o v e r l o o k s i m p l e p r o b l e m s t h a t contri b u te grea t l y to t h e pa tien t's d i sc o m fo r t . H o w i s m u sc u l os k e l e ta l d y s fu nc t i o n a ffe c t i n g t h e p a t i e n t's a bi li t y to res p o n d t o t h e d i s e a s e p rocess ? For e x a m p l e , r e s tr i c t i o n o f t h e t h o r a c i c cage a n d d i a p h ragm, w h i l e d etri m e n t a l to a n y o n e , is p a r t i c u l a r l y d e l eter i o u s to a p a t i e n t with p u l m o n a r y d i se a s e . D o e s t h e mec hanica l c o m p o n e n t of t h e s o m a t i c d y s fu nction res u l t i n venous a nd/or lymph a t i c sta s i s ? Efficient movement o f the thoracic i n let, thoracic cage, a b d o m i ­ n a l d iaphragm, mesen teries, a n d pelvic d ia p h ragm i s necessary for opti ma l low­ press u re flu id ( lymphatic a n d veno u s ) d y n a m ics a n d tissue perfu sion. Inefficiency o f t h is mec h a n ism funner adds to the tend ency to develop tissue congestio n .

DISCUSSION When c o n s i d e r i ng t h e care o f a p a ti e n t w i t h s ignifican t v i scera l p a t h o l ogy, i t i s e a s y to b e c o m e foc u se d u p o n t h e p r ec i s e thera p e u t i c p r o t o c o l fo r t h e spec i fic d i sease process and l ose sight of t h e i n d i v i d u a l p a tient. The u rgency of many d i sease processes c a u se s u s to focus o n ly upon the i n te r v e n t ion that offe rs t h e greatest i m m e d i a te thera p e u tic effect. Trea tmen t of perip h e r a l , seem i n g l y u n re l a ted a n d trivi a l co n d i t i o n s m a y b e consid ered i n effect i v e a n d i n appro p r i a t e . I f o n e c o n s i d ers s o m a ti c d ys fu n c t i o n onl y i n t h e c o n text of the m u sc u l o s k ele ta l syste m , it cou l d a rgu a b l y be seen as trivial in the presence o f s u c h d isease p rocesses a s m y o c a rd i a l i n fa rction, p y e l o n ep h ri ti s , or Cro h n 's d i s e a s e . From a d i s t i ncti ve l y osteopathic p e rspective, however, somatic d y sfu nction in t h e presence of sign i fi ­ ca n t v i s c e r a l pa tho l ogy becomes high l y signifi c a n t . Viscerosomatic reflexes a re a u sefu l p a r t of t h e physica l d iagnosis o f v i scera l p a t h ology bec a u se they a re som a tic d ysfu nction t h a t develops specifica l l y i n response to v i scera l p a t h ol ogy. They offer d iagnostic clues to t h e l oca t i o n and severity of the etio l ogic p a t h o logy. Viscerosoma tic reflexes a re identifia ble a s tiss u e textu re a bn o r­ m a l i ty a n d tenderness i n the derma tomes a nd myotomes that s h a re i nnervation with the etiologic p a t h o l ogy. They are most e a s i l y p a l p a b l e i n the pa raverte bral soft tis­ sues a nd in t h e specific a reas represen ted a s C h a p m a n 's reflexe s . Viscerosoma tic r e f l e x e s o ffer v a l u a b l e d i a g n o s t i c i n fo r m a t i o n , p a r t i c u l a rl y i n t h e a bsence o f overt viscera l c o m p l a i n t s . T h e recogn i t i o n of a p o te n t i a l v isceroso­ m a tic refl ex a s s i sts i n the d i ffere n ti a l d i a g n o s i s of s o m a t i c p a i n , o ffe r i ng the c l i n i ­ c i a n i n s i g h ts t h a t m i g h t o t herwise go u n recog n i ze d . O bj ective pa l p a tory fi nd i n g s o f a v i scerosom a t i c reflex w i t h o u t a ssoc i a ted d isease s h o u l d l e a d to a m o re foc used r e v i e w of t h e p a t i e n t 'S h i s tory. S o m a tic dysfunction that res i s ts m a n i p u l a t i ve treat­ m ent s h o u l d r a i s e th e q ue s t i o n of viscerosoma tic origi n .

C h a pter 5 • V i sce roso m a t i c a n d S o m atovi sce ra l R e f l exes

49

Viscerosomatic refl exes a re d e fi n i ti vely trea ted first by trea ting the c a u s a t i v e vi scer­ al pathol ogy. Somatic d ys functi o n , however, a ffects v i scera l physiology through its mecha nical e ffect as well a s through s o m a toviscera l reflexes. OMT of v iscerosomatic reflexes h a s been a dvoca ted to red uce somatic d ysfu ncti o n a nd interrupt t he reflex a rc, thereby in fl uencing the viscus through sti m u l a t i o n o f somatov iscera l effects. A d d itiona l l y, the l i n k a ge between the musc uloskeleta l system a nd spec i fic viscera through the segmental a rrange m e n t of the central nervous system a llows the p hysi­ c i a n to associate see m i ngly u n re l a ted a reas i n to an i ntegrated h o l istic a pproa c h to patient care. Anatomic systems a re a convenient way of s t u d y i n g h u m a n p h y s i o l ogy a n d pathology, and although not entirely a r b i trary, the d ivision o f the human body i nto sLlch systems is a rtifici a l . There a re a d va n ta ges to being a ble to recogn ize the connections between the d i fferent systems o f the body through viscerosoma tic, somatoviscera l , soma tosoma tic and viscerovisce r a l connecti o n s . To a pproach the patient in thi s context means tha t the p h ys ici a n must c o n s i d e r t he i nterre l a ti o n s h i p of otherw ise seem i ng l y u n r e l a ted structu res a n d syste m s ; i t fosters the h o l istic c l i n i ­ cal approach for w h i c h osteo pathic m e d i c i n e is k n o w n .

Proced u res The fo l lowing a re exa mples o f proce d u res that a re v a l u a ble for d i a g n os i ng soma tic d ys fu n c t i o n of v i scera l reflex origi n a n d of O MT procedures t h a t m a y be e m p loyed for t h e i r s o m a to v i scera l effect. P l e a s e n o te : The proced u re s tha t fo l l o w a re ex a m p les o f m a n i p u l a tive tre a t m e n t t h a t y o u m a y w i s h to e m p l o y. T h e a c tu a l choice o f p roced u res u s e d s h o u l d b e d e t e r m i n e d by the u n i q u e c i r c u m s ta nces o f e a c h i n d i vid u a l p a t i e n t .

D i a g nosis Palpa tion for Tissue Texture Abnormality, Layer Palpation

This proced u re is e m p l o yed to i d e n t i fy t i s s u e tex t u re c h a nge t h a t m a y be fou n d i n assoc i a t i o n w i t h visce r o s o m a tic refl exes . T h e p a ti e n t m a y be i n a n y p o s i t i o n t h a t l e n d s i ts e l f t o t h e exa m i n at i o n a n d the r e q u i re me n ts of t h e hea lt h s t a t u s of t h e patient. T h e physici a n 's p o s i t i o n d e pe n d s u p o n the p a t i e nt's p o s i t i o n . T h i s proce­ d u re i s descr i bed i n C h a pter 3 . Red Reflex

Th i s proced u re i s e m p l oyed to a ssess fo r v a s o m o tor i r r i ta b i l i ty a s a n i n d icator o f s p i n a l segme n t a l fac i l i t a t i o n c o m m o n l y fo u n d i n a ssoc i a t i o n w i t h a c u te s o m a ti c d ysfunction, i n c l u d i ng viscero s o m a t i c reflexe s . Patient positi o n : sea ted o r pro n e . P h y s ic i a n position: standing behind the sea ted p a t i e n t o r to t he side of the prone p a ti e n t . Proced u re

1.

Stroke t h e pa raverte b r a l s k i n . (The sta n d a rd p a l patory exa m i n a t i o n of t h e p a rave r­ t e b r a l soft t i s s u e s i s a l so s u ff i c i e n t to p ro d u ce a red ref l e x . )

2.

O b s e rve for a reas t h a t b e c o m e h y p e re m i c . F a c i l itated s e g m e n t s d e m o n strate vaso­ motor i n sta b i l i ty and b e c o m e h y p e re m i c s oo n e r, d e m o nstrate a g reater d e g ree of h y p e re m i a , and re m a i n h y p e re m i c l o n g e r t h a n a d j a c e n t seg m e n ts .

Skin Drag

T h i s proced u re is employed to assess for sudomoror hyperactivity as a n ind icator of spi n a l segmental soma tic d y s fu ncti o n fac i l i ta tion, i n c l ud i ng viscerosomatic reflexes.

50

Section I • Ph i l os o p h y a n d P r i n c i p l e s of P a t i e n t Care

Patient position : seated or prone. Physic i a n pos i t i o n : s ta n d i ng behind t h e seated p a t i e n t o r to the side of the prone p a t i e n t . Proced u re

1.

W i t h t h e p a d s of t h e f i n g e rs , l i g h t l y stroke t h e pa ravertebra l s k i n .

2.

Areas o f s u d o motor hyperact i v i ty i n d icative of a c u t e dysfu ncti on w i l l b e m o i st a n d p rovi d e g reater f r i ct i o n (s k i n d ra g ) t h a n a dj a ce n t t i ss u e s w h e n stroked with t h e p a d s of t h e f i n ge r s . Areas of c h ro n i c dysf u n ct i o n w i l l be d ry a n d p rovide l e ss f r i ctio n .

Beal's Compression Test

T h is proced u re , emp loyed to d iagnose s o m a t i c d ysfu nction, is p a r t ic u l a r l y v a l u ­ a b l e fo r assess i ng t h e pa tient w h o i s c o n fi n e d to a h o s p i t a l bed . Patient po s i t i o n : s u p i n e . Physic i a n p os i t i o n : sea ted at the s i d e of the bed fa cing the p a tient. Proced u re

1. 2.

S l i d e t h e h a n d s, p a l m s u p , b e n e a t h t h e p a t i e n t . P l a c e t h e p a d s o f t h e f i n gers i n contact w i t h t h e pa rave rte b ra l soft t i s s u e o n the s i d e o f t h e s p i n e c l osest to t h e exa m i n e r a n d to t h e a rea o f m a x i m a l t i s s u e textu re a b n o r m a l i ty a n d m u sc l e c o n tracti o n . Pal pate t h e pa raverte bra l soft t i s s u es .

3.

A p p l y g e n t l e press u re i n a n a n t e r i o r d i rect i o n re l a t ive to t h e s u p i n e p a t i e n t , t h u s co m p ress i n g t h e pa ravertebra l soft t i s s u e s .

4.

U s i n g t h e p r i n c i p l es of l ayer p a l pa t i o n , co m p a re t h e s oft t i ss u e s at e a c h verte bra l l eve l w i t h those of t h e seg m e n t a bove a n d b e l ow. Loo k for t h e s p i n a l level of max­ i m u m tissue textu re c h a n g e i n the c o n text of s u bcuta n e o u s t u rg i d i ty, f a sc i a l te n s i o n a n d d e e p pa raverte b ra l m u s c l e te n s i o n .

5.

Th i s p roced u re c a n b e repeated u p a n d down t h e pa raverte b r a l soft t i s s u es o f the t h oracic a n d l u m ba r reg i o n s on t h e side n e a r e r t h e p hysic i a n .

6 . To exa m i n e t h e o p posite s i d e , it is n ecess a ry to move to t h e ot h e r s i d e of t h e bed and repeat the p roces s .

A s a n a l tern a tive method i n which both sides a re examined sim u l taneou sly, t h e physi­ cia n can sit a t the head o f the bed and slide the h a nds, pa lms up, beneath the s u pine pa tient o n either side of the spine. From this position, the p h ys i ci a n can eva l uate and compa re left side with right side and segments a bove and below. This a p proach is l i m ­ i t e d , however, t o eva l u at ion of t h e cervica l regio n and u p p e r thoracic spine.

Treatm e n t Inhibitory Pressure

T h i s proced u re is e m ployed to treat a n y d ysfu nction severe enough to d i scou rage more aggres s i ve i n terventi o n . It is i n te n d e d to reduce tissue texture a b n o r m a l ity and m u scle spasm . I t i s particularly va l u a ble fo r a d d ressing the somatov iscera l component of an a c u te v i scerosomatic reflex. The patient may be treated in any pos i t i o n t h a t l e n d s itself to the a rea being a d d ressed a n d t o the hea l th sta t u s requ irements of t h e p a tient. The position of the p hy s i c i a n depends u p o n the position i n which the p a t i e n t is treated . For p u rposes of t h i s d is c u s s i o n , the p a t i e n t i s s u p i n e bec a u se this i s the position typica l l y re q u ired when t re a t i n g severely i l l i n d i v i d u a l s . The p h y s i c i a n i n t h i s i nsta nce s h o u l d therefore be seated or s ta n d i ng a t the s i d e o f the bed or treatment ta b l e fac­ ing the p a t i e n t .

Chapter 5 • V i s c e r os o m a t i c a n d S o m a tovi scera l R e f l e x e s

51

Proc e d u re

1.

S l i d e t h e h a n d s , pa l m s u p , b e n e a t h t h e p a t i e n t a n d p a l pate t h e p a rave rte b r a l soft t i ss u e s .

2.

P l a ce t h e p a d s of t h e f i n g e rs i n contact w i t h t h e a rea of m ax i m a l t i s s u e textu re a b n o r m a l ity a n d m uscle contracti o n .

3.

A p p l y g e n t l e p ress u re t o t h e t i g h t m u sc l e s .

4.

G ra d u a l l y i n c rease p re s s u re a s t h e m u s c l e s re l a x .

5.

W h e n ma x i m u m p ress u re h a s b e e n a p p l i e d , h o l d it f o r 1 t o 2 m i n utes a n d t h e n ve r y s l ow l y re l e a s e i t .

S t o p the intervention, slow l y releasing, i f y o u detect spasticity. A t no time should t ne treated tissu e be rapidly released . Such a ction will res ult in immediate reestab­ l i snment of muscle spa sm. Treatment of Chapman 's Reflexes (Figs. 5. 1 an d

5.2)

This procedure is emp loyed to treat viscerosomatic Ch apman's reflexes. Such re fl exes exhib it the fol lowing traits: Sma l l ( 2-3 mm) nod u lar masses that are pal­ pable in soft tissu e and that demonstrate sharp pinpoin t nonradia ting ten de r ness. They exe r t a tnerape u t i c soma tovisce r a l effect when treated . In t h e past , the an terior points have been design ated as diagnostic and the pos­

te rio r poin ts as treatmen t pointsP Many clinicians today who emp loy Cha pman's refl exes t nerape u t i cally treat e i t ner or both t n e anterior a n d posterior points. The p a t i ent may be tre a ted in any position that lends i tself to t n e a rea bei ng addressed a nd the heal th status requ irem ents of the p a tie n t . The position of the physician depen ds u pon the position in whi ch the pa tient is treated. It has a lso been recom­ me n d ed that the specific treatment of the reflex poi nts shou l d not be init i ated until the pel vis has been thoroughly treated for somatic dysfunction P-19 P roced u re

1.

P l a c e t h e p a l m a r d i st a l p a d of t h e i n d ex f i n g e r i n c o n t a c t w i t h t h e p a l p a b l e n o d u ­ l a r m a ss of t h e C h a p m a n 's p o i n t to b e treated .

2.

A p p l y p ress u re to t h e p o i n t . The a m o u n t of p ress u re n e c e s s a ry wi l l be " so m ew h a t

3.

A p p l y t h e t h e ra p e u t i c p ress u re i n a c i rc u l a r fash i o n , m a ss a g i n g t h e p o i n t i n a n

4.

T h e t reat m e n t ceases w h e n t h e p a l p a b l e p o i n t res o lves o r w h e n t h e p h y s i c i a n

h e a vy a n d u n co mforta b l e "

18

for the patient

atte m pt to g ra d u a l l y d i s s i p a t e it Th i s t r e a t m e n t u s u a l l y req u i res 1 0 t o 3 0 seco n d s . fati g u e s . Soft Tissue/Range o f Motion, Patien t o n Side, a Stimulatory Procedure (e. g., Thoracic [Fig.

5. 3]

an d L umbar [Fig.

5. 4]

Regions)

For a descr iption of t n e cerv i c a l soft tissue an d ra nge-of-motion procedure, see Cha pte r 1 6 .

This procedu re is emp loyed to decrease m uscle spasm and soft t iss u e tension i n

a m anner that i s su ffi ciently aggressive t o resu lt i n somatovisceral stimu lation . T n e description is direcred at treati ng t h e right paraverte b ral region. Patient pos i tion : lying on the left side, with one or two p i l lows under the head and the knees ben t. Physician position: standing at the side of the table facing the pat i en t . Proced u r e

1.

Pos i t i o n t h e p a t i e n t 's bott o m a r m u n d e r t h e h e a d a n d t h e t o p a r m w h e rever i t i s c o m f o rta b l e a n d o u t of t h e way. F l ex t h e p a t i e n t 's h i ps f o r sta b i l ity.

52

Secti o n I • P h i l os o p h y a n d P r i n c i p l e s of Pat i e n t Ca re

FIGURE 5.3 2.

Sti m u l at o ry p roced u re f o r t h e t h o r a c i c r eg i o n .

H o o k t h e f i n g e r s o v e r t h e p a ra s p i n a l m u sc u l a t u re o f t h e s i d e faci n g u p at t h e l ev e l of t h e t h o ra co l u m b a r j u n ct i o n . Wra p t h e h a n d s o v e r t h e p a t i e n t 's f l a n k .

3.

A p p l y a c o n t ro l l e d fo rce t h ro u g h both h a n d s t h a t i s d i rected a n terol atera l ly, c e p h a ­ l a d , a n d ca u d a d . K e e p you r b a c k stra i g h t . P l a ce o n e f o o t i n f ro n t of t h e o t h e r. Lea n b a c k a n d u s e yo u r f u l l body we i g h t .

4.

R e l e a s e t h e fo rce i n a c o n t ro l l e d fash i o n . Wo r k u p t h e t h o ra c i c s p i n e a n d down t h e l u m ba r s p i n e a s n ecessa ry.

Soft Tissue/Ra nge of Motion, Patient Prone (Fig.

5. 5)

This proced u re is e m ployed to d ecre a s e muscl e spasm a n d s o ft tiss u e te nsion in a m a n ner t h a t is a ggressive e n o ugh to res ult in s o m a toviscera l sti m u l a ti o n . The description is d i rected a t t rea t i n g the right p a r a verte bra l re g ion T h e pa tien t s h o u l d be lying prone a n d the physic i a n s t a n d i n g Pa ti e n t pos i t i o n : prone on t h e bed or trea tment ta ble. Physici a n position : sta n d i ng .

a t the l e ft side fa c i n g the p a ti e n t . Proce d u re

1.

P l a ce t h e t h e n a r e m i n e n ce a n d hypot h e n a r e m i n e n ce of t h e treat i n g h a n d b etwe e n t h e s p i n o u s p ro cesses a n d t h e p a ra s p i n a l m us c l e g ro u p o n t h e p a t i e n t 's r i g h t s i d e . P l a ce t h e o t h e r h a n d ove r t h e o p p osite p a ra sp i n a l m u s c l e s .

C h a pter 5 • V i sce roso m a t i c a n d S o m a t o v i s c e r a l R e f l exes

FIGURE 5.4

2.

53

St i m u l a t o ry proce d u re f o r t h e l u m b a r re g i o n .

U s e t h e treat i n g h a n d to a p p ly a c o n t ro l l e d force i n t h e a n te ro l atera l d i recti o n . T h e d e p t h a n d rate o f t h e a p p l i e d force d e te r m i n e s w h e t h e r y o u a re p r i m a r i ly treat i n g t h e soft t i s s u e s (soft t i s s u e p ro ce d u re) o r a rt i c u l a t i n g t h e ve rte b ra e ( d e e p a rt i c u l a ­ t i o n p roced u re) .

3.

Sto p a d va n c i n g t h e fo rce w h e n t h e b a r r i e r is rea c h e d ( l i m i t of t i s s u e stretch i n g o r p a t i e n t 's to l e ra n ce ) .

4.

R e l ease t h e forces i n a c o n t ro l l e d fa s h i o n . Wo rk up a n d down t h e t h o r a c i c l u m b a r s p i n e a s n ecessa ry. C o n t i n u e u n t i l t h e pa ravert e b ra l soft t i ss u es a re re l a xed .

Rib Raising to Stimulate Sympa thetic A ctivity (Fig.

Tr e a t m e n t by

5. 6)

r i b r a i s i n g red uces c o n s t r i ction o f la rger l y mp h a t i c vessel s . Ri b r a i s ­

i n g t h a t ra ises the r i b hea d s a l s o sti m u l a tes the t h o r a c ic s y m p a th e ti c c h a i n g a n g l ia . T h i s treatment i n i ti a l l y s t i m u l a tes regi o n a l s y m p a t hetic e ffere n t a c t i v i ty to orga ns re l a ted to that s pi n a l l e v e l o f s y m p a t hetic i n nervati o n , but i n the l o n g r u n , r i b r a i s ­ i n g res u lts i n a prolo nged r e d u c t i o n in s y m p a t hetic o utfl o w from t h e a rea tre a t e d .

Free i n g r i b m o t i o n a l so frees the e x c u r s i o n o f t h e r i b c a g e d u r i n g resp iration.

Freeing the ri b heads i ncre a s e s t he exc u rs i o n of t h e ches t d ur i n g b r e a t hi n g a n d i m pro ve s ly m p h a t i c f l o w .

Patient pos i ti o n : s u p ine Physic i a n posi t i o n : stand i ng or sea ted a t the pa tien t's side. .

54

Sectio n I • P h i l os o p h y a n d P r i n ci p l es of P a t i e n t Ca re

FIGURE 5 . 5

S oft t i s s u e a n d ra n g e o f mot i o n , p a t i e n t p r o n e .

P r o c e d u re

1.

P l a c e t h e h a n d s ( p a l ms) u n d e r t h e p a t i e n t 's t h o rax, c o n t a ct i n g t h e r i b a n g l es w i t h t h e p a d s of t h e f i n g e rs

2.

F l e x t h e f i n g e rs to a c h i eve co ntact w i t h t h e r i b a n g l e a n d t h e p at i e n t 's poste r i o r t h o ra x .

3.

A p p l y t r a ct i o n o n t h e r i b a n g l e .

4.

W h i l e m a i n ta i n i n g tract i o n , b e n d y o u r k n ees a n d l o w e r yo u r t r u n k , w h i c h r a i ses t h e r i b s w h e n yo u r h a n d s m ove u p . T h i s i s a f u l c r u m/lever act i o n ; t h e w r i sts a re not b e n t . ( P a rti c u l a rly i f t h e pati e n t is i n a h os p i ta l bed, it i s e a s i e r to m ove the h a n ds u pw a r d if i n t h e p rocess y o u reci p roca l l y p u s h t h e f o re a r m s down )

5.

M ove t h e h a n d s to s u bseq u e n t r i b a n g l e s u n t i l a l l r i b s a re treated .

6.

Treat t h e o p p o s ite s i d e of t h e r i b c a g e i n t h e s a m e m a n n e r.

FIGURE 5 . 6

R i b ra i s i n g .

C h a pter 5 • V i s c e r o s o m a t i c a n d S o m a t o v i s ce r a l Refl exes

55

References L H a zza r d e. P ri n c i p les o f O s teo pa t h y. 3 r d e d . K i rk sv i l l e , MO: A u th o r, 1 8 9 9 ; 8 - 1 1 . 2 . Ta s k e r D L . P ri n c i p l es o f Os teo pa th y. 2 n d e d . Los A n g e l es : Ba u mga r d t , 1 9 0 5 ; 2 1 1 -2 5 6 . 3 . Berna rd e. Le<;o n s d e p h ysiologie, e x pe r i m e n ra le a p p l i q u e e a l a m e d i c in e . P a r i s : Ba i l l i e r e , 1 8 5 5- 1 8 5 6 .

4 . H e a d H . O n d i s t u r ba n c e s o f s e n s a t i o n w i t h espec i a l refe r e n c e t o t h e p a i n o f v i scera l d isease. Bra i n 1 8 93 ; 1 6 : ] -1 3 3 . 5 . M a c K e n z i e J . Some poi n ts bea ri n g o n t h e a s soc i a t i o n o f sen so r y d isord e r s a n d v isc era l

dis-

ease. B ra i n 1 8 9 3 ; 1 6 : 3 2 1 -3 5 4 .

L u ci a n i L . H u m a n Ph y s i o l ogy . Vol 4 . Lon d o n : M a c m i l l a n , 1 9 1 7 : 6 8 . P o tte nge r F M . S y m ptOms o f Visce r a l D i sea se . 5 t h ed . S r . Lo u i s : Mos by, 1 9 3 8 . 8 . B u r n s L. Visce r o - s o m a t i c a n d soma to- viscera l s p i n a l r e f l e x e s . J Am O s teo p a t h Assoc

6.

7.

1 9 0 7 ; 7 ( 2 ) : 5 1 -6 0 . 9. Burns

L . S y m pos i u m o n t h e A . T. S t i l l

Resea rch Institute. J

A m O s t eo pa t h A ssoc 1 9 3 0 ; 2 9 :

4 3 3 -4 3 7 . 1 0 . B u rn s

L . Certa i n c a r d i a c co m p l ica tio n s a n d v e r te b ra l l e s i o n s . J A m O s teo p a t h A ssoc 1 9 4 7 ;

4 7 : 1 9 9- 2 0 0 .

1 1 . D e n s l o w .I S . A n a n a lys i s o f t h e va ri a b i l i t y o f s p ina l refl ex t h resho l d s . J N ell rop h y s i o l 1 94 4 ; 7 : 2 0 7-2 1 5 . 1 2 . K o r r 1 M . The nell l'a l basis o f the os teopa t hic

lesion. J

A m Osteoparh Assoc 1 9 4 7 ;4 7 :

1 91-1 98.

1 3 . K o r r 1 M . S k i n res i s ta nce pa tte rn s associ a ted w i t h v i sce ra l d i se a s e . Fed Proc 1 94 9 ; 8 : 8 7 . 1 4 . K o r r 1 M , e d . The N e u ro b i o l og i c Mec h a n i s m s in Ma n i p u l a t i ve T her a p y. New Yo r k : P l en u m , 1 978. 1 5 . Va n B u s k i rk R L .

Nociceptive reflexes and

the s oma tic dysfu ncti o n : A

m od e l . J

A m O s t eo p a t h

Assoc 1 9 9 0 ; 9 0 : 7 9 2 - 8 0 9 [ re v i e w J . 1 6 . I C D - 9 C M I n tern a t i o n a l C l a s s i fi c a t i o n of D i sea ses . 9 t h rev i s i o n . C l i n ic a l M od i fi c a t ion. 5 t h

ed . Sa l t L a k e City : M e d icode , 1 99 9 . 17.

Owens e . A n E n d oc ri n e I n t e r p retati o n o f C h ap m a n 's Reflexes. 2 n d ed . I n d i a n a p o l i s :

Ac a d e m y of A pp l i e d O s teo pa t h y ( A merica n A ca d e m y of Os t e o pa t h y ) , 1 9 6 3 . 1 8 . Pa t r i q u i n D A . Visc e roso m a t i c re f l e xes .

I n : Pa t te rs o n M M , H o w e l

IN,

ed s . T h e Ce n t r a l

Con nect i o n : S o m a t o v iscera l V isce ros o m a ti c I n te r a ct i o n s . A t h e n s , OH: U n i v e r s i t y C l a ss i c s , 1 9 92 ;4-1 2 . 1 9 . Pa t r i q u i n D A . C h a p ma n 's reflexes.

I n : Wa r d RC, e d . Fo u n d a ti o n s fo r O st e o pa r h i c M e d i c in e .

2 n d e d . Ph i l a d e l p h i a : L i p p i n co t t W i l l i a m s & W i l k i n s , 2 0 0 2 ; 1 05 1 -"1 0 5 5 .

M e . Vi sce ros o ma r ic re flexes: A revi ew. J Am O s reo pa t h Assoc. 1 9 8 5 ; 8 .5 : 7 8 6- 8 0 1 . 2 1 . C o l e wv. The body eco n o m y. I n : H oa g J M , ed. O s te o pa rh i c M e d i c i n e . N e w Yo r k : Mc G ra w H i l l , 1 969;68-1 00.

2 0 . Beal

2 2 . Do w l i ng DJ . N e u r o p h y s i o l ogic m e c h a n i sms re l a ted to osteopa t h i c d i a gn os i s a n d trea t m e n t . I n : D i G io v a n na E L , Sc h i o w i t z S , e d s . A n O s teo p a t hi c A p p ro � c h to D i a gn os i s a n d Tre a t m e n t .

2 n d ed . P h i l a d e l p h i a : L i p p i n cott, 1 9 9 7 ; 2 9 .

2 3 . Va n B u s k i r k R L, N e l so n K E . O s teo pa r h i c fa m i l y prac t ice : A n a p p l ica ti o n o f t h e p r i m a ry ca re

m o d e l . I n : Wa rd RC, ed . Fo u n d a ti o n s for Osteopa t h ic M e d i c i n e . 2 n d e d . P h i l a d e l p h i a : Li p p i n co tt W i l l ia m s & W i l k i ns , 2 00 2 ; 2 8 9- 2 9 7 . 2 4 . K u c h e r a M L , K uchera WA . O s teo pa t h ic C o n s i d e r a t i o n s in S y s t e m i c D y s fu nc t i o n s . 2 n d e d . Col u m bus, O H : G rey d e n , 1 9 9 4 . 2 5 . S li m i n o R, NOl.a k i S, K a to M . C e n tra l pathway of rrige m i no-neck r e fl e x . I n : O ra l - fac i a l s e n ­ so ry a n d m o t o r fu n c t i o n s . I n te r n a t i o n a l Sympo s i u m . R a p p o n gi , Tok y o . O r a l P h y s i o l 1 9 8 0 ; 2 8 [ a b s t ra ct] . 2 6 . La rson NJ. S u m ma ry of s i te a n d occ u rrence o f p a ra sp i n a l s o fr t i s s u e c h a nges of p a ti e n t s i n rhe i n re ns i ve ca re u n i t . J A m O s te o p a th Assoc 1 9 7 6 ; 75 : 8 4 0-84 2 .

CHAPTER

6

Psychoneu roi m m u nology Jan Lei Iwata

"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 man­ age this great engine of life. To obtain good results, we must blend ourselves with and travel in harmony with Nature's truths."

A T

Still'

INTRODUCTION The biopsychosocial model is one of the tenets of family medicine.2 A good starting place, therefore, is to consider history while examining the role that psychoneuroim­ munology (PNI) has played in bringing together the best in basic scientific research as it applies to the holistic framework of total patient care. Psychoneuroimmunology and osteopathic medicine should be synonymous when one is talking about the role of osteopathic manipulative medicine in primary care. Osteopathic family physicians care for the whole patient, providing a strong doctor-patient interface and psycho­ logical support in the form of listening, empathy, and compassion. Therefore, their excellent medical diagnostic skills and osteopathic manipulative treatment (OMT) position them as unique and distinctive health care providers and help to distinguish osteopathic medicine from other forms of health care.3 56

Cha pter 6 • Psychoneuroimmunology

57

The holistic integrated view of patient care and how stress can affect one's

and focus. Os teopath ic for chronic spinal pain results in greater short-term improvement

health should be the starting point in care management man i p ulation

than acupuncture or medication,4 and it has been shown to lessen the use of pain

medicatio n s compared to standard care in subacute low back pains and to require less physical therapy. 6 Since t here is a close association between the spinal verte­ brae and the

autonomic nervous system via the sympathetic nervous system and

the sympathetic trunk and ganglia, the neuromuscular system is considered to play a vital

role in main t a ini n g homeostasis. Any changes

in the musculoskeletal system

can affect other organs (somatovisceral reflex) or al l ow visceral pa thology to man­ ifest as musculoskeletal tissue texture and intervertebral joint motion (visceroso­ matic reflex) changes, hence somatic dysfunction. 7 Historically, in osteopat hi c medicine, Andrew Taylor Still is credited with stat­ ing that the best way to

fight disease was by nat urally stimulating the body's

immune system. He also believed that the solution to disease was to find out what was creating t he bodil y disturbance and remove that interference, so that the body

could return to its normal state of homeostasis.

5tiJi believed that we possessed all

of the "elements a nd p rinciples of remedy in the divine chemical laboratory within the body."8 He also believed that the body and mind were inseparable. Future

neuropharmacologic and neuroscience research eventually pro ved his premise to

be true, that the " c h e m ical factory " included various peptides that com m un ic ated early inflamma­

with and regulated many systems, i ncluding pain perception and

tory events, when an injury occurred. In pe rhaps the first publication addressing

the " psy chic or igin of disease," Hoover9 summarized these concepts and proposed a theoretical construct that w as r emarka b l y ins i ght fu l .

A primary goal of PNI resea rch is to translate basic research into cl inically rel­

evant health applications . In this context, PNI's premier position in evidence-based health care in

the twenty-first centur y is increasingly recognized and is poised to

be the gold standard in the next decades.lo PNI is a relatively new scientific field that defines and describes

the concept

of a vast unified psychosomatic communi­

cation network of neuropeptides in brain and other nonneural tissues and their correspond ing receptors in the immune, endocrine, and central nervous systems,

link ing body to mind.j\ T hey do

not exist independently, as

was once believed, but

are in constant communication with one another via neuropeptide ligands and

their identical target receptor molecules.12 This has been strengthened by and

human

research

demons t rati n g

relationships

be twee n

animal

behavior

and

immune fun ctio n. To understa nd its application to clinical medicine, it is important to review the research behind p sychosoma t ic illness and how it applies to wellness models. Robert Ader,13 who demonstrated neuropeptide-mediated regulation of

that immunosuppression could be behaviorally conditioned in rats, coined the term "psychoneuroimmunology" in 1981.

HISTORY Much credit goes to the pioneering work led by Candace Pert at Johns Hopkins

University in the 1970s. Pert,

as a neuropharmacologist and neuroscientist,

discovered and identified the first brain receptor, the opioid receptor. This receptor bound exogenous opioid drugs and analogs and endogenous opioid neuropeptides

(endorphins) w ith powerful pain- and mood-modifying properries.14,15 Through

brain mapping, Pert found that the highest concentrations of these receptors resided in the limbic, amygdala,

and hippocampus system, i mpl ying that neuropeptides and

58

Sectio n I • Philosophy and Principles of Patient Care

their receptors join the brain, glands, and immune system in a network of commu­ nication between brain and body. Later on, as section chief of the brain chemistry and clinical neuroscience branch at the National Institute for Mental Health

(NIMH), she demonstrated how endogenously produced neuropeptide ligands

bind to their cell surface receptors . This communication system operates outside the hardwired linear channels of neurotransmissions via

a

parallel extracellular

parasynaptic system. T he extracellular system allows neurope ptides to flo w throughout the brain and body and act at distances without linear connections to their cellular targets, there by effecting their change through receptor signal speci­

ficity.'6,'7 This new paradigm explained how peptides could act as neurotransmit­

ters and hormones. This led to brain mapping of other endogenous neuropeptides and study of the actions of molecules, such as morphine, phencyclidine, benzodi­

(ACTH), cholecystokinin, vasoac­ (VIP), neurotensin, transferrin, and insulin receptors.

azepine, substance P, bom besin, corticotro pin tive intestinal polypeptide

She believed that the 70 to 80 neuropeptides identified to date are the " biochemi­ cal correlate or su bstrate of emotion." Most, if not all, alter behavior and mood states. Also, many of these ligands influence immune cell function and immune system trafficking, influencing the intensity and duration of immune response to foreign entities. II

Specific "nodal points" of neuropeptide receptor distribution, identified by Pert and colleagues,'6 include emotion-mediated brain areas, the mobile cells of the immune system, and the dorsal horn of the spinal cord, where information from glands, skin, and other peripheral organs

first make their contact with the central

nervous system (CNS). Other receptor-rich loci include the periaqueductal gray region of the brainstem, which is hard-wired to limbic and emotional brain struc­ tures by neuronal pathways and has been shown to modulate pain thresholds. Additional nodal points include the gastrointestinal tract

from the esophagus to

the large intestines, which is lined with neuropeptides and receptors, including serotonin. The kidney, testes, and pancreas are other such sites. Other nodal points lie along the spinal cord ( with a distribution similar to that of autonomic nervous system ganglia), internal organs, and skin. Since "in formational su bstances" reside in all systems, Pert suggested that the neuromusculoskeletal syste m stores informa­ tion in the form of "tissue memory" of injury, trauma, or disease. Nerve cells secreting immune products, such as interleukins, tumor necrosis factor, and cytokines, communicate directly with the brain via the vagus nerve or through the blood-brain barrier and cere brospinal fluid.18 Malfunction of the operation of cell receptors can cause disease, which suggests that perhaps emotional states can alter the course and outcome of biological illnesses.'4

Per t also discovered peptide T ( D APTA). This peptide is the first viral entry

of neuro-AIDS. It blocks the chemokine (CCR5) to reduce the HIV viral load to

inhi bitor proving hopeful in the treatment receptor-mediated chemotaxis receptor

undetectable levels. This action permits a safe reversal of the devastating mental and neurological damage and cognitive impairment commonly seen in neuro-AIDS patientsl9-22 and again demonstrates how the behavioral effects seen with endogen­ ously produced neuropeptides can affect emotion and immune disease states. Receptors for thyroid-stimulating hormone, pheromones, leuteinizing hormone­ releasing hormone-like

peptides, thyrotropin-releasing hormone-like peptides,

endorphin-related peptides, and interferon-related peptides are found in higher plants and unicellular microorganisms ( bacteria, protozoa) that bind to these su bstrates, resembling receptors. The manner of binding is analogous to that of the hormone receptors found in higher animals, which leads to the assumption that

Chapter 6 • Psychoneuroim m unology

59

the molecules of i ntercellular communication are highly conserved and probab ly arose much earlier in evolution than the endocrin e, nervous, and immune systems in mammals and ot her verte b rates. 23

1981, J. E d win Blalock, an immunologist at The University of Texas, was the of the immune system He reported the presen ce of endor phi n s and ACTH receptors boun d to lymphocytes 24 Other papers confirmed that In

first to stu dy this aspect

.

­

.

ACTH and endorphin receptors and ligands found on lymphocytes were iden t ical

to those produced by the pituitary IS In fact, the i m mune system was capable not .

only

of sen d ing information to the brain via immunopeptides but also of receiving

in for mation

from the bra in

macrophages, and

via neuropeptides.25

I mmunocyt es

,

monocytes,

T lymphocytes also were found to produce many other neuro­

hormones: VIP, somarostatin, substance P, oxytocin, neurophys in , gonadotropin, grow th hormone, and throtropin.26

The Vagus Nerve and Substance P The vagus nerve was identified as one of several routes through whi ch cyrokin es sign a l the brain that the immune system has been activated. The vagus is thus an

important conduit for neuroimmunomodulation.1s Blal ock viewed the immune system as a sense organ t h at alerted the brain to the presence of detected pathogens and infectious agents via th e neu roendocrine system 2S The par a gan gli a of the .

vagus nerve possess proinflammatory immune-associated cy tokines to do just this. Also

,

it has been postulated that cyto k ines released within the brain itself, by

accessory lymphoid cells and/or glial cells, could activate neural str uctures Y

Substance P also is highly concentrated in the sp leen at t he site of antigen uptake and processing, which suggests that it is involved as well in the control of sensory functions of the i m mune system. In the intestinal tract, it evokes potent excitatory action. In sensory nerves sup plying local sites of chronic inflammation, elevated levels of substance P have been detected, i n d icat i ng a role for sub stance ating

a l l erg ic

P in medi­ reactions while mod u lat in g the severity of joint i njury in experimen­

tal arthritis.2�.29 It is well known that in the CNS the vagus nerve is in volved with p ain neuro­ transmission from its act ivity in the dorsal horn of t h e spinal cord , b ecau se it is

(PANs). T hese periph­

capable of directly irritating periph eral afferent noc icepror s

eral nociceptors are the small-caliber pain fibers that are activated by the high mechanical, thermal, and chemical stimuli that are highly damaging or that are

i nvolve d in local ti ssue inj ur y This rapid firi ng of projections communicates to the .

l im bi c system as pain, causing the neuroendoc rin e and emotional responses known

as "sickness

b ehavior," or acute ph a se response (decreased locomotion, decreased

li b id o, decre a sed exploration and aggression, decreased food and water intake, and hormonal changes). Local signaling of the PAN to the spinal cord at the level of the dors a l horn therefore is critical to t he formation of spinal fa cili tation and its effect

on

tl1e body. The output of the glial cyto kin e response is enhanced pain per­

ception (hyperalgesia) and

a ct ivatio n

of the arousal s ystem 30 .

Locally, substance P release from the PAN fi be rs causes mast cells to release his­ ta mine and

vascular endothelial cells to release prostagland ins,

p roduci n g

s wel ling whi l e bradykinin is released from the numerous cell types in fascia. White ,

blood cells migrate to the area and release cytoki nes

.

These proin flammatory

neurop e ptide s tri gger increased sensitization of the stimulated nerves, leading to fu rt her secretion of substance P to a ctivate sympat hetic aged tissue.

catecholamines in the dam­ Other neuropeptides released are calcitonin gene related polypeptide -

60

Sectio n I • Philosophy and Principles of Patient Care

and somatostatin, vasodilators that release more histamine in the area, causing fur­ ther swelling and inflammation. Tissue acidosis ensues, which activates PAN in the skin, contributing to tissue texture changes that indicate somatic dysfunction. If this spinal facilitation continues, producing excitatory toxicity (further production of dynorphin) leading to interneuron (pain inhibitory fiber) death, the dorsal horn neurons compensate by undergoing membrane molecular changes.

"In this mode,

dorsal horn neurons have altered their membrane properties such that they over­ respond to very minimum input, and in some cases, to no input at all. "30 This cre­ ates an ongoing spinal facilitation that links the complex network of information shared between the endocrine, brain, and immune systems during painful events.30 Hence, somatic dysfunction increases cytokine and PAN activity in hyperalgesia. Visceral afferent fibers in the vagus signal dysfunction to the solitary nucleus in the brainstem, releasing proinflammatory cytokines by macrophages, dendritic cells, and other immune cells at the nerve endings, thereby stimulating the primary afferent fibers. This signal ascends through the brainstem to

the thalamus and the

limbic forebrain, initiating behavioral changes, sllch as activation of the sympa­ thetic nervous system and of the hypothalamic-pituitary-adrenal axis

(HPA), to

arrive at a general adaptive and protective response. The amygdala is associated with fear or negative memory and has descending projections to the locus coeruleus, known as the sympathetic nervous system of the brain, in the brainstem. The arousal system of the brainstem therefore receives sensory stimuli (somatic, visceral, visual, and acoustic) and emotional stimuli and channels this warning information into a wide-ranging output circuitry that significantly alters activity in the nervous, endocrine, and immune systems. From the locus coeruleus, projec­ tions go to the hypothalamus to coordinate the release of corticotropin-releasing hormone and the secondary release of

ACTH, cortisol, and norepinephrine.30 This

phenomenon is known as the locus coeruleus-norepinephrine axis, which is acti­ vated in hyperalgesia.

Vasoactive Intestinal Polypeptide Implications In sensory areas of the brain (the olfactory bulb, thalamic nuclei, several cranial nuclei, the area postrema), and the inner walls of the blood vessels of the brain and spleen, VIP receptors are abundant. VIP itself is a potent vasodilator and smooth muscle relaxant (esophageal sphincter, stomach, and gallbladder), inhibits gastric acid secretion and absorption in the intestinal lumen, and stimulates secretion of water into bile and pancreatic juice. VIP-secreting cells and receptors line the entire gastroin­ testinal tract, which suggests that they are possible mediators of so-called gut feelings.

VIP, substance P, and calcitonin gene-related peptide were proved to be potent lymphocyte and monocyte chemoattractants, verifying the role of these peptides in immune system trafficking.!! The distribution patterns in brain and lymphoid tissues indicate interrelatedness of the two organ systems and may serve as one biochemical

rationale for a biopsychosocial view of health and disease since the gut is known as the

ancient brain of the body and

is rich with serotonin receptors.

Other Local Events Seen with OMT (Nitric Oxide, Endocannabinoids)

Nitric oxide (NO), operating as a neurotransmitter and locally acting hormone, recently has been implicated in osteopathic manipulation by restricting the devel­ opment of inflammation and down-regulating the process.3! Physical manipula­ tion induces NO synthase (NOS) release of NO. Other beneficial effects include

peripheral vasodilation and warming of the skin, decrease in heart rate, and an

Chapter 6 • Psychoneuroimmunology

61

overwhelming sense of well-being, referred to as the relaxation response, along with salutary anti-lipid peroxidation, antibacterial, and antiviral effects. It does so by modulating neurotransmitter release, neurosecretion, and behavioral activities.32 NO is

a

major signaling molecule in the immune, cardiovascular, and nervous

systems. The presence of an endothelial mu opioid receptor further substantiates the role of opioids in vascular coupling in NO release.33 Diabetic endothelium is known to have fewer mu opioid receptors present, and it has diminished constitutive basal and morphine-stimulated NO rele�se.J4 Other signaling molecules also in the blood notably include the endocannabinoids (anandamide [arachidonylethanolamine] and 2-arachidonylglycerol, interleukin (IL) 10, and 17-beta estradiol. These are naturally occurring constitutive NOS-derived,

NO-stimulating signaling molecules that are expressed by nerve tissue and diffused into the blood. These signaling molecules can further initiate profound physiological effects when osteopathically stimulated (through the physical mechanotransduction mechanism).31 Anandamide, as part of the ubiquitous arachidonate and eicosaid signaling cascade, as well as estrogen , through NO release, can down-regulate immunocyte and vascular function in women and may provide an additional mech­ anism whereby osteopathic treatment may aid in the relief of female-associated dysfunction (i.e., those occurring post-partum)JI Similarly, 2-arachidonylglycerol can cause reduction in cytokines and adhesion molecules, an immunosuppressive response similar to that of anandamide35 (Fig. 6.1). "Furthermore, naturally occurring signaling molecules such as morphine, anan­ damide, interleukin-10, and 17-beta-estradiol appear to exert, in part, their bene­ ficial physiological actions, i.e., immune and endothelial down regulation by the stimulation of cNOS. "33 Morphine, given its long latency before increases in its levels are detected in fUllnan tissue and blood, arises after high-impact motion. It and the other signaling molecules, through an NO mechanism, down-regulate the activities within neural and immune tissues, thus providing a possible mechanism for the analgesic effects attributed to high-impact manipulation. "The capacity of the cannabinoids to regulate immune function is well estab­ lisbed."36 Cannabinoids have been reported to have anti-inflammatory effects and reduce joinr damage in animal models of arthritis. Anandamide has been shown to prevent cartilage resorption by inhibiting cytokine-induced NO production by

chondrocytes and also

by inhibiting

proteoglycan

degradationY John

McPaniandJ8 demonstrated in a randomized, blinded, conrrolled clinical trial that in contrast to controls, cannabimimetic effects (i.e., the relaxation response) were

seen post-OMT in patients receiving manipulation. Also, serum anandamide levels doubled post-OMT compared to pretreatment levels, using chemical ionization gas chromatography and mass spectrometry measures. During pain modulation,

when nociceptors are firing in the dorsal horn of the spinal cord, cannabinoid receptors can dampen the efficacy of activators and sensitizers and prevent the nociceptors from firing, preventing peripheral sensitization and hyperalgesia,

o

FIGURE 6.1

Chemical structure of the endocannabinoid anandamide.

62

Section I • Philosophy and Prin c i p l e s of Pati ent Care

especially in n europathic and inflammatory pain. OMT can restore axoplasmic flow and restore the receptors to their active sites.38 This restoration is critical to reestablishing homeostasis and restoring function after a painful or traumatic event that produces somatic dysfunction. Thermal changes, in which temperature reduction occurs within 30 minutes following manipulative treatment, have been shown to occur in chronic somatic dysfunction areas of known musculoligamentous strain. Spontaneous localized motor activity that was seen on electromyography in patients who had chronic midthoracic back pain had an immediate reduction or cessation of spontaneous potentials, indicating that a change in the electromyographic pattern also occurred after osteopathic manipulation that correlated with palpatory changes.39.4o This may be due to local NO effects. The piezoelectric transducer model has been proposed to be operating in improved nerve conduction as well as in the functioning of tissue enzymes.41 According to Bassett, piezoelectric properties are present in many biological systems and may the­ oretically control cell nutrition, local pH (skin tissue acidosis), enzyme activation and inhibition, orientation of intracellular and extracellular macromolecules, migratory and proliferative activity of cells, contractility and permeability of cell membranes, and energy transfer, including biomechanical deformation

and physiological activi­

ty.41,42 In fact, experimental acidosis in skin is due to nonadapting nociceptor excita­ tion in a spatially restricted volume of tissue and appears to be a dominant factor in inflammatory pain.43,44 Bassett proposed that the crystalline properties of bone and tendons produce electrical potentials when the co.llagen matrix is deformed (organic constituent). This was also found to be true in dentin and carrilage.42 Manipulation therefore may be helpful in restoring proper tissue pH and in reducing nociceptor excitation, reducing pain through local NO-mediated events. Travell trigger points have been implicated to produce somatic dysfunction and to be evoked from abnormal depolarization of motor end plates, producing the presynaptic, synaptic, and postsynaptic mechanisms of abnormal depolarization of acetylcholine, defects of acetylcholinesterase, and up-regulation of postsynaptic nicotinic receptors. When a person is under physical, chemical, or psychological stress, the hyperexcitability evokes trigger points in muscles. Since impaired circu­ lation increases metabolic demands of muscle cells, resulting in an adenosine triphosphate

(ATP) crisis, this further triggers presynaptic and postsynaptic decom­

pensation. When circulation i s impaired, increased contractile activity ensues; then all the local factors contributing to edema and inflammation are activated.4s

Cranial Osteopathic Implications In cranial osteopathy, it is believed that if there are imbalances in the circulation within the skull, neurological (nervous) and endocrine (hormonal) disturbances can follow. The pituitary lies cradled in the sphenoid, and distortions of the sphenoid bone are fairly common. Theoretically, therefore, pituitary dysfunction can result.46 Many children with birth injuries have been treatecl successfully using cranial osteopathy. The primary respiratory mechanism, coined by William Sutherland,47 is related to the fluctuation of the cerebrospinal fluid that occurs within the ventricles of the brain and the cisterns of the subarachnoid space, the meninges, the eNS, the articular mobility of the cranial bones, and

the sacrum between the ilia.48 Radiographic evi­

dence has shown t h at 96.1 % of patients treated using the cranial vault procedure exhibited measurement differences at three or more sites.49 More recent findings are that cranial manipulation affects the blood flow velocity oscillation in its low­ frequency Traube-Hering-Meyer components, believed to be mediated

t h r o u gh

Cha pter 6 • Psychon euroi mmunology

63

parasympathetic and sympathetic activity and affecting the autonomic nervous sys­ tem.so Since it is known that the periaqueductal gray region surrounding the cerebral aqueduct is contiguous with the fourth ventricle and rich with cannabinoid rece p­ tors that are activated by hydrostatic pressure, theoretically, a

CV-4 (compression

of the fourth ventricle) treatment can activate these receptors in the limbic system and cerebral cortex, causing cannabimimetic effects and resulting in an effective relaxation response.38 Pain Behavior and Allostasis

Frank Willard, a neuroanatomist, states that allostasis and its unhealthy effeers on the body can lead to inflammatory and degenerative injury of the body and mind. He believes that somatic dysfunction activates related spinal cord circuits and releases humoral factors summating at the level of the brainstem and that these factors initiate general arousal and associated protective endocrine and neural 5[

reflexes, known as "sickness behavior. "27,30,

Willard concludes that the osteopathic approach to patient care is aimed at helping the patient restore a more natural homeostatic condition. Long-term allostasis has been correlated with increased sympathetic tone in the body that affeers the cardiovascular system, hypertension, chronic pain, and insulin resist­ ance. Any of these long-term effects can lead to other devastating diseases or mor­ tality. Memory loss and depression are two manifestations of the effect of allosta­ sis on the central nervous system. Long-term elevated levels of cortisol have been associated with significant damage to the hippocampal formation from dysregula­ tion of the corticotropin-releasing hormone feedback control from the hippocam­ pus to the hypothalamus. This also affects the renal and gastrointestinal systems, leading to increased water retention, sodium retention, hypervolemia, hyperten­ sion, and increased gastrointestinal and skin delayed-type hypersensitivity. Many inflammatory, neoplastic, and degenerative disease processes that we accept as common aging phenomena may be the result of accelerated compensation of dys­ regulated homeostatic processes.3] The impact of psychoneuroimmunology on osteopathic medicine and primary care is, therefore, huge.

Application to Primary Care and Osteopathic Manipulative Medicine From the perspective of psychoneuroimmunology, the body and mind are insepa­ rably connected through the emotions via the peptide ligand network. In reality, this system is holographic and protective in its response to outside stimuli. More important, when the communication system breaks down on any level, the system becomes dysregulated and sets the course for disease and/or pain to occur and be maintained. As might be expected, chronic stress can contribute to this, as can emotional states (depression, anxiety, worry, hostility, fear) and diseases and dis­ orders (e.g., cancer, diabetes , hypertension, asthma, sinusitis, allergies, dermatitis, irritable bowel syndrome). The concepts of psychoneuroimmunology have application and profound impli­ cations for the primary care physician confronting disease prevention and health maintenance. Since the neuromuscular system is closely linked to the CNS and therefore the PNI pathways inherent in the body, many of the disorders and diseases presented by patients to the primary care doctor have a PNI component. In fact, when a person gets sick, the related feelings, or "sickness behavior' (fever,27 fatigue, malaise, loss of interest in usual things, social isolation, loss of appetite, and altered sleep), are associated with an increase in proinflammatory cytokines similar to depression

(IL-I, IL-6, and/or tumor necrosis factor). Psychomotor sickness behav­ IL-I; IL-I-beta also influences food intake, body

ior and sleep are related to

64

Sect i o n I • Philosophy and Principles of Patient Care

temperature, and pain

sensitivity in the hypotbalamus and thalamus.52 Disturbances IL-2 a nd in part to ATNF-alpha.

of memory and cogniti ve impairment are related to

Furthermore, since cytokines and their rece ptors are ubiqu itous ly distributed in the

brain, they have been shown to activate astrocytes and microglia in the CNS to pro­

duce even more cyto kines locally.53 Hypersecretion of cytokines has been implicated in schizophren ia and dep ressi ve

disorders (IL-2, IL-6, res pec ti ve ly ) .52

The effects are far-ranging since lymphatic and neuroendoc rine tissues are

ubiq­

uito us in the bo dy, and the effects that are produced locally can simultaneous ly p ro­

duce e ffects cent rally, via the limbic-amygdala-hippocampus system (the emotional centers of the brain), affecti ng the whole body. These tissues also are in direct com­ munication with the HPA, which is activated when stress and emotional responses influence the level of corticosteroid hormones released. In turn, these hormones modul ate the immune cell function through an infl ammatory response. Also, a hypothalamic-pituitary-gonadal feedback loop is regu lated by thymosi ns .54 Init ia lly,

acute stress up-regulates the immune system, increas ing natural killer ce lls; howe ver, c hron ic inescap ab le stress produces an opioid-like state thar eventua ll y down­ reg u lates the immune system toward

disease.5'

It is the

HPA and locus

coeruleus-norepinephrine axes together that constitute the major stress system of the body, providing the quick release of cortisol and norep inephr ine into the system. Somat i c dysfunction

relays an

excitatory

drive on

the

locus caeruleus­

release of

norepinephrine and HPA axes of the midbrain and hypothala mus . The

cytokines from inflam matory tissues stimulates the HPA through humoral routes. The first phase is mediated by the peripher al nervous system (less than

and the second phase develops more slowl y (more than

1 hour ) , 3 h ou rs ) , paral leling the

rise of the in fla.mmatory event. Overall, this sequence of events sets up the potential

for c umulative ca techolamine stress to continue the sym p ath e tic nervous

system-HPA couplin g, le a ding to a long-term allostatic load an d event ually dam­ aging end organs. Immunosuppression and this loss of feedback autoregulatory control result in organ systems damaging one another.30

In the context of family practice, this implies that any treatment done medically

and osteopathically can direct ly influence the

PNI sta te of the body. The three

aims of OMT are restoration to normal of the su pporting tissues (bone, m uscle, lig­

ament, and fascia), normalization of movement and art ic u lation, and normalization

the mechanica l influences on the body as a whole.46 Additional ly, the aim is for t he neu rological integ ration, incl ud i ng cent ra l , pe riph ­

of the reflexes and/or

eral, autonomic, neuroendocrine, neurocirculatory, and somatic elements , to be integrated with general p atient care.56 Any form of hands-on therapy, such as OMT,

therefore, can improve local blood flow while reduci ng pain signals to the spinal cord and mit igating tbe concurrent effects on pain behavior. Cutaneous vascular c h anges in the region of the segmental spinal d isorder have been demonst rated ,s7 and the relationsh ip

of blood s upply to the level of an organ function is important.

There has been spec u l ation that vital organ system funct ion may be influenced by spinal segmental disorders, as seen in the facilitated segment . It has

been shown that

under conditions of strong emotion, organs innervated from levels of skeletal dis­ turbance in areas with al ready altered autonomic outflow are espec i ally

vulnerable

to facilitation-induced changes in vascul ar supply. Any attention given to correc ti n g

somatic dysfunction therefore may benefit the patient both in the local d ysfuncti on­ al area and for ge ne ral

body reactions by reducing excessive cerebral excitation.18

Additio nally, OMT has been shown to provide immune enhancement.7 OMT can effect a change by stimu lating the cannabinoid receptors periphera lly at nocicepto r sites and in the dorsal horn, do w n-reg ulating proinflammatory changes and central sensitization through the retrograde signaling of N O-i nduced anandamide

C h a pter 6 • Psychoneu roi m m u nology

65

postsyn a ptica l ly. Th is retrogra d e sign a l a cts on the c a n n a b i n o i d receptors presynapti­ ca l l y by cl o s i ng the excitatory ca l c i u m cha n n e l s and stoppi ng t h e rel ease of s u bst a nce P a n d gl u ta m a te, resto r i ng axop l a s m i c fl ow to the recept or s . 3 8 The red uction of s o m atic d ysfu n ction u s i ng OMT c o u l d theoretic a l l y restore homeostatic m ech a n is m s by d isrupting the p a i n feed back l oops t h a t a re loca l l y a n d centrally med iated . O n e of t h e k n own b a r r iers-o r sha l l we s a y c h a l lenges-facin g fam i l y p ra c t i c e res i d e n ts to d a y i s the l a c k of t i m e a v a i l a b l e t o perform m a n ip u la t i o n . Ti m e fo r OMT is fu r t h er red u ced i n a managed care setting. T h u s , very few oste o p a thic p h ys i c i a n s use OMT i n th e i r d a i l y practice once they g r a d u a t e from oste o p a t h i c med ica l i n te r n s h ips o r res i d e n c i es , 5 9-63 e v e n though m a n y of t h e s e p h y s i c i a ns re g a r de d h o l istic med i c i n e a s b e i n g the most d i s t i ng u i s h i n g c ha r a c teri s t ic of the i r professio n . 6 2 Ma n y b e l ieve t h a t O MT is effi c a c i o u s a n d tha t the osteopa th ic a p p r o a c h to treatment is a p r i m a r y d ist i n g u i s h i ng fea t u re of thei r p r ofes s i o n , i nco rpora t i ng , as i t d o e s , a ca r i n g d o c t o r-pa t i e n t re l a ti o n s h i p a n d a h a n d s- o n style o f c a r i n g in the practice o f med i c i n e . 64 A rece n t s t u d y s howed t h a t fa m i ly p h y s i c i a n s w e re more a pt to use HVLA t h ru s t , or l y m p ha t ic or m u scle e nergy proce d u res t h a n non-p r i m a r y care spe c i a l i sts a n d O MT spec i a l is t s . 6 5 A fo c u s e d t rea tme n t plan c a n p ro v id e a n i m m e d ia te option i n rega rd to u s i ng O M T i n a b u s y p ractice setting. Also, s i nce s o m e p a t ients seeing osteo p a t h i c p h y s i c i a ns for spec i a l ­ i z e d OM T ca re m a y h a v e poorer q u a l i t y of l i fe t h a n t he genera l p o p u l a ti o n, ea rly detec t i o n a n d tre a t me n t of m u sc u l os k e l e t a l con d i t i o ns may b e i mporta n t fa ctors i n preve n t i ng c h ron i c i ty a n d i t s interference w i t h o n e 's q ua l i t y o f li fe . 6 6 Con d i tions i n t h e osteopa t h i c l i tera t u re t h a t h a v e s hown pos i t i v e responses o n use o f m a n i p u l a t i v e proce d u res i n c l u d e the fo l l o w i ng : • Acute otitis med ia67 • Cardiac d i sease, co r o nary h e a r t d ise a s e 6 8 , 6 9 • C h r o n i c te nsi o n h e a d a c he70 a n d neck p a i n , m igra i n es , 7 J -77 cerv ica l c o m pressive

myel o pathy with her n i a ted d isc/8 i n t r a oc u l a r pre ss u re79 • F i bro m y a lgi a ,80 r h e u ma t i c d isease 8 1 , s 2 •

Si n us i t i s 83 , 8 4

• U p p e r and low back p a i n 5 ,58,8 5-95 • S h o u l d er p a i n 96,97 •

• • • • • • • • • •

Upper respi r a t o ry con d i t i o n s : a c u te res pirato r y fa i lure,98 a s t h m a ,99, 1 00 c o l d s, l o l p ne u m o n i a 1 0 2- 1 05 Temporoma n d i b u la r j o i n t d ys f u n c t i o n , 1 06 ma locc l u s i o n 1 0 7 Cere bra l p a l sy, l OS m u l t i p l e s cl e ro s i s , 1 09 i d i o p a t h i c pa r k i n s o n ism 1 1 0 , 1 1 1 M il d osteoart h r i t i c p a i n , t h or a c i c o u tl e t sy n d rome 1 1 2 Sc o l i o s i s l u P o st s u r ge r y, ! 1 4 post p u lmonary resection , 1 1 5 post knee a n d h i p a rthr o p lasty I 1 6 , 1 1 7 C a rp e l t u n n e l , I I I . I J S la teral e p i c o n d y l i ti s , 1 1 9 b u rs i t i s , Ac h i l l e s t e n d o n i t i s , p lant a r f asci i t i s l 2 0 P re n a ta l care, 1 2 1 b i rth t r a u m a 4 S , J 22 C h ro n i c muscu los k e l e t a l pa in4,5.95 H o s p i ta l i z a t i o n , 3 t r a u m a t i c bra in i n j u r y l 2 3 H y pertens i o n 1 24 , 1 25

Other e ffec t i v e m a n i p u la t i v e therapies i n c l u d e myo£a s c i a l release, pos i ti o n a l release, s o ft t i s s u e d ee p a rt i c u l a t i o n , cra n i a l , c o u n terstra i n , torq u e unw i n d i ng, a nd m usc l e e n e rgy proced ures . HVLA o f the cer vical spine, however, h a s fostered c o n ­ troversy a n d i s contra i nd i c a ted i n cases of severe osteopo rosis u n d e r a n y cond i t i o n . T h e re h a v e b e e n reports i n t h e l i tera t u re of i a troge n i c cerv ica l fr a c t u r e s 1 2 6 and of verte b r a l b a s i l a r a rtery a nd ca rotid a rte ry d i ssection i n v o l v i n g chiro practic, l 27- u .2

66

Sect i o n I • Philosophy and Princi ples o f Pat ient Care

less so with physical therapy, 1 33 and rarely OMT J 34 Current ly the American Academy of Osteopathy recommends that information regarding the risks be provided to trainees and that all physicians continue to offer this form of treatment along with

other moda lities to r reat the cervica I spine. 1 3 5 Soft tissue myofascial release includes

vario u s proce d u res: effleurage, petris sage , friction, and tapotement. Man ipulative p rocedures have been shown to improve f l exibility, decrease the perception of pain, and decrea se t h e leve l s of stress hor mones . 1 36 S ince

6 0 % of the bod y is bone, tendon, and ligaments , w ith 206 bones in the

human structu re, it is important for wellness therapies46 to consider treating the mus­ culoskeletal system. Poor postural mechanics, strain, repetitive stress, and injuries can benefit from OMT procedures, s i nce any structural or mechanical abnormality can affect the body's natural homeostas is. The relations hip between structure and function not only is relevant to the treatment of di sease; it provides a framework in which the body may begin the process of resuming its natural order. For example, in ast hma, a focused treatment plan for manipulation would include using the l y mphatic pump procedure to sti mulate the i mmune system to reduce infla mmation and would also include using any appropriate form o f manipulation t o t reat the correspond i ng viscerosomatic dysfunctions found in the upper thoracic and cervica l areas . In low back pain, the standard of care necessi­ tates a focused t reatment plan that includes treatment of the lu mbosacral region with manipulation.94 It is also important to adm inister the initial manipulation in conjunction w i th an exercise p rogram for the first 2 weeks of treatment. A patient home care and t reatment plan at a freq uency of up to two to three times

a

week

may incorporate an active exercise p rogram during the first month as pa rt of a st rengthening program. Clea r-cut therapeutic goals s hould be establis hed at the onset of t reatment . Lack of improvement after three to four treatment sessions s hould res ult i n

discontinuation of the cur rent treatment plan and a reassessment

a

of t h e proble m . 9S Other adj unctive care that contributes to relaxing the patient, that provides support in bringing the body back into homeostasis and balance, and that has been ad vocated and used with success in primary care includes massage, acupuncture, m i ndfulness meditation, guided imagery, relaxation training, low-frequency pu lsed electromagnetic field, essential oils , and herbal remedies. 1 3 7- 1 44 Therefore, comprehen­ sive holi stic care aimed at addressing the cause of disease, com bined wit h indivi dua l­ ly tailored treatment and p reventati ve meas u res, examin ing the environmental, social, mental and behavioral as pects of d i sease, is paramount for understanding how PNI and OMT are related . Additionally, any pos itive action, such as treating a somatic dysfunction t hat results in a change in the psychoneuroimmunologic milieu of the mind and bri ngs about an effective change in outcomes warrants further consideration by the fam ily practice phys ician.

References l . S t i l l AT. The P h i l o s o p h y a n d Mec h a n i c a l P r i n c i ples of O s teo p a t h y. K i r k s v i l l e , M O : Am e r i c a n Sch oo l o f Osteo p a t h y, 1 8 9 2 .

2 . Tr i l l i n g

]5. Selections

from c u r re n t l i teta t u re . Psyc llOne u ro i m m u n o l ogy: v a l i d a ti o n of t h e

b i opsyc h os oc i a l m ode l . Fam P r a c t 2 0 0 0 ; 1 7 : 90-9 3 . 3 . S h u btook ]H,

ment

Dooley ]. E ffects o f a s t r u c t u red c u rricu l u m i n osteop a t h i c ma n i p u la t i v e

tre a t ­

( O MT) o n o s te o p a t h i c s t r u ct u r a l exa m i n a t i o n s and use o f O M T for hosp i t a l i zed

p a t i e n t s . J Am O steo p a t h Assoc 2 0 00 ; 1 0 0 : 5 5 4-5 5 8 .

4 . G i l es L G , M u l l e r R . C h ro n i c s p i n a l pa i n : A ra n d o m ized c l i n i c a l tria l c o m p a r i n g med i c
C h a pter 6 • Psychoneu roi m m u nolog y

67

5 . A n d e r s s o n G B , Lucente T, D a vi s A M , et a l . A com p a r i s o n o f o s t e o p a t h i c s p i n a l m a n i p u l a ­

t i o n s t a n d a r d ca re fo r p a t i e n ts w i t h l o w b a c k p a i n . N E n g l J Med 1 9 9 9 ; 3 4 1 : 1 4 2 6- 1 4 3 l .

6 . A s s e n d e l fr W.! , M o rton S C ,

Y u EI, e t

a l . S p i n a l m a n i p u la t i v e t h e r a p y for l o w b a c k p a i n .

A m e t a -a n a l y s i s o f e fiec r i v e n es s r e l a t i ve t o o t h e r thera p i e s . A n n I n te r n M e d 2 0 0 3 ; 1 3 8 : 8 7 1 -8 8 \ . 7 . Les h o E P. A n o ve r v i e w o f os te o p a t h i c m e d i c i n e . A rc h F a m M e d 1 9 9 9 ; 8 : 4 7 7--4 8 4 .

8 . S t i l l AT. A m e r i c a n m a n u a l thera py. I n : T h e A u t o b i o g r a p h y o f A . T. S t i l l . K i rksv i l l e , M O :

A u t h o r, 1 9 0 8 .

9 . Hoover H V. S e l ected osteopa thic p a p e r s : P l a ce o f p s y c h o s o m a t i cs i n osteo p a t h y. [ n o No r t h u p T L . Aca d e m y 0 1 Ap p l i e d O s t eo p a t h y 1 9 5 0 Yea r b o o k . M o r r i s to w n , NJ: A m er i c a n Osteopa t h i c Associa t i o n , 1 9 5 0 : 8 5-8 6 . ( N ow a v a i la b l e t h r o u g h the A m e r i c a n A ca d e m y o f Osteopa t h y, I n d i a n a p o l i s . )

10. P r o l o P, C h i a p p e l l i F, F i o r u c c i A, et a l . P s yc h o n e u ro i m m u n o l o gy. N e w a v e n u es of r e s ea r c h fo r t h e t w e n t y- f i r st c e n t u ry. A n n NY Acad S c i 2 0 0 2 ; 9 6 6 : 4 0 0--4 0 8 . 1 1 . Pert C B , D r e h e r H E , R u ff MR. The p s y c h o s o m a t i c netwo r k : F o u n d a t i o n s of mi nd - b o d y med i c i ne . A l te rn T h e r H e a l t h M e d 1 9 9 8 ; 4 : 3 0--4 1 . "1 2 . Pert C B . T h e w i s d o m o f the rec e p tors : N e u r o p e p ti d e s , t h e e m o t i o n s , a n d b o d ym i n d . Adva nces 1 9 8 6 ; 3 ( 3 ) : 8- 1 6 . 1 3 . A d e r R , Co h e n N . Be h a v i o ra l l y c o n d i t i o n e d i rn rn u n osu ppressi o n . P s y c h o s o m M e d 1 9 7 5 ; 3 7 : 3 3 3 -3 4 0 . 1 4 . Pe rt

CB,

Snyder

SH.

O p i a te

r ec e p to r :

D e m o n stra t i o n i n n e r v o u s t i s s u e . S c i e n ce

1 9 73; 1 79 : 1 0 1 1 - 1 0 1 4 . 1 5 . P e r t C B , P a s te r n a k G , S n y der S H . O p ia te a g o n i s t s a n d a n tagon i s t s d i scri m i n a ted h y recep­

to r b i n d i n g to b r a i n . S c i ence 1 9 7 3 ; 1 8 2 : 1 3 5 9 - 1 3 6 1 . 1 6 . Pen C B , R u ff M R , We ber

somatic network. J

RJ,

H e r k e n h a m M . N e u rope p t i d e s a n d t h e i r r e ce p t o r s : A p s yc h o ­

I m m u n o l 1 9 8 5 ; 13 5 ( 2 s u p p l ) : 8 2 0 S - 8 2 6 S .

1 7 . Sch m i tt F O . M o l ec u l a r r e g u l a t i o n o f b r a i n f u n c t i o n : A n e w v iew. N e u r o s c i e n c e 1 9 8 4 ; 1 3 : 9 9 1- 1 0 0 1 . 1 8 . Pe rt C B . M o l ec u l es of Emoti o n : W h y Yo u Fee l t h e Wa y Yo u Fee l . Lon d o n : S i m o n & S c h u s t e r, 1 9 9 7 ; 1 4 3 .

1 9 . Po l i a n ova MT, R u scerti FW, Pert C B , e t a l . A n t i v i ra l a n d i m m u n o l o g i c a l benefits i n H r v

p a t i e n t s rece i v i ng i n t r a n a s a l p e p t i d e T ( D A PTA ) . P e p t i d e s 2 0 0 3 ; 24 : 1 0 9 3 - 1 0 9 8 . 2 0 . Pert C B , H i l l ]1vl , R u ff M R , e t a l . A p e p ti des d e d uced fro m t h e n e u r o pe p t i d e rece ptor- l ike

pa ttern of a n tigen T 4 in b r a i n p o te n t l y i n h i b i t h u ma n i m m un o d e f i c i e n c y v i r u s rece p t o r

b i n d i n g and T-ce l l i n fe c r i v i ty. P roc N a t! A c a d S c i U S A 1 9 8 6 ; 8 3 : 9 2 5 4 - 9 2 5 8 . J D , et 3 1 . Pe p t i d e T b l o c k s G P 1 20/CC R 5 c h e m o k i n e recep t o r­ med i a ted c h e m o r a x i s . C l i n I 01 m u n o I 1 9 9 9 ; 9 3 : 1 2 4 - 1 3 l . 2 2 . Hese l t i n e P N , Goo d k i n K , A tk i n so n JH, e t a l . Ra n d o m i ze d d o u b l e - b l i n d p l a c e b o - c o n r r o l l e d 2 1 . Red w i n e LS, P e n C B , R o n e

t r i a l of p epr i d e T i n H I V- a s s o c i a ted cogn itive i m pa i r m en r . A rc h Ne u ro l 1 9 9 8 ; 5 5 : 4 1 -5 1 . 2 3 . Roth .1 , Le roith D L , C o l l i e r E S , e t 3 1 . E v o l u r i o n a ry o r i g i n s o f n e u r o p e p r i d e s , flO r m o nes a n d

r e cep t ors : Poss i b l e a p p l i c a t i o n s t o i m m u n o l ogy. J r m m u n o I 1 9 8 5 ; 1 3 ( 2 s u p p l ) : 8 1 6 S-8 1 9 S . 2 4 . S m i t h E M , B l a l ock J E . H u m a n l y m p h o c y t e p rod u c t i on o f c o r t ico tro p i n a n d e n d o r ph i n ­

l i k e s u b s ran ce s : Associ a r i o n w i t h l e u kocyte i n te rferon . P roc N a t l A c a d Sc i USA 1 9 8 1 ;

7 8 : 75 3 0- 7 5 3 4 . 2 5 . B l a l oc k

JE. A

m o l e c u l a r b a s i s fo r b i d i re c r i on a l com m u n ica t i o n between t h e i mm u n e a n d

n e u roe n d oc r i n e s y s te m s . P h y s i o l R e v 1 9 8 9 ; 6 9 : 1 -3 2 .

2 6 . B l a l o c k J E . The s y n t a x o f i m m u ne - n e u ro e n d o c r i n e c o m m u n i ca t i o n . r m m u n o l Tod a y 1 9 9 4 ; 1 5 : 5 0 4-5 1 1 . 2 7 . F l es h n e r M , La u d e n s l ager M L . Psych o n e u ro i m m u n o l o g y : Then a n d now. Beh a v Cogn

Neu rosci R e v 2 0 0 4 ; 3 : 1 14 - l 3 0 . 2 8 . Wi e d e r ma n n Cj , S e r t l K , Pert C B . S u bsta n c e P rece p tors i n r a r s p l e e n : C h a racteriza t i o n a n d

d u to ra d i og r a p h ic d i s t r i b u t i o n . B l ood 1 9 8 6 ; 6 8 : 1 3 9 8 - 1.4 0 1 . 2 9 . W i e d e r ma n n q , S e n l K, Z i pser B, et a l . Va so a c t i ve i n t est i n a l p e p t i d e receptors i n r a t s p l e en

a n c! b ra i n : S h a r e d c o m m u n i c a t i o n nerwor k . Pe p r i d e s 1 9 8 8 ; 9 ( s u p p I 1 ) : 2 1 -2 8 . 3 0 . W i l l a rd F H . N o c i c e p r i on , t h e n e u roendocr i n e i m m u n e s y s tem, a nd o st e o p a t h i c m ed i c i n e . In :

Wa rd RC, ed . F o u n d a t i o n s fo r O s t e o p a t h i c J"le d i ci n e . P h i l a d e l p h i a : L i p p i ncott Wi l l i a m s & W i l k i n s , 2 0 0 2 : 13 7- 1 5 6 .

68

Section I • P h i l o s o p h y a n d P r i n c i p l es of Pat i e n t Ca r e

3 1 . S a l a m o n E, Z h u W, Ste fa n o G B . N i t r i c o x i d e a s a p o s s i bl e m e c n a n i s m fo r u n d e r s ta n d i n g t h e th e ra p e u t ic effects of osteo p a t h i c m a n i p u l a tive m e d ic i n e . l n t J M o l

Med 2 0 04 ; 1 4 ( 3 ) :

4 4 3 -4 4 9 [ r e v i e w ] . 3 2 . Stefa n o G B , O t t a vi a n i E. Tne b i oc h e m ic a l s u b s t r a t e of n i tric o x i d e s i g n a l i n g is p re s e n r i n p r i m i r i v e non-cognitive o rga n i sm s . B ra i n R e s 2 0 0 2 ; 9 2 4 : 8 2- 8 9 .

3 3 . Stefa n o G B , G o u m o n Y, B i l fi n g e r TV, e t a l . B a s a l n i tric o x i d e l i mits i ln m u n e , n e r v o us a n d c a rd i o v a sc u l a r e x c i ta t i o n : H u m a n e n d o t h e l i a express

a

m u o p i a te receptor. P r o g N e u r o b i o l

2 0 0 0 ; 6 0 : 1 3-3 0 .

3 4 . B i l fi n ger TV, Vosswinkel l A , C a d e t P, e t a l . D i rect a ssessment a n d d i m i n i s h ed p r odu c t io n o f m o r p h i ne s t i m u l a te d N O b y d i a betic e n d o thel i u m f r o m sa p h e n o u s v e i n . A c ta P h a r m a c o l S i n 2002;23 : 9 7-1 0 2 .

3 5 . Stefa n o G B , B i l fi nger TV, R i a l a s C M , oxi d e r e l e a s e from h u m a n

Deutsch D G . 2-A r a c b i d o n y l -g l y ce ro l s t i m u l a t e s n i t ric i m m u ne a n d v a s c u l a r tiss ues a nd inverte b r a te i m m u n o c y te s b y

c a n n a bi n o i d receptor 1 . P n a r m a c o l Res 2 0 0 0 ; 4 2 : 3 1 7-3 2 2 . 3 6 . R o t h M D . P h a rm a c o l ogy: M a r i j u a n a a n d y o u r h e a r t . Na t u r e 2 0 0 5 ; 4 3 4 : 70 8-70 9 .

3 7 . M b v u n d u l a E C , B u n n i n g R A , R a i n s ford K D . E ffects o f c a n n a b i n o i d s o n n i t r i c o x i d e pro­ d uc t i o n b y ch o n d r o c y te s a n d p r oteo g l y c a n d e g ra d a t i o n i n c a r t i l a g e . Biochem P h a r m a c o l 2 0 0 5 ; 6 9 : 6 3 5-64 0 . 3 8 . McPa rda n d j M . T h e e n d o c a n n a b i n o i d system a n d O MT. Lect u r e n o tes. A me r i c a n A c a d e m y of O s te o p a t h y New I d e a s F o r u m . C o l o r a d o Spri ngs , C O , M a rc h 1 9 , 2005 .

3 9 . D e i b e r t PW, E ng l a n d RW. C r y s ta l l og ra p h i c s t u d y : Th e r m a l c h a n g es a n d t h e o s te o p a t h i c l e s i o n . J Am O st e o p a t h Assoc 1 9 72 ; 72 : 2 23-2 2 6 .

4 0 . Eng l a n d RW, D e i bert PW. E l e c trom y ogra p h i c s t u d i es : Pa r t I . C o ns i d e r a t i o n i n t h e e v a l u a t i on o f o s t e o p a t h ic thera p y. 1 A m O s t e o p a th Assoc 1 9 7 2 ; 7 2 : 2 2 1 -2 2 3 .

4 1 . Bog u s l a w L. B i o l o g i c a l s i g n i fic a n c e of p i ezoe l e c t r i c i ty i n re l a t i o n to a c u p u nc t u r e , h a t h a

yoga , osteo p a t h i c m e d i c i n e a n d a c t i o n s o f a i r i o n s . M e d H y p o t h e se s 1 9 7 7 ; 3 : 9 - 1 2 .

4 2 . B a s s e t t C A . Bi ologi c a l s i g n i ficance o f p i e zoe l e c t r i c i ry. Ca l c i f Tissue R e s 1 96 8 ; 1 : 25 2-2 7 2 . 4 3 . S teen KH, I s s b e r o e r U, R ee h P W . Pa i n d u e ro e x p e r i m e n t a l a c i d os i s i n h u m a n s k i n : E v i d e n c e fo r non-a d a p t i n g n o c i c e p t o r exc i ta tion. Neurosci Lett 1 9 9 5 ; 1 9 9 : 2 9-3 2 . 4 4 . Steen K H , Steen A E , K re y s e l H W, Reeh PW. I nfl a mma to r y m e d i a tors p o te n t i a te p a i n i n d uced by ex p e r i me n ta l t i s s u e a c i d o s i s . P a i n 1 9 9 6; 6 6 : 1 6 3-1 7 0 .

4 5 . McPa rtl a n d j M . Tr a v e l l trigger points: m o le c u l a r a n d osreop a t h i c pe r s p e c r i v e s .

j Am

O s t e o p a t h Assoc 2 0 04 ; 1 0 4 : 244-24 9 .

4 6 . Cha i to w L. O s t e o p a t h y : H e a d -to-To e He a l t h T h r o u g h M a n i p u l a t i o n . We l l i n g bo r o u g h , U K : T ho r so n s , 1 9 74 ; 2 3 , 7 2 .

4 7 . S u t he r l a n cl W G . T h e C r a ni a l B o w l. M a n k a to, MN: Free Press, 1 9 3 9 .

4 8 . K i m be r l y P E . Osteopa t h i c cra n i a l l e s i o n s . J A m O s t e o pa t h As soc 1 94 8 ; 4 7 :2 6 1 -2 6 3 . 4 9 . O l e s k i S L, S m i r h G H , C r o w W T. R a d i o g r a p h i c evidence o f c r a n i a l bone m o b i l i ty. C r a n i o 2 0 0 2 ; 20 ( 1 ) : 34-3 8 .

5 0 . Serg u e e f N , N e l s o n K E, G l o n e k T. The e ffect o f cra n i a l m a n i p u l a ti o n on t h e Tra u b e · H er i ng­ Mayer osci l la t i on a s

m e a s u r ed by l a s e r- D o p p l e r fl o w m e t ry. A l te r n T h e r Hea l rh M e d 2002;

8 ( 6 ) : 74-76 . 5 1 . H a rt B L . B i o l og i c a l b a s i s of the b e h a v i o r of s i c k a n i m a l s . N e u rosc i e nce B i o b e h a v Rev 1 9 8 8 ; 1 2 : 1 23 - 1 3 7 .

5 2 . M u l ler N , A c k e n he i l M . Psychone u roi m m u no l ogy a nd t h e c y r o k i n e a c t i o n i n t h e C N S : I m p l i c a t i o n s fo r psyc h i a tric d is o r d e r s . P r o g N e u ropsyc h o p h a r m a c o l B i o P s y c h i a t r y 1 9 9 8 ; 22 ( 1 ) : 1 -3 3 .

5 3 . H a a s HS, Scha uenstei n K . Ne u r o i m m u nomod u l a t i o n via l i m bi c s t ru c t u re s : The n e u ro a n a to m y of p s y c h o i m m u n o l o gy. hog Ne u ro b io 1 1 99 7 ; 5 1 : 1 9 5-2 2 2 .

5 4 . Wied e rma n n CJ . S h a r e d recogn i t i o n m o l ec u l e s i n the b ra i n a n d l y m p h o i d tissues: The p o l y p e p t i d e m e d ia tor n etwork o f psycho n e u ro i m m u no logy.

I J11 m u n o l

Len

1 9 8 7; 1 6 :

3 7 1 -3 7 8 . 5 5 . S h a v i t Y, D e p a u l is A , M a r t i n F C , e r a l . I n v o l v e me n t o f b ra i n o pi a te r ec e p r o r s i n t h e i m m u n e ­ s u p p ress i v e e ffec t of m o r p h i n e . Proc

Nat! A c a d S c i US A 1 9 8 6 ; 8 3 : 7 1 1 4- 7 1 1 7 .

5 6 . S e ffi nger, M A , K i ng HH, Wa rd RC, et a l . Section 1 . O s r e o p a t h i c p h i l oso p h y a n d h i s t o r y. T n :

Ward R C , ed . F o u n d a t i o n s f o r Osteopath ic M e d i c i n e . P h i l a d e l p h i a : Lip p i n cotr W i l l i a m s & Wi l k i n s , 2 00 2 ; 4 - 1 8 .

C h a pter 6 • Psyc h o n e u ro i m m u n o l ogy

69

5 7 . K o r r 1 M , T h o m a s P E , W r i g h t H M . S y m p o s i u m o n t h e f u n c t io n a l i m p l i c a t i o n s o f s e g m e n t a l b c i l i ta t i o n . J Am O s t e o p a t h Assoc 1 9 5 5 ; 5 4 : 2 6 5 -26 8 . 5 8 . Brad ford S G . R o l e o f os te o pa th i c m a n i pu la t i ve t he r a p y i n e m o r io n a l d isorders: A p h y s iologic h yp o t h e s i s . J Am O s t e o p a t h A ssoc 1 9 6 5 ; 6 4 : 4 84-4 9 3 . 5 9 . G a m b e r R G , G i s h E E , H e r r o n K M . S tu d en t p e r c e p t i o n s o f o s t e o p a th i c m a n i p u l a t i v e treat­

ment a fter completing a m a n i p u l a t i v e med i c in e rota t i o n . J A m O s te o p a th Assoc 2 00 1 ; 1 0 1 : 3 9 5-4 0 0 . 60.

Fry LJ . P r e l im i n a r y fi n d i ngs on t h e u se of os te op a t h i c m a n i p u l a t ive tre a tment by o steo pa t h i c p h y s ic i a n s . J A m O st e o p a t h Assoc 1 9 9 6 ; 9 6 : 9 1 -9 6 .

6 1.

Jo h n s o n

S M , K u rtz M E , K u r rz J C . Va r i a bles i n fl u e n c in g the use of o s t eo p a t h ic m a n i p u l a t i v e trea t m e n t i n fa m i l y p ra c t i c e . J Am O s teo p a t h Assoc 1 99 7 ; 9 7 : 8 0- 8 7 . 6 2 . J o h n s o n S M , K u r tz M E . D i mi ni s h e d u s e o f osteop a t h ic m a n i p u l a t i ve rrea t ln e n t a n d i ts i m p a c t o n t h e u n i q u e n e s s o f t h e o s te o p a t h i c p ro fess i o n . A c a d M ed 2 0 0 1 ; 7 6 : 8 2 1 -8 2 8 .

6 3 . Ma n n D D , E l a n d D C , Pa t r i q u i n D A , J o h n s o n D F. I n c r e a s i n g osteop a th i c m a n i p u l a t i v e trea t­ m e n t s k i l l s a n d co n fi d e n ce t h ro u gh m a s t e r y l ea rn i ng . J Am O ste o pa t h Assoc 2000; 1 00 : 3 0 1 -3 0 4 , 3 0 9 .

S M , K u rtz M E . P e rc e p t i o n s o f p h i l o so p h i c a n d p ra c t i c e d i ffe rences between US t h e i r a J l o pa th i c co u n te r p a r t s . Soc Sci Med 2 0 0 2 ; 5 5 ( 1. 2 ) : 2 1 4 1 -2 1 4 8 . 6 5 . J o h n s on SM, Ku rtz M E . O s t e o pa t h i c m a n i p u l a t i ve trea t m e n t tec h n i q u es p r e fe r red b y c o n ­ te m p o ra ry os t e o pa th i c p h ys i c i a n s . J A m O s t e o p a t h A s s o c 2003 ; 1 0 3 : 2 1 9-2 2 4 . 6 6 . Licc i a r d o n e JC, G a m be r R G , R u ss o D P. Q u a l i ty of l i fe in r e ferred pa t ie n ts presen t i ng to a s p e c i a l t y c l i n i c fo r os t e o p a t h i c m a n i p u l a t i v e t r e a t m e n t . J A m O s t e o p a t h A s s o c 64.

Jo h n son

os teo p a t h i c p h ys i c i a n s a n d

2002; 1 02 : 1 5 1 -1 5 5 . 6 7 . Za p h i r i s A , M i l l s

M\I, Jewe l l N P, B o y ce W T. O s t e o p a t h i c m a n i p u l a t i ve t r e a t m e n t a n d o t i t i s

medi a : D o e s i m p ro v i ng somatic d ysfu n c t i o n i m prove c l i n i c a l o u tcome ? J

Am

O s te o pat h

Assoc 2 0 04 ; 1 04 : 1 1 - E O A .

6 8 . Jo h n so n FE. S o m e o bse rva t i o n s o n t h e u se o f osreo p a th i c thera py i n the c a r e o f p a t i e n ts w i t h c a rd i a c d i se a s e . J A m Os te o pa t h A s s o c 1 9 72 ; 7 1 : 7 9 9-8 0 4 . 6 9 . Rogers JT, R ogers J c . T h e r o l e o f o ste o p a t h i c ma n i p u l a t i v e t he r ap y i n t h e trea t m e n t o f c o r o ­

nary h e a r t d i sea s e . J A m Os teo p a t h A s s o c 1 9 7 6 ; 7 6 : 2 1 -3 1 . 7 0 . B ro n fo r t G , Asse n de l ft WJ , E va n s R , e t a l . E ffi c a c y o f s p i n a l m a n i p u l a t i o n fo r c h ro n i c h e a d a c h e : A s y s te m a t i c

rev iew. J M a n i p u l a t i v e Physiol Th e r 2 00 1 ;24 : 4 5 7-4 6 6 .

7 1 . S l oo p P R , S m i t h D S , Go l d e n be rg E , D o r e C . M a n i p u la t i o n fo r c h ro n i c neck p a i n : A d o u b l e­ b l i n d co n t ro l l e d s tu d y. S p i n e 1 9 8 2 ; 7 : 5 32-5 3 5 .

7 2 . B ro n fo r r G , E v a ns R , N e J so n B, et a l . A ra nd o m i zed c l i n ica l t ri a l of exercise a nd s p i n a l ma n i p u l a t i o n fo r p a ti e n ts w i th c h ro n i c n e c k pa i n . S p i ne 200 1 ; 26 : 7 8 8-797; d i sc u s s i o n

798-799.

73 . S w e n so n R S . T h e r a pe u t i c m o d a l i t i e s i n the ma n a gem e nt o f n o n s p e c i f i c n eck pa i n . P h ys M e d R e h a b i l C l i n N o r t h A m 2003 ; 1 4 : 6 05-6 2 7 .

and mye l o pa thy : I m a g i ng, c o n se r v a t i v e trea tment, and su rgica l i n d i c a ti o n s . [ nstr Cou rse Lect 2 0 03 ; 5 2 : 4 8 9-4 9 5 . 7 5 . Ha rd i n J J r. Pa i n a n d t h e cervica l s p i n e . B u l l R h e u m D i s 200 1 ;5 0 ( 1 0 ) : 1-4 . 7 6 . K riss TC, K riss VM. Neck pa i n : Pri m a r y c a r e work - u p of a c u te a n d c h r o n i c s y m p toms. G e r i a t r i c s 2 0 0 0 ; 5 5 ( 1 ) :4 7-4 8 , 5 1 -5 4 , 5 7 . 7 7 . C a s s i d y J D , L o p es A A , Yo n g - H i n g K . The i m m e d i a te effec t o f m a n i p u la ti o n vs . m ob i l iza t i o n 74 . B o y c e R H , Wa n g J c . E v a l u a tion o f ne c k pa i n , rad i c u l o p a thy,

on pain and range o f

motion i n t h e c e r v ica l s p i ne : A ra n d o m i zed con tro l l ed t r i a l . J M a n i p

P h y s i o l T h e r 1 9 92 ; 1 5 : 5 70-5 7 5 .

7 8 . B ro w d e r D A , E r h a rd R E , P i va S R . Interm itten t c e rvi c a l t r a c t i o n a n d t h o r a c i c ma ni p u l a t ion fo r m a n a ge m e n t o f m i l d c e rv i c a l co m p r e ss i v e m y e l o p a t h y a tt r i b u te to c e rv i c a l h e r n ia ted d is c : A c a se s e r i e s . J O rr h o p S p o rts P h ys Ther 2004 ; 3 4 : 70 1 -7 1 2 . 7 9 . I w a t a J L, M u l ta c k RF, K a p p le r R , G l o n e k T. Effectiveness o f u s i n g o steopa t h i c m a n i pu l a ti o n in t rea ti ng ocu l a r tension h ea d a c h e p a t i e n ts i n a n a m b u l a tory se t t i ng with c o rres p o n d i ng red uction in i n t r a ocu l a r p ress u re . J Os t e o p a th C o i l O ph th a l m O t o l a r yng o l 2000; 1 2 : 1 5- 1 9 . 8 0 . G a m be r R G , S h o res J H , R u sso D P, et 3 1 . O s te o p a t h i c ma n i p u l a tive trea t me n t i n co n j u n c t i o n w i t h m e d i c a ti o n re l i eves pa i n a s s oc i a ted w i th f i b r o m ya l g i a s y n d ro m e : Re s u l ts o f a ra n d o m ­ ized c l i nieJ ! p i l o t project. J Am O steo pa t h Assoc 2 0 02 ; 1 0 2 : 3 2 1 - 3 2 5 .

70 81.

Section I • P h i l o s o p h y a n d P r i n c i p l es of Pa t i e n t Ca re

F i ec hrn e r JJ , Brod e u r R R . M a n u a l a n d m a n i p u l a t ion tec h n i q ue s for r h e u m a t i c d i s e a s e . R h e u m D i s C l i n North

8 2 . Ernst E .

Am

2 0 0 0 ; 2 6 ( 1 ) : 8 3- 9 6 , i x .

Com p l e m e n ta r y a n d a l t e r n a t iv e m ed i c i n e i n r h e u m a tol ogy. B a i J l ieres Best P r a ct R e s

C l i n Rh e u m a to l 2 0 0 0 ; 1 4 : 7 3 1 -7 4 9 . 8 3 . D u d ley G . S i n u s i t i s : S u p p l e m e n t m is s i n g osteo pa t h ic c o m p o n e n t .

J A m O s t eo pa t h

Assoc

1 9 9 8 ; 9 8 : 5 3 9-5 4 0 . 8 4 . H o p p RJ . R e v i s i ti n g t h e

role o f osteo p a t h ic m a ni p u l a t i o n i n p r i m a ry c a r e . J A m Osteo p a th

Assoc 1 9 9 9 ; 9 9 : 8 8 . 8 5 . Lee H , N i c h o l son L L , Ad a m s R D . Cerv i c a l ra nge o f motion a ssoc i a t i o n s w i t h s u bc l i n i c a l

n e c k p a i n . S p i n e 2 0 0 4 ; 2 9 : 3 3-4 0 . 8 6 . C o u g h l i n P,

K r i e be l R, Foge l R . N e w Eng l a n d J o u r n a l o f Med i c i ne a r r i c l e

may

be m i s l e a d ­

ing a bo u t O M T. J Am Osteo p a t h Assoc 1 9 9 9 ; 9 9 : 5 6 1 -5 6 5 .

8 7 . J e rm y n R T. A n o n s u rgical a p proach t o l o w b a c k pa i n . J A m O s teopa th A s s oc 2 0 0 1 ; 1 0 1 ( 4 s u p p l p t 2 ) : 5 6 -5 1 1 . 8 8 . B ton forr G , H a a s M , Eva n s

RL, Bouter L M . Effi c a c y o f s p i n a l m a n i p u l a r i o n a n d m o b i l i z a ­

t i o n fo r l ow b a c k p a i n a n d n e c k pa i n : A s y s te m a t i c rev i e w a n d b e s t e v i d e n c e s y n thesis . S p i ne 2 0 0 4 ; 4 : 3 3 5 -3 5 6 . 8 9 . Da n to J B . R e v i e w o f i n tegrated n e u r o m u s cu l a r re l e a se

and

t h e novel a p p l i c a ti on o f

a

seg­

menta l a nrerior/posterior a pp r o a c h in rhe t h o ra c i c , l u m b a r, a n d sacra l region s . J Am

O s te o p a t h Assoc 2 0 0 3 ; 1 0 3 : 5 8 3-5 9 6 . K L , Wa r fi e l d C A . S p i n a l m a n i p u l a t ion for b a c k p a i n . Hosp Pracr ( O ff E d ) 1 9 8 9 ; 24 ( 3 ) :

9 0 . R a ft i s

8 9-90, 9 5 - 9 6 , 1 0 2 p a s s i m .

O S . O s teopa t h i c m a n i p u l a t i o n f or l ow b a c k pa i n . Postgra d M ed 1 9 9 7 ; 1 0 1 : 5 6 , 5 8 . H o w t o i d en t i f}' t h e few w h o need extra a ttent i o n . Postgrad M e d 1 9 9 6 ; 1 0 0 : 1 4 3- 1 4 6 , 1 4 9 , 1 5 0 , 1 5 5 - 1 5 6 . 93 . W i l l i a m s N H, Wi l k i n s o n C, R u sse l l I , e t a l . R a n d o m ized o s te o p a t h i c m a n i p u l a t i o n s t u d y ( RO MA N S ) : P r a g m a t i c tr i a l for s p i n a l p a i n i n p r i m a r y ca r e Fa m P r a c t 2 0 0 3 ; 2 0 : 6 6 2 -669

9 1 . Abend

9 2 . Con n e l l y C . P a t i en ts w i t h low back p a i n :

.

.

9 4 . Ev i d e n ce - B a s e d

M ed i c i n e

C oc h ra n e

G u i d e l in e s .

Back

R e v i e w R e s o u rces .

Helsi nki:

D lI od e c i m M e d i c a l , 2 0 0 5 . 9 5 . M i o r S . JvL1Il i p ll i a t i o n a n d m ob i l i z a t i o n 2 00 1 ; 1 7 ( 4 s u p p l ) : 5 70-5 7 6 . 9 6 . K n e b l l A, S h ores J H , G a m ber R G , e t a l .

i n t h e rreatmenr of c h ro n i c p a i n

.

C l i n J Pa i n

I m p r o v i n g fu ncti o n a l a b i l i t y i n t h e e l d e r l y v i a t h e

S pencer tec h n i q u e , a n osteo p a th i c m a n i p u l a t i v e t rea t m e n t : A r a n d o m i zed c o n tro l l e d t r i a l . J A m O s teo p a t h A s s o c 2 0 02 ; 1 0 2 : 3 8 7- 3 9 6 . 9 7 . J a c o bs o n E C , lockwood M D , Hoe fner VC Jr, et a l . S h o u l d e r p a i n a n d re p e t i t i o n s t ra i n

i n j ury t o the s u pra s p i n a t u s m u s c l e : Eti o l og y and m a n i p u l a t i v e t r e a t m e n t . J A m O s t e o p a t h Assoc i 9 8 9 ; 8 9 : 10 3 7- 1 0 4 0 , J 04 3 - 1 04 5 . 98.

5 tr etfa n s k i IV! F, Ka i s e r G . O s t e o p a t h i c p h i l oso ph y a n d e m e rgent t r e a t m e n t i n a c u te resp i r a ­ tory fa i l u re . J A m Osteopath A u g 2 0 0 1 ; 1 0 1 : 4 4 7-4 4 9 .

9 9 . Bockenha uer S E ,

J u l l i ard K N ,

L o K5, et a l . Q u a n t i fi a b l e e ffects o f osteo p a t h i c m a n i p u l a t i v e

tec h n i q u e s on p a t i e n ts w i t h c hronic asth m a . J A m O s t e o p a th Assoc 2 0 0 2 ; 1 0 2 : 3 7 1 -3 7 5 . 1 0 0 . R o w a n e WA , R o w a n e M I'. A n osteo p a t h i c a p proa c h t o a s t h m a . J A m Osteo p a t h Assoc 1 9 9 9 ; 9 9 : 2 5 9-2 6 4 . 1 0 1 . Mago u n

HI. M o re a bo u t t h e u s e o f O M T d u r i n g i n fl u e n za e p i d e nli cs.

J Am

Osteo p a t h

Ass oc 2 0 0 4 ; 1 0 4 : 4 06-4 0 7 . 1 0 2 . Norrhrup T L .

P n e u m o n i a u n d e r os te o p a t h i c ma n i p u l a tive t h e r a py. I n : Nor t h r u p TL, e d .

Aca d e m y o f A p pl i e d Osteop a t hy 1 9 4 5 Yea r boo k . M a n i p u l a t i ve T h e r a p y D e m o n s t r a t i o n s .

A n n A r b o r, M J : Ed w a r d s B w t h e rs , 1 94 5 : 1 0 1 - 1 0 5 . ( No w a v a i l a b l e th r o u g h t h e A m erica n

Aca demy 103. 1 04 .

of O s teo p a t h y, Ind i a n a po l i s . )

N o l l D R , S h o res J , G a m be r R G , e t a l . Bene fi ts o f osteo p a t h i c m a n i p u l a t i v e treatme n t fo r hospi ta l ized e l de r l y p a t i e n t s w i t h pne u m o n i a . J Am O s teo p a t h A s soc 2 0 00 ; 1 00 : 776-7 8 2 . F a c to L L . T h e osteopa t h i c trea t m e n t o f l o ba r p n e u mo n i a . J A m O s t e o pa t h Assoc 1 9 4 7 : 4 6 : 3 8 5 -3 9 2 .

1 0 5 . C h i l a A G . P n e u mon i a : Hel p i n g o u r b o d i e s h e l p them s e l v e s . C o n s u lta n t 1 9 8 2 : 1 74 - 1 8 8 . 1 0 6 . K n u tson G A , J a cob M . Poss i b l e m a ni festation o f t e m poroma n d i b u l a r j o i n t d y s fu n c t i o n c h i ­

r o p r a c t i c cerv i c a l

X - r a y s t u d i e s . J Man i p Physiol Ther

1 9 9 9 ; 2 2 : 3 2-3 7 .

C h a pter 6 • Psychon e u roi m m u nology

71

1 0 7. Jecmen J M . A c r a n i a l oste o p a t h ic a p proach to correcting m a loccl u s i o n s em p loying K e rnott a nd fixed l a b i a l a p p l i a nce thera py. J Am Ac a d G n a t h o l O rt h o p 1 9 8 8 ; 5 ( 1 ) : 1 0- 1 5 , 1 7 . 1 0 8 . D u n c a n B, B a rton l, Ed monds D, B l a s h i l l BM . Pa re n t a l percep tions of t h e thera p e u t i c effec t from osteopa t h i c m a n i p u l a t i o n or a c u p u n c t u re in c h i l d re n w i t h s p a stic cere b r a l pa l sy. C l i n Ped i a r r ( Ph i l a ) 2004 ; 4 3 : 3 4 9-3 5 3 . 1 0 9 . Ya tes H A , Va rdy TC, K uc h era Ml, e t a t . E ffects of osteop a t h i c m a n i p u l a r i ve trea t m e n t a n d concentric a n d ecce n t r i c maxima l - e ffo r t exe rcise on w o m e n w i t h m u l ti ple sclerosis: A p i l o r

s t u d y. J A m Osteopa th A s s o c 2 0 0 2 ; 1 0 2 : 2 6 7-275 . 1 1 0 . R i vera - M a rtinez S, We l l s M R , C a p o b i a nco J D . A retrospec t i ve s t u d y of c ra n i a l strain p a t­

terns in p a t i e n ts w i t h i d io p a t h i c Pa r k i ns on's d i se a s e . J Am Osteopath Assoc 2 0 0 2 ; 1 02 : 4 1 7-4 2 2 . 1 1 1 . We l l s M R , G i a n ti n o to S, D ' Aga re D , e t a l . Sta n d a rd osteop a t h i c m a n i p u l a t i ve trea t m e n t a c u t e l y i m proves ga i t perfo r m a n ce i n p a t i e n ts w i t h Pa r k inson's d i sease. J A m O s t e o p a t h A ssoc 1 9 9 9 ; 9 9 : 9 2-9 8 . 1 1 2 . S u c h e r B M . P a l patory d i a g n o s i s a nd m a n i p u l a ti v e management o f c a r p a l t u n n e l s y n d r o m e :

II. " D o u b l e c r u s h " a n d t h o racic outlet syndrom e . J A m O s t eopa t h A s s o c 1 9 9 5 ; 9 5 : 4 7 1 -4 7 9 .

1 1 3 . Co l l ege of Osteo p a t h i c Physic i a ns a n d S u rgeons . H a nd b o o k o f O steo p a t h i c Tec h n i q u e . los A nge l e s : H a ynes Pri n ters, 1 94 1 : 9 6-] 0 l . 1 1 4 . N i c h o l a s A S , O l es k i S L . Osteopa t h i c m a n i p u l a ti v e t rearment for postopera ti ve pa i n . ] A m Osteopa th Assoc 200 2 ; 1 0 2 ( 9 s u p p l 3 ) :55-S 8 . ] 1 5 . H i ra y a m a F, Kageya m a Y, U r a b e N , S e n j y u H . The e ffec t s o f postopera t i v e a ta r a lgesia by m a n u a l thera py a fter p u l m o n a ry resecti o n . M a n T h e r 2 0 0 3 ; 8 ( 1 ) : 4 2-4 5 . 1 1 6 . Liccia rdone J C , S t o l l ST, C a r d a rell i K M , e t a ! . A r a n d o m i zed c o n t ro l led t r i a l o f oste o p a th i c m a n i p u l a t i ve

trea t m e n t fo l l o w i ng

k n ee

or

h i p a rth ro pla sty.

J Am O ste o p a th

Assoc

2004 ; 1 0 4 : 1 93-2 0 2 . 1 1 7 . M i l l et t PJ , Johnson B, C a r lson J , et a ! . R e h a b i l i t a t i o n o f t h e a rr h rofi brotic k n ee .

Am J

O r t h o p 2 0 0 3 ;3 2 : 5 3 1 -5 3 8 . ] 1 8 . S ucher

H i n richs

BM,

RN.

M a n i p u l a tive

t re a t m e n t

of

carpa l

tunnel

synd rome:

B i o m e c h a n ica l a n d os teop a t h ic i n te r v e n t i o n t o i n c re a s e the l e n g t h o f the t r a n s verse c a rp a l l i g a m e n t . J Am O s teo p a t h Assoc 1 9 9 8 ; 9 8 : 6 79- 6 8 6 . 1 1 9 . Stru i J s PA, D a m e n PJ , Ba k ker EW, et a ! . M a n i p u l a t i o n o f t h e w rist for t h e ma nagement o f l a te r a l e p i condy l i t i s : A r a n d o m i zed p i l o t s t u d y. Phys Ther 2 0 0 3 ; 8 3 : 6 0 8 -6 1 6 . 1 2 0 . H u a n g H H , Q u res h i A A , B i u n d o JJ J r. S ports and o t h e r soft tissue i n j u ries, te n d i n i t i s , b u r­ s i t i s , a n d occu p a t i o n - re l a te d s y n d romes. C u r r O p i n R he u m a to l 2 0 0 0 ; 1 2 : 1 5 0-1 5 4 . ] 2 1 . K i n g H H , Te rr a m be l MA, lockwood M D , e t a l . Osteop a t h ic m a n i p u l a t i ve trea t m e n t i n

p r e n a t a l c a r e : A retrospec t i v e case c o n t r o l d esign s t u d y. J A m O s t e o p a th Assoc 2 0 0 3 ; ] 0 3 :

5 77-5 8 2 . 1 2 2 . Tu rney J . Tac k l i n g birth t ra u ma w i t h cra nio-sacra l therapy. P r a c t M i d w i fe 2 0 0 2 ;5 ( 3 ) : 1 7- ] 9 . 1 2 3 . Green m a n PE, McPa n l a n d J M . C ra n i a l f i n d i ngs a n d i a trogenesis fro m c r a n i os a c r a l m a n i p ­ ulation

in

p a ti e n t s

with

tra umatic

b ra i n

s y n d ro m e .

J

Am

O s t eo p a t h

Assoc

1 99 5 ; 9 5 : 1 8 2-1 8 8 , 1 9 1 - 1 9 2 . 1 2 4 . M o rga n J r, D i c k e y J l , H u n t H H , H ud g i n s P M . A c o n t ro l l.ed t r i a l o f s p i n a l m a n ipu l a t i o n i n t h e m a nagement of h y perte n s i o n . J A m O s te o p a t h Assoc 1 9 8 5 ; 8 5 : 3 0 8 -3 1 3 . 1 25 . S p i egel A], C a p o b i a n c o J D , K r u ger A , S p i n ner W D . O ste opa t h i c m a n i p u l a ti v e med icine in the

t re a t m e n t

of h ypenensio n :

An

a l re r n a t i v e,

conventio n a l

a pproac h .

Heart

Dis

2 0 0 3 ; 5 : 2 72-27 8 . 1 2 6 . E a H K , We ber AJ , Yon F, Liote F. O s teoporotic fractu re of the dens revealed by c e rv i c a l m a n i p u l a t i o n . J o i n t B o n e S p i n e 2004 ; 7 1 : 2 46-2 5 0 .

] 2 7 . Parenti G , O r l a n d i G , B i a n c h i M, et a l . Ve rte b r a l a n d c a r o t i d a rtery d i ssec t i o n foJ l o w i n g c h i ­ ropractic cervic a l ma n i pu l a t i o n . Neu ros u rg Rev 1 9 9 9 ; 2 2 ( 2-3 ) : 1 27- 1 2 9 .

1 2 8 . H u rw i r z E l , Morgenstern H, Va ss i la k i M , C h i a n g lM . Adve rse re a c t i o n s t o c h i ro p ra c t i c treatme n t a n d t h e i r e ffects o n s a t i s fa c t i o n a n d c l i n i c a l o u tco mes a m ong p a ti en ts e n r o l led i n t h e U C L A Nec k P a i n S tu d y .

J M a n i p u l a t i ve P h y s i o l T h e r 2 0 0 4 ; 2 7( 1 ) : 1 6-2 5 .

1 2 9 . H a ld e m a n S , K o h l beck FJ , M c G regor M . S troke, c e r e b r a l a rtery d i ssec tion, a n d c e r v i c a l

s p i ne m a n i p u l a t i v e t h e r a p y. J N e u roI 2 0 0 2 ; 24 9 : 1 0 9 8 - 1 1 0 4 .

1 3 0 . Core P, C a s s i d y J D , H a l d e m a n S . Sp i n a l m a n i p u l a t i v e thera p y i s a n i n d e pendent r i s k fa c t o r f o r ve r teb r a l a rtery d i ssectio n . Neurology 2 0 0 3 ; 6 1 : 1 3 1 4- 1 3 1 5 .

72

Sectio n I • Phi losophy a n d Princip l es of Pat i e nt Care

1 3 1 . Ha l d em a n S, Ca re y P, Townse nd M, P a p a d o po u l o u C. C l i n ica l perce ptio n s o f t h e r i s k o f v e r ­ t e b r a l a r t e r y d i s s ec t i o n a her c e rvica l

m a n i p u l a t i o n : t h e e ffect o f re fer ra l

bias. Spine

2 0 02 ; 2 : 3 3 4-34 2 . 1 3 2 . H a l d em a n S , Ca rey P, To wns end M, P a p a d o po u l o u C . Arter i a l d issec t i o n s fo l l ow i n g cerv i ­ ca l m a n i p u l a t i o n : t h e ch i ro p ra ctic ex pe rie nce . CM AJ 20 0 1 ; 1 6 5 : 905-9 0 6 . 1 3 3 . D i Fabio RP. M a n i p u l ation of t h e cervica l s p ine: Ri s k s a nd benefits. Phys T h e r 1 9 9 9 ; 79 : 5 0-6 5 .

1 3 4 . V i ck D A M c K a y C, Zenge rle C R . The s a fe t y o f m a n i p u l a t i v e tre a t m e n t : Rev iew o f t h e l i t­ ,

era t u r e fro m 1 9 2 5 to 1 9 9 3 . J Am O s teopa th Assoc 1 9 9 6; 9 6 : 1 1 3- 1 1 5 . 1 3 5 . A O A Position P a p e r s . A m e r i c a n O s t e opa th ic Assoc i a t i o n H o u s e o f D e lega tes Meet i ng . Ch ic ago : A m e r i ca n Osteopa t h i c Association, A ug u s t 2 0 0 4 . 1 3 6 . N a d l e r S F. N o n p h a r rn a co l og i c m a n a g e m e n t o f pai n . J A m Osteo p a t h A s s o c 2 0 0 4 ; 1 04 ( 1 1 s u p p l 8 ) : S 6-S 1 2 .

1 3 7 . F u rl a n A D , B ross e a u L , I m a m u ra M , Irv in E . Evidence-based med i c i ne g u i d e l i n e s : Massage for l ow bac k p a I n . Coc h r a ne D a t a b a s e Syst Rev 2 0 04 ; ( 2 ) : C O l 9 2 9 .

1 3 8 . As t i n J A . M i nd - body thera pies fo r t h e m a n a geme nt o f p a i n . C l i n

]

Pa i n 20 0 4 ; 20 : 2 7- 3 2 .

1 3 9 . S h e r m a n KJ , Che r k i n DC, Con nelly MT, et a l. C o m plementa r y a nd a l terna ti ve med ica l t h e r ­ a p ies for c h r o n ic l o w b a c k p a i n : W h a t trea t m e n ts a re pa ti e n ts w i l l i n g ro tr y ? B M C Co m p le me n t A l te r n M e d 2 0 0 4 ;4 ( 1 ) : 9-1 6 . 1 4 0 . A s t i n J A , S h a p i ro S L , E isen b erg O M , Forys K L . M i n d - b o d y m e d i c i n e : Sta te o f th e science, i m p l ic a tions for p ra ctice . J Am Boa rd Fa m P r a c t 2 0 0 3 ; 1 6 : 1 3 1 - 1 4 7 . 1 4 1 . L a z a r .I S . M i n d - b o d y m e d i c i n e i n p r i m a ry c a re : I m p l i c a t i o n s a n d a p p l i c a t i o n s . P r i m Ca re 1 9 9 6 ; 2 3 : 1 69-1 8 2 . 1 4 2 . J a c o b s G O . C l i n ica l a pp l ica ti o n o f t h e re l a x a t i o n res po n se a nd m i nd - b o d y i n terv e n t i o n s . J A l te r n Co m pl e m e n t Med 2 0 0 1 ; 7 ( s u p p l l ) : S 9 3-S 1 0 1 . 1 4 3 . Ba ssett

CAL.

B i o e l ectro m a g n e t i c s

in

t h e s e r v ice

of

medicine.

In:

Bla n k

M,

ed .

Electro m a g n etic Fiel ds : B i o l og ica l I n teractions a n d M ec h a n i s m s . Adva nces i n C h e m i s tty Series N o 250. Wa s h i ngton : A me rica n C h e m ica l Sociery, 1 9 9 5 ; 2 6 1 -2 7 7 .

1 4 4 . P r i c e S , P r i c e L. A ro m a th e tapy f o r Hea l t h P r o fess i o n a l s . 2 n d ed . Lon d o n : H a rcou rt, 2 0 0 0 .

, I

SECTION

II

Patient Populations

The Psychiatric Patient Andrew Lovy

INTRODUCTION The f u nda m e n ta l s of osteopa th ic medicine are a pp l ica b l e not onl y to the p ractice of family med icine b u t a lso to the diagnosis a n d trea tment of the psyc h i a tric patient. Si nce i t s i nception osteopa thic m edicine h a s a pproached t h e p a tien t as a n ind i v i sib l e u nit. This concept goes bey ond a ho listic approa c h t o the body to include the m i n d and spirit as the tri u n e n a t u r e of humanity.l T h us, m e n ta l func­ t io n a n d d ysfu nction h a ve al w a y s been p a rt of the osteopa thic a pproa c h to pa tient care. ]. Martin L i t t l e j ohn , an early stud ent of osteopa thic medicine, fou n d e r of the Chicago College o f O s t eopat hic Medicine, and l a te r of the British School o f O steopathy i n England, s u m ma r i z ed this holism i n his description of psychia try a s foll ows: "Mind, however,

IS

not in the brain, but in the body. In the psychology of the mind the

entire nervous system is included, and this includes, in addition to the nervous system proper, the entire terminal system, that is, muscle, mucous membrane, etc. To under­ stand the mind and the mental diseases, we must have (a)

a

knowledge of the structure,

functions and relations of every part of the body to the nervous system, and (b) the clin­ ical facts brought out by those cases in which the mind is in an abnormal state. Hence our knowledge of the mind is based on anatomy,

psychopathology. "2

physiology, psychology and

73

74

Section II • Patient Populations

Because of this a pproach there has a l wa y s been the possibi l ity of consid ering the impact of somatic d y sfu nction and its effective trea tment upon menta l health.3 Throughout the first ha l f of the twen tie t h ce ntu ry, the Still-Hildreth Sana torium, an osteopathic in stitution in Macon, Missouri, was ded icated exclusively to t he study a nd tre a tment of menta l and nervous d i seases.4-7 Attem pts to correla te spec ific manifesta tio ns of somatic dysfunction with va rious forms of menta l illness met w ith only limited success.6-8 Anecdota l reports descri be efficacy with t he use of osteo­ pa thic ma nip u l a tive treatment (OMT) in the trea tment of schizop hre n i a, but there a re i n s u fficie nt s u bsta n tial d a ta to verify this sta tisticall y.4-6,9 Recently, however, a sma ll pilot s t u d y ( treatment N 8; control N 9) has sta tistically demonstrated positive effects for hospita lized depressed p a tients treated w i t h OMT.JO Whe t her or not o ne wishes to a ccept Littlejoh n's global interpreta tio n of the m i n d , the p resence of the nervou s syste m thro u gho u t the body a nd recent infor­ ma tion supporting the co n cepts of psyc honeuroimm u n o l ogy ( see Chap ter 6) make a hol i s t i c unders t a nding of physical a n d menta l we l lbei ng readily a pprecia ble . I I Thu s , the intera ction between d y s fu n ction i n the periphery and the neural and endocrine effects of the cen tral nervo u s sy s tem on the per i phery ma kes the red uc­ tion of peri p h e r a l nocice ption w i th OMT a pote ntia l ly via ble contr ibution to psychothera peu tics. =

=

CONTEMPORARY PRACTICE The fa mily phys i c i a n is by definition a pri m a ry health care p rovider and as s u ch ass u mes responsi b i lity for a l l man ner of patients. It has been estimated that as ma n y as 50% of a ll primary care vis i ts i nvol ve chief complaints with strong psychologic undercurrents.12 Patients wit h obvio u s psych ia tric proble m s a re, however, in a minori ty. A l l too often the presen ting complaint is a n e l u sive physical symptom. Acr u a l l y, nea rly every physica l compla int h a s a psyc hic compo nent. A list of com­ mon physica l com pla ints tha t may be psychologically m otiva ted or at least linked i n c l u des low back pain, chro n ic pe lvic pain, tin n i tus, heada che, d izziness, a typical c hest pa in, d y s pnea, te m poromand ibu lar joint pa in, generalized musculoske letal pain, fa tigue, irritable bowel s yndrome, hypoglycem i a , and mul tip le chemical sen­ si tivity.13 Many of these compla i n ts a re obviously refera ble to the m u scu loskeleta l system a nd consequentl y are pa rticular l y l ikely to ap pear before a practitioner who uses OMT. These patie n ts have bee n said to be soma tizing. T h u s, these s ymptoms m a y a p p ropri a te l y l e n d consideration to psychiatric diagnoses a nd the need for treatmen t. Certa in psychia tric diagnoses are more likely than others to involve som­ a tizat ion foc u sed u pon the musculoske leta l system. Personality disorders, tho se of c l uster B i n the DSM-IV-TR (a n tisocial, histrionic, narcissistic, and borderline) are likel y to soma tize . Ad d i tiona l l y, a ffective d i sorders, i nc lud ing m a j o r depress ive dis­ ord er, d y sthymia, a nd minor depression, can cause soma tic complain ts, as c a n the paranoid ty pe of schizophrenia a n d anxiety d isorders, su ch as panic disord er, gen­ e ra lized a nx iety disorder, a nd obsessive-compu l sive d isorder.14,1.1 The irony of t hese situ a tions is that when the somatizing patient with a muscu­ loskeleta l or viscera l compla i nt is subjected to a thorough osteopa thic structlLral exa min a tion , soma tic dysfunction consistent wit h the complaint is often identified . This is because t he patient is not necessa rily fa bricating t he complaint but ra ther is i n te n sely focused upon it. The association between soma tic dysfunction a n d psycho­ somatic symptoms has bee n recogn i zed in the osteopa thic literature for decades.lo-Is The term psychosomatic refers to the inseparable i n teraction between t he psy­ che (m i n d ) a n d the soma (bod y ) . More prope r l y referred to a s psychophys iologic

Chapter 7 • The Psychiatric Patient

75

disorders, this group of illnesses presents primarily as phy sical conditions that are affected by emotional factors. They typically involve

a

single organ system and are

usually a s soc i a ted with increased activity of the autonomic nervous system. Symptoms result from physiologic changes that normally accompany certain emo­

tional states, but these changes are more intense and sustained than normal.14

It is not difficult to understand the neurophysiology of viscerosomatic and soma­ tovisceral reflexes. 19 (See Chapter 5.) The psychophysiologic relationship is acknow l ­ edged, s o why should there n o t b e similar psychosomatic a n d somatopsychologic pathways? The psychosomatic pathway can be explained neurophysiologically by the ability of [he segmenta l faciliration, found in association with spinal s oma tic d ysfunc­ tion, to focus descending neurologic impulses from increased cortical a c t i vity, as m igh t

be found in many psychiatric conditions.2o-n This produces segmental hyper­

sensitivity to nociceptive stimuli, which in turn results in increased cortical awareness of structures, somatic and/or visceral, innervated by the facilitated segment.21 It also explains how emotional distress, acting through descending pathways, can be direct­ ed by the facilitated segment to result in gastrointestinal hypermotility or bron­ chospasm, depending upon the anatomic level of the spinal cord facilitated. A somatopsychologic pathway is equally plausible. It is generally acknowledged that when an individual has discomfort, there is commonly an accompanying psy­ chologic response. Painful discomfort is transmitted to the central nervous s y s tem by noc i ceptive neurons. This results in segmental facilitation, and impulses continue up the spinal cord and through the limbic system, where emotional associations

can be made, eventually reaching cortical awareness.

Osteopathic medicine has always considered the integration of psyche and

soma, just as it has soma and viscera, as part of its theory and practice. Physicians who incorporate manipulative therapy into their practice will inevitably use the integrative concepts to treat some patients who present with psychopathology.

Conversely, they treat many individuals with physical symptoms who have psycho­ logic issues affecting the soma and viscera. In a holistic model, soma tic dy sfunc­ tion and psychologic dysfunction a re inseparably linked. Manipulation has been recommended to reduce stress-related musculoskeletal tension and sympathetic hyperactivity found in association with a multiplicity of psychiatric illnesses, including sch izophren i a ,s,17 depression,1o anxiety,17,23,24 and somatoform disorders.16-18.23,24 OMT has been recommended as an appropriate

procedure for a ll age groups, including childrens and the elderly. IS

The family physician must learn to recognize psychiatric issues. Among these are somatic presentations that originate in psychologic and emotional issues. The ques­ tions, then, are these: How does one integrate the diagnosis and treatment of somatic dysfunction into the treatment of the patient whose musculoskeletal dysfunction is significantly linked with psychologic dysfunction? Under what circumstances is OMT indicated? What forms of OMT are appropriate, and when is OMT contraindicated?

The Somatizing Patient Somatization is a defense mechanism, an a utoma tic psychologic process that protec ts the individual from anxiety a nd the awareness of internal or external stressors or dangers. It mediates the individual's reaction to externa l stressors and emotional conflicts. Somatization as a defense mechanism is charac terized by physi cal complaints not fully explained by an existent medical condition but severe enough to result in medical treatment or alteration in lifestyle. Symptoms can include pain in various a na tomic areas, often suggest ne u r ologic involvement, and often involve the ga s t r o i ntestinal

a nd

reproductive systems.J4

76

Section II • Patient Populations

To be classified as havin g somati zation disord er, a complex of symproms known in the past as hysteria or Briquet's syn d rome , the patient must demonstrate a con ste l lation of pain a n d gastroin testinal, sexual, and pse u doneurologic symp­ toms before age 30, and the condition m u st have been prese nt for years. This is one of the somatoform disorders, the ot hers bein g und iffere ntiated somatoform disorder, conversion disorder, pa i n disorde r, psychoge n ic pain disorder, hypochon­ driasis , ne u rast h e nia, and pse u docyesis.'4 Patie nts with m a n y types of me nta l disorders e m p loy somatizat ion as a defe nse. Affective disorders, incJu d i ng major d e pressive disorder, dysthymia, and minor d e p ressio n , can ca u se somatic comp lai nts, as ca n anxiety diso rders, suc h as panic disord er, genera l i zed anxie ty disord e r, and obsessive-comp ulsive disor­ der.15 An anxiety disorder of child hood and ado lesce nce , ove ranxio us disorder, considered by some to be equivale n t to the ad u lt diagnosis of generalized anxie ty d isorder, may present as ge ne ral te n sion and an i nabi lity to relax, with recurrent somatic comp lai nts for w h i ch no orga nic cau se can be fou n d . Persona l ity disor­ de rs, particu lar l y those comp rising C l u ste r B in DSM-IV-TR (histrionic, antiso­ cial, narcissistic, and borderl ine) are like l y to somatize .14 Among psy chotic patients, schizophre n ics may d e m o n s trate somatic concerns that can reach d elu­ sional propo rtio ns. Posttraumatic Stre ss Disorder

Another group of individ uals like l y to seek treatme n t for a somatic complaint that is intimately l inked to psyc h ologic issues are patients with posttraumatic stress dis­ order ( PTSD). This is a specific fo rm of anxiety disorder invo lvi n g exposure to an exce pt ional me nta l or phy s ica l stressor, s u c h as expe rie n cing, w itnessing, or con­ fronting an event i nvolving actual or threatened deat h or injury of oneself or anot her. The immediate reaction is intense fear, help lessness, or horror. It is fo l ­ lowed by recurrent re living o f the eve nt, avoidance o f stimuli associated with the event or n u mbing of ge neral res po nsiveness and by manifestations of fear and increased arousal. T his can occ u r immediately or may not ap pear for months or much longer afte r the trauma . Re l iving of t he event can occ u r as rec u rrent, intru­ s i ve, and distressing recollections of it, as images, t h o u g hts, or perceptions. PTSD also can manifest as recurren t dist ressing d reams of the event or a s u d den feeling as if the eve nt were rec u rring. In t hese patients some aspect of rhe body can be lit­ erally or sym bo l icall y linked to the past tra uma. Patie n ts can expe rience powe rful psychologic distress or physiologic reactiv ity if they are exposed to intern a l or exter nal cues t h at sym bolize or resem ble some part of the original event: The affected pe rson wi ll conseque n t l y try to avoid tho u g hts or fee lings associated with the event or anythin g that might arou se recollection of it. The re can be am nesia of an important aspect of the event, or it may be entirely repressed , as is often the case with PTSD from sex ual a buse . Such patients may lose interesr in signif icant activiries . They may fee l d etached or estranged from othe rs, have a sense of a fore­ shortened fut u re, have d if ficu lty s l eeping, be irrita b le , be prone to a ngry outbursts, have difficulty in concentrati n g , or demonstrate an exaggerated startle res ponse . According to Hans Se lye i n his key work on gene ra l a daprive syndrome, once there is a stress, tiss ues react in the i r character istic way.25 Factors that influe nce the effect of trau ma inc l u d e ge netic p redis posirion, p lasticity of the individ ual brain (as the brain develops, t he s ignifica nce of a stressor or its permane n ce may chan ge), the c hemical matrix, past expe riences includ i ng formative t u torial s (w hat one is t a u ght ear l y in life a bout onese l f, one's abilities, and how safe or unsafe rhe

Chapter 7 • The Psychiatric Patient

77

world is), and the dur ation, intensity, and frequency of the trau matic event. These factors determine how one defends ones elf. A further d eterminant is the individ ual's perception of the viability of d efense. A person who feels that d efense is viable may d efend or attack. If the ind i vidu al

does not feel i t is viable, flight is the alternative. If defense is perceived as unviable and no escape is pos s i ble, the res ponse is freezing. Experiments us i ng executive animal mod els (rats,26 monkeys27) d emon s trate that learned helples s ness over time can res ult in integrated altered chemis tri es, altered structure, altered brain path­ ways, and altered pos ture. We are all familiar with the differe n c e betwe e n the gait

and station of an i n d ivi d ual who i s profoundly depressed or anxiou s and the same person's mobility when be or she is fee l i n g well. Charac ter defenses are traits of the ind iv i d ual's personal i t y that serve uncon­

scious protective purposes . W i lhelm Reich, a s t udent of Freud's, d escribed

a

link

between suppressed or repres sed as pects of an indivi d ual's personality and the bod y, and he d eveloped the concept of body language. He conclud e d that people form a kin d of armor to protect themselves from the blows of the outsid e world and from their own desires a n d i n s tincts. The mechanism of PTSD is a form of character d efense in which in part unconscious posit i on i n g that stems from pre vi­ ous physi cal or psychologic trauma provides the patient with a symbolic or real postural defense against further attack. Thus, the soma comes to symbolize an aspect of the un conscious psyche. Reic h went on to develop tec h n iques to in terpret pat ients' defensive body lan g uage and to help them deal with it by u nders tanding how it came abo u t in the first place.n The main d efense mechanism active here is repression . When somethin g is so painful, so unacceptable, that one cannot deal w i th it and continue to survive, the memory is shut out of awarenes s . It is s till pre s e n t, b u t it has been moved into the unconscious . It still has power, shown by the way people act, some times in way s that are not necessarily driven by what is happen i ng at the time. The treatme n t from the psychiatric per spective often i s to make the p erson aware of the original trauma, to bring it back i n to consciou sness a n d d eal w i t h it in the present . When a

traumatic memory is sup pressed and e v e n t u ally repre ssed, it is not only the

thought that is blocked but possibly also the assoc i a ted action or need for action, because the two are intimately l i nked. For example, if a boy m u s t re peatedly raise his right han d to prote c t himself from being s truck, he may not only repress the fact that he has been struck b u t also the reason he rai s e d his hand. When this occurs, the muscles employed in defe n s e are freq u e n tly tense. In this circu mstance, the psychologic i ssues that the trauma created accompa n y physical issue s . Muscles tig hten o r become slack; inte r nal organs res pond by either shutting down or becoming hyperactive. The individual surv ived the init ial trauma and pushed it i n to the un conscious, where it is taken out of awareness. The person can func tion but mus t expend energy to keep the original hurt from conscio u s awareness. Occas i onally such a d efense fails . I f a thought, feeling, body pos t u re, or some other reminder occurs, the body agai n reacts for an i n stan t or longer, not to what i s occurring now, but to what occ u rred in the pas t . Osteopathic phy sicians are sensitive t o the medical problems the pat i e n t faces a n d their

effect

upon

the

musculoskele tal

sys tem

as

viscerosomatic

reflexes.

Conseque ntly, the osteopathic physician can d iagnose visceral malfunction through palparory skills and the ability to integrate this information into the musculoskeletal findings. In the same sense, the os teopathic p h ysician should address psychologi c issues. The term somatoemotional has been used t o d escribe the relationship between the soma and the psyche, but the relationship goes far bey ond this. This relationship

78

Section II • Patient Populations

m a y be viewed as a mind-bod y-m i n d feed back loop or synd rome. As w ith the inter­ relatio n s hip between v i scerosoma tic and som a toviscera l reflex es there is a reve rber­ a ting rela tionship between menta l action a nd reaction and the soma. C lini cal experience demonstrates that muscles are freq u ently tense, and somatic dysfunction prod uces tro u bl esome imbala nce . This is often not because the origin was physica l or mec ha nica l b u t rather because t h e origin was emotiona l . The res u lta n t somatic res ponse is an attempt at phy sical resolution. Just as emotiona l blocking occurs at a n unconscio u s level, m u sc u loskeletal d y s f u nction m a y res ult from unconscious m echa nisms . If the patien t is observed ca re fully, the links bet\vee n emotio n a l issues a n d phy sica ll y d efensive pos i tions, s u c h as a rm, leg, or h e a d position, c a n be ident i fied . The p a tient does not separa te the experience into i ts e le m e n ts, a l though m a ny eleme nts of an exp erience are stored in di ffe rent areas of the brain a nd can be triggered by differing sti m u l i . It is possi b l e for some of the elements to be s u ppressed while o t h e rs are f u l ly active . Frequent ly indivi d u a ls pick up o n l y portions of a memory, whi l e other parts require more t r i gge r i n g or cueing before they a re recalle d . Occasionally, any nons pec i fic stim u lus triggers recollection of t he entire experi­ ence or perhaps only t h e anxiety a n d fear that the origi n a l experience c a u se d . The osteopa thic physician can p a lpate the e ffects of this recollection in the m usculoskele­ tal system. Certain issues a re more l ikely to c a u se suppression tha n repressio n . I t i s n o t a qua ntum l e a p to s e e that some u np leasa n t incid e n ts invo l ve the patient's e motions, bod y, and tota l life and s urvi val. These incidents are a versive, pa inful, and u naccepta ble, a nd the patient moves them, or at least t h.e dangerous portions, out of consciousness. The patient can now conti nue to fu nction withou t being preocc u pied by d efending against tra uma. This defense, however, extorts a p rice; psychologic effort expends mental energy. Many events that m a y trigger a pa rtial recall of th.e origina l painfu l incid ent ca n occur during the rest of life. The patient respon d s partia l l y to the triggering event in the presen t situation but a lso part ially as a defense aga i nst the former, now u nconscio u s , insult. Much u ncove ring psychotherapy is based upon this return to consciou sness of what was repressed and dea ling with the situation in the present. Tra u m a to the ind i v i d ual c a n c a u s e temporary or pe r m a n e nt cha nges in struc­ ture, fu nction, a n d a bility to i ntegrate the total bod y mechanis m . Whe n the tra u m a i s e motion a l, t h e i n fl u e n ce can b e f e l t not o n l y a t t h e time of t h e tra u m a b u t long afterwar d . If the tra uma is suffic ient to overload the person's defenses, the actu a l i ncident may b e pushed d eep i n to t h e unconscious s o tha t the person c a n continue to fu n ction. It does, however, take its toll. The individ u a l may reflect the effect of ti1e trauma i n u ncon scio u s ways. It may result in partia l me mories or fear, even when there seems to be no connection to the original situa tion in the present. These fea rs can l e a d to part i a l and even tota l immobilization of the individual, who then ca n not fu nction in most areas of life. Whether the diagnosis is PTSD, soma toform d i sord er, or any other of the a nx iety d i sord ers, the effe ct is d eva s ta t ing . ,

The Psychodyn amics of Soma tic Dysfun ctio n

Somatic dysfu nction, be i t the result o f postura l i m b a la nce, sprain, strain, o r viscero­ som a tic reflexes, can be present without psychologic implica tions. In somatic dys­ func tion with psychologic implica tions, however, there is literal or sy m bo l i c signifi­ cance to associa ted muscle ten sion, a position that may ha ve been h.e l d as a means of expression or defen se, s u ch. as tilting of t h e head or moving an arm i n to a certain position, as if to defen d onese lf. Sometimes a m u scle will tense although there is no

Chapter 7 • The Psychiatric Patient

79

actual motion, and the al erting mechanism is called i n to play; the defense is mobi­

lized, bur the muscle does not mov e for any of several possi ble reasons. Sometimes the symptom manifes ts during conversation; the person takes a par­ t i c u lar pos i tion whe n disc ussing a certain topic. This is diffe r e n t from a ha b i t, whic h causes the person to ass u me a particular body position. Sometimes the voice or demeanor c hanges regardless of the topic-although that, too, can be a result of unconsc ious fe elings. Consider an indi vidual trying to mov e a partic u lar body part b u t not being able to, as when be i ng forcibly held. Muscular tens ion c a n be identified in those bod y partS even though the muscle did not act ually con tract. Neurolinguistic phenomena occasionally manifest as an image, a sou nd, a smell, or

a

tacti l e sensation rather than verbal output. The comment "This makes my

skin crawl," for example, ill ustrates the somatic equivalent of a psychic feeling. It is as if e very memory, e v ery trauma, and every pleasan t as well as unpleasan t

experience is stored in the brain. When recalled, the e n tire pic ture may reappear: sights, sound s, smells, bod y positions, emotions, an d so forth. The experience may be stored in a hid d e n place, the uncon scious, for d iverse reasons. This u s u ally i s the result o f a happening so u npleasant that it had t o b e blocked o u t o f aware n e s s and h i d d e n from consciousness. Some times a partial memory comes back; thi s can be triggered deliberately or by accid ent and result in inexplicable symp toms. So some people assume certain body postures. The osteopathic physician may not know exactly why a patie n t does so or why it occurs at specific times i n the patient's life, bur und erstan d ing how the person came to assume the pos ture can help the physician understand the patient. Without u nders tanding, it is d i fficult to explain why a particular m uscle or group of muscles is tense. Sometimes it is possi ble to gai n u nderstan d ing while working with the patient. From a psychiatric p erspective, talk­ ing to patients and listening to what they say lets the clinic ian pick u p themes and build upon those themes. Similarly, patients respond to the physical examination and trea tme n t with OMT. Often treatme nt s uccessful l y alleviates the somatic dysfu nc­ tion. Occas ionally, though, those problem areas return in spite of expert treatmen t. In that case it is necessary to reevaluate . Has treatment addressed only the symptom of

a

more pervasive underlying problem? Is there postura l imbalance, a leg length

d if ference, an overuse syndrome, or viscerosomatic in�uence? Sometimes the somatic dysfunctions do not stay corrected. Possibly an emotional conflict causes a phys ical response , and sometimes a physical situation has emotion s attached to it. The cycle contin u es until it becomes diffic ult to tell which came first. Alt hough the fund of osteopathic literature ded icated to t h e treatme n t of psy­ chiatric patie n ts is limited, it is significant in terms of the recognition of the m i nd­ body in terface and actions and i s worthy of s t u dy. Man y of the writings are single case studies or s m a ll sam plings, b u t they poi n t out not only

a

n e e d for further

research but also a need for prac tition ers to ad dress these phenome n a. Re view of old psychiatri c literature reveals that concepts and models of behavior rarely change , and so the y are worth examin i ng for an u nderstandi n g of the thi nking of the times. What c hanges as scien c e progresses is n e u rologic, neuropharmacologic, and psychologic knowledge. Bas ed upon thi s adva n c i n g knowl edge, treatme n t modalities change, b u t they seldom n egate the valu e of the original h ypotheti cal constru cts and the theoretical models.

The Role of OMT Patients' patterns of somatic dysfunction are as unique as the individual. If somatic dysfunction is diagnosed and appropriately treated wi th OMT, it should resolve.

80

Section II • Patient Populations

Manipulative procedures may be classified according to how aggressive they are as physical intervention. (See Chapter 4.) It is thought th.at psychiatric patients are probably most appropriately treated with procedures from the least aggressive end of this continuum . Certainly, high-velocity, low-amplitude treatment should be avoided under most circumstances.J8•24 It is recommended that treatment begin in the least painful areas, starting with soft tissue and avoiding forceful procedures. If vertebral mobilization is attempted, it is best accomplished by rhythmic articu­ lar rocking or springing procedures.16 Touch is a primal form of communication, and because of the possibility of mis­ interpretation, it must be employed with the greatest caution in treatment of a patient with psychopathology. OMT is contraindicated if the patient does not wish to be touched or feels that the intervention is too uncomforta ble. 24 OMT is the definitive treatment for somatic dysfunction only. Just as the recog­ nition of a viscerosomatic reflex offers diagnostic information that can lead to the specific treatment of visceral pathology, recognition of the linkage between somatic dysfunction and psychologic dysfunction can provide

entree for effective

psychotherapy. Recognizing

a

Connection

After the structural evaluation and treatment with OMT, an unanticipated response may occur. Something happens to the patient, who reports a smell, a sound, a tune in the head, or a change in muscle tension that is not explained entirely by the manipu­ lation or by the reduction of somatic dysfunction. This should alert the physician that there is something more ,

an

unidentified emotional component. The treatment of the

somatic dysfunction has not corrected the entire problem. It is no different from using the musculoskeletal component as an indicator of a visceral phenomenon, a viscero­ somatic reflex. In that case, the visceral pathology must be addressed, whether it is the gallbladder, stomach, heart, or lungs, before the reflex-associated somatic dysfunction will respond to treatment. The converse also is true. Through somatovisceral action OMT can affect cholangitis, gastroenteritis, or any internal organic problem with musculoskeletal manipulation. Altbough it is appropriate also to treat the visceral component specifically, the task is not complete until both visceral and somatic components of the reflex relationship, that is, all of th.e components responsible for maintaining a state of dysfunction, have been treated. This relationship also applies between the somatic and emotional components . Changing position or relieving muscular ten­ sion with OMT may alleviate the emotional component. If the patient then is able to link that response to the present, the defensive position may no longer be nec­ essary. The symptomatic relief may drive the repressed memory from the uncon­ scious into the conscious, allowing it to dissipate. Once traumatized, the patient reacts, and treatment is directed toward repair­ ing the damage, regardless of the etiology. Finding the etiology may help explain the presence of the trauma and assist in prevention of further trauma . Etiology is important in understanding the cause of the reaction, but it does not necessarily direct one to the most effective course of treatment . Which came first, the chicken or the egg? The somatic dysfunction or the emo­ tional issue? The complex interaction between the soma and the psyche often makes this a difficult question . In the case of PTSD, the trauma, if it was emotional, most probably preceded the somatic response; if the original trauma was physical, the somatic and emotional components may have occurred almost simultaneously.

The somatizing patient, whose physical complaint is focused upon an area of

Chapter 7 • The Psychiatric Patient

81

somatic d ysfu nct i o n, o n the ot h e r ha n d , may well have beco m e foc u se d upon a prior musc u l oskeletal discomfo rt . In any case, because the family phys i c i a n deals with the here and now, the clinical quest i o n s are t hese: How much o f this ca n or s h ould the pri mary care p h ysicia n attempt to treat? When does it become neces­ s a ry to co nsult a psyc h i atrist to a d d ress the e m oti o n a l c o m p o n e nt? The fa m ily p h ysicia n c a n d iagnose a nd treat many emotiona l con ditio n s . But more c o mplex issues, ind ivid uals who demonstrate extensive or persistent d i sa b i l ity, sho u l d be referred to the spec i a list for concomita nt psyc hotherapy while the family physici a n may conti n u e , i f a ppropriate, t o a d d ress the s o m a t i c c o mponent. Anxiety and Tension

Does red u ction of a nxiety red uce tension? Is red u ct i on of ten s i o n eno u g h? N ot a l l psychopathology i s a re su lt o f tensio n , but tensi o n c a n m ake it worse. The p hysi­ cia n can make the perfect c o rrecti on, use the appr opr i ate proced u res, but u ncove r a n u nexpected som atoemotional component . O n occ a s i o n a c l i nici a n who uses OMT becomes aware of so meth i n g happening that app ears to go beyo n d the p hys­ ical to uch or the posit i o n i ng of the p atie nt, so mething t hat defies i ntervention. As the ph ysician m oves the patient d u r i ng treatment, t h e p u rpose i s to rel i eve te nsion, red uce m u sc l e spa sm, enhance ava ilable ra nge of motion, and correct pos iti o n a l i m b alance . It is fairly common for t h e emotional component t o become trou b l esome again. The c l i n ician m a kes a physica l d iagnosis, identifies a therapeutic p l a n, and imple­ ments it, o nly to find that the patient received little or no rel ief and that the original dysfu nction, poss i b l y along w it h others, is sti l l tro u b lesome. Another try fa i l s to pro­ d uce the desi red therape utic respo nse. Possi b l y the OMT or even the diagnostic eva l ­ uation appears t o h ave greater significa nce for the patient tha n w a rra nte d . The Emotional Release

Many patients a re s h y. They have pro blems with l o oki n g at othe rs, exp o s i n g them­ selves, or having thei r bod i es pa l pated, but t h i s reaction c a n go beyond simple m odesty. Othe rwise ne utra l areas of the body may be d efended vigoro u sly, or sig­ nifica nt areas may n ot be defe n d e d at all. The patient may become frightened, tense up, even begin to cry u n c o ntro l l a b ly. The patient has a n e m otiona l resp onse or a brief reco llection of a forgotte n past event. It is seld om a total recall experi­ ence, but it can be. Some body areas, some move m e nts, some pos itions, a n d some therapists a re pa rtic u l a rly likely to t rigger these e motions that seem unrelated to the sti mu l us. When t his occu rs, notice whether there is m u scu l a r ten sion or total relaxat i o n and try to l i nk the person's position at the m o m ent to a s i m ilar or i d e n ­ tica l tra u m atic pos ition i n the pa st. The response may be s u r re n d e r, a s the m u scles go flaccid, or it m a y be rigid ity, particula rly i f the defe n s ive behav i o r w a s u sefu l at the t i me of the orig ina l t ra u ma . Put t i n g the person in the position of t h e orig i n al inju ry freq uentl y exposes but n o t necess a r i l y rele ases the e m ot i o n al compo nents. Physical, emotional , or sexual a b use, either at key t i mes in deve l o p m e nt or ove r a protracted period, wit h the person n ot a ble to l a u n ch a n effective d efen se, is fre­ quent l y the c u l p r it. The patient had to tolerate the a bu s e to survive or s u rvived i n spite o f the a b u se . The person was a b l e t o d e fend i n some w a y b y blocking out what was happe n i ng or what could not be controlled . The pers o n e ither did n ot o r c o u l d not physically d e fe nd against t h e abuse. O n c e one reac h e s this point in the treatme nt session, the rea l work begi ns: the process o f i ntegrating the patie nt'S e motions with the b o d y. Althou g h it ma y not m ake sense to the physic i a n at the time, t h i s proce d u re is very s i m il a r to perfor m i ng a myofa scial rele a s e . O n e works

82

Section II • Patie n t Populatio ns

thro ugh th e tension of the variou s fascia l p l anes. One ca nnot g u i d e the process, or force it; one can mere l y try to follow it. At this point, one needs to a sk oneself and the patie nt: Has t h is eve r happened before? Has it h a ppened before und er s im i l a r c i rcumstances? Does this remind the pati ent of somet h i ng? Sometimes the patient has avoided the particu l a r pos ition beca use it was so well d efe n d e d . Other times the patient may have accidenta l l y ass u m e d the pos ition, had a reaction, d i d not u n d erstand it, did not l i n k i t w ith a nythi ng, and so did not see a p h y s i c i a n to explore it. Many have had ful l neuro­ log i c eva l u ations beca use the problem seemed more n e u rologic tha n somatoemo­ tiona l. A str a nge sme l l, a p artial paralysis or weakness, or seeing bright flashing lights can lead one in that di rectio n , a n d of course, it is a ppropriate to go there. When looking at an organic component as the p roblem, it is also necessary to con­ s i d e r the orga nic find ing as p a rt of a full somatoemotio n a l constel lation. By now, the physicia n should realize that a repressed memory may h ave been triggered , and until t h i s aspect of the patient'S p roblem is d e a lt with, a l leviation of the somatic sym ptom is impossi b l e . Moreover, the d ept h , natu re, a n d severity of the emotio n a l tra u m a is not always mirrored by the severity of the associated somatic d ysfu nct ion. Som e d ysfu nctions a re very resistant to treatment w ithout fu l l y exp lor i ng the origin a l incident, while others are not. An origin a l incid ent t h at was terribly sign ificant at the time may in t h e b road scope of things turn out not to be aU t h at important a n d m a y be s h rugged off. At other times, what appears to be a minor tic or a n noya nce may in fact have a representatio n from chi l d hood o f something very tra u matic a n d i mportant t o the d eve lopment of the person's per­ sonality. Th u s, the phys ician must consider defense mechanisms from a psychologic perspective as we ll as from a biomecha nic a l one.

OMT: Re l e a sing the Emotiona l Compone nt Bearing i n mind that a patient's anatomically neutral (the physical mid point), fu nc­ tionally n eut ra l ( b alanced m uscula r tension), and e motionally balanced (comfort­ a b le , at equ i librium) states may not a l l necessaril y reflect t h e same position, the physici a n attempts to p ut the patient i nto a neutr a l position where oppos i ng ten­ sions a re balanced. Tissu e tension m u st d irect the physician, not vice versa . While moving the patient into position, it is u se ful to vis ualize the muscle groups that might have been i nvo lved in the o r iginal trauma and attempt to place them in the least physically stressful position. It may require tri a l and error to id entify the posi­ tion of m a xi m u m relaxation. This is a d y n amic process. Each time the p hysician successf u l l y pos itions the patient, the patient rea djusts a nd new tensions emerge. As t h e patient shifts into each new ne utral pos ition , the p h ys icia n d evelops new con­ cepts and thoughts a bout the origin of the patient's p ro blem. Through this process, new hypotheses arise as old ones fa d e. Any sensory stim u l us-sounds, sights, smells-may origin a l ly have been involved. Although the physician is dea ling with bod y position in terms of intervention, a new defensive position may be assu med as a result of the p resence of anot her h i d d e n memory associated wit h a sound, a smell, or a thought or when the patient is under stress or t i red . As the p h ysician proceeds with the intervention, the emot ion a l component will eventually b e released, and the patient may s u d d e n l y feel s a d, a ngry, or frightened or begin to cry, bringing repressed emotio n s into the present moment where they can be d e a lt wit h . A s d efenses a r e re moved , the release c a n be s o p ronounced that a n emotional crisis may be prec ip itated , and the p h ysic i a n must be prepared to make an a ppro­ priate response. The physician ma y find a raw, exposed psyc h e s u d d enly revea led,

C h a pt e r 7 • The Psychi atric P a t i ent

83

a n d it m u s t be dea l t w i t h . U s u a l l y one c a n not lea ve the patient in t h a t p o s i t i o n physical l y or e m o t i o n a l l y i n o r d e r to c a l l t h e spec i a l i s t a nd say, " Here 's w h ere w e a re. Here 's w h a t we have. S o w h a t d o I d o n o w ? " Someti mes t hat may be t h e o n l y optio n , a nd o n e m u s t s a y, " H a ng on there a n d le t me see if I c a n get a p s ych i a tr i s t on t h e p h o ne . " B u t i t is better to h a v e b a s i c psyc h i a t ric k n ow l e d g e , a c o n c eptu a l model t o w o r k w i t h , a n d p r oced u re s t h a t w i l l a l leviate t h e e m o t i o n a l d i s tres s a nd seal it back u p-wh i l e m a k ing it a v a i l a b l e again fo r treatment by a spec i a l i s t.

Pitfa l l s . Pratfa l ls . a n d Preca u t i o n s A nu mber of p a t i e n ts with psyc h i a t r i c conditions h a ve s o m a t i c c o m p l a i n t s . The c h a ll enge fo r the p r i m a ry c a re p hysici a n is how to i de n tify these p a t i e n ts and a d d ress th e i r p h y s ica l c o m p l a i nts a s we l l as their psychologic i s s u e s . These p a t ients h a v e somatic d y s funct i o n . There fo re, w h e n they are e x a m i n e d a n d somatic d ys­ fu n c t i o n is d i a g n osed , their s o m a t i z a t i o n i s corro b o r a te d . O MT, if i t f u rth ers t h i s corrobora tion or fu lfi l ls needs fo r a tten t i o n , c a n c rea te dependence. l s So m a t i z i n g p a t i e n ts who a re not m a n i festing overt psyc h i a t r ic s y m p toms before trea t m e n t c a n deve l o p them when thei r somatic dysfu n c t i o n i s effectively resolved w i t h OMT. T h i s m a y be t h e resul t o f the u s e o f soma tic s y m ptoms a s a d e fense mec h a n is m that the treatment has d i sa b l e d , so that s o m a ti za t i o n i s n o lo nger effec t i v e . At t h i s p o i n t the p a t i e n t 'S u n d e r l y i n g psych i a tr i c i s s ues rise to the s urfa c e . The q u estion i s not w hether OMT is i n a pprop r i a te . The questions a re when the proper ti me is, what the prope r p rocedu res fo r m a x i m u m benefit to the p a t i e n t a re , w h a t psychothera p y is a pp r o p r i a te, a n d w h e n i t s h o u l d b e employed . Defenses, l i ke somatization a nd repress ion, serve p r o tect i ve p u rposes, a n d dis r u p tion of them leaves the p a t i ent v u l n era ble. The s i m p lest reco u rse for the pat i ent is to cl i ng tenaciously to the d i s r upted defense in an a ttempt to restore it. This is why, when the soma tic component of the somati zing patient is effectively treated with OMT, the patient may demonstra te a p a rad oxica l response. E ven though the o bj ective fi n d i ngs assoc iated w i th the d ysfunction are decreased, the patient may report that the s u bjective compla i n t is worse. Identifyi ng the somatic dys fu nctio n corrobora tes the patien t's defensive position. Treating the d y sfu n ction re m o ves o r significa ntly wea kens the d e fense, i mp e l l i n g the patient to try despe ra te l y to m a i n ta i n it. If t h a t p a r tic u l a r defense cannot b e mai n ta i ned, the focal point o f t h e somatization m a y b e s hifted t o a new a rea o f the body, or there may be a swi tch t o an e n t i re l y d i fferent defense. l s If the patient'S d efenses have been systematica l ly str i p p ed away w i t h o u t prov i d i ng a l ternative methods of coping, t h e patient m a y be left with no alternative but s u icide. Conseq uently, when a defense is e l i m inate d , an effective a l ternative must be p r ovided . Fa i l u re here can resu l t in serious prob lems for the patient. The p hysicia n-pa tient relat i onship is idea l l y based upon rec iproca l , honest comm u n ication with m u t u a l respec t and u ndersta n d i ng. Patients with delusions a n d m is i n terpreta tions a re honest i n their presentation of t h e phenomenon a s t h e y perceive it. The m i si nterpretations and d e l usions can be wo rked out as the physic i a n-patient r e lationsh i p sol id ifies and the patie n t's trust i n the physician increases. The psychi a tric pati e n t , however, p resents a c o m p l e x c l i ni c a l p r o b le m . It i s i m possi b l e to tre a t soma tic d y s fu nc t i o n w i t h the p h y s i c a l i ntervention o f O MT w i t h o u t e x e r t i n g a psyc h o l og i c e ffect. Tra n s ference i n psyc h i a tric terms is t h e u nconsci o u s assign m e n t to others of fee l i ngs a n d a t t i t u d e s t h a t were orig i n a l l y a ssoc i a ted w i t h i m p o rta n t figu r es ( e . g . , p a r e n ts , s i b l i n gs ) i n e a r l y l i fe . T h e tra nsfer­ ence relationship fol l ows the pa ttern of i ts p rototype. In the p a t i e n t-phys i c i a n re l a t i o ns h i p, the tra nsference m a y be nega t i ve ( hosti l e ) o r p o s i t i v e ( a ffec tion a te ) . ­

­

84

Sect i o n I I • P a t i e nt Po p u l a t i o n s

In c l a s s i c a l psyc h o a n a l y s i s , t h e p hysici a n a v o i d s a l l phys i c a l c o n tact w i t h the p a t i e n t to prevent tra n s ference from i n te r fe r i n g w i t h the p u re psychothera p e u t i c r e l a t i o n s h i p . Psych o t h e r a pists fro m o t h er schoo ls o f t h o u g h t m a y u se this p h eno m ­ e n o n a s a ther a p e u tic t o o l to he l p t h e p a ti e n t u n d ersta n d e m o t i o n a l p r o b lems a n d t h e i r o r ig i n s . If s i m p l y s h a k i n g h a n d s ca n fo ster tra nsference, one ca n i m a g i n e w h a t c a n res u l t fro m p h ysica l c o n tact th a t enta i l s t h e d i a g n o sis o f s o m a t i c d y s ­ fu nction a n d i ts treatme n t w i t h O MT. T h e s i m p l e s t tra n s ference betwee n t h e p a t i e n t a n d p h ysician i s the recog n i t i o n tha t the p h ysici a n is a p e r s o n of a u t hor ity.

In the m e d ica l l y focu sed rela t i o n sh i p t h a t most c o m mon l y occ u r s be tween a p h ys i ­ c i a n a n d p a ti e n t , this ca n b e very b e n efic i a l ; howe ver, beca u s e touch is s u c h a p r i ma l form of c o m m u n i c a t i o n , it is open to m i s i n terpreta t i o n . O n e o f Freud 's co ncepts w a s th a t i t i s n o t w h a t h a p p e n e d b u t t h e fea r a n d c o n ­ cern t h a t somet h i n g b a d co u l d h a ve h a p pened t h a t crea tes the p r o b l em . O n e d oes n o t a lways a cc u ra tely r e m e m be r i nc i d e n ts beca u s e t h e y were e m o t i o n a l l y c h a rged. S u ggesti b i l ity is h eighte n e d , and m e m o r i e s of j u st who did w h a t , a nd h o w, a n d w h e n m a y be fa l s e . The body, h o w e ver, is not fo o l ed ; i t respo n d s w i t h

a

d e fe n s e

tha t m a y h a ve b e e n u s e d to w a r d off t h e o r i g i n a l negative s t i m u l u s . It i s i nc u m bent upon the p h y s ici a n , therefo r e , to exp l ore a l l o f the l i n k s-the soma tovi scera l , the s o m a topsych o l ogic, the m u s c u l oskeleta l a nd the rest-a n d to keep a n o p en m i n d regard i n g a l l e t i o l ogic pos s i b i l i ti e s . The pa tient w h o h a s b e e n a b used fre q u ently c o m e s i n to th era p y, w h e t h e r g e n ­ e r a l med i c a l , muscu loskel eta l spec i a l ty, or psych i a tric s p ec i a l ty, w i t h c o n c e r n s a n d fea rs of a u th o r i t y figu res. T h e p a t i e n t c a n be v e r y s u ggesti b le , wa n t i n g ba d l y to p l e a s e so as to u n d o t h e p a i n . It i s ess e n t i a l t h a t the p h y s i c i a n u n d e rsta nd th i s a n d be tra i n ed in t h e prese n t a tion a n d interpretation o f d a ta w i th o u t j u d g m e n t pri or to t h e i n i t ia tion of treatm e n t . W i t h the ind i v i d u a l 's d es i re to get well a n d the a u t h or i t y of the p h y s i c i a n , some­ t i m e s t h e p a ti e n t 's n e e d to p l ease and t h e p h y s i c ia n 's desire fo r a q u i ck a nd rea s o n ­ a ble a nswer c a n l e a d to p r o b l e m s . M e m o ries h a ve b e e n k n own t o be ma n u fa c t u red when a t h e r a p i s t g u i d e s a p a t i e n t to see issues o f a b u s e in c h i l d h ood th a t e i t he r never occ u rred or d i d n o t occu r as a n tici pa ted . 1 rec a l l o n e pa tie n t w h o ca m e t o m e fo r psy c h i a tr i c h e l p a n d w h o h a d c l e a r e v i d e n ce of e m o ti o n a l a n d p h ysica l a b u s e . There was no d o u b t t h a t h e r fa t h e r d i d a c t u a l l y a b use the pati e n t i n h e r e a rl y y e a r s . Howe ver, I d i d n o t p l a n t a n y s u ggesti ons; I m e re l y fo l lowed her w h ere she w a n ted to go, w i th comments, s ugge s t i o n s , a n d p o s i t i o n s t h a t gave her e i t h e r re l i e f o r m o re d i scomfo r t . As t h e r a p y d evelope d , s h e clea r ly rec a l led a key i n c i d e n t h i d den from h e r consc i o u s ness i n w h ich she w a s i n d e ed sex u a l l y a s s a u lted , n o t by her fa ther but by an u n c l e . T h i s fa ct w a s l a te r v e r i fied by fa m i l y m e m bers . who

thought that s h e had fo rgotten the i n c i d e n t .

If we trea t the s o m a t i c d y sfu nc t i o n , a re we t re a t i n g the core pro b l e m or the c o n ­ seq uences o f emoti o n ? It is i n the fee d b a c k fr om t h e p a t i e n t t h a t we ga in o u r grea t­ est c l u e s rega r d i n g t h i s . I f it w a s a core i s s u e , the s o m a t i c d y s fu n c t i o n w i l l m ore t h a n l i k e l y respond a n d c l e a r u p . If, on the other h a n d , it is a soma toe m o t i o n a l c o n s e q u e n c e , t h e soma tic d y s f u n c t i o n m a y move to a no t h e r part of t h e b o d y in a process s i m i l a r to u n w i n d i n g as e a c h d e fe n s e is a n a l y zed a n d worked th r o u g h u n t i l t h e c o r e i s s u e o r d efe n s e is revea l e d .

CONCLUSION Beca u s e t h e practice o f fa m i l y m e d icine n ecess i t a tes tha t t h e p r a c t i t i o n e r a d d ress a ll of the h e a lth issues of the p a t i e n t fro m a l l a s pects o f med icine a nd s u rgery a n d beca use o f t h e i n sepa ra b i l i ty o f physica l a n d m e n t a l h e a l t h , osteo p a t h i c m e d i c i ne,

Chapter 7 • The Psych iatr i c Patient

85

wi t h i ts recogn i t i on of t h e t r i u n e n a t u re of t h e patient, offe rs an effective mod e l for the u n d e rstan d i ng of these com plex i s s ues. The d i a gnosis and treatme n t of somatic d y s function provi d e the practitioner w i t h a s y s tem of cl i nical problem s olving that prov i d es a n opportun ity to ap p roa ch the p a ti e n t h o l i s t i ca l l y At e v e r y level of the .

central ne rvou s system along the s p i n e , the neurop h y s i ology of somatic d ysfunct i on insepa r a bl y l in k s v i scera, soma, a n d psyche through compl ex v i scerosomatic, som a tovi scera I , soma topsyc h ologi c an d p s y cho s o m a t i c fee d back in te rrela ti o n s hips

­

20-22

.

One com pone n t of the se com p l ex rel a t i ons cannot become pro ble m atic w i tho u t affect i n g the o t h e r t w o , a n d trea t me n t o f n o one aspect is co m pl ete w ithout c o nsid­ era t i o n of the ot h e rs . P ree x i s t i n g organic p a thology a n d func t i o n a l com p l a ints whether v i sce ral o r ,

s o m a t i c , m a y be a u gmented by pe rs o n a l i ty tra i ts. V i sc era l o r so m a ti c c o n d itions ca n prov i d e d e fenses aga i n s t ps y c h olog i c stress. These condit i o n s in themselve s m a y prove m o r e d e bi l i tati ng than t h e or i g i nat ing stres sors wou l d have b e e n if the y had b ee n m o re e f fect i v e l y d e a l t w i th . A mbi g u o u s physical compl a ints m a y repre­ sent oc cu l t orga n i c pa t h o l ogy or t h e y m a y be ma n i fe s tat i o ns of repressed psycho­ ,

logic i s s u e s . Thus, in d a ily cli n ical pra c t ice the f amily phy s i c ian must possess a thoro ugh know l edge of psy c h opa thology, a n d the osteopa t h i c family p h y s i c i a n i s i n a u niq ue pos i tion t o integrate tha t know l e dge thoroughly i n to a high l y orga n­ i zed ho l i s ti c a p p roac h to the pa tient.

Refe re n ces 1. S t i l l AT. P h i l os o p h y o f O s teop a t ny. K i r ksv i l l e , MO : A u t h o r, 1 8 9 9 . R e pr i n ted b y th e A m e r i c a n A c a d e m y o f Osteo p a t h y, I n d ia n a po l i s , 1 9 7 1 ; 2 6 .

2 . L i t r i ej o n n j M . Psyc h i a try. Bou n d m onogra p h i n t h e pers o n a l l i b ra r y o f K . E. N e l s o n . Pu b l i s h e r a nd d a te u n k n ow n; p p 1 - 2 . 3 . S t i l l AT. O ste o p a t h y Resea rch a n d P r a c t i c e . K i rk s v i l l e , M O : A u t h o r 1 9 1 0 . R e p rinted b y East l a n d Press, Seatrie, WA 1 9 9 2 ; 1 3 6- 1 3 9 . 4 . Gerd i n e LV H . Osteopa thy a n d i n sa n it y. j Am O steo p a t h Assoc J u n e 1 9 1 7 ; 1 1 9 9- 1 2 0 0 . 5 . H i l d re t h A G , S t i l i F M . S c h i z o p hr e n i a . J A m O st e o pa th Assoc 1 9 3 9 ; 3 8 : 4 2 2 -4 2 6 . 6 . S t i l l FM. D e m entia praecox. j Os t eopa t h y 1 9 4 0 ; 3 3 : 5 3 4 -5 3 6 . 7 . Wood s J M , Woo d s R H . A p h y s i ca l fi n d i n g re l a ted t o psyc h i a t r i c d i sorders . J A m O s t e o p a th ,

,

,

Assoc 1 9 6 1 ; 6 0 : 9 8 8- 9 9 3 . 8 . I w a t a j L , R o d os JJ , G l o n e k T,

H a b e n i c h t A . C o m p a r i ng psych otic and a ffective d isord ers by

m u s c u l os k e l e ta l s t r u c t u r a l ex a m i n a ti o n . J Am O s t e o pa t h Assoc 1 9 9 7 ; 9 7 : 7 1 5-72 1 .

9 . Mago u n H I Sr. T h e c r a n i a l concept i n g e n era l p r a c t i c e . Os teo p a t h Ann 1 9 7 6 ; 4 : 2 0 6 -2 1 2 . P l o t k i n BJ, Rodos JJ , K a p p l e r R , et a l . Adj u n c t i v e o s t e op a t h i c m a n i p u l a t i ve treatment i n w o m e n w i t h d e p ress i o n : A p i l o t s t u d y. J A m Osteo p a t h A s s o c 2 0 0 1 ; 1 0 1 : 5 1 7-5 2 3 . 1 1 . K ro p i u n igg U . B a s i cs i n psyc h o n e u ro i m m u n o l ogy. A n n M e d 1 9 9 3 ; 2 5 : 4 7 3 -4 7 9 . 1 2 . K ro e n k e K , M a nge l s d o r ff D . C o m m o n s y m p to m s i n a m b u l a tory c a r e : I n c i d e n c e , e v a l u a t i o n , 10.

t he r a p y a n d o u tcome . A m J M ed 1 9 8 9 ; 8 6 : 2 6 2-2 6 6 .

1 3 . Wa l ke r E A . M ed i c a l l y u n e x p l a i n e d p h ys i c a l s y m ptoms. C l i n O b s tet Gynecol 1 9 9 7 ; 4 0 : 5 8 9-f, O O l re v i e w l .

1 4 . D i a g n o s t i c a n d S t a t i s t i c a l Ma n u a l of M e n t a l D i s o r d e r s : D S M- IV-TR Text R e v i s io n . 4 t h e d . Wa s h i ng to n : A m e r ic a n Psyc h i a t r ic Assoc i a t i o n , 2 0 0 0 . 1 5 . B a r s k y AJ. A c o m p re h e n s i v e a p p r oac h to t h e c h ro n i c a l l y s o m a t i z i n g pat i e n t . ] Psychosom R e s 1 9 9 8 ;4 5 : 3 0 1 -3 0 6 .

FE. T h e osteopa t h i c m a n ageme n t o f psyc h o s o m a t i c p ro b l e m s . j A m Os t eo p a t h AS50c J 9 4 8 ;4 8 : 1 9 6-1 9 9 . 1 7 . D u n n F E . O st e o pa t h i c c o n c e p ts i n p s y c h i a t ry. j A m O s t eop a t h Assoc 1 95 0 ;4 9 : 3 5 4 - 3 5 7 . 1 8 . B ra d fo r d S G . O s teopa t h i c co n s i d e ra t i o n s i n p sy c h i a t r ic d i sord ers o f t h e e l d e r l y. O s teop a t h 16. Dunn

A n n 1 9 74 ; 2 : 2 6-2 7 , 2 9-3 1 .

M M , H o we l l IN, e d s . T h e Cen t r a l C o n n ec t i o n : S o m a rovi scer a lNisceroso m a ti c Proceed i n gs o f t h e 1 9 8 9 A m e r i c a n A c a d e m y o f O s teo pa t h y I n te r n a t i o n a l S y m po s i u m . A t h e n s , O H : U n i v e rsi t y C l a s s i c s , 1 9 9 2 .

1 9 . P a t terso n

I nt e r a c t i o n .

86

Section I I • P a t i e n t Po p u l a t i o n s

2 0 . Korr LM . T h e n e u r a l basis o f t h e osteo pathic l e s i on . 2 1 . Korr

J Am O s teo pa t h A ssoc 1 94 7 ; 4 7 : 1 9 1 - 1 9 8 . 1 M . T h e e m e r g i n g c o n c e p t o f t h e osteo p a thic le s i o n . J A m O s t eop a t h Assoc

1 94 8 ; 4 8 : 1 2 7-1 3 8 . 2 2 . Korr 1 M .

I V.

C l i n i ca l

s i g n i ficance o f the

fac i l i ta ted

state.

Am

O s te o pa t h

A s soc

1 9 5 5 ; 5 4 : 2 7 7-2 8 2 .

2 3 . M a r k B T. Psyc h o l ogic stress a n d m u s c l e tens i o n . Osteo p a t h A n n 1 9 7 7 ; 5 : 2 1 2-2 1 7 . 2 4 . O s b o r n G G . M a n u a l m e d ic i n e a n d its r o l e in psyc h i a try. AAO J 1 9 9 4 ; 4 ( 1 ) : 1 6-2 1 . 2 5 . S e l y e H. The genera l a d a pt i v e sy n d rom e a n d t h e d i sease of a d a p t a t i o n . J C l i n E n d oc r i n o l 1 9 4 6 ; 6 : 1 1 7- 2 3 0 .

2 6 . We i s s J . Psyc ho logic a l fa ct o rs i n stress a n d d i s e a s e . S c i A m 1 9 7 2 ; 2 2 6 ( 6 ) : 1 04-1 1 3 . 2 7 . Brady J v. U l c e r s i n execu tive mon keys . S c i A m 1 9 5 8 ; 1 9 9 ( 4 ) : 9 5 - 9 8 pass i m . 2 8 . R e i c h W. C h a r a ktera n a l ys e : Tec h n i k u n d G r u n d l a ge n . V i e n n a : Zel b s t v erlag ( M a n zs c h e , Vie n n a ) , 1 9 3 3 .

The Pediatric Patient Nicette Sergueef and Kenneth E. Nelson

INTRODUCTION Pediatric anatomy, physiology, and specific disease processes encountered in clinical practice can be relatively predictable. Specific disease processes , once diagnosed, have well-defined therapeutic protocols. However, clinical practice is not quite that simple; every patient is unique. All patients have their own individual history, anatomic variations, and consequently functional (and dysfunctional) differences. As well as treating disease processes, the osteopathic clinician must optimize function wherever possible. Effective diagnosis and treatment of somatic dysfunction enhances the self-healing ability of human physiology, which should enhance the efficacy of aU other appropriate therapeutic protocols in the treatment of disease processes. Yet all too often, clinicians , even those skilled in the use of osteopathic manipu­

lative treatment (OMT) for their adult patients, hesitate to use manipulation upon their younger patients. The preverbal patient will not provide a specific complaint , so the diagnostician must think to look for contributory somatic dysfunction.

And

even if somatic dysfunction is suspected, the clinician may be hesitant to employ

OMT for fear of injuring a delicate infant or child. This concern is unjustified if the somatic dysfunction is specifically diagnosed and the treatment modality is judi­ ciously selected. The purpose of this chapter is to provide the clinician a logical approach to the diagnosis and treatment of somatic dysfunction in the neonatal and pediatric population. 87

88

Section II • Patient Populations

PEDIATRIC SOMATIC DYSFUNCTION It has been said that infants and children do not demonstrate somatic dysfunction. This is not true. It is true that the pediatric patient almost never has the muscu­ loskeletal complaints commonly associated with adult somatic dysfunction. Dysfunctional mechanics of the neuromusculoskeletal system d o, however, exert significant influence upon the health status of these patients. Primary somatic dysfunction in the adult is frequently the result of trauma (macro or micro) associated with the individual's neutral postural mechanical pat­ tern. Compensatory postural mechanics, as encountered in accommodation for minor inequitie s of leg length, is recognized in adult patients. Similarly, neonatal

or pediatric somatic dysfunction is often caused by birth trauma and/or childhood injuries upon the mechanical pattern of intrauterine posture and environment. Neonates may have asymmetric musculoskeletal mechanics that are the result of asymmetric intrauterine positioning preferentially assumed during the prenatal period These asymmetries, confounded by the physical stress of birth, produce .

somatic dysfunction. As the infant or child matures, this pattern is further affected by the evolution of developmental milestones and weight-bearing mechanics and possibly by trauma. A thoroug h und erstanding of anatomy offers particular insight into the role of somatic dy sfunction in the development of functional complaints and in specific disease processes. We know that structure and function are intimately related, that

form follows function in both the intrauterine and extrauterine environments. Malposition of the bones of the pelvis can produce the positional dysfunctions of the lower extremities and gait errors encountered in pediatric practice. It is obvious that the ulnohumeral articulation of the elbow acts as a hinge joint. So too, poten­ tial patterns for motion between the bones of the skull may be extrapolated by closely observing the anatomy of their articulations. Knowledge of the anatomy of the skull and face is extr emely important. Malpositional molding of the bones of the skull and face can contribute to functional ear, nose, and throat problems, such as poor feeding, strabismus, and recurrent otitis media. Such cranial dysfunction can also result in symptoms of cranial nerve entrapment. We know that movement of the unossified articulations of the human skull is possible. The molding that occurs in

an

infant's skull during birth makes this read­

ily apparent. At birth , the sutures of the cranial vault provide sufficient mobility that overlapping of adjacent bones frequently occurs during delivery. The cranial base consists of several synchondroses, where the tissue connecting the osseous components is cartilage that turns into bone before adult life.

A signif­

icant synchondrosis, the spheno-occipital or sphenobasilar synchondrosis (SBS), exists between the occipital bone and the sphenoid. Synchondroses are also found between the component parts of the sphenoid bone and between the petrous and squamous portions of the temporal bones. The occipital bone at birth consists of four parts, each separated by a synchondrosis. The anterior intraoccipital synchon­ droses, between the basiocciput and the bilateral exocciputs, have clinical signifi­ cance because when they fuse, they form the occipital condyles and the hypoglossal canals (Fig.

8.1).

The synchondroses function as hinges during birth and are sometimes stressed . Persistent dysfunctional patterns between different bones are interosseous , while persistent dysfunctional patterns between the component parts of a bone are intraosseous. In most i n di vid uals these synchondroses ossify before ad ulthood. Ossification ,

of the intraosseous synchondroses of the sphenoid and temporal bones is usually

Chapter 8 • The Pediatric Patient

89

Condylar part (exocciput)

FIGURE 8.1

The occiput at birth.

complete in the first 2 years of life and in the occipital bone at

7 to

9 years. The

SBS is ossified in most individuals between 8 and 18 years.I-5 Thus, the greatest therapeutic effect of OMT upon these areas is expected before the synchondroses ossify. Somatic dysfunction throughout the body is often described as impairment of articular mechanics, while cranial dysfunctions have been described as membra­ nous articular strains.6.7 This designation is made because of the significance of the dural membranes in the embryologic development of the skull and consequently in

cranial somatic dysfunction (ICD-9CM 739.08). Embryologically the outer layer of the dura mater and the future skulJ are of the

same origin. They are both derived from the ectomeninx. The ectomeninx divides into an inner layer that becomes the dura mater and an outer layer that forms the bony structures. "The retationship between the developing skull and the underly­ ing dura mater continues during postnatal life when the bones of the calvaria are still growing."9 It is very difficult to separate the bone from the dura in the skull of an infant. The dura membranes play a mechanical role in the transmission of intracranial forces. The dura is a template for the growing bones, and any imbal­ ance in the tension of its fibers will give rise to disturbance in the bone growth processes. Also, the venous sinuses lie between layers of dura, and the cranial nerves go through or are surrounded by dural fibers. Dural strain can therefore result in venous stasis and cranial nerve entrapment. Using functional OMT to balance the dural fibers is a fundamental aspect of the treatment of the infant or child.

The palpa ble phenomenon of the cranial rhythmic impulse (CRI) has been demonstrated to correspond to low-frequency fluctuations in blood flow velocity. 10 T hese fluctuations are a manifestation of rhythmicity in the autonomic nervous system. I I It has further been demonstrated that cranial manipulation increased the amplitude of these fluctuations and the fluctuations of simil ar frequency in

intracranial fluid content.12-14 A l t h o u g h the therapeut ic implications of these

observations are

n ot

treatment should rhythms.

yet clearly identified, for maximum efficacy manipulative

be applied in association with these fundamental body

90

Section II • Patient Popu lations

DIAGNOSIS AND TREATMENT OF THE PEDIATRIC PATIENT An osteopathic physician begins the diagnosis of an infant or child in the same fashion as the adult patient, approaching pediatric care with these things in mind and answering the foll owing questions: 1. How does dysfunction of the musculoskeletal system mechanically affect the

patient? 2. What effect does the sympathetic nervous system have upon the patient? 3. What effect does the parasympathetic nervous system have upon the patient? 4. How does circulatory stasis affect the patient?

OMT may be employed to decrease physical discomfort, to improve function, and ultimately to affect structure. The malleability of very young tissue makes the application of functional and cranial procedures more effective in youngsters than in older individuals, in whom ossification has more rigidly fixed dysfunc­ tional patterns. Treatment of dysfunction may augment the effectiveness of specifically indicated treatment protocols. It may also offer a specific therapeu­ tic approach for conditions otherwise treated only by symptom suppression or watchful waiting. Because of the rapid growth rates of infants and small chil­ dren, recognizing and treating reversible dysfunctional asymmetries, as opposed to watchful waiting, fosters symmetric musculoskeletal development. While manipulative treatment for adult patients is often directed at alleviating discom­ fort and improving function, the effect of functional balance upon structure is much greater for the infant or child. Dysfunction of the musculoskeletal system will affect functional and eventually structural development. The physical discomfort associated with somatic dysfunc­ tion of upper thoracic, cervical, suboccipital, or cranial mechanism may affect infant latching, sucking, and swallowing, and may result in gastroesophageal reflux. Similarly, dysfunction of the lumbar or pelvic region and/or the lower extremity may inhibit the infant from sitting or crawling according to the normal developmental schedule. Pain and discomfort may manifest as irritability, failure to meet developmental

milestones,

and/or the asymmetric use of muscles.

Continued asymmetric use of muscles will hypertrophy the overused side and fur­ ther weaken the underused side. Forces transmitted through muscles and fascia, including the dura, may contribute to asymmetric skeletal growth, delay in the developmental milestones, and structural dysfunction in adulthood. The clinician must consider how somatic dysfunction can affect specific sys­ tems, such as upper respiratory and gastrointestinal tracts, along with their affects upon tbe general growth and development of the patient. Somatic dysfunction can predispose the patient to the development and/or recurrence of disease processes, such as otitis media, and reduce the ability to respond to any such disease process. Somatic dysfunction can also present as functional symptoms, such as gastroin­ testinal irritability or sleep disturbance. An osteopathic examination should be performed upon every infant and child, particularly those at high risk for the development of somatic dysfunction: pro­ longed labor and complicated prenatal courses, cephalopelvic disproportion, breech deliveries, deliveries using vacuum extraction or forceps, cesarean sections, and multiple births. At birth the infant should be able to assume all positions. Persistent asymmetry with or without discomfort in certain positions may be a sign of dysfunction requiring further intervention. The physician should not feel intimidated by pediatric somatic dysfunction; the same principles apply as for diagnosing and treating adults. Infants and small

Chapter 8 • The Pediatric Patient

91

children are apt not to cooperate with this process. The diagnosis and treatment of somatic dysfunction necessitate that the diagnostician physically invade the patient's space. Obviously this is more easily accomplished when the clinician is able to explain the process and its intent to the patient. For infants and children, who do not understand the verbal communication, physical communication and sincerity of approach are more important as the clinician addresses the child's total envIronment. Infants and children require great delicacy of touch and sensitivity to asymmet­ ric tension for the effective diagnosis of somatic dysfunction. The best results are obtained when the diagnosis and treatment are done without causing distress. The patient should not cry. Preverbal infants and children may not be able to tell you specifically when something feels good or not, but they will express themselves by cooperating when the procedure is properly applied and resisting when it is not. It is not possible to persuade

an infant or child that what feels bad is ultimately going

to be good for them. Because you are attempting to place the patient in the posi­ tion of comfort, these patients offer you the ultimate feedback as to the proper application of your approach. OMT is categorized as direct or indirect according to how the manipulative procedure is applied in relation to diagnosed motion restriction. By definition, indirect

OMT takes the area of somatic dysfunction away from the dysfunctional

restrictive barrier. Often it is said that the patient is placed in a position of ease. The etiologies of pediatric somatic dysfunction and the pliability of the pediatric

musculoskeletal system make indirect procedures the treatment modalities of choice. Physiologically these patients are typically hyperreactors. As such, they tend to respond rapidly to low doses of OMT. Therefore, constant monitoring of their response to treatment is essential. Inexperienced clinicians are often hesitant to use OMT on infants and children because they are concerned about injuring them . It

is almost impossible to injure

any patient with indirect OMT. It is necessary to be very careful if the patient cannot react, as perhaps with an infant who is extremely premature or small for gestational age. During application of indirect OMT, the dysfunctional barrier is

dIsengaged and the patient is gently moved to a position of ease. This approach is ideal when treating the preverbal patient because when properly done the patient will experience comfort

and cooperate with the process.

The principles of indirect functional OMT apply here.IS,16 The examination of the pediatric musculoskeletal system is directed at identifying the patterns of dys­ functional imbalance. Imbalance necessitates compensation, which is less efficient than unencumbered functional balance. The infant should be observed at rest. The infant will assume a posture that most approximates its position of comfort. Infants usually assume their intrauterine position. When dysfunctional mechanics are identified, adjacent anatomic areas should be evaluated for contributory dys­ function. Dysfunctional patterns following intrauterine posture very often involve several regions, for instance occipital, cervical, and thoracic.

CLINICAL CONDITIONS The following is a list of problems frequently encountered in pediatric patients

along with the dysfunctional mechanics that can produce them. The use of

OMT

is specifically indicated to treat the somatic dysfunction that results in a myriad of

functional conditions. It should not substitute for a thorough history and physical examination to rule out organic pathologies.

92

Section II • Patient Populations

Dysfunction of the Skull and Axial Skeleton Plagiocephaly

Plagiocephaly!7 is distorted shape of the infant's skull, typicalJ y recognized in the fi rs t year of life. Functional p lagiocephaly must be differentiated from synostotic plagio­

.

cephal y, a condition brought on by premature fusion of the cranial s u tur es Sy nos t o tic plagiocephal y is demonstrable radiographically and treated surgica lly. In functional plagiocephaly, the cranial sutures are unfused and there is dysfunctional mol di ng of the infant's skull. Etiologies proposed for f u nc t ional plagiocephaly inc l ude intrauter­ ine position, trauma during birth, and feeding and sleeping positions. IS D y sfunctional patterns between t he occi p u t and the atlas (Cll and la t eral strain of the SBS have been reported in corre lat i on with p lagiocephal ies Y In 1992, the Am eri can Academy of Pediatrics s u ggested that to prevent sudden infant death syndrom e (SIDS), infants be placed sup i ne to sl eep . Since then the incid ence of pos­

terior plag ioceph aly has increased dramaticall y. 20 Asymmetric sleeping and/or feed i ng posture is a likely contrib u tin g factor for this condi t ion . A baby should be able to rest comfo r tably. If only one side or position is ch ronica lly chosen, the head will become a s ymmet ric . The infant with posterio r plagiocep haly has asymmetric flatten i ng of the occ ip i tote m poral region and commonl y contralateral flattening of

the fr o n t al region . Rota t ional dysf u nction of occ ip ut upon the at las (Cl) will rre­ d ispose the infant to sleep with a prefere ntial asymmetric head position, foste r in g the de v elopment of u ni la t eral occipitotemporal flattening (Fig. 8.2).This res u lt s in a para l lelogram de formity of the head viewed from above that is consiste n t with SBS lateral strain.21 The effects upon the cervical and thoracic spine may also be grossly evident. Torticollis

Torticollis, or w ryneck , a malposition of the head and neck u pon the torso, is the result of muscular i mbalance involvin g the sternocleidomastoid, trapezius, and/or

Left

-..;;;:==;;;;....:

Right

FIGURE 8.2 Viewed from above. the parallelogram shape of posterior plagiocephaly on the right. illustrating the relationship between occipital flattening (right). o cc ipi toat lantal rotation (A) to the r i g h t and spheno-occipital synchondrosis right lateral st r ain pattern (B).

Chapter 8 •

The Pediatric Patient

93

scalenes. In infan ts , " con g en ita l torticollis" m o st commonly appears as cervical side ben d i ng

and rotation in opposite

directions. Various eti o log ies have been sug­

gested: intrauterine pos it io n, impairment of the vascularization of the sternoclei­

domastoid, compartment sy ndr ome,22 and dysfunction between the first cervical and the occipital bone.21 The two components, side bending and rotation, may man ifest to d ifferent

degrees. Whe r e side-bending mechanics are d o m ina nt, sign if ica nt dysfunctionallat­

eral translation of the occipu t may be found. Torticollis may also be associated

with dysfunction of the upper thoracic and cervical reg ions. Cranial dysf un ct ion often i nvolve s the occiput and te m poral bones, both acting upon cranial nerve XU4

Infantile Scoliosis

Infantile scoliosis manifests between birth and age 3. It is o ften a non-weight­ bearing sp inal c urvatu re. Intrauterine compressive forces were sugge sted as an eti­

ology as early as Hippocrat es.25 So mat ic dysf unctio n of t he

upper thoracic verte­ brae is a straightforward cause of scoliosis in ea rl y life. The spinal curvature can

also be the result of compensation from cranial somatic dys fun ct i o n . Infantile sco­ liosis is found in ass oc ia tion with asymmetric developmental deformation o f the

occiput. Intra osseou s dy sf un cti o n o f th e occi p ut can produ ce asymmetry of the

occ ipital con d ylar p a rts, res ult in g in compensatory mechanics in the spine below. Somatic dysfun cti ons of the SBS, torsion, s ide b endi ng, rotation, and lateral strains

will also pro du ce asymmetric head position that affects spinal mechanics.

A ddit ionally, compensatory sp inal curves can occur as the res ul t of somatic dy s­ function caudal to the scoliosis. Intr aosseous d ys funct ion of resultant

asymmetry of the sacral base should be considered.

the sacrum with

OMT is effect iv e for inf anti l e scoliosis that is the result of somatic dysfunction. Incomplete r es o lut ion should lead to a search for more si g nif icant etiolog ie s , such

as g e n etic disorder or c ongen i tal malformation. Kyphosis

Similar

to the side-bending defo rmity of infantile scoliosis, increased anteroposterior of the thoracic spine can occur as t h e result of p ri mary thoracic somatic dys­

curva tur e

function or c o mpensatory mechanics. Dy sfunction al mechanics should be sought in the upper thorac ic vertebrae, ribs, or pectoral girdle. As a compensatory e ti ology, dys­

funct iona l extension of the occip ut upon the atlas (Cl) can position the head upon the cervical spine such th at increased cerv ical lordosis and thoracic kyphosis result. Pectus Excavatum and Pectus Carinatum

Posterior deformation (pectus excavatum) of t he sternum can result from d irect

d e rang ement

of the internal fascia I structu re of the thoracic cage and int r aosseou s dysfunction of the sternum. This can be associated with internal rotation of t he pa ir ed structures, spec i fica lly the pectoral g ird le. In pectus ca rin atum, similar mechanisms exist but with a tendency fo r external rotation of the pair ed st r u ctu res . Disorders of Weight-Bearing Mechanics Disorders of the Hip

Hip d i sorde rs have va ry ing deg r ees of severity. Co ngen ital dislocation of the hip is an orthopedic cond i t ion. Sublu xat io n, however, may res po n d well to OMT. Ortolani's sign indicates the need for further radiographic or ultrasonic d iagn os is .

94

Section II • Patient Populations

Location of the fem o ral capital epiphys is within the acetab ula r space is indication for conservative treatment. Insuffici ent depth of the a ce ta b ulu m withou t d islocatio n of the femoral head can be associated with pelvi c so matic d ysfuncti on. I n t raosseo us dysfunction at the co n ­ j u nction o f the i l ium isch i um a n d pu bes results i n a shallow acetabulum. There may ,

,

also be associ ated dysfunctio n between the sacrum and homolateral i n nominate. This d i so rder demonstrates the i m po rtance of fu nctio n on str ucture. Patellar Disorders

Recurrent dislocati o n of the patella associa ted w ith i m proper t rac k ing can res u lt from in ap p ro p r iate myofascial tension in the q u ad r i ceps. If the co n d i tion is uni late ral tibial internal ro tation, external rotation or gl id e dysfun ction upon the femur should be co n sidered Bilateral conditions are more li kely to have sig n ifi ca n t somatic dysfunc­ .

tion affecting the pe l vi s or even upper thoracic or craniocervical j u nction

.

Valgus and Varus Patterns of the Lower Extremity

Varus pro blems of the knees and ankles a re very often associated w i th flexio n and external rotatio n patterns on the same side at the level of the lower e x tre m it y the ,

pelvis, the tempo ra l bo n e or tbe occi p i tal bone . Similarly, valg u s pro blems are associated with extension and i n ter n al rotation patterns of these same areas. ,

Flat and Hollow Feet

It is n ece ssary to d ifferentia te to tal flatfoot or bollow foot from par tiall y flat foot or bollow foot . In the latter, only the poster i o r portion of tbe lo n g itudi n al arch is i n v olved, res ulti ng from dysfunctio n of the taloca lcaneal j unct i o n . Total flat fo o t is usually a s soc iated with a pattern of exte ns i on and internal rotati on. To tal bollow foot is a ssocia ted with a pattern of flexion and external r otati o n .

D ysfu nct i o nal mechanics may be found at the level of the feet as well as

elsewhere i n the lower extremi ty. Or the pro b lem may be the result of weight bear­ ing associ a ted with d ys functio n of the m idl i n e bones. Extens ion of the sacrum, in cr eased a ntero p os terio r cur vatures of the s p ine, e x tensio n of t be occiput u pon the atlas (Cl), a n d extension of the SBS can be associated with fla t feet. In con

­

trast, flexio n of the sa cru m

,

decreased ante ropos terior curvat ures of the sp ine,

flex i o n of the occiput upon the atlas (Cl), and flexion of the SBS

are

associated

with ho llow feet.

Disorders of the Digestive Tract Suckling Dysfunction

Su ckli ng is a reflex-mediated acti vi ty W hen d i fficu lty with suckling is encoun­ .

a nipple w ith a larger o p eni ng or a softer con sisten cy to reduce the effort necessary for successful nursing. Altho u gh t h is

tere d , a co m m on solution is to provid e solution may be effecti v e

,

it r ed u ces the amount of muscular effort req u ired .

Adequat e muscular act i on contributes t o the growt h o f orofacial structures and may pre vent malocclusion. Tre atment of cran ial s omatic dys fu nction offers an additional app r o a ch when a ddre ssing suckling difficulties. Somatic d y s fu n cti on between the occi pi tal an d the tem poral bones affects cranial n erve IX, the gloss opharyngeal nerve, as it p asses t h r o u gh

the j ug ular foramen. Intraoss eous d ysf u n ctio n of the occipital bone can

result in e n tra p me n t of cranial nerve XII, the hypoglossal nerve (Fig. 8.1).

Chapter 8 • The Pediatric Patient

95

Gastroesophageal Reflux

Infants normally bring up small amounts after feeding. Excessive vomiting may be associated with overfeeding or with the consumption of formula that is irritating to the infant. Often, however, in spite o f carefully controlle d feedings an d mu ltip le attempts to identify an acceptable formula, the infant continues to vomit excessively. OMT can be used to treat somatic dysfunction of the base o f the skull to improve upper gastrointestinal irritabi lity. Somatic dysfunction between the occipita l and the tempora I bo nes affects cranial nerve X, the vagus nerve, as it passes through

the jugular foramen. Ad ditionally, somatic dysfunction o f the thoracoabdominal diaphragm shou l d be treate d to ad dress the relationship between the esophagus an d the diaphragm. Colic and Constipation

The colicky infant is often irritated and crying. The constipate d chil d may stay se v­ eral days with incomplete or no bowel movements. Organic causes, such as con­ genital megacolon, hypothyroi dism, cystic fibrosis, or Hirschsprung's disease, must be ruled out. Treatment of somatic dysfunction of the lumbar and pel vic regions commonly relieves the functional conditions of the gastrointestinal tract.

Ear, Nose, and Throat Treatment of ear, nose, and throat problems shou l d first ad dress somatic dysfunction of the upper thoracic region, origin of the sympathetic supply to the head and neck. The suboccipital region is also important, possibly because of the reflex relationship with the trigeminal nerve, the final common pathway of both sympathetic an d parasympathetic upper respiratory innervatio n.26 Cranial somatic dysfunction may be specifically identified in relationship to various ear, nose, an d throat dysfunctions. Conditions of the ear, such as recurrent otitis media, have been demonstrate d to respon d to the treatment of somatic dysfunction.27 After considering upper tho­ racic

and cervico-occipita l dysfunction, attention can be directed at the mechanics The occiput, sphenoid, and temporal bones provide attach­

of the base of the skull.

ment for muscles of the oropharynx. The tensor veli palatini and levator veli pala­ tini affect the efficient opening and closing of the auditory tube an d drainage of the mid dle ear. Also, the cartilaginous portion of the auditory tube that lies beneath at the petrosphenoi d articulation is directly affected by dysfunctional mechanics between the sphenoid and temporal bones. Nasal dysfunction may resu lt from compression of the frontal bone with the ethmoid, lachrymal, maxillary, and nasal bones. This often arises from stresses place d upon the frontal bone by the maternal pelvis in the last trimester of preg­ nancy and during vertex delivery. Dysfunctiona l mechanics may result in nasal obstruction, noisy nasal respiration, and a predisposition to rhinitis and mouth breathing. Recurrent pharyngitis in to d d lers can be associate d with cervica l somatic dys­ function. Somatic dysfunction may contribute to impaire d lymphatic drainage of the area with resulting edema and pain.

Dental Disorders Oral respiration disrupts muscu lar forces exerted by the tongue, cheeks, and lips upon the maxillary arch. Oral respiration can be associated with malocc lusion, gingi vitis, and dental caries. Malocclusion and temporomandibular joint dysfunction can be

Section II • Patient Populations

96

produced by te mporal, maxillary, and mandibular asymmetries . Bruxism may be asso­ ciated with te mpor a l dys function, temporomandibular dys function, and malocclusion.

Eyes Myopia, hyperopia, certain types of strabismus, and lachrymal duct obstr uction

can be the result of craniofacial somatic dysfunct ion . The sagittal diameter of the orbital c avity is decreased with flexion and exter nal rotation of the cranial bones

and incre a sed with ex te nsion and internal rotation. Myopia is associated with

an

i ncrea sed anteroposterior diameter of the eyeball, hyperopi a with a decreased diameter. Because the extraocular muscles or ig i n ate from the sph eno id and frontal bones and the maxillae, disorders involving asymmetr ic muscle pull m ec han ics, such as strabismus,

can

be addres sed by ch ec k i ng for d ysfun c ti o ns in this area.

Dysfu nction of cran i a l nerve VI, the abducens nerve, can occur because of mechan­ ical stress es upon it as it pa sses beneath the petrosphenoid ligament. Altered mechanics between the temporal bones and sp heno id can produce this. In me c ha nics similar to those described in the discussion of the nasa l dy s func­

tion, the frontal bone is co mpre s sed downward du r i ng the del ive ry. Compression of the lachry mal cana l will result from dy sfunc t i on between the fr on tal , l a chry mal , and maxilla ry bones. This condition s h ould be addressed as soon as possible to prevent infection. Patients often respond dramatically to a s i ngle trearment.

Pulmonary Disorders Bronchitis and asthma can be i mproved following the treatment of somatic dys­ fun ct ion of the upper thoracic and cervical areas. In asthma, exper i ence shows that

T2 is freq uen t ly involved. The upper thoracic dys function is comm only encoun­ tered and is pos sibly the consequence of stress put u pon the thoracic region when the shoulders are delivered du r i ng the birth process.

Psychomotor Development Dysfunctions D e layed prone to supine posi t ion ( a v era ge 3 to 6 m onth s ), s upi ne to pro ne ( aver­ age 4 to 7 months ) , or t r ipod sit (average 4 to 6 mont h s ) may be the co n se quence

of cervical or thorac ic dysfunction. D elay ed sit position (average 4 to 6 m o nth s ) , creeping (average 4 to 8 mon th s ) , and craw ling ( a vera ge 9 months) may result from pelvi c dysfun c tio n s .

Sleep Disorders Somatic dysfunction anywhere in the body will disturb the infant and can result in irritability and sleep disorders. Somatic d y s fu nction of the skull is enco u n tered in

sl eep disorders. A s tatistical correlation has been d emonstrated between cranial dysfu nction, specifically l a teral strain of the SBS, and sleep disorder.19 The SBS dysfunct ion can be treated with sp ecific procedure descri bed later in the chapter. Membranous articular dysfu nction of the vault should also be addressed.

DIAGNOSING AND TREATING THE PE DIATRIC PATIENT The pal pato ry diagnosis of s oma tic dysfunction is di scussed at length in Cha pter 3. However, a di sc ussion of the most basic mechanics of cranial os teo p a t hy is warran ted here. Midline bones, inc lud ing the ethmoid, vomer, sphenoid, occi p ut, and all of the vertebral seg m e n ts , in c l ud ing the s a cr um and coccyx, demonstra te

Cha pter 8 • T h e P e d i a t r i c P a t i e n t

97

flexion a n d exte n s i o n a s their p r i m a r y moti o n s . The p a i red bones o f t h e s k u l l , r i b s , p e l v ic, a n d u pper a n d l ower extre m i t i e s d e m o n strate exte r n a l rota t i o n , n o r m a lly c o u p l e d w i t h m i d l i n e f l e x i o n . I n ter n a l rota t i o n is n o r m a l l y c o u pled w i t h m i d l i n e e x t e n s i o n . A d e t a i l e d d e s c r i p t i o n o f t h e spec i fi c m o t i o n s of i n d i v i d u a l b o n e s i s a v a i l a b l e from t h e tex t b ooks o n t h e s u b j ec t . 6,28-3o The fo l l ow i n g p rotocol i s i n te n d e d to provi d e the c l i n i c a l d i a gn o s t i c i n form a ­ t i o n a n d t h e t h e ra p e u t i c seq u e n ce needed t o i n i t i a te a n i n terven t i o n . I n a l l o f t h e c l i n i c a l co n d i t i o n s d e s c r i b e d i n t h i s c h a p te r, t h e exa m i n a t i o n a n d trea t m e n t c a n proceed a s the fo l l o w i n g s e r i e s o f s te p s . T h e y a re d e s c r i bed here, b u r t h e exa c t s e q u e n c e i n w h i c h t h e y a re performed s h o u l d be d i cta ted by the preferenc e o f t h e i n d i v i d u a l p a t i e n t . There s h o u l d be n o sep a r a t i o n b e tween t h e d i a g n o s t i c ex a m i ­ n a t i o n a n d trea t m e n t . A s dysfu nc t i o n a l a s y m metries a re i d e n t i fied , they a r e tre a ted usi ng i n d i rect pri n c i p l e s . A l l o w i n g t h e p a ti e n t to d i ctate th e prefe re n t i a l seq u e nce for the e x a m i n a t i o n and tre a t ment a p pl i e s t h e concept of ind irectn ess to the entire i n terv e n t i o n . T h e c o n nection with the c h i l d i s esse n t i a l . No h a rm s h o u l d b e done i f one p a y s close a tte n t i o n to t h e rea c t i o n o f the c h i l d . A child w ill n o t l et a n ything u n co m forta b l e h a p p e n ; he or s he w i ll respond to any d i scomfo r t . Tre a ti n g i n fa n ts a n d c h i l d re n with OMT is a good schoo l . The p a t i e n t is the te a c h er a n d w i l l prov i d e fe ed b a c k o n h o w we l l t h e tre a t m e n t i s p rogres s i n g . Con n ect w i t h t h e chi l d . T h e fi rst a n d poss i bly most i m p o r t a nt step i s to esta b ­ l i s h nonve r b a l c o n t a c t w i th the p a t i e n t . A l l o f t h e a c t i o n to foll o w i n the exa m i n a ­ t i o n a n d trea t m e n t m u s t be pe r fo r m e d respectfu l l y a n d w i t h t h e fu l l c o n s e n t o f the c h i l d . I n the case of the p r e v e r b a l i n fa n t , t h i s w i l l m a n i fe s t a s overt a ccep t a n c e . O b s e r v a t i o n is v e r y i m p orta nt . O bse rve t h e c h i l d 's p r e fe re n t i a l resting p o s t u r e , p o s i t i o n a n d m o v e m e n t s o f t h e feet, t h e l e g s , t h e p e l v i s , t h e t o r s o , t h e a nns, a n d t h e nec k ( s i d e bend ing a n d rota tion ) . O bs e r v e t h e s h a p e o f t h e h e a d a n d the fa c e . C hi l d re n a l most a l wa y s p o s i t i o n i n t h e dysfuncti o n a l p a ttern . T h e y w i l l l i e a s y m ­ m e t r i c a l ly a n d prefe r t o m o v e a w a y f r o m the dysfu nc t io n a l b a r r i e r. A s tute o b s e r ­ v a t i o n w i l l a l low o ne to recog n i ze t he a r e a s o f d y sfunction a l m o t i o n res triction . Esta b l i s h p h y s i c a l c o n t a c t w i th t h e c h i l d . O l d e r c h i l d re n c a n be i n s t r u cted to l i e on t h e exa m i n a t i o n t a b l e i n the s a m e m a n ner a s the a d u l t p a tien t . The p h y s i c a l exa m i n a t i o n of t h e i n fa n t o ften presen ts d i ffi c u lties th a t req u i re a c c o m m o d a t i o n on t h e p a rt o f t h e p h y s i ci a n . T h e b e s t p o s i ti o n for examin a t ion a n d tre a t m e n t i s lying o n t h e e xa m i n a t ion ta b l e . T h e i n fa n t , h o wever, m a y n o t w i l l ingly a s s u me t h is position, a nd therefore, a l te r na t ive positions sho u l d be cons i d e re d . The i n fa n t can be e x a m i ned w h i le being he l d on t h e p h y s i c i a n 's l a p o r in t h e p a rent's a r ms . The pa l p a tory exa m i n a t i o n c a n beg i n w i t h t h e pe l vi s . Place o n e w a r m h a n d u n der t h e s a c r u m p a l m u p , w i t h t h e i n d e x a n d l i tt l e fi ngers e a c h c o n t a c t i n g o n e o f t h e posterior s u perior i l i a c s p i n e s . Assess s y m metry a n d motion restriction o f th e i n n o m i n a tes to o n e a n o t h e r a n d t h e s a c r u m between t h e i n n om i n a te s . M a i n ta in i ng sacral contact, p l a c e the o t h e r h a n d b e n e a t h t h e p a t i e n t so th a t t h e fi ngertips a re pa l p a t i n g t h e l u m ba r s p i n o u s p rocesses . Assess t h e s a c r u m a n d t h e l u m b a r spi n e . Correct a n y dy sfu n c t io n a l p a tte r n w i th i n d i rect pri n c i p l es o f t re a t m e n t . Next, e xa m i ne t h e torSo w i t h a tten t i o n t o t h e t h o racic cage . With o n e h a n d st i l l i n contact w i th t h e sacr u m , p l a ce t h e o t h e r h a n d o n the ster n u m . Assess for a bnorm a l i ­ ties i n t h e s h a pe o f the torso. Assess the i n h ere n t rhythm o f t h e c h i ld 's body, CRI, a n d costa l res p i ra tion . Determ i n e whether the s a c r u m a n d sternum move i n h a rmony. Any l a c k of freedom in the ste r n a l a rea should lead to consi deration of s o m a tic d ys func­ tion of the thoracic s p i n e . Aga i n , correct a ny d ysfu n c tiona l pa ttern . Le a v e one h a n d u n der t he pe l v is in contact w i t h the s a c r u m a nd p l a ce t h e o t h e r h a n d o n t h e to p o f t h e he a d , a ssess ing t h e s h a p e o f t h e s k ull, p a l p a t i n g t h e va u l t, the fore h e a d , a n d the te m p o r a l a n d t h e occ i p i ta l pa rts . Lea v e this h a n d on the

98

Sect i o n II • P a t i ent Popu l at i ons

vau lt or on a n y area more com forta b l e for t h e ch i l d . Determine whet h e r the s a crum and s k u l l move in har mony. Palpate for asy m metry in the i n h erent mo t i on

,

cor r e c t any d ysfu n c tiona l patter n . Now p l a c e b o t n n a n d s u pon t h e sk u l l a n d assess t h e S B S a n d a n y ot h e r cranial area and c or re ct any dy s f u n c t ional p a tte rn .

Descri ption of Basic Pro ced ures Pl ease n o te: The p roce d u r e s t h a t fo l l ow a re examp l es of m a n i p u l ative treatment t h a t you may w i s h to employ. Tne a ct u a l choice of p roced u res us ed s h ould be de termined by t h e u n i q u e circ u mstances o f each individual pat i e n t Lumbopelvic Release (Fig.

.

8.3)

This proced ur e is used to trea t s o m a t i c dys fu nc tion of t n e l u m ba r s p i ne a n d pelvis. P a t i e n t pos i t ion : supine. P n y s i c i an pos i tion: s tan di n g or seated fac ing i n tne di r e c tion of the p at i e n t

'S

head and to the s i de of t h e patient sucn that the p h ys ician s '

dom inant h a nd is c l os e s t to t n e pat i e n t . P roced u r e

1.

P l a ce yo u r d o m i n a n t h a n d u n d e r t h e s a c r u m pa l m u p , w i t h t h e i n d ex a n d l itt l e f i n ­ g e rs each co nt a ct i n g o n e of t h e poste r i o r s u p e r i o r i l i ac s p i n e s .

2.

Assess sym m et ry a n d m o t i o n rest r i ct i o n of t h e i n n o m i n a tes t o o n e a n ot h e r a n d t h e s a c r u m between t h e i n n o m i n ates .

3.

P l ace t h e oth e r h a n d b e n e a t h the p a t i e n t so t h a t yo u r f i n g e rt i p s a re pa l p ati n g t h e l u m b a r sp i n o u s p rocesses .

4.

Assess t h e sa c r u m a n d t h e l u m b a r s p i n e a n d p a l pate t h e m ot i o n associ ated with

5.

U s i n g i n d i rect p r i n c i p l es, c o r rect a ny dysfu n ct i o n a l patte r n .

6.

W h e n t h e p roce d u r e i s co m p l e te, reassess t h e dysfu n cti on a l a rea .

myofasc i a l te n s i o n s and t h e i n h e re n t motion of the C R I .

T horacic Release (Fig.

8.4)

This p roced u r e is used to treat somatic d y s f u n c tion of the t h orac ic cage . Pati e n t positi o n : sea t e d or s u pine . P h y s ic ia n pos i t ion: s ta n d i n g or sea ted to the side.

FIG U R E 8 . 3

Lu m b o p e l v i c re l e a s e .

Cha pter 8 • T h e Ped i a t r i c Pat i e nt

F I G U R E 8.4

99

T h o r a c i c re l e a se .

P roc ed u re

1.

P l a ce o n e h a n d u n d e r t h e t h o ra x p a l m u p , w i t h t h e t i ps of t h e fi n g e rs c o n t a ct i n g t h e s p i n o u s p rocesses o f t h e t h o ra c i c s p i n e .

2

P l a ce t h e o t h e r h a n d on t h e stern u m , p a y i n g atte n t i o n to t h e ste r n ocosta l J o i n t s .

3.

Pa l pate t h e m o t i o n a s s o c i a ted w i t h myofa s c i a l t e n s i o n s , p u l m o n a ry res p i ra t i o n , a n d t h e i n h e re n t m o t i o n o f t h e C R t .

4.

I d e n t i f y a sy m m e t r i c t e n s i o n s a n d m o t i o n rest r i ct i o n .

5.

U s i n g i n d i rect p r i n c i p l es , c o r rect a n y dysfu n ct i o n a l patte r n .

6.

W h e n t h e procedu re is com p l ete, reassess t h e dysfu n ct i o n a l a rea .

Cranial Membranous Release (Fig. 8. 5) T h i s i s a g e n e r a l p r oced u re u s e d to ba l a nce m e m b ra n o u s tension i n the s k u l l a nd beyo n d . l t

can

be e m p l o yed as

a

fi rst step to t r e a t cra ni a l d ysfunction. Th e p a t i e n t

i s prefe r a b l y s u p i n e ( b u t m a y be sea ted a s i n F i g . 8 . 5 ) , a n d the physici a n i s sea te d a t t h e h e a d o f t h e ta b l e . Proce d u re

1

P l ace o n e h a n d u n de r t h e occ i p u t .

2.

P l ace t h e ot h e r i n c o n t a ct w i t h t h e f ro n t a l b o n e .

3

P a l p at e t h e m ot i o n associated w i t h m e m b r a n o u s te n s i o n s betwe e n t h e f ro n t a l a n d occ i p i t a l b o n e s .

4.

P a l pate t h e rate a n d a m p l i t u d e of t h e i n h e re n t m o t i o n of t h e C R L

5.

I d e n tify asy m m et r i c te n s i o n s a n d m ot i o n rest r i ct i o n .

6.

U s i n g i n d i rect p r i n c i p l e s , c o r rect a n y dysf u n ct i o n a l p a t t e r n .

7.

W h e n t h e p roced u re i s co m p lete, reassess t h e dysfu n ct i o n a l a rea .

Sphenobasilar Release (Fig. 8. 6) T h is p roced u re i s u s e d to tre a t s o m a tic d ys fu nc t i o n between t h e occ i p u t a n d t h e sp henoid at the SBS.

The p a t i e n t i s p r e fe r a b l y s u p i n e , a n d the physici a n i s s e a ted

at the head o r to the s i d e o f t h e ta b l e . Proce d u re

1.

P l ace yo u r n o n d o m i n a n t h a n d t r a n sv e r s e l y i n c o n t a ct w i t h t h e o cc i p u t so as t o avo i d c o n t a c t w i t h t h e occ i p i t o m asto i d s ut u res .

2.

P l a ce y o u r d o m i n a n t h a n d with t h e p a l m rest i n g g e n t l y a c ross t h e fro n t a l b o n e w i t h t h e t i p of t h e t h u m b i n c o n t a ct w i t h t h e l a t e ra l a s pect o f t h e g re a t e r w i n g of t h e

1 00

Sect i o n II • Patient Populat ions

F I GURE 8 . 5

C ra n i a l m e m b r a n o u s r e l ease.

s p h e n o i d o n one s i d e a n d with t h e tip of t h e m i d d l e f i n g e r in contact w i t h t h e l at­ e r a l a s pect of the g reater wi n g of the s p h e n o i d on the o t h e r s i d e .

3. 4.

Pa l p ate t h e rate a n d a m p l i t u d e o f t h e i n h e re n t m o t i o n o f t h e C R I . P a l p ate t h e m o t i o n betwe e n t h e s p h e n o i d a n d occi p i t a l b o n e s , t h u s eva l u a t i n g t h e

S B S . Assess fo r f l e x i o n , exte n s i o n , tors i o n , s i d e - ben d i n g rota t i o n , l a t e r a l a n d v e rt i ­ ca l s t r a i n s , a n d co m p ress i o n .

5.

I d e ntify asym m et r i c t e n s i o n s a n d m o t i o n rest r i ct i o n .

6.

U s i n g i n d i rect p r i n c i p l es , co rrect a ny dysf u n ct i o n a l patte r n .

7.

W h e n t h e p ro ce d u re is c o m p l et e , reassess t h e dysf u n ct i o n a l a rea .

F I G U R E 8.6

S p h e n o b as i l a r re l e a s e .

C h a pt e r 8 • T h e Ped i at r i c P a t i e n t

FIG U R E 8 . 7

1 01

Occi p i t a l r e l e a s e .

Occipital Release (Fig. B. 7)

Th i s p roce d u re i s used to tre a t d y s f u n c t i o n o f t h e c ra n iocervi ca l j u n c t i o n T h e p a t i e n t i s su p i n e ( b u t m a y be seated a s i n F i g . 8 . 7 ) , a n d the p h y s i c ia n i s s e a t e d a t .

t l 1e h e a d o f t h e ta b l e . P roced u re

1.

P l a ce yo u r d o m i n a n t h a n d p a l m up b e n ea t h t h e p a t i e n t 's h e a d , c o n t a ct i n g t h e occ i p u t b u t not t h e occi p i t o m asto i d s u t u res .

2.

P l a ce t h e t i p of t h e i n dex o r m i d d l e f i n g e r of t h e o t h e r h a n d at t h e l e v e l of t h e s p i n ­ o u s p ro cess of t h e a t l a s

3.

(C 1 ).

Pa l pate the m o t i o n betwe e n t h e occ i p i ta l b o n e a n d t h e a t l a s

(C 1 )

Assess f o r f l e x -

i o n , extens i o n , s i d e be n d i n g , a n d rotat i o n .

4.

I d e n t ify asym m e t r i c te n s i o n s a n d m ot i o n rest r i cti o n .

5.

U s i n g i n d i rect p r i n c i p l e s , co rrect a n y dysfu n ct i o n a l p a tte r n .

6.

W h e n t h e p roced u re i s co m p l ete, reassess t h e d ysf u n ct i o n a l a rea .

Occipitomastoid Release (Fig. B. B) Th i s p roce d u re i s used to tre a t d y s fu nc t i o n of t h e o c c i p i t o m a s t o i d s u t u r e . I n th i s exa m p l e , t h e r i g h t occi p i to m a s t o i d s u t u re w i l l be trea ted . P a t i e n t pos i t i o n : s u p i n e or sea te d as i n Fig. 8 . 8 . P h y s i c i a n p os i t i o n : seated a t t h e h e a d o f t h e ta b l e . Proced u re P l a ce yo u r left h a n d tra nsverse l y p a l m up beneath t h e p a t i e n t 's h e a d , c o n t a ct i n g t h e occ i p u t s u c h that t h e t i p of the f i n g e rs a re m e d i a l to t h e rig ht occ i p i t o m a stoid s u t u re .

2.

P l a c e t h e r i g h t h a n d s u c h t h a t t h e t i p s o f t h e i n d e x a n d m i d d l e f i n g e rs a re i n c o n ­ tact with t h e m a sto i d p o r t i o n of t h e t e m p o r a l b o n e .

1 02

Sect i o n II • Patient Pop u l ations

F I G U R E 8.8

O cc i p i t o m astoid re l e a s e .

FIGURE 8.9

F r o n t a l re l e a s e .

C h a pter 8 • T h e Ped i a t r i c P a t i e n t 3. 4. 5. 6.

1 03

Palpate the motion between t h e occ i p i t a l a n d t e m p o ra l b o n e s . motion rest r i cti o n . U s i n g i n d i rect p r i n c i ples, co rrect a n y d ysf u n ct i o n a l patte r n . W h e n t h e p roce d u re is co m p l ete, reassess the dysf u ncti o n a l a rea . I d e nt i f y

Frontal Release (Fig. 8. 9) This p roce d u re is used to tre a t somatic dysfunction of the fronta l bone. I t i s particu­ larly importa n t to treat soma tic d ys fu nction

of the fron ta l bone before a ny a ttem p t to

treat spec i fic pro b l e m s i n v o l v i ng the face . P a t i e n t p o s it i o n : s u p i ne or sea ted as i n F i g .

8 . 9 . Phys i c i a n p o s i t i o n : s e a t e d

at t h e

h e a d o f the ta b l e .

Proced u re

1.

P l ace bot h h a n d s i n contact w i t h t h e fro nta l b o n e , s u c h

a l i g ned

on e i t h e r s i d e

of

that

t h e i n d ex f i n g e rs

a re

t h e m e to p i c s u t u re a n d t h e ot h e r f i n g e rt i ps contact t h e

brow r i d ges b i l at e r a l l y.

2.

P a l pate

the

m o t i o n between t h e l eft a n d r i g h t h a lves

rate a n d a m p l i t u d e

3.

of

t h e i n h erent m o t i o n of t h e

of t h e

fronta l b o n e a n d t h e

CRI.

I d e n t i fy m o t i o n restrict i o n .

4.

U s i n g i n d i rect p ri n c i p l es , correct a n y d ysfu ncti o n a l patte r n .

5.

W h e n t h e p roced u re is c o m p l ete , reassess t h e dysf u n ct i o n a l a rea .

Refe rences 1 . I r w i n GL. Roe ntgen determ i n a t i o n of th e t i m e of c l o s u r e of the s p h e n o - occ i p i t a l s y n c h o n d ro ­

s i s . R a d i o logy 1 9 6 0 ; 7 5 : 4 5 0-4 5 3 . 2 . M a d e l i n e L A , Elster A D . S u t u re c l o s u re i n t h e h u m a n c h o n d rocra n i u m : C T as sess m e n t . R a d i o logy 1 9 9 5 ; 1 9 6 : 74 7-5 6 . 3 . M a n n 55, N a i d i c h TP, Tow b i n R B, D o u n d o u l a k is S H . I m a g i ng o f postna ta l m a t u r a ti o n o f th e

s k u l l b a s e . N e u r o i m a g i n g C l i n N orth A m 200 0 ; 1 0 : 1 -2 1 , v i i . 4 . Melsen B . Ti m e o f c l o s u re o f t h e s p h e n o-occ i p i t a l s y n c h o n d rosis d e te r m i n e d o n d r y s k u l l s : A r a d i o g ra p h i c craniometric stu dy. A c t a O d o n t o l Sca nd 1 9 6 9 ; 2 7 : 7 3-9 0 . 5 . O k a mo to K , I r o J , To k ig u ch i 5 , Fu r u s a w a T. High-resolution CT find i ngs i n t h e de vel opment o f sphenoocc i p i t a l s y n c h o n d r o s i s . A m J N eu rora d iol 1 9 9 6 ; 1 7 : 1 1 7- 1 2 0 . 6 . M agou n H I . Os teopa t hy i n t h e C ra n i a l F i e l d . 2 n d e d . K i r k s v i l l e , M O : J o u r n a l. , 1 9 6 6 . 7 . S u t h e r l and W G . T h e Cra n i a l B ow l . M a n k a to , M N : F ree Press, 1 9 3 9 : 4 5 . 8 . I C D -9 C M I n tern a ti o n a l C l a ss i fication of D is ea ses , 9 t h Rev i s i o n : C l i n ica l M o d i fica t i o n . 5 t h e d . S a l t La k e C i ty : M ed icode , 1 9 9 9 . 9 . C o l l i n s P. E m b ry o logy a n d development. I n : W i l l i a m s P L , e d . G r a y 's A n a to m y. 3 8 r h e d . E d i n b u rgh : C h u rc h i l l L i v i ngsto n e , 1 9 9 5 : 2 5 7 . 1 0 . N e l s o n K E , Se rgu e e f N , L i p i n s k i C M , e t a l . C ra n i a l r h y t h m i c i m pu lse rela ted to t h e Tra u be­ He r i n g - M a y e r osci l l a t i o n :

Compa ring

l a s e r- D o p p l e r

fl o w m e t r y

and

palparion.

J

Am

Osteopath Assoc 2 0 0 1 ; 1 0 1 : 1 6 3 - 1 7 3 .

1 1 . Ak s el rod 5 , Gordon D , M a dwed lB, e t a l . H e m o d y n a mic r egu l a t i o n : I nvestiga t i o n b y s pectra l a n a l ys is . Am J P h ys i o l 1 9 8 5;24 9 ( 4 pt 2 ) : H 8 6 7-H 8 7 5 . 1 2 . Sergueef N, N e l s o n K E, G l o n e k T. T h e e ffect o f c r a n i a l ma n i p u l a ti o n u p o n t h e Tr a u be ­ H e r i ng - M a y e r osci l l a tion as m e a s u red by l a seI-Do p p l e r fl o w met ry. Altern T h e r H e a l t h Med 2002; 8 : 74-7 6 . 1 3 . M o s k a l e n k o Y E, K ra v c h en k o TI. Wa v e p h e n o mena i n moveme nts o f i ntra c ra n ia l l i q u id m e d i a a n d t he p r i m a r y respi ratory m echa n i s m . AA O

J

200 4 ; 1 4 ( 2 ) : 2 9-4 0 .

1 4 . Nelson K E , Sergueef N , G l o n e k T. C ra n i a l m a n i pu l a t i o n i n d uces seq u e n c i a I c h a nges i n b l o o d fl ow velocity o n d ema n d . A A O ] 2004 ; 1 4 ( 3 ) : 1 5 - 1 7 .

1 04

Section II • P a t i e n t Pop u l at i o n s

1 5 . BowJes C H . A functio n a l orien tation for tec h n i c . 1 9 5 5 Yea r b ook . I n d i a n a p o l i s : A m er i c a n A ca de my o f Oste o p a t hy, 1 9 5 5 ; 1 77-1 9 J . 1 6 . J o h n ston WL,

Friedman H D . Function a l Methods: A M a n u a l for Pa l pa tory S k i l l Deve l o pmenr

i n Osteopa t h i c Exa m i n a t i o n a n d Ma ni p ula t i o n o f Motor F u nctio n . i n d i a n a po l i s : A m e r i c a n A c a d e m y o f Os teopa thy, 1 9 9 4 . 1 7 . Sergueef

N . App roche osteopa th i q u e d e s p l a g iocep h a l ies a vec o u s a n s tortico l i s . P a ris: S p e k,

2004 . 1 8 . Peitsch WK, Keefe r CH, L a B ri e

R A , M u l l i k e n J B . Inci d e n c e of c ra n i a l a s y m m e try in h e a l thy

new b o r n s . Ped i a t r i c s . Dec 2 0 0 2 ; 1 1 0 ( 6 ) :e72 . 1 9 . Sergu e e f N,

N e l s o n KE, G l o n e k T. Pa l p a tory d i a g n osis of p l a g i oce p h a l y. Com p l e m e n t T h e r

C l i n P r ac t 2 0 0 6 ; 1 2 : 1 0 1 - 1 1 0 . 2 0 . K a n e A A , M i tchel l LE, Cra ven K P, M a r s h J L . O b s e r v a t i o n s on a rece n t i ncrease i n p l a g i o ­

cepha l y w i t h o u t s y n ostos i s . Ped i a rrics 1 9 9 6 ; 9 7 ( 6 Pt 1 ) : 8 77-8 8 5 . 2 1 . Sergueef

N, Nelson K E , G l o n e k T. P a l p a tory d i agnos i s of p l a g i ocepha l y. J A m Os teo pa t h

Assoc 200 4 ; 1 0 4 : 3 3 9 . 2 2 . D a v i d s J R , We nger D R , M u b a ra k S] . C o n g e n i t a l m u s c u l a r torticol l i s : S e q u e l a o f i n t ra u te r i n e

J P e d i a t r O rth o p 1 9 9 3 ; 1 3 : 1 4 1 - 1 4 7 . P. L e to rtico l i s " co n g e n i t a l " est-iJ s i m p l emen t u n torticolis O bstetr i -

or p e r i n a ta l compa r t m e n t s y n d ro m e . 23 . Jacque m a r t M, P i e d a l l u

ca l ? C o n c o u r s Med 1 9 6 4 ; 3 6 : 4 8 6 7-4 8 7 0 . 2 4 . Sergueef

N . La th era p i e c ra n io-sa cree c h e z l ' en fa n t . P a r i s : S p e k , 1 9 8 8 .

2 5 . D u n n P M . Conge n i t a l post u r a l d e form i t i e s . B t Med B u l l 1 9 76;3 2 : 7 1 -7 6 . 26. Sumino

R , Noza k i S , K a t o M . C e n t r a l pathway of t r i ge m i n o - nec k re f l e x . [0 : O r a l - fa c i a l

sensory a n d m o t o r fu n c t i o n s . I n t e rn a t i o na l S y m p os i u m . R a p p o ngi, To k y o ; O r a l P h y s i o l . 1 9 8 0 : 2 8 [ a b s t r a c t) . 2 7 . M i l l s MV, He n l e y CE, B a r n e s

LL, et a l . The use of os t eopa t h i c m a n i p u l a t i v e t re a tm e n t a s

a d j u va n t t h e r a p y in c h i l d r e n w i t h rec u r r e n r a c u te o t i t i s med i a . A r c h Ped i a t r A d o l esc M e d 2003; 1 5 7: 8 6 1 -8 6 6 .

M N : Free P ress, 1 9 3 9 ; repr i n te d 1 9 8 6 . U p l edge r J E , Vredev oogd j D . Cra n i o s a c r a l T h e r a py. Ch icago : E a s t l a n d , 1 9 8 3 . 3 0 . K i n g H H , L a y E. Os teo p a th y i n t h e cra n i a l fie l d . I n : Wa rd R C , e d . Fo u n d a t i o n s for O s te op a t h i c M e d i c i n e . 2nd ed . P h i l a d e l p h i a : Li p p i n co t t W i l l i a m s & Wi l k ins, 2 0 0 2 ;

2 8 . S u th e r l a n d W G . The Cra n i a l Bow l . M a n k a to, 29.

9 8 5- 1 0 0 1 .

CHAPTER

9

The Female Patient Kenneth E. Nelson and Joey Rottman

INTRODUCTION The practice of osteopathic medicine stresses the importance of dysfunction of the neuromusculoskeletal system in all aspects of patient care. Somatic dysfunction may be primarily responsible for the patient's complaints. It may contribute to a greater or lesser extent to concomitant illness. Or it may be

a

reflection (viscero­

somatic reflex) of existent visceral pathology. Application of this understanding to the diagnosis and treatment of gynecologic and obstetric patients affords

a

distinc­

tive approach to care . The skills necessary to diagnose somatic dysfunction and the effects of its treat­ ment offer multiple advantages in the practice of obstetrics and gynecology. The identification of viscerosomatic reflexes augments physical diagnosis. The ability of clinicians skilled in the diagnosis of somatic dysfunction to palpate lightly and appreciate subtle tissue texture abnormalities is also useful for diagnosis of gyne­ cologic and obstetric conditions other than somatic dysfunction. Emphasis upon dysfunction of the neuromusculoskeletal system, with its resultant pain, neural facilitation (somatovisceral effects), and circulatory compromise, gives the osteo­ pathic approach to medical practice an advantage in the treatment of the condi­ tions unique to female patients . The ability to employ specifically controlled forces as applied in osteopathic manipulative treatment (OMT) can be beneficial in obstetric procedures. 105

Section II • Patient Populations

106

It is not the purpose of this chapter to review the practice of gynecology and obstetrics.

That information is readily available elsewhere. Rather this chapter

addresses the diagnostic and therapeutic approach to the care of the female patient that is unique to osteopathic medicine.

GYNECOLOGY A significant number of gynecologic patients present with pelvic pain as a chief

complaint. The pain may be deep within the pelvis, in the perineum, in the lower abdomen, or in the low back. Many gynecologic problems, such as endometriosis, adenomyosis, mittelschmerz, and various pelvic infections, present as pelvic pain. These conditions result in viscerosomatic reflexes involving the spinal segments innervating the site of pathology.

Viscerosomatic Reflexes Viscerosomatic reflexes offer diagnostic clues. They are mediated through general visceral afferent neurons in either the sympathetic or parasympathetic nerves. The resultant reflex manifests as palpable tissue texture abnormality and tenderness in the dermatomes and myotomes of the spinal cord level from which the primary cell bod­ ies of respective sympathetic and parasympathetic efferent neurons originate. The intensity of the palpable tissue texture abnormality of a viscerosomatic reflex offers an indication of the severity of the visceral pathology responsible for the reflex. T he locations of viscerosomatic reflexes may demonstrate slight variation among individuals . Yet they are reliable because of the overall consistency of the anatomy of the nervous system. The sympathetic gynecologic viscerosomatic reflexes are as follows: ovaries TlO to TIl lateralized, uterus T9 to L2 bilateral, fallopian tubes TIO to L2 lateralized. The preponderance of parasympathetic innervation of the female genitourinary tract emanates from the pelvic splanchnic nerves, 52 to 54. The lateral half of the fallopian tubes, however, receives parasym­ pathetic innervation from the vagus nerve. Thus, the high cervical vagal visceroso­ matic

reflex may explain the occurrence of

some

headaches in association

with

various gynecologic problems. If visceral inflammation involves the parietal peritoneum because it is innervated by somatosensory nerves, a somatosomatic reflex

will be present at the spinal level

innervating the inflamed peritoneum. The identification of tissue texture abnormality and tenderness resulting from viscerosomatic and somatosomatic reflexes in any of these paraspinal regions should lead the physician to consider the possibility of segmentally related visceral pathology as part of the differential diagnosis. Treatment of these somatic findings results in transient pain relief at best and more often has no effect. The definitive treatment of the underlying visceral pathology is the only effective treatment.

Somatovisceral Reflexes The segmental spinal facilitation associated with a viscerosomatic reflex also results in increased efferent stimulation (sympathetic or parasympathetic depend­ ing upon the spinal level) to the site of visceral pathology. OMT can be employed adjunctively to affect these somatovisceral reflexes. OMT may also be employed to treat residual somatic dysfunction after the primary visceral pathology has been treated.

Chapter 9 • The Female Patient

107

Primary spi nal somatic dysfu n c t i on results in facilitation that can affect seg­ menta l ly related organs through increased sympathetic or parasympathetic activity. Functional visceral symptoms that are the result of somatovisceral refl exes may be alleviated by treatin g the un derlying somatic dysfunction an d wh en appropri ate, postural imba l ance that predisposes the ind ivid u al to that somatic dy sfun ction . It has been suggested that correction of inequality of leg length, which is responsible for chronic sac ral somatic dysfunction, may be a prime factor in the treatmen t of pathophysiologic chan ges affecti n g t h e pel vic organs.

I

Dysmen orrhea is cramping pel vic pain associated with menstru ation. A l though this is an oversimplification, sympathetic activity results in uterine contraction, and parasympathetic activity results in uterine relaxation. Treatmen t of thora­ columbar somatic dysfunction wil l red uce sympathetic input to t h e uterus. Clinical experien ce has d emonstrated that pressure applied over the sacrum of a prone patient frequently red u ces the severity of menstrual c ramps. If effective, the proce­ dure can be taught to a fami l y member.

Somatic Dysfunction It is fairly common for a specific organic cause for pelvic pain to fail to be identi­ fied an d for the patient to be described as having c hronic pelvic pain, t h at is, pelvic pain of unid entified etiology of more than 6 months' duration. More than one­ third of 60 women in

a

random series of outpatient gynecologic visi ts presented

with pain as the primary symptom. Of th ese individ uals, 75% had no iden tifiable organic cause.2 Commonl y, the somatic d ysfunction responsible for persisten t pelvi c pain first devel ops during o r ju st after pregn ancy because o f the stresses placed upon the low back and pelvis. Somatic dysfu nc tion mu st n ot be overlooked as an etiology for pain resemblin g gynecologic pathol ogy. Because visceral pain is often d ull and vague as to location, it is often mimicked by muscu loskeletal pain of somatic dysfunction. Spinal and sacropelvic somatic dysfunction can result i n low back, lower abd omin al, and per­ ineal pain. Recognizing this may save many a patien t from un necessary diagnostic procedu res. Spasm of psoas major often produces lumbosacral pain. There may also be pain in the inguinal region an d in the upper in ner thigh, where the iliopsoas tendon crosses over the pubic ramus and where it inserts upon the l esser trochanter of the femur respectively. The pri mary d ysfunction in this in stance is often Fryette's type II flexion mechan ics in the upper lumbar spine. Such dysfunctional mechan ics may

also result in inguinal pain because of segmen tal facil itation with resul tant hyp er­ sensitivity in the Ll, L2 dermatomes. Sacropelvic somatic dysfun c tion produces pelvic pain. Sacroiliac somatic dys­ function is complex. A complete d iscussion of these mechan ics is beyond the scope of this chapter. Man y sources are avai l ab l e to the in dividual who wishes to review this subject in d epth.3-8 Within the pelvis are three articulations, the pubic symphysis and the two sacroil i ac joints, that can become dysfunctional. When there is dysfunctional motion restriction in one of these articulations, compensatory stresses are placed on the other two, and the pelvis often twists in accommod ation.9 The patient'S pain complaint may therefore be in the region of the primary dysfunction or in an ad jacent area that is u nd er compen satory stress. Sac roiliac articular somatic d ysfunc tion results in restricted motion of the involved joint. Sacroiliac d ysfunction often resu lts in pain d irectl y referable to the

108

Section II • Patient Populations

involved joint. It is often accompanied by pain in the buttocks and-in response to involvement of the ilium-inguinal region. Pubic symphysis dysfunction results in symphyseal suprapubic pain and per­ ineal pain. It is often encountered as a result of the stress of walking with a change in the center of gravity caused by the ever-expanding uterus. Or it may be encoun­ tered post partum as a result of the stresses placed upon the pelvis by labor and delivery. Pubic symphysis dysfunction typically occurs as a superior or inferior shearing stress. The pelvic bone on the side of the superiorly displaced pubis will be displaced slightly superiorly and posteriorly. This will tend to produce pain in the superior aspect of the sacroiliac joint and the inguinal ligament on

that side.

The pelvic bone on the side of the inferiorly displaced pubis will be displaced slightly inferiorly and anteriorly. This will tend to produce pain in the inferior aspect of the sacroiliac joint on that side. Twisting of the pelvis, whether from sacroiliac dysfunction, pubic symphysis dysfunction or from mechanics above (psoas spasm, scoliosis) or below (unequal leg length) the pelvis, will result in asymmetric stresses upon the soft tissues within the pelvis. Pain in the musculature of the pelvic floor and the sacrospinous and sacrotuberous ligaments may be confused with pain from pathology of the pelvic organs . Tenderness of these structures produces dyspareunia. Asymmetric spasm of the levator ani muscle (levator ani syndrome or proctalgia fugax) confuses clinicians who do not understand pelvic somatic dysfunction.

Central Facilitation Chronic pelvic pain patients are commonly incapacitated by the pain. The pain is frequently exacerbated by emotional factors. The fact that no etiology has been identified may lead the patient to question her own perceptions. Further, because no etiology has been identified, no definitive treatment is available other than symptom suppression. In a significant number of cases, chronic pelvic pain is associated with childhood sexual abuse and as with other forms of chronic pain, with current or past

physical abuse, which necessitates a thorough psychosocial history to elucidate somatoemorional and somatoform mechanisms that may be active in pelvic pain. (See Chapter 7.) The frustration, anger, and anxiety of patients with chronic pelvic pain results in a state of facilitation within the central nervous system. This central facilita­ tion may lower thresholds for nociception, making even normal sensory i n p u t painful.1o

OBSTETRICS The practice of obstetrics has been an integral part of osteopathic medicine since its inception.l1 Osteopathic principles and the diagnosis and treatment of somatic dysfunction in the obstetric patient are the same as for any other patient. The o bstetric patient, however, is subject to al tered musculoskeletal mechanics as the gravid uterus expands.

The patient'S weight increases, and her center of

gravity shifts anteriorly. This affects the lumbar lordosis. The area of T8 to TIl generally becomes the area of transition between the lumbar lordosis and thoracic kyphosis due to the anterior shift of

the center of gravity and the exaggeration of 27.)

the thoracic and lumbar curves that progresses during pregnancy. (See Chapter These alterations also cause a progressively widening gait.12

Chapter 9 • The Female Patient

109

Most people have inequality of l eg length. 13 (See Chapter 26.) The weight-bearing stresses of pregnancy introduce new or aggravate preexisting compensated dysfu nc­ tional mechanics and make low back pain one of the most frequently encountered complaints during pregnancy. Al t h ough these cond ition s are unavoid able, the effec­ tive treatment of somatic d ysfunction alleviates discomfort without the use of unnec­ essary medications and makes pregnancy significantly more tolerable. Total bod y water increases progressively d urin g p regnancy, reaching 6 to 8 L, most of which is d istributed in the extracellular space.14 Fluid exchange between the i ntravascular and i nterstit ial spaces, as d escribed by Starli ng's equilibrium, is such that more than 10% of the water that leaves the intravascul ar space must be returned to t h e general circulat i on via the lymph atic system. Swe l ling of the extrem­ ities is a common complaint d u ring pregnancy. Interstitial ed ema can be sufficient to coni promise structures within confined spaces. Carpal tunnel syndrome d urin g pregnan cy is extremel y common. The d iagnosis and treatment of myofasc i a l dysfun ction of the extremities may b e used to enhance the efficiency o f t h e muscu­ lar pump's ability to d econgest the interstitial space. Direct stretching of the tran s­ verse carpal ligament,15 active articulation of the carpal bones, and treatment of pectoral gird l e and upper thoracic (sympathetic supply to t he upper extremity) somatic d ysfunction 16 h ave been shown to reduce med ian nerve compression within the carpal tun nel. As the uterus expan d s, it d i splaces the abd omin al c ontents u pward , limitin g excursion of the d iaph ragm and c on sequently the mechanical efficiency of t h e res­ piratory effort. Pulmonary respiratory efficiency actually increases during preg­ nancy in compensation for the m echanical c omp romise of respiration. Alternating positive and negat i ve int rathoracic pressure as the resul t of inspiratory and expi­ ratory mecha n i cs is also responsible for return ing venous blood and lymph to t h e heart. I t i s therefor e appropr i ate to ad dress somatic dysfunction o f the thoracic spine, ribs, and diap h ragm to optimize the function of t h e thorac i c cage as a cen­ tral lymphatic pump.

DIAGNOSIS AND TREATMENT The diagnosis and treatment of somat ic dysfunction in obstetric and gynecologic patients is no different from that of any other ad ult. There are, however, some issues that are particularly commonly encountered in this patient popu lation. Low back pain is a common complaint of obstetric patients. Chronic an d ac u te pelvic pain is a frequent ly perplexing gynecologic d iagnosis t h at may simpl y ind icate un d iagnosed somatic d ysfunction. Dyspareunia may have i ts origin in somatic d ysfunction. The osteopathic approac h to the female p atien t provides u niqu e diagnostic methods and treatment mod a l ities to support the patient with obstetric and gyne­ col ogical need s. It is an obligation that OMT be one of t h e tools at t h e osteo­ pa thic practitioner's d is posal. No pregnant patient who c omplains of low back pain should leave the office with only a prescri ption for acetaminophen . No non­ pregnant patient with pel vic pain shoul d be sched uled for an imagin g stud y or an invasive surgical procedure without a thorough evaluation for somatic d ysfunc­ tion, includ ing an inter n al pelvic st ructural examinatio n . Therefore, this c h apter focuses upon the d iagn osis and treatment o f pelv i c somat ic dysfunction. T h e d iagnosis o f pelvic somatic d ysfunction must in c l ude consideration of st ructu res ab ove and below the pelvis. T h at a patient'S c omplaint iden tifies a specific anatomic structure or area d oes n ot necessarily mean that is the primary site of somatic d ysfun ction responsibl e for the comp l aint .

1 10

Section II • Patie nt Populations

The diagnosis of somatic dysfunction necessitates a thorough knowledge of anatomy. If one knows the structure of an area, one can understand its function and recognize how the functional limitation of somatic dysfunction can produce the patient's complaint. One of the problems encountered when attempting to diagnose nonvisceral pelvic pain is the failure to identify the specific painful struc­ tures. When performing the gy necologic bimanual examination, it is standard procedure to palpate the uterine cervix, fundus, and adnexa. Rarely does anyone consider the sacrospinous and sacrotuberous ligaments, the iliopsoas tendon, the levator ani muscles, or the small muscles of the perineum. When a patient complains of chronic pelvic pain or dyspareunia, such an internal pelvic structural examination is imperative. Notice asymmetric tension (tissue texture change) when the muscles and ligaments are palpated and on which side a painful response (tenderness) is elicited. Correlate these findings with the findings of the remainder of the structural musculoskeletal examination. Once treatment is initiated, recheck the muscles and ligaments internally for change and note the difference. The anatomy of the female neuromusculoskeletal system , with the exception of the fine anatomy of the perineum, is not unique. The ordinary mechanics of somatic dysfunction apply for diagnosis and treatment here. The obstetric patient, however, does present some difficulty, particularly in the later months of pregnancy, when it is not possible for her to comfortably lie prone. For this reason, descriptions of diagnostic methods in the following section focus upon an approach suitable for diagnosis of a patient in the third trimester of pregnancy. With one exception, these procedures are done with the patient supine or laterally recumbent. Many authors3-8 have described somatic dysfunction of the sacrum and pelvis. Although initially these descriptions may appear incongruous, one who thoroughly understands pelvic anatomy can appreciate the commonality and differences of the various descriptions. Somatic dysfunction typically involves restrictions of muscu­ loskeletal physiologic motion. These are the mechanics reviewed in this chapter. However, the potentially traumatic forces of the birth process upon the pelvis result in a multitude of shearing stresses that can result in aberrant dysfunctional patterns.

Sacropelvic Somatic Dysfunction The Physiologic Motion of the Sacrum Sacral mechanics can be considered relative to the ilia (anterior and posterior sacrum) or relative to the lumbar spine (forward and backward torsion). Under both circumstances, sacral rotation occurs about either the right or left oblique axis. Sacroiliac dysfunctions typically demonstrate the pattern of rotation and side bending in opposite directions.

The Sacrum and the Ilium Anterior and Posterior An anterior sacrum by definition is anterior to the ipsilateral ilium. Therefore , if the ilium is described relative to the sacrum, it is posterior to the sacrum. This does not necessarily mean it is a "posterior ilium." The terms anterior ilium and poste­ rior ilium refer to the position of one ilium relative to the other. This may result

from asymmetric soft tissue tensions, dysfunctional sacroiliac articulation, pubic symphysis, or lumbosacral mechanics. A similar relationship exists between the sacrum and ipsilateral ilium on the side of the posterior sacrum. As the sacrum moves, so goes the ilium: When rotational forces are applied to the sacrum from above and the sacrum rotates, the sacroiliac ligaments are placed on tension and the ilia move with the sacrum but to a lesser degree.9

Chapter 9 • The Female Patient

11 1

Sacroiliac somatic dysfunction is associated with spasm and pain of pelvic mus­ cularure. A posterior sacrum is often accompanied by spasm in the piriformis muscle. As the sacrum rotates posteriorly, its ventral surface moves away from the greater trochanter, placing the ipsilateral piriformis muscle on tension. This initiates a stretch reflex, which results in spasm. A similar relationship between an anterior sacrum and gluteus medius tension is less immediately obvious. The anterior sacrum is anterior to the ipsilateral ilium. Posterior movement of the sacrum relative to the ilium on the dysfunctional side is restricted. With normal weight bearing, forces acting upon the anterior sacrum from above through the lumbar spine tend to pull it posteriorly (toward a neutral position). Because of the sacroiliac restriction, the ilium is also pulled posterior relative to the femur. This places tension upon the gluteus medius (and gluteus minimus), which originates on the ilium between the iliac crest and the posterior gluteal line above and the anterior gluteal line below and inserts upon the lateral aspect of the greater trochanter. The increased tension on the muscle results in spasm.

Lumbosacral Mechanics, Sacral Torsions Side bending of the lumbar spine upon the sacrum engages the sacral oblique axis on the side of the bending. That is, side bending right engages the right oblique axis, and side bending left engages the left oblique axis. With neutral weight bear­ ing (absence of significant forward or backward bending), the sacrum relative to L5 moves forward on the side opposite the engaged oblique axis. This forward tor­ sion is further identified by the sacral mechanics on the involved oblique axis, that is, right on right or left on left. In the presence of significant forward or backward bending, the sacrum relative to L5 will move backward on the side opposite the engaged oblique axis. T his backward torsion is further identified by the sacral mechanics on the involved oblique axis, that is, left on right or right on left.

The Symphysis Pubis Superior and inferior shearing mechanics are most commonly seen in association with pubic dysfunction. This dysfunction is seen both ante and post partum and following strenuous use of the adductor muscles of the thighs.

Iliopsoas Mechanics Psoas spasm occurs bilaterally; however, one side frequently exerts more force. This asymmetry of muscle pull produces an active pelvic side shift in the direction away from the side of the predominantly tight psoas. Psoas spasm may be classi­ fied as primary or secondary.

Primary Somatic dysfunction in the upper half of the lumbar spine produces psoas spasm. Type II mechanics of LIon L2 or L2 on L3, typically in flexion with rotation and side bending toward the side of the predominant psoas muscle, are the most com­ monly encountered dysfunctional etiology.

Secondary In the presence of lumbosacral inflammation (discitis) or instability (herniated nucleus pulposis, spondylolisthesis), physiologic splinting of the surrounding musculature results in psoas spasm. The forward displacement of the patient'S center of gravity as

112

Section II • Patient Populations

the gravid uterus grows results in increased stress upon the lumbosacral junction, with resultant psoas spasm

a

common occurrence.

Forces Acting Upward (See Chapter

26)

and sacro­ pelvic somatic dysfunction. (See Chapter 6.) Errors in locomotion, another cause

Short leg mechanics result in sacral unleveling, producing lumbosacral

of lumbosacral and sacropelvic dysfunction, affect the pelvis from below. Forces Acting Downward (See Chapters

26,27,

and

28)

Psoas spasm and idiopathic scoliosis are two examples of conditions above the pelvis that p roduce sacropelvic dysfunction. (See Chapters

26 and 28.)

Cranial Considerations

The sacrum and pelvis are thought to be linked to the cranial mechanics through the reciprocal tension membrane. Viscerosomatic Considerations (See Chapter

Hyperactivity in

5)

visceral afferent nerves due to visceral disease or dysfunction will

produce segmentally related reflex somatic dysfunction. Genitourinary and lower gastrointestinal pathology produce reflexes referable to the lower spine.

Structural Examination of the Obstetric Patient (See Also Chapter 3) Because of the shift in center of gravity that results from fetal growth and uterine enlargement, examination of the obstetric patient for somatic dysfunction may seem difficult. In particular, during the latter stages of pregnancy, the

patient

cannot

com­

fortably lie prone. In fact, with minimal modification the structural examination of the pregnant patient is relatively simple. The following sequence may be employed. Patient Standing 1.

Monitor gait. Is the gait symmetric from side to side 7 How wide is the patient's galt! Evaluate spinal anteroposterior curves. As the pregnancy progresses, the transition between the thoracic kyphosis and the lumbar lordosis tends to shift upward to between T11 and T8.

2.

Evaluate for asymmetry of bilateral landmarks:

mastoid processes, acromion

processes, inferior angles of the scapulae, iliac crests, sacral sulcae, and greater trochanters. Do a pelvic side shift to test for iliopsoas mechanics.

3.

Instruct the patient to bend forward, and do a standing flexion test to assess iliosacral mechanics.

4.

While the patient is bent over, observe for asymmetric paravertebral prominence indicative of the spinal rotation associated with type I spinal curves.

Patient Seated on an OMT Table 1.

Stand behind the patient and perform a seated flexion test to assess for sacroiliac restriction.

2.

To evaluate the sacroiliac motion restriction more specifically, with the patient again Sitting up straight , palpate the right sacral sulcus and rotate the patient's upper torso to the left. This will introduce rotation down through the sacroiliac joints. The sacrum should rotate with the trunk to the left and side bend to the right. The right sacral sulcus should become deeper.

3.

Repeat the process for the left sacroiliac Joint by rotating the patient's torso to the right and palpating the left sacral sulcus.

Chapter 9 • The Female Patient 4.

1 13

Palpate the superior and inferior poles of the sacroiliac Joints for tissue texture abnor­ mality and tenderness. Compare tissue reactivity of the superior pole to that of the inferior pole. This information, in association with findings of asymmetric motion restriction, will allow you to diagnose articular sacroiliac somatic dysfunction. Tissue reactivity greater at the inferior pole is consistent with

a

posterior sacrum on that

Side. Tissue reactivity at the superior pole is consistent with an anterior sacrum.

5.

Assess the lumbar and thoracic spine for TART (tenderness to palpation, asymmetry of position, restriction of motion, and tissue texture change) findings.

Patient Supine

1.

Evaluate the rest of the musculoskeletal system with the patient supine. This por­ tion of the examination may be less efficiently performed in the lateral recumbent position if the uterus compresses the inferior vena cava when the patient lies supine. Include the occipitoatlantal, thoracolumbar, and lumbosacral transition areas. These areas are the most stressed as the pregnancy progresses.

2.

Palpate the sacrum by placing your hand palm up beneath the patient and rock it to assess restriction of articular motion. Assess the inherent sacral motion of the cranial rhythmic impulse (C RI)

3.

Check anterior counterstrain points and innominate and pubic bone dysfunction.

Procedures Please note: The procedures that fol l ow are examples of manipulative treatment t ha t you may wish to employ. The actual choice of proced ures used should be determined by the unique circumstances of eac h i n d iv i d ual patien t

.

Sacrum, Inhibitory Pressure (Fig. 9.1) This procedure is employed to dec rease the severity of dysmenorrhea. It is simple and effective and may appropriately be taught to the patient's family members. (For diagnosis see C ha pter 3.) ,

Patient position: pron e Physic i an position: stand ing to one side at the level of .

the patient's pelvis.

FIGURE 9.1

Inhibitory pressure applied over the sacrum for dysmenorrhea.

114

Section II • Patient Populations

Procedure 1.

Place one hand palm down along the patient's vertical axis upon the sacrum (the direction, cephalad or caudad, of the fingers should be determined by personal comfort) and place your other hand palm down over the first hand.

2.

Fully extend your elbows and lock them.

3.

Apply pressure slowly to the sacrum through your arms by gradually lowering the

4.

When you have applied as much weight as is tolerable to the patient, hold this pres­

weight of your torso onto the patient's pelvis. sure steadily for at least 1 or 2 min utes. 5.

Release the pressure very slowly by gradually lifting your torso.

6.

Repeat as necessary.

Lumbar Paravertebral Muscles (Soft Tissue) (Fig. 9.2)

This procedure is employed to relax hypertonic lumbar paravertebral muscles. It is useful in the third trimester and during labor, as it reduces the low back discom­ fort of this time. It is described here with the patient on her side. It can be modi­ fied, since during labor position changes become inappropriate or difficult. Under these circumstances allow the patient to remain supine and slide your hands palm up beneath her low back and perform the soft tissue stretch in a fashion similar to that employed for rib raising. (See Chapter 5.) These procedures are simple and effective and may appropriately be taught to the patient's family members. The patient lies on either side with her hips and knees comfortably flexed to provide stability for her torso. The lower arm may be placed under her head and the other arm, wherever it is comfortable and out of the way. The physician stands facing the patient at the level of the lumbar spine. Procedure 1.

Wrap your hands over the patient's flank and grasp the upper paraspinal muscula­ ture at the level of the thoracolumbar Junction.

2.

Place one of your feet in front of the other for stability.

FIGURE 9.2

Lumbar paravertebral muscles soft tissue stretching.

Chapter 9 • The Female Patient 3.

1 15

Keeping your back straight, lean back and use your bod y weight to apply antero­ lateral traction slowly through both hands.

4. 5.

Hold this position until the muscles relax. Release the force slowly and work up and down the lumbar spine, treating tight areas.

6.

When the procedure is complete, reassess the dysfunctional area.

7.

Have the patient roll to the other side and repeat the procedure.

Psoas Release (Indirect) (Fig. 9.3) This procedure is empl oyed to reflexively reduce hypert onicity of the ps oa s major muscle. (See Chapter 26.) Patient

position: supine. Physician position : standing on the sid e of the tight

psoas muscle at the l evel of the pelvis, facing the pati ent's head . Procedure (Example: Right Psoas Muscle)

1.

Stand on the patient's right side.

2.

Place your left hand under the right upper lumbar paraspinal musculature and pal­ pate for areas of tension. The paraspinal musculature that is antagonistic to the tight right psoas muscle will be palpably tight.

3.

Monitor the area of palpable paravertebral tension with your left hand throughout the remainder of the procedure.

4.

Grasp the patient's right leg in the region of the tibial tuberosity with your right hand and flex the knee and hip.

5.

When you have flexed the patient's hip to approximately 90 d egrees, begin to apply very small amounts of additional flexion and extension, external and internal rota­ tion, and abduction and adduction

6.

Adjust these fine-tuning motions until the paravertebral tension that your left hand is monitoring begins to dissipate

7.

Hold the hip in this position and allow the paravertebral and psoas muscles to relax.

FIGURE 9.3

Indirect release for psoas spasm.

116 8.

Section II • Pat i e nt Populations M a i n ta i n i n g yo u r m o n i t o ri n g h a n d i n p l a ce, slowly l ower t he patie nt's ri g ht leg to t h e table . As y o u pe rfo rm this p a rt of t h e p ro ce d u re, m ove no faster t h a n t he p a r­ ave rteb r a l te n sion w i l l al l ow. If t h e m o nitored m u s cles begin to t i g h te n, use fi ne t u ni n g m o t i o n s as desc r i bed in s te p 5 to fi n d the m o st effective r o u te to ret urn t he p a t i e n t's leg to the t a b le a n d yet m a i ntain parave rte b r a l re l axat i o n.

9.

W h e n t h e p roce d u re is co m p lete, re a ssess t h e d ysfu n ct i o n a l area.

Psoas (Muscle Energy) (Fig. 9.4) This procedure is em ploy e d to relax a spastically contracted psoas major muscle and thereby reduce low back pain and improve extension of the ipsilateral hip.

(See Chapter 26.) Patient position: supine. Physi cia n position: standing be s i d e the table on the side of the tight psoa s muscle. Procedure

(Example: Tight Right Psoas Muscle)

1.

The pat i e n t's r i ght hip is toward t he edge of the rig ht s i de of the t a ble .

2.

Sta nd i n g next to t h e p a tient's r i g h t side, l owe r the r i ght leg off t he s i de of the t a b le.

3.

P l a ce yo u r left h a n d u p o n t he p atie n t's a n te r i o r t h i g h p rox i m a l to t he pate l l a.

4.

Stabil ize the p a t i e nt's pelvi s u p o n t h e ta b le by a p p l y i n g a h o ld i n g force with yo u r

5.

Exte nd the p a t i e n t's right h i p by g e n t l y p u s h i n g t h e thi g h downward u n t i l the bar­

rig h t h a n d ove r t h e left a nte rio r s u pe r i o r i l i a c s pi ne. rier is re a che d .

6.

W h i le m a i nta i n i n g a h o l d i n g force a g a i n st the p a t ie nt's t h i g h, i n struct her to l i ft It

7.

It is i m p o rt a nt to a l l o w the patie nt to re l a x b riefly

i n t o y o u r h a n d f o r 3 seconds and t h e n to re l a x.

(2 seco n d s) bef o re e n g a g i n g t he

new b a rr i e r.

8.

Exte n d t h e patient's h i p f urt h e r u n t i l the new b a r r i e r is rea ched .

9.

Re peat the e n t ire seq u e n ce as necessa ry to s t retch the tig h t m u scle .

1 0. W h e n t h e p roce d u re is com plete, rea s sess the dysfu n ctio n a l a rea.

FIGURE 9.4

This same muscle energy pro cedure may be used to treat both psoas spasm and i psilateral posteri or innominate.

Chapter 9 • The Fema Ie Patient

FIGURE 9.5

1 17

Anterior sacrum, muscle energy.

Anterior Sacrum (Muscle Energy) (Fig. 9.5) This procedure is employed to introduce motion to

a

dysfunctional sacroiliac artic­

ulation. (See Chapter 3.) Patient position: on the side on the treatment table with hips and knees flexed. Physician position: standing at the patient's hips. Procedure (Example: Left Anterior Sacrum, Sacral Rotation Right on the Right Oblique Axis, with Motion Restriction of the Superior Pole of the Left Sacroiliac Articulation) Patient position: on the right side.

1

Using your left hand, place the pads of your index and middle fingers over the patient's left sacral sulcus to monitor the dysfunctional sacroiliac articulation.

2 3

With your right hand, grasp both of the patient's legs just above the ankles. Flex the hips until you palpate motion between the sacrum and ilium in the left sacroiliac articulation.

4.

Further flex the patient's left hip and allow the left leg to drop off the side of the treat­ ment table. This produces external rotation of the left hip and introduces side bending of the sacrum to the right It also rotates the sacrum to the left between the ilia.

5.

Brace the patient's left leg with your right thigh to stabilize her on the table and to

6.

Switch your monitoring hand and palpate the patient's left sacral sulcus with your

maintain the introduced side bending and rotation. right hand.

7.

Grasp the patient's right arm above the elbow with your left hand and pull toward you until you palpate left rotational force in the left sacroiliac Joint.

8.

Maintain the left rotational forces applied to the sacrum by releasing the patient's right arm and contacting the left anterior shoulder with your left forearm.

9.

Keep your left forearm in contact with the patient's left shoulder, and again, switch hands

10

50

that you are monitoring the patient's left sacral sulcus with your left hand.

Contact the patient's left iliac crest with your right forearm and rotate the pelvis toward you, rotating the pelvis to the right with your right forearm while maintain­ ing sacral rotation to the left from above with your left forearm.

118

Sect i o n I I • Patie nt Pop u l atio n s

1 1 . Te l l t h e p a t i e n t t o p u s h t h e p e l v i s b a c k a g a i n st t h e h o l d i n g fo rce of yo u r r i g h t forearm a n d/o r t o p u s h the l eft s h o u l d e r a g a i n st y o u r l eft forea rm for 3 to 5 seco n d s .

12.

M a i n ta i n yo u r h o l d i n g force d u r i n g t h e pat i e n t 's c o n t r a ct i o n .

1 3.

I n s t r u ct t h e p a t i e n t to r e l a x for 2 to 3 seco n d s .

1 4.

In cre a s e p ress u re t h ro u g h yo u r r i g h t fore a r m to rotate t h e p a t i e n t 's p e l v i s fa rt h e r to t h e r i g h t w h i l e m a i nta i n i n g s a c r a l rot a t i o n to t h e l eft by h o l d i n g t h e u p p e r t o rso with yo u r l eft forea r m a s in step 1 0 to ree n g a g e t h e b a r r i e r, and re peat steps 1 1 t h ro u g h 1 4 a s m a n y times a s n e c e s s a ry to esta b l i sh t h e d es i red s a c ro i l i ac ra n g e of m o t i o n .

1 5 . W h e n t h e p ro ce d u re i s co m p l et e , reassess t h e dysf u n ct i o n a l a re a .

Anterior Sacrum Leg Pull (H VLA) (Fig. 9. 6) This p r oced u r e i s employed to trea t s a cr o i l i a c a r tic u la r dysfu nction fo u n d i n asso­ cia tion w i t h sacra l fo rward tors i o n . With an a n te r i o r sa c r u m , t h e i n n o m i n a te is pos ter ior to the sacr u m . D u ring t h i s proced ure the l e g does not have to b e e x te n d ­ ed to l o a d the q u a d riceps g r o u p , b e ca u s e t h e aceta b u l u m l i e s a n terior t o the s a c r u m . ( S ee Chapter 3 . ) P le a s e note: This pr o ce d u r e s h o u l d n ot be used if the p a t ient has poten t i a l i n sta b i lity of t h e k nee o r h i p

on

tbe s i d e bei ng trea ted .

Pa t i e n t p o s i t i o n : s u p i n e . P hysi c i an p o s i tion : sta n d ing at the foot of th e treat­

ment ta b l e . P roce d u re ( Exa m p l e : Right A n t e rior S a c r u m , S ac r u m Rotated Left on t h e Left O b l i q u e Axis, Rest riction of the Right Sacroi l i a c Joint, S u p e rior Pol e )

1.

G ra s p t h e p a t i e n t 's r i g ht a n k l e j u st a bove t h e m a l l e o l i w i t h b o t h h a n d s .

2.

I n st r u ct t h e p a t i e n t t o re l a x a l l of t h e m u scles i n t h e l o w b a c k a n d l e g .

3.

I n t e r n a l l y rotate t h e l e g t o acc u m u l ate fo rces at t h e r i g h t s a c ro i l i a c j o i n t . T h i s p u l l s t h e i l i u m away f r o m t h e s a c r u m , t h e reby g a p p i n g t h e s a c ro i l i a c j o i nt . T h e p a t i e n t 's l e g a n d t h i g h s h o u l d n o t be l i fted f r o m t h e t reat m e n t ta b l e , so t e n ­ s i o n is m a i n ta i n e d u p o n t h e a n te r i o r t h i g h .

F I G U R E 9. 6

HVLA leg pull for anterior

sacru m .

Chapter 9 • The Female Patient

FIG U R E 9.7

4.

H V LA l eg pul l fo r

a

posterior

119

sacru m .

Apply t h e final corrective force with a q uick pull on the patie n t 's leg, car rying t h e right innomin ate anteriorly t o meet the sacrum.

5.

When the procedure is complete, reassess t h e dysfunctional area.

Posterior Sacrum Leg Pull (HVLA) (Fig. 9. 7) T h i s p rocedure is em ployed to treat spec i fic s acro i l i ac arti cul ar dysfu n ction i n assoc i ation wit h sacral forward torsion. Consi deri n g a posterior sac r u m , t h e innom i nate w i l l b e relative l y anteri or t o t h e sac r u m . When emp l oying this proce­ dure, the hip must be flexed to load the hamstri ng m u scular group. Please note: T h i s procedu re should n o t be used if the p atient h a s poten tial instab i l i ty o f t h e k n ee or hi p on the si d e bei ng treated . Patient position: sup ine. P h ysician posi tion: standi n g at the foot of the treat­ ment table. Procedure (Example: Right Posterior Sacrum, Sacrum Rotated R i ght on the R ight Oblique Axis, Restrict ion of the Right Sacroil iac Joint, I nferio r Pole)

1.

Grasp the patie nt's rig h t ankle just above t h e malleoli with both hands .

2.

Instruct the patien t to relax all of the muscles in the low back a n d leg .

3.

I n ternally rotate t h e leg t o accumulate forces a t the right sacroiliac j oint. T his pulls

4.

Wh ile keeping t h e k nee extended, flex t h e hip until ten sion is placed o n t h e

5.

A pply t h e final corrective force with a q uic k pull on the patie nt's leg, carry i n g t h e

the ilium away from the sacrum, t h ereby gapping the sacroiliac Joint. hamstrings. r i g h t innominate posteriorly t o m eet t h e sacrum.

6.

When the procedure is complete, reassess t h e dysfunctional area.

Piriformis Muscle (Muscle Energy) (Fig. 9. 8)

This procedure is empl oyed to i n crease restric ted i nternal rotat i on of t h e hip. T h i s dysfunction is often seen as a r esu l t o f spasm o f t h e p i ri formis musc l e .

1 20

S e cti o n I I • P atie nt

FI G U R E 9.8

Po p u l a t i o n s

M u s c l e energy for p i rifo r m i s s p a s m .

Patient po sition: s u p i n e . P h y s i c i a n po s i ti o n : s t a n d i n g a t t h e side of the table on the side of the d ysfu n c t i o n a l h i p , fa c i ng the pat i ent .

Procedure ( E x a m ple: Rest r i ct i on of the E xternal Rotators of 1.

t h e R i g h t H i p)

G rasp the patie n t 's r i ght k n ee with yo ur l eft hand and the right leg with your right ha nd.

2.

F l ex the right h i p and k n ee each to 90 degrees .

3.

C radle the patient's right calf i n your right ha nd so that the an kle is f i r m l y held between you r r ight arm a n d side.

4.

P lace your left palm upon the lateral aspect of the patient's right k n ee .

5.

I n te r nally rotate t h e patie nt's right thigh by abducting the leg from the midl i n e while maintai ning the k n ee i n a fixed position un til t h e barrie r

6.

IS

en gaged.

I nstruct the pat i e n t to exte r n ally rotate the thigh by con tracting the hip m uscles and atte m pting to move the foot back to midl i n e for 3 to 5 seco nds.

7.

Mainta i n your holding force du ring the patient's contraction.

S.

I n str uct the pat i e n t to relax for 2 to 3 seco nds.

9.

Fu rther i nt e r nal ly rotate the patie n t 's ri ght thigh as in step 5 to ree ngage the barri­ er. Rep eat steps 6 to S as ma n y t i mes as necessary to esta b l ish the desired ra nge of motion .

1 0 . Whe n the procedu re is comp l ete, reassess the dysfu nctio nal area.

An terior and Posterior Innominate (Muscle Energy)

This proced u re is em p l o y ed to i m p rove m o t ion o f the dy sfunct iona l innomi nate . Dy sfu n cti o nal res triction of motion between the two pelvic bo n e s c a n occ u r s u c h that o n e i n n o m i n a te b o n e is a n terior ( a nterior i n n o m i n a te d y s fu n c t i o n ) or p o st e ri o r ( p oste r i or i nn o m i n a te d ysfu nction) to the other. P a tient p o s itio n : s u p i n e . P h y s i c ian positi o n : standing at the side of the ta ble o n the s i d e o f the i n n o m i n a te , fa c i n g the p a t i e n t .

Chapter 9 • T h e F e m a l e P a t i e n t

121

Posterior Inn ominate Dysfunction (Muscle Energy) (Fig. 9. 4) Proce d u re 1.

Draw the patient's pelvis toward the edge of table on the side of the dysfunctional innominate sufficient to permit the lower extremity on that sid e to hang off the table.

2.

Reach across the table and p l ace one hand upon the opposite innominate to stabi­ lize the patient's pelvis upon the table .

3.

Place your other hand above the knee o f the lower extremity that has been allowed to hang off the side of the table.

4.

Apply a downward force to the thigh, extending the hip to engage the barrier.

s.

Instr uct the patient to push the knee upward against your holding force for 3 to

5 seconds. 6.

Maintain your holding force during the patient's contraction.

7.

Instruct the patient to relax for 2 to 3 seconds.

8.

Further extend the patient's hip as in step 4 to reengage the barrier. Repeat steps

9.

When the procedure is complete, reassess the dysfunctional area.

6 to 8 as many times as necessary to establish the desired motion of the innominate.

Anterior Innominate Dysfunction (Muscle Energy) (Fig. 9. 9) Proce d u re 1.

Place one hand beneath the patient 's pelvis on the side of the dysfunctional innom­ inate so that your finger tips are contacting the posterior superior iliac spine and sacroiliac Joint

2.

With your other hand flex the patient's knee and hip on the dysfunctional side until the barrier is engaged.

3.

Instruct the patient to lace the fingers together, reach down, and grasp the flexed knee, and hold it in the flexed position .

4.

Place the hand flexing the patient's hip over the hands upon the knee.

s.

Instruct the patient to extend the hip by pushing the knee against the holding force for 3 to 5 seconds.

FIGURE 9.9

M u s c l e e n e r g y for a n t e r i o r i n n o m i nate.

1 22

Sect i o n II • Patient Pop u l a t i o ns

6.

M a i n ta i n t h e h o l d i n g fo rce d u r i n g t h e p a t i e n t 's contract i o n .

7.

I n st r u ct t h e p a t i e n t to re l a x for 2 to 3 seco n d s .

8.

F u r t h e r f l e x p a t i e n t 's h i p a s i n step 2 to re e n g a g e t h e b a r r i e r a n d repeat steps 5 to

9.

W h e n t h e p roced u re is co m p l et e , reassess t h e dysfu nctio n a l a re a .

8 as m a n y t i m e s as n ecess a ry to esta b l i s h t h e d es i red m o t i o n of t h e i n n o m i nate .

Symphysis Pubis Superior or Inferior Shear (Muscle Energy) (Fig. 9. 1 0) This proced ure is em pl oyed to improve

m o ti o n

between the two pelvic b o n es at

the pubic symphysis. Dysfu n ctiona l r estri c t i o n of motion between t h e two pelvic bones can occur at the pubic sy mphysis such t h a t one p u bi c bone is held in a s u pe­ rior (superior pu bic dysfunction) or inferior ( i n fe r i o r p u bic dysfunction) p o s i tion

rela t i v e to the o t h er. Since the re l a tio n s h ip between these two b o n e s i n v ol v e s a s i n ­ gle articulati on, t h e symphysis, t h i s nomenclature is somewhat arbitra ry. Pat i e nt p os i tio n : supin e . Physician position: st a nd i n g beside the table and fac­ ing t he patient. Procedure

1.

Te l l t h e p a t i e n t to f l ex the h i ps a n d k n ees a n d to k e e p t h e feet f l a t on the ta b l e .

2.

T h e p a t i e n t 's foot o n t h e s i d e o f t h e s u p e r i o r l y d i s p l aced p u b i c b o n e m a y be s l i g ht­ l y f a rt h e r fro m t h e b u tto c k s than t h e oth e r foot. This asym m et r i c foot p l acem e n t flex e s t h e h i p on the s i d e of t h e s u p e r i o r l y d i s p l aced p u b i c bone s l i g h t l y l ess t h a n t h e o t h e r h i p . I t i s t h o u g h t that w h e n t h e p a t i e n t p e rfo r m s t h e t h e ra p e u t i c i s o m et· r i c c o n t r a ct i o n , t h i s res u lts i n

a

m o re i nf e r i o r l y d i rected fo rce a p p l ied t h ro u g h t h e

a d d u ct o r m a g n u s o n t h e s i d e of t h e s u p e r i o r l y d i s p l aced p u b ic b o n e

3.

Abd uct t h e patient's t h i g h s a n d p l ace yo u r forea rm betwee n them s u c h that yo u r p a l m

4.

W i t h y o u r oth e r h a n d p a l pate t h e p a t i e n t 's p u b i c s y m p h ys i s .

is i n contact with o n e of the patient's k n ees a n d yo u r el bow is i n contact w i t h the other. 5.

I n st r uct t h e p a t i e n t t o a d d uct t h e k n e e s f o r 3 to 5 seco n d s a g a i nst t h e h o l d i n g force of y o u r f o re a r m betwe e n t h e k n ees.

6.

O n ce g a p p i n g i s fe l t at t h e s y m p h ys i s p u b i s , i n st r u ct p a t i e n t to re l a x for 2 to

3 seco n d s .

F I G U R E 9. 1 0

M u s c l e e n ergy fo r p u b i c s y m p h y s i s dysfu n ct i o n .

Cha pter 9 • T h e F e m ale Pat i e n t

FIGURE 9. 1 1

7.

1 23

Myofasc i a l re l e a se, i s c h i a l t u b e ro s i ty s p r e a d .

F u rt h e r a b d uct t h e p a t i e n t 's t h i g h s a s i n s t e p 2 to re e n g a g e t h e b a r r i e r, a n d re p e a t s t e p s 4 to 6 a s m a n y t i m es a s n e cessa ry to esta b l i s h t h e d e s i red m oti o n of t h e of the p u b i c sy m p h ys i s .

8.

W h e n t h e p roce d u re is co m p l ete, reassess t h e d y sf u n cti o n a l a rea .

Ischial Tuberosity Spread (Myofascial Release) (Figs. 9. 1 1 and 9. 12)

T h i s p roc e d u re is e m ployed to separa te t h e isch i a l tu beros i ties and c o n s e q u e n t l y to promote motion between t h e s a c r u m a n d the i n n o m i n a te s . It m a y be empl oyed a s a genera l a rti c u l a r proced u re to re d u ce s a cr a l to r s i o n a nd f l ex i o n d y s fu nc t i o n s .

FIGURE 9. 1 2

Th u m b p l a c e m e nt, m e d i a l to t h e i s c h i a l t u b e r o s i t i es, f o r m y o f a sc i a l re l e a s e o f i s c h i a l t u b erosity s p re a d .

1 24

Section I I • Pat i e n t Po p u l at i o n s

I t i s a l s o inten d e d to fa c i l ita te p e l v i c d i a phragm rela x a t i o n d u r i n g r e s p i r a to r y

ex h a l a ti o n . It m a y t h u s be employed as a soft t i s s u e myofa sc i a l p roced u re to im p rove the fu nction of the u roge n i ta l a n d p e l v i c d i a ph r a g m s as p a r t of t h e m a n ­ agement o f such

c o nd i t i o n s

a s dyspareu nia, c h ro n ic pe l v i c p a i n , cysti t i s , prosta t itis,

p roctitis, hemorrhoids, and co ns t ipa ti o n

.

P a t ient posi tion: pro n e , or i n t he k nees to chest p o s i t i o n i f p r e g n a nt, w i th t h e

p e l v i s a s c l ose to t h e fo ot o f t h e ta b l e a s comfo r t a n d p os i t i o n i n g s ta b i l ity pe r m i t. P h ys i ci a n pos i t i o n : sta n d ing a t t h e foo t of the table . Proced u r e 1.

If the pat i e n t is pro n e , flex the kn ees to 90 degrees In the k n e e chest positi o n , the

2.

I n te r nally rotat e the patie n t 's th ighs by keeping the k n e es fixed upon the table and

k n e es will already be flexed. ab duct i n g the legs. This tends to d raw the pelv i c b o n es away fro m the sac r u m and places t e nsio n upon t h e pe ri n eum.

3.

Place the pads of your thum bs bilaterally upon the m edial aspects of t h e pati e n t 's ischial t u b e rosities.

4.

Apply firm and co n t i n uous late ral press u re upon the ischial t u berosi ties.

5.

I nst ruct the patient to coug h .

6.

A s t h e perin eum i s felt t o relax , with s e n sitiv ity for patie nt discomfort, apply i n c reased cephalad pressure upon the pelvic diaphragm and late ral pressure against the ischial tub e rosities .

7.

Repeat steps 5 a n d 6 as many times as n e c essa ry to establish the d eSired relaxat ion of the pelvic diaphrag m an d/or sacral motion .

8.

Whe n the procedure is complete, reassess the d ysf u n ctional a rea.

Sacrum Diagnosis and Treatment (Cranial) (Fig. 9. 13)

The CRI m a y be p a l p a te d thro u g h o u t the body. Cran i a l osteopat h i c theory p l aces g r e a t sign i fica nce upon harmon i o u s motion of t h e sacrop e l v ic r eg i o n with c r a n i a l m o t io n . Th i s recip roca l re l a t i o n s h i p m e a n s t h a t tre a t i ng t h e sa cr u m a nd p e l v i s c a n ha v e b r o a d i n fl u e n ce upon the w h o le b o d y 's cra n i a l mech a n i s m . T h is p roce d u re is

FI G U R E 9 . 1 3

Cra n i a l osteopathy d i a g nosis a n d treat m e nt of the sacru m .

C h a pter 9 • The F e m a l e Pa t i e n t

1 25

e m p l oyed to e n h a nce s y m m e t r i c m o t i o n of the sacr u m a n d co n s e q u e n r J y of the en tire c r a ni a l mec h a n i s m .

The p a tien t l i e s s u p i n e , a n d t h e p h y s i c i a n s i ts b e s i d e t h e ta b l e , fa cing t h e h e a d o f t h e ta b l e a n d w i t h t h e d o m i n a n r h a n d t o be e m p l o y e d for pa l p a tion a n d treat­ m e n t c l osest to the ta b l e . Proc e d u r e f o r Diag n o s i s a n d Treat m e n t

1.

P l a ce yo u r p a l p at i n g h a n d a n d fore a r m betwe e n t h e p a t i e n t s t h i g h s p a l m u p u p o n '

t h e t a b l e , w i t h yo u r f i n g e rs p o i n t ed towa rd t h e p a t i e n t 's h ea d .

2.

I n s t r u c t t h e p a t i e n t t o f l e x t h e k n ee fa rt h e r from y o u , p u t t h e foot f l a t u p o n t h e t a b l e , a n d l i ft t h e p e l v i s off t h e ta b l e .

3.

S l i d e yo u r h a n d b e n e a t h t h e p a t i e n t's sac r u m s u c h t h at y o u r f i n g e rt i ps contact t h e b a se of t h e sacru m a n d t h e s a c ra l s u l c i b i l a t e r a l l y. T h e a p e x of t h e s a c r u m s h o u l d l i e i n t h e pa l m o f yo u r h a n d

4.

.

I n str u ct t h e p a t i e n t to l ower t h e p e l v i s o n to yo u r h a n d a n d to stra i g h t e n o ut t h e leg

5. 6.

Lea n y o u r w e i g h t o n y o u r e l bow. Pa l pate the C R I . D u r i n g cra n i a l f l ex i o n , the base of the s a c r u m m oves i n to y o u r f i n ­ g e rt i p s , a n d d u r i n g c ra n i a l exte n s i o n , t h e a pex o f t h e s a c r u m m oves i n t o t h e pa l m of yo u r h a n d .

7.

Assess t h e q u a l i ty q ua n t i ty a n d s y m m e t ry of t h i s s u b t l e m o t i o n a n d i d e n t if y a s y m ­ ,

,

m e t r i c moti o n , p ro p e n s i ty for flex i o n o r ext e n s i o n , a n d d i m i n i s h ed a m p l i t u d e of t h e

C RI. 8.

M a i n ta i n i n g yo u r h a n d i n t h e s a m e p o s i t i o n

,

u s e i n d i rect t re a t m e n t m e t h o d s a n d

a p p l y g e n t l e force t o m ove t h e s a c r u m towa rd t h e f re e d o m of moti o n , o r u s e d i rect t re a t m e n t m e t h o d s a n d a p p l y g e n t l e fo rce to m ove the s a c r u m toward the res t r i c ­ t i o n of m o t i o n .

9.

H o l d t h e s e l ected i n d i rect or d i rect p o s i t i o n a n d awa i t a re l e a s e of t h e s a c r u m .

1 0 . W h e n t h e p roced u re i s co m p l ete, reasse s s t h e dysfu n ct i o n a l a rea .

Refe re n ces 1 . B u r r o w s EA. D i s o r d e r s of the fema l e reprod u c t i ve syste m . I n : Hoag JM, ed . Osteopath ic Med ici n e . New Yo r k : McG r a w H i l l , 1 9 6 9 ; 676-6 8 4 . 2 . M o t t is N , O ' N e i l l D . O u t-pa t i e n t g y n a e c o l ogy. B r M e d J 1 9 5 8 ; 1 4 : 1 0 3 8 -1 0 3 9 . 3 . H e i n k i n g KP, K a p p l e r R E . P e l v i s a n d sacru m . I n : Wa rd R C, ed . F o u n d a ti o n s fo r O s te o p a t h i c lvled i c i n e . 2 n d ed . Ph i l a d e l p h i a : l i p p i n co t t Wi l l i a m s & W i l k i ns , 2 0 0 2 ; 6 0 1 -6 2 2 . 4 . D i G i o v a n n a E l , Sch i o w i tz S . Eva l u a t i o n o f t h e p e l v i s a nd s ac r u m . T n : A n O s teopa t h i c A p p ro a c h r o D i a g n o s i s a n d Trea t m e n r . P h i l a d e l p h i a : l i p p i ncott, 1 9 9 1 ; 1 8 9 -2 1.2 .

5 . Fryetre H H . P r i n c i p l e s o f Osteo p a t h i c Tec h n i c . I n d i a n a p o l i s : A m e r i ca n A c a d e m y o f Osteopa thy, 1 9 5 4 , 1 9 8 0 ; 6 7- 1 0 7 . 6 . G r e e n m a n P E . Pe l v i c g i r d l e d ysfu n c t i o n . I n : P r i n c i p l e s of M a n u a l M ed i c i n e . 2 n d e d . P h i l a d e l p hia : W i l l i a m s & W i l k i n s , 1 9 9 6 ; 3 05-3 6 7 . 7 . K u c he ra WA , K u c h e ra M L . D i a g n o s i s a n d m a n i p u l a t i v e trea t m e n t of t h e l u m bo pe l v i c reg i o n . I n : Osteopa t h i c P r i n c i ples in Practice. 2nd e d . Co l u m b u s , O H : G re y d e n , 1 9 9 4 ; 3 93-5 1 .2 . 8 . N e l s o n K E . The s a c r u m : A bone of c o n te n t i o n . A A O

J

1 9 9 7 ; 7 ( 4 ) : 1 7-24 .

9. S t r ac h a n WF, Bec k w i t h C G , la r s o n NJ, Gra nt J H . A s t u d y of [ h e m e c h a n i c s of t h e s a c ro i l ia c j o i nt .

J

A m O s teo p a th Assoc 1 9 3 8 ; 3 7 : 5 76-5 7 8 .

1 0 . P e a rce S . A Psyc h o l o g i c a l I n v es t i g a t i o n o f C h ro n ic PeJ v i c Pa i n i n Wo men. U n i ve r s i t y o f lond o n , 1 9 8 6 [ P h D t h e s i s ] . 1 1 . St i l l AT. Ph i l os o p h y of O s teo p a t h y . Ki r k sv i l J e , M O : A u t h o r, 1 8 9 9 . R e p r i nted by t h e A m e r i c a n A c a d e m y of Os teop a t h y, I n d i a n a p o l i s , 1 9 7 1 : 2 3 4-24 9 .

1 26

Sect ion II • Pat i e nt Po p u l at i o n s

1 2 . Te ttam bel M . O b stetr i c s . I n : Wa rd R C , ed . Fou n d a t i o n s fo r Osteo p a t h i c Med i c i n e . 2 n d ee L

P h i l a d e l p h i a : L i p p i ncot[ W i l l i a m s & Wil k i n s , 2 0 0 2 ; 4 5 0-4 6 l . 1 3 . Ne lson K E . T h e m a n a g e m e n t o f l o w b a ck pai n . A A O J 1 9 9 9 ; 9 ( 1 ) : 3 3-3 9 . 1 4 . P h ysiology o f pregn a n c y. I n : West ] B , e d . Best a n d Ta y l o r 's P h Y S I o logica l B a s i s o f M e d i c a l P r a c t i c e . Phi l a del p h i a : Wi l l i a m s & Wi l k i n s, 1 9 9 0 ; 8 9 2-9 3 4 . J 5 . S u c h e r B M . Pa l p a tory d i a g n o s i s a n d m a n i p u l a t i v e m a n a ge m e n t o f c M p a l t u nnel s y n d r o m e .

J Am Osteopath A s s o c 1 9 9 4 ; 9 4 : 6 4 7-6 6 3 .

1 6 . R a m ey K A et a l . M R I a s sess m e n t o f cha nges i n swe l l i n g o f w t i s t structu res fo l l o w i n g O M T i n p a t i ents w i t h c a r p a l ru nn e l s y n d r o m e A A O J 1 9 9 9 : 9 ( 2 ) : 2 5-3 1 . .

The Surgical Patient Janet M. Krettek

INTRODUCTION The art of surgery is significantly enhanced when the osteopathic model is used to manage

a

patient's care. Surgery can be used as a diagnostic test andlor as a meas­

ure to provide a c u re The osteopathic model assists in diagnosis and treatment .

perioperatively. There are various aspects of the patient's care to consider, depend

­

ing on when the patient is encountered. These aspects of patient management fall into three phases: preoperative, intraoperative, and postoperative . Though we arti­ ficially dissect the patient into se parate systems to reveal the physiological processes, it is important to treat the patient as a whole, integrated person.

PREOPERATIVE For minor surgical procedures little or no other treatment is necessary. The removal ,

of a skin lesion,

for example, is minimally stressful to the patient. However, if the

patient is undergoing a more extensive procedure such as arthroscopy or breast ,

biopsy, preoperative considerations include checking the patient for overall state of health, nutrition, and hydration. Optimize the patient'S circulation, arterial, venous,

and lymphatic, to the proposed surgical area. Check for local or viscerosomatic areas of somatic dysfunction. If the patient will be undergoing general anesthesia, ensure optimal pulmonary function, including the musculoskeletal component of respiration. 127

128

Section II • Patient Populations

For major surgery, it is desirable to optimize patients' health status prior to sur­ gery. However, surgery is often required on an urgent or emergency basis, which makes this impossible. Patients should be prepared mentally, emotionally, and spir­ itually to optimize recovery. Patients should understand the procedure, benefits, risks, possible complications, and likelihood that these will occur in their situation. Patients should be confident in the skills and compassion of all personnel involved in their care. Thus, every caregiver must be kind and attentive to patients' needs.

All affected systems , including pulmonary, renal, cardiac, gastrointestinal, neu­ romusculoskeletal, and circulatory (arterial, venous, lymphatic, and primary respi­ ratory) should be checked. Age and nutrition should be considered as well. Smoking cessation ideally begins 2 weeks prior to surgery.! A II systems should be functioning as well as possible preoperatively. Preparation may include osteopathic manipulative treatment (OMT), medications, nutrition, and education.

The use of OMT varies according to the individual needs and the areas of somatic dysfunction. Ensure that the thoracic cage, the diaphragm, and the cervi­ cal spine all have good motion and are free of significant somatic dysfunction. Midcervical (C3-C5) somatic dysfunction is associated with increased postopera­ tive pulmonary complications. This has been described as a somatovisceral mech­ anism. In reality, it most likely represents a somatosomatic reflex in which the cervical somatic dysfunction affects the thoracoabdominal diaphragm through the phrenic nerve, and the resultant dysfunction predisposes the patient to develop pulmonary complications. The use of OMT preoperatively to reduce midcervical somatic dysfunction has been shown to significantly decrease postoperative pul­ monary complications.2 Further, specifically treating somatic dysfunction reduces postoperative complications and discomfort.3-5

Diagnosis Diagnosis of acute abdominal pain is often perplexing. Heightened palpatory skills of the astute examiner offer insight into abdominal processes. Viscerosomatic reflexes in particular can be helpful in diagnosis. (See Chapter 5.) Viscerosomatic reflexes are segmentally predictable dermatomal and myotomal responses to inflammatory visceral pathology. The location of the reaction identi­ fies the involved organ, and the intensity of the tissue texture abnormality indi­ cates the degree of visceral inflammation. Neoplastic lesions that are not specifi­ cally innervated may not produce a viscerosomatic response commensurate with the severity of the disease process unless a significant inflammatory reaction is pro­ duced in the tissues surrounding the neoplasm. The tissue texture change of the viscerosomatic reflex is most readily palpated in the paravertebral soft tissues of the spinal level, sympathetic or parasympathetic, that innervates the structure responsible for the reflex. General visceral afferent nociceptive neurons return to the spinal cord in the same nerves that carry the efferent autonomic fibers. The reflexes lateralize to the paravertebral soft tissues on the same side of the body as the viscus. Midline organs produce bilateral reflex reactions. The location of these palpatory findings is often at the spinal level, where the patient may report referred pain. Consequently, cholecystitis results in a right-sided response in the area of T5 to TIO; appendicitis produces tissue texture abnormality at T12 on the right, the dermatomal level of McBurney's point; and pancreatitis produces a bilateral reaction in the mid thoracic region, T5 to T9. Although the somatovisceral impact of a viscerosomatic reflex may be treated preoperatively, the definitive treatment of the underlying pathology is the specific

Chapter 10 • The Surgical Patient

129

surgical procedure. These areas of tissue texture c h ange, and tenderness to palpa­ tion resulting from viscerosomatic reflexes are manifestations of visceral pathology, not primary somat ic dys function .

INTRAOPERATIVE Intraoperat ively, the osteopathi c physic ian must demonstrate extreme respect for the patient . T he patient is in a vulnerable position, and great care to preve n t unin­ tended visceral, somatic, or emotional inj ury is necessary. Warm, gentl e s p eech should be used in the operating room. The patient must be placed in a positi on that is both comfortable for the patient and convenient for the surgeon. For exam­ ple, when pos iti o n ing a patie nt in stir rups for a pe l vic or rectal procedure, ensure sy mme try of posit ion. Asymmetric placement of the lower extremities may result

in sacr op el vic so m at i c dysfunc t ion posto pe ratively. When operating, the surgeon must take care to respect the tissue. The tissue should be retracted gen tly and s m oothly a n d only as needed. S tudents must be taught how to touch the various tissues to avoid injury. Before incising the skin, the area of incision can be injected with local anesthetic, even if the patie n t is undergoing ge n eral anesthesia. This preve n ts the pain reflex by blocking the C fibers, thereby red u ci ng postoperative pain and som a tos om atic re fle x es .

POSTOPERATIVE During the first 1 to 3 p osto p e r ative days, the systems a p pro a ch should be taken to re ga in or develop health overall . The syst em s to be concentrated upon first are those that are central to life , the p u lm onary and c i rc u latory systems. It is appro­ priate to use procedur es to facilitate lym ph at i c flow and improve t h e mobility of the thoracic diaphragm and the crania l mechanism. Ensure that gentle care is given with attention to the patient's level of pain and tolerance to your treatment as well as co nsider ation of the sur gical site. Goals at this t ime a r e prevention of atelecta ­ sis and m ai n t aining adequate circulation. The most common reason for postoper­ ative fever is atelectasis. General anesthesia causes some al veolar collapse, which can be easily corrected if the patient is alert, active, and able to resume full, nor­ mal respiration postoperati vely . However, chest or abdo min a l surgery will in hib i t the patient'S respirat i ons as a result of sp li nt ing secondary to pai n . Prolonged bed rest , such as post hip p inning , will also decrease full diaph rag m atic excursion. Manipulative proced u res to consider include lymphatic pump, rib raising, pedal pump, compression of the fourth ventricle (CV-4), and d i ap h ragm and soft tissue proced u res. Pain control is very importa n t. The most obvious reason is to decrease suffer­ ing , but there are other reasons. Treating the patient's pai n earl y breaks the pai n cycle and interrupts the v i scerosomatic and so m ato somatic reflexes. If it is left unchecked, pain can be m u ch harder to manage the second or third postoperative day as the patient'S pa i n tolerance falls in response to hyperactivity of the sympa­ thetic nervous system. When the pain is lessened or obliterated, the patient can take deeper breaths and increase activity, thus improving the pu Imonary, lymphatic, gastroi n testin a l , and cranial systems . This has a spiraling effect to a better recov­ ery. Op io i ds and their derivatives are most useful ear l y and in combi n ation with pain relievers using other mechanisms of actions, such as a n onste r oid a I anti­ inflammatory drug or aceta m inophen . D i min i s he d gastro i ntesti n a l mot ility is less

130

Section 1/ • Patient Populations

important than pain control. Do not be concerned at this time with the possibility of starting an addiction. Addiction will not result from adequate treatment of postoperative pain. Additional treatment modalities may be added at day 2 to 4, depending on the type of surgery. Remember to have the patient participate in the healing by breathing deeply to improve pulmonary function and walking as soon as possible to improve circulation and gastrointestinal motility. Today, with the use of minimal-access proce­ dures, more about the effects of early activity on recuperation from surgical trauma is revealed. Patients can have less pain and less ileus, leading to more physical activity, earlier discharge times, and more rapid resumption of normal activities. Patients are often discharged from the hospital so early that the physician does not get a chance to provide any further extensive postoperative care in the hospi­ tal setting. For patients who remain hospitalized, however, the gastrointestinal tract and renal and autonomic nervous systems may now be approached. Though patients are discharged earlier, this does not change the body's reaction to the stress and injur y of surgery. The first phase of healing, the inflammatory stage, takes place over the first 3 postoperative days. One can change the intensity of this phase with ice, rest, elevation, anti-inflammatory medications, and OMT, but it still takes place. On postoperative day 4, the diuresis phase begins, in which the patient loses the retained fluids from the intracellular and extracellular spaces, including the surgical site. This is the time to ensure that renal and circulatory functions are at their peale The lymphatic system picks up 8 to 12 L of fluid daily, of which 2 to 4 L returns to the venous circulation via the thoracic duct. The remainder returns via capillary exchange in the lymph nodes.6 During the diuretic phase, the fluid load increases. Thoracic cage mobility is imperative, not only for efficient respiration but also for returning lymph to the general circulation. The thoracic duct terminates into the left subclavian vein; therefore, mobility of the thoracic outlet is critical to prevent obstruction to the flow of lymph. Rib raising is of great value in reducing postoperative atelectasis and conse­ quent pneumonia.4 Motion of the thoracoabdominal diaphragm, which may be decreased by abdominal splinting, should be enhanced. Cephalic traction on the anterior axillary folds of the supine patient pulls the thoracic cage into the posi­ tion of inhalation. This transiently reduces thoracic cage excursion, necessitating that the patient breathe by using the diaphragm, thereby stimulating diaphragmatic motion. Various modifications of thoracic lymphatic pump may be employed if the patient (and the surgical site) can tolerate them. The motion of the diaphragm results in alternating negative and positive intrathoracic pressure coupled with alternating positive and negative intra­ abdominal pressure. This two-chambered pump mechanism and the unidirectional flow that results from the presence of valves in the lymphatic vasculature pulls the lymph centrally into the venous circulation. Enhancing thoracic cage mobility preoperatively is directed at postoperatively reducing lymphatic congestion and the likelihood of pulmonary stasis. Lymphatic flow occurs as the result of lymphatic vasomotion augmented by movement of structures surrounding the lymphatic vasculature.7 The cranial rhythmic impulse (CRI) has been demonstrated to be synchronous with the Traube-Hering (baroreflex) fluctuation in blood flow velocity and pressure.s This fluctuation in sympathetic tone may also be a driving force behind lymphatic vaso­ motion and is a possible explanation for how cranial manipulative procedures, such as CVA, affect the patient.9-l1 Preexistent spinal (and to a lesser extent appendicular) somatic dysfunction should be identified and treated. Spinal somatic dysfunction results in spinal

Chapter 10 • The Surgical Patient

131

cord-level segmental facilitation with somatovisceral effects. High cervical and sacropelvic

dysfunction results in parasympathetic somatoviscera l reflexes.

Thoracolumbar dysfunction res u lts in sy mpat h et i c somatovisceral reflexes. Check for te m poral bone dysfunction and uppe r cervical dysfunction when considering the function of the vagus nerve. The patient may need some assistance in stimulating the gas t roi n testi nal tract via stimulation of the underactive parasympathetic nervous system and inhi biting the overactive sympathetic nervous system. Increased sympa­ thetic tone contributes to postoperative ileus and results in vasospasm that decreases tissue perfusion.

The supply of arterial blood will decrease, and diminished

lymphatic and venous capacity will increase passive congestion. The sympathetic ganglia lie between Tl and L2. Com b i n in g the two procedures, inhibitory pressure and rib raising, when treating the thoracic and lumbar spinal regions, can inhibit

sy m pathetic tone. The parasympathetic nervous system is div i ded into cranial and

sacral portions. The vagus n er v e innervates the pulmonary, gastrointestinal, and cardiac systems. The parasympathetic nervous system should be stimulated with manipulation, therefore, to resolve an ileus. Somatic dysfunctions occur just from inactivity, lying in a hospital bed for a few days. Be sure to ask the patient about any b ac k , neck, or ap p endic ular discomfort. The treatment of these somatic dys fun ctio n s may be without

an

a

bit difficult, pa r ticularly

OMT table, but procedures can be modified for application in a hos­

pital bed, and the benefits are great. The patient'S comfort will be much improved. This will

a

l l ow the patient to recuperate more quickly.

LATE POSTOPERATIVE A few weeks after surgery is the ti m e to work more on the so matic dysfunctions of

the fa sci a and other layers of tissue involved at the time of the surgery. If there were co m p licati ons of the su rgica l si te , such as infection, the timing of t he OMT should be further delayed. The residua l somatic component from preoperative visceroso­ matic reflexes is best treated at t h is time. The area has had time to settle down from the

trauma

of the disease process and that of the surgery. If somatic dysfunction is

still present at the area of a viscerosomatic reflex, it now should be treated. The con­ dition postcholecystectomy syndrome is an example of a viscerosomatic reflex that persists postoperatively. The postcholecystectomy patient has the symptoms of cholecystitis even though the gal l b ladder is no longer present. Treatment of the resid­ ual ga ll bladder viscerosomatic reflex effective ly treats this condition.

Determining OMT Dosage Dosage and tolerance are important to the treatment of the surgical patient. (See Chapter 4.) Tole ra n c e is determined by age, by severity of illness, and postopera­ tively, by the circumstances of the surgical site. How much OMT is e no u gh? One should choose a procedure the patient will tolerate and treat the patient until a response occurs. What kind of response should the clinician look for? Relaxation of the soft tis­ sues in the area being treated is a good response, often referred to as a release. Vasodilation resulting in increased skin temperature or redness and increased sudo­ motor activity indicates it is time to stop treatment. Increased heart or respiratory rate also indicates that the patie nt has reach ed the level of tolerance. If the patient feels that the intervention is too uncomfortable, the clinician should sto p and choose another approach or return later and try again. It is often best to apply small doses of OMT dai ly or even several times da ily.

132

Section II • Patient Populations

CONCLUSION Every patient should be examined and treated using the osteopathic model. As long as the clinician respects the patient's tolerance and the integrity of the surgi­ cal site, employing OMT preoperatively a n d postoperatively should increase the patient's comfort, dec rease postoperative compli c a tions and red u ce the potential ,

for late postoperative somatic dysfunction.

Procedures Th e diagnosis and treatment of somatic dy s f u nction offers the osteopiilthic surgeon a

v a lua ble tool. Viscerosomatic reflexes add to the armamentarium of physical

diagnosis. Som a tic dy s fu nction should be t r ea ted preoperatively whenever possi­ ble. The selectio n and ap p l icati o n of

a

procedure are determined by the somatic

dysfunction and the physical status of the patient

.

Treatment of the postoperative patient is determined by the same prin c ipl es as the treatment of the preoperative patient. The postoperative period, however, does consist of the relatively predictable series of events of the recuperative process. The following procedures are examples of OMT that can be employed to treat the postoperative surgica l patient. Please note: The p rocedures that follow are examples of m ani pu l a ti ve treatment that yo u may wish to employ. The actual

choice of procedures us e d should be dete rmi ned by the unique circumstances of each ind i vid ua I pa tient. Inhibitory Pressure

This procedure is emp l oyed to affect reflex activity by suppressing the somatic component of

iii

somatovisceral reflex. (See Chap te r 5.)

Compression of the Fourth Ventricle, CV-4 (Cranial) (Fig. 10. 1)

This procedure is employed to stimulate the body's inherent recuperative ability by p r o m ot ing fluid interchange; it is thought especially to influence lymphatic a nd cer e brospi nal fluid circulation. Patient position: supine. Physician position: seated at the patient'S head.

FIGURE 10.1

Compression of the fourth ventricle, CV-4.

Chapter 10 • The Surgical Patient

133

Procedure 1.

Place your hands, palms up with one resting in the palm of the other so that the thenar eminences are parallel, beneath the patient's head in contact with the lateral angles of the occiput. It is very important that your thenar eminences, the points of contact with the patient's head, are medial to the occipitomastoid suture.

2.

The weight of the patient's head should be resting upon your thenar eminences, placing medially directed pressure upon the lateral angles of the occiput.

3.

Palpate the occiput for the flexion and extension phases of the CRI for a few cycles. As the occiput moves into flexion, you will perceive a sense of lateral and caudal dis­ placement of your thenar eminences. As the occiput moves into extension, you will perceive a sense of medial and cephalad displacement of your thenar eminences.

4.

Begin treatment by following the occiput into extension and gently increasing the medial pressure from your thenar eminences upon the lateral angles of the occiput.

5.

After the occiput reaches full flexion, you will feel it reverse direction and enter the extension phase of the cycle. Gently resist this and maintain the occiput in flexion.

6.

Repeat this process of following the occiput into extension and resisting flexion. The amplitude of the palpable CRI will become smaller with each cycle until a still point is reached, the moment when the CRI seems to stop.

7.

After the still point, wait for the motion of the CRI to return and move with it into flexion and extension.

8.

When the procedure is complete, reassess the amplitude of the CRI.

Cervical (Soft Tissue/Articulation) (Fig. 10.2) This procedure is employed to decrease cervical tissue tension and en hance the

symmetric range of motion of the cervical spine.

FIGURE 10.2

Soft tissue and articulation of the cervical spine.

Section II • Patient Populations

134

Patient position: supine. Physician position: seated at the head of the treatment ta ble. Procedure

1.

With both hands, place the pads of your fingers bilaterally over the cervical paraspinal tissues at the level of maximal palpable paravertebral tension.

2.

Symmetrically apply bilateral anterior and cephalad pressure until you sense the stretch of the cervical paraspinal soft tissues. Applying more pressure will produce articular motion.

3.

Hold with this degree of applied force position until the tissues relax.

4.

Slowly release the holding force, exerting care not to unload the muscles too rapidly.

5.

Repeat this sequence several times, working up and down the cervical spine, until the desired decrease in paraspinal tension is achieved. As you become proficient with this procedure, you will learn to focus specifically upon asymmetric areas of paraspinal tension.

6.

When the procedure is complete, reassess the dysfunctional area.

Thoracic, Patient on Side (Soh Tissue) (See Fig. 5.3)

This procedure is employed to decrease paravertebral muscle spasm and sofr tis­ sue tension of the thoracic spine. Patient position: lying on one side with a pillow beneath the head and the knees bent to stabilize the torso. Physician position: standing at the side of the table or bed facing the patient. Procedure

1.

Curl your fingers over the paraspinal musculature beginning at the thoracolumbar junction.

2 3.

Place one foot In front of the other for stability. Keeping your back straight, lean back and use your body weight to apply antero­ lateral traction slowly through both hands.

4.

Hold this position until the muscles relax.

5.

Release the force slowly and work up and down the thoracic spine, treating tight areas.

6.

Have the patient roll to the other side and repeat the procedure.

7.

When the procedure is complete, reassess the dysfunctional area.

Lumbar Paravertebral Muscles (Soft Tissue) (See Fig. 5.4)

This procedure is employed to relax hypertonic lumbar paravertebral musdes. It is described here with the patient on the side. It can be modified to accommodate the postoperative patient since position changes may be inappropriate or difficult for the patient. Under these circumstances, allow the patient to remain supine and slide your hands, palm up, beneath the low back and perform the soft tissue stretch in a fashion similar to that employed for rib raising. (See Fig. 5.6.) Patient position: lying on one side with hips and knees comfortably flexed to provide stability for the torso. The bottom arm may be placed under the head and the other arm placed wherever it is comfortable and out of the way. Physician posi­ tion: standing facing the patient at the level of the lumbar spine

.

Procedure

1.

Wrap your hands over the patient's flank and grasp the upper paraspinal muscula­ ture at the level of the thoracolumbar Junction.

2.

Place one of your feet in front of the other for stability.

Chapter 10 • The Surgical Patient 3.

135

Keeping your back straight, lean back and use your body weight to apply anterolateral traction slowly through both hands.

4.

Hold this position until the muscles relax.

5. Release the force slowly and work up and down the lumbar spine, treating tight areas. 6.

Have the patient roll to the other side and repeat the procedure.

7.

When the procedure is complete, reassess the dysfunctional area.

Rib Raising

(See

Fig.

5.6)

Rib raising reduces constriction of larger lymphatic vessels. Raising the rib heads also stimulates the thoracic sympathetic chain ganglia. This treatment initially stimulates regional sympathetic efferent activity to organs related to that spinal level of sympa­ thetic innervation, but in the long run, rib raising results in

a

prolonged reduction in

sympathetic outflow from the area treated. Freeing rib motion also frees the excur­ sion of the rib cage during respiration. Freeing the rib heads increases the excursion of the

chest during breathing and improves lymphatic flow.

Patient position: supine. Physician position: standing or seated at the patient's side. Procedure 1.

Place your palms under the patient's thorax, contacting the rib angles with the pads of your fingers.

2.

Flex your fingers to achieve contact with the rib angle and the patient's posterior thorax.

3.

Apply traction on the rib angle.

4.

While maintaining traction, bend your knees and lower your trunk, which raises the ribs when your hands move upward. This is a fulcrum and lever action; do not bend your wrists. (Particularly if the patient is in a hospital bed, it is easier to move the hands upward if you reciprocally push your forearms down.)

5.

Move your hands to subsequent rib angles until all ribs are treated.

6.

Treat the opposite side of the rib cage in the same manner.

7.

When the procedure is complete, reassess excursion of the thoracic cage.

Rib Balancing

This procedure gently balances the right and the [eft sides of the thoracic cage, pro­ moting ease of respiratory excursion. Patient position: supine. Physician position: standing at the side of the table or bed facing the patient. Procedure 1.

Place the palmar surfaces of your hands on the right and left side of the lower rib cage of the patient with your fingers pointing toward the surface of the table or bed and your thumbs pointed toward each other.

2.

Move both halves of the thoracic cage cephalad and caudad, rotate left and right, and laterally translate left and right, and determine the directions of restriction and freedom of motion.

3.

Move the thoracic cage in the direction of ease of each of these motions, individu­ ally or in combination, and hold.

4. 5.

Wait for a release, the perception of relaxation of tension, to occur. At this point, if the patient tolerates the procedure, you can move the thoracic cage back in the direction of the previously observed restrictions to enhance the release.

6.

When the procedure is complete, reassess the dysfunctional area.

136

Section II • Patient Populations

FIGURE 10.3

Dalrymple's pedal lymphatic pump.

Pedal Pump (Dalrymple's Pump) (Fig. 10.3)

This procedure is employed to enhance low-pressure venous and lymphatic return to the heart and thereby reduce passive congestion of the lower extremities, abdominal contents and lungs. Patient position: supine. Physician position: standing at the patient's feet. Procedure

1.

Grasp the patient's toes with both hands.

2

Abruptly push cephalad, dorsiflexing the patient's ankles, and then quickly return them to the neutral position. This action should send a wave of motion cephalad, followed by a rebound wave.

3.

As the rebound wave returns to the feet. reapply the dorsiflexion force, creating an

oscillatory pump. 4.

The oscillating motion moves the lower extremities in approximation of the muscu­ lar pump. It also moves the abdominal contents intermittently up against the tho­ racoabdominal diaphragm, facilitating alternating positive and negative intra­ abdominal and intrathoracic pressure and decongesting the liver and spleen.

Pectoral Traction to Enhance Motion of the Diaphragm (Fig. 10.4)

This procedure enhances thoracoabdominal diaphragmatic excursion. It can be used with relative ease for postsurgical patients and for patients in the intensive care unit, where multiple lines, tubes, and monitoring devices may be in place. Patient position: supine. Physician position: standing at the patient's head. Procedure

1.

Curl your fingertips bilaterally over the inferior border of the pecto ral muscles of the anterior axillary folds, taking care not to gouge or tickle the patient. Alternatively, apply traction through the arms, as in Fig. 10.4.

2.

Lean back, using your body to produce cephalad traction on the anterior thoracic cage.

Chapter 10 • The Surgica l Patient

FIGURE 10.4

137

Pectoral traction to enhance motion of the diaphragm.

3.

While maintaining the traction, instruct the patient to breathe deeply.

4.

Because the pectoral traction tends to pull the anterior thoracic cage into the posi­ tion of inhalation, to breathe deeply the patient must employ the motion of the thoracoabdominal diaphragm.

5.

When the procedure is complete, reassess motion of the thoracoabdominal diaphragm.

Wound or Scar Release (Indirect) This procedure may be employed to reduce asymmetric tens i o n and restore func­

tional balance to stresses transmitted through a s u r gi c a l wound or scar. The position of the patient a nd physician d e p en d upon the site of the wound being treated. In this example, an abdominal

oun d may be treated with the

w

patient supine and the physic ian standing or seated beside the patient at the level of the pelvis. Procedure 1.

Place the palms of your hands parallel to and on either side of the wound. You may spread your fingers, depending upon the surface of the abdomen it is appropriate to cover.

2. 3.

Approximate your hands gently, reducing tension on the wound. Move the tissues on either side of the wound gently in different directions (cephalic, caudal, left, right) to determine the tension pattern in the surrounding tissues.

4.

Gently move your hands and the tissues on either side of the wound in the direc­ tion that most reduces tension until you perceive a sense of balance.

5.

Hold both sides of the wound in this balanced position until you perceive a release (further relaxation of tension)

6.

Having the patient exhale and hold the breath, if feasible, dUring step 5 may be employed to enhance the balance of tension.

7.

When the procedure is complete, reassess tension of the soft tissue surrounding the wound or scar.

Section II • Patient Populations

138

References 1. Town sen d CM, Beaucham p RD, Evers BM, Mattox K, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Pr a ct i ce. 17th ed. Philadelphia: Saunders, 2004;1769. 2. Henshaw RE. Manipulation and postope r a t ive pulmonary complications. DO 1963;4( I): 132-133. 3. Sriles EG. Oste opa th ic treatment of surgica l patients. Osteopath Med 1976;1(3):21-23. 4. Larson NJ. Ma n ip ulati ve care befote and after surgery. Osteopath Med 1977;2( 1):41-49.

5. Sleszynski SL, Kelso AF. Compa riso n of thoracic manipulation wit h incentive spirometry in preventing pos to pe rati v e atelectasis. J Am Osteopat h Assoc 1993;93:834-838, 843-845. 6. Townsend CM, Beauchamp RD, Evets BM, Mattox K, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Su rgical Practice. 17th ed. Philadelphia: Sa u n ders, 2004;93. 7. Johnston MG, ed. Experimental Biology of Lymphatic Ci rcu l at i o n . Vol 9. Research Mon ographs in Cell and Tissue P h ysiolo g y. Amsterdam: Elsevier, 1985;8-9. 8. N elso n KE, Sergueef N, L ipins k i CM, et al. C r anial rhythmic impulse related to the Traube­ Hering-Mayer os c i l l ation : Comparing laser-Doppler f10wmetry and palpation. J Am Osteopath Assoc 2001;101:163-173.

9. Sergueef N, Nelson KE, G l on e k T. The effect of cranial ma nipulation on t he Traube-Hering­ Meyer oscillation as measured by laser- Dop pler flo wme try.

Altern Ther Health Med

2002;8(6}:74-76. 10. Nelson KE, Sergueef N, Glonek T. Cranial mantpuJation induces sequential changes in blood flow v eloc it y on demand. AAO J 2004;14(3):15-17. 11. Nelson KE, Setgueef N, G lonek T. The effect of all alrernative medical procedure (C V-4 ) upon low-ftequency oscillations in cutaneous blood flow velocity. J Manip Physiology Ther 2006, 111

p res s.

The Athlete Kurt P. Heinking

INTRODUCTION Osteopathic physicians are u n i que l y

suited to care for a thletes.

Andre w Tay lor Still

saw athletic pa tients. Still a lso e ncoura g ed students, both men and women, to join the athletic association at the Ame rican Scho o l of O steopathy

.

I

Still was a pioneer

in trea ti ng professional athletes and pa tie nts in collegia te sports.2 The

School of

American

O steopat hy had numerou s sports teams and a v ery good reputation for

producing many fam o u s athle tes a nd coach es

.

O steopa thic primary care s ports

medicine focuses on treating injuri es a nd i m pro v i ng athletic performance while

e nha ncing the function of the musculoskeletal system.

Sports injuries account for a large portion of visits to the primary care physi­ cian's

office. Approximately 20% of the America n public regul a rly participa tes in

exercise programs, and t hi s health-conscious attitude about physical fi tn e ss is

encouraging.3 This increase in athle tic p articipati on also means an increase in injuries seen by the primary care practitioner, not only in adults but in children and geriatric patients as well. It is estimated that every year more than 17 m illi o n Americans seek medical care because of a thl etic and recreational issues.4 More

in recre a tional sports annually, and by 2030, of OLIr populat ion will be more than 65 years old.s This la rge number of geri­ atric ath letes especially tho se older than 85, are the most rapidly gr o wing segment than 55 million women par ticip a te 20%

,

of the popu lati on 6 .

139

140

Section II • Patient Populations

Patients exercise for a number of reasons. Some have specific reasons based on published guidelines. Some of these include protection against an initial cardiac episode, reducing the risk of recurring cardiac events, obtaining a more favorable lipid profile, controlling obesity, decreasing blood pressure, improving glucose tol­ erance, increasing bone density, improving self-image, and reducing stress and ten­ sion.5 Others exercise as part of a social routine, and still others for general health. Athletes exercise because they love to participate and compete. They compete against themselves and others. They are p roud of their abilities and define who they are throug h their athletic prowess. It is because of this that athletes seek med­ ical care for many unusual reasons. Athletes hold off seeking the physician for pain, but they do consult when they see poor p erfor mance or inability to do what they like. Athletes also tend to procrastinate and ignore "little" aches and pains. Sometimes they consult only because they were pulled from a game by a coach or a trainer. On the field, the management of i[1jured athletes is primarily focused on elimi­ nating urgent conditions and determining whether they can go back into the game. Sometimes it is necessary to confiscate the helmet or to move the patient to the training room for protection; otherwise the injured athlete will go back inro the game. Primary care physicians are an integral part of athletes' health care team, along with orthopedic surgeons, ph ysi c al therapists, certified athletic trainers, physiatrists neurologists, pediatricians, geriatricians, rheumatologists, and cardi­ ologists . It is this team that provides the best care for injured athletes. Physicians not only are gatekeepers; they also must motivate discour aged players and reduce risks to p layers Primary care physicians must also make medical decisions based upon spec ialists recommendations and help guide patients down the appropriate medical pathway. ,

.

'

THE HISTORY A complete history is essential. Many athletes have multiple complaints. Each should

be de l ine a te d and fully prioritized at the initial visit. Why is the patient presenting now? Is the patient getting better, staying the same, or worsening? What has been done so far? Determining the specifics re gard ing pain is i m porta nt, but equally important is determining the specifics of any functional limitations. Was there only one specific injury (macrotrauma) or is a repetitive overuse syndrome (microtrauma) present? If microtrauma has occurred over time, are abnormal stresses applied to normal tissues, or are normal stresses applied to abnormal tissues? Clinical investigation of these questions is of paramount importance when obt a ining a history. Taking a history from athletes includes the who, what, where, why, and how of the chief complaint; however, it also has some unique compo­ nents, such as patients' level of play or activity. Do they participate in more than one sport? Do they play othe r sports, or are they participating in club activities? Where are they in the season? How long is the season? How is the team doing? Do they use specific gear or protective equipment? Do they take ergogenic aids to maintain their performance? These types of questions assist in clinical problem solving by elucidating the causes of their p roblems. Young athletes may not give a reliable history, and older athletes may be stoic and not provide all of the necessary information. Dealing with the parents of an injured athletic child or the family member may be difficult. The history leads to a differen­ tial diagnosis. The physica I examination can be performed in a problem-focused fash­ ion. T he clinician uses osteopathic palpatory skiHs, the physical e xamina t io n , and

Chapter11 • The Athlete

141

other studies t o narrow the differential diagnosis. An adequate history and physi­ cal, including

a

thorough structural examination, will provide the diagnosis in

90% of cases. Do not rely heavily on diagnostic tests; on the contrary, diagnostic

tests should complement a thorough history and physical.

THE PHYSICAL EXAMINATION An efficient physical examination includes the palpatory diagnosis of somatic dys­ function throughout the examination. Specific orthopedic tests should be selected and integrated according to the patient's specific complaint . The examination should start with gait and balance. Then evaluate the patient seated, supine, and prone (if tolerated). It is critical to examine not only the injured region but also distant'regions that may be related. Palpating for tissue texture abnormality is fun­ damental to the evaluation of the injured athlete.7

Evaluation of Gait When observing gait, look at the patient's stance for the initial foot pOSitIOn. Evaluate the arches, overpronation, supination, and hind foot position. Evaluate the heel strike, midstance, swing-through and push-off phases. Always evaluate for a

limp, and look to see

if the patient

is favoring one extremity or the other.

Look for leg rotation or hip hiking. Evaluate the shoes for wear; inquire about use of orthotics, and examine the feet for calluses. MitchellS described a cycle of walking that described motion of the pelvic bones, sacroiliac joints, and postural compensations during gait. Understanding this turns the evaluation of the patient's gait into a whole-body assessment.

The Standing Structural Examination The standing structural examination of the athlete focuses on asymmetry, with evaluation of anatomic landmarks for levelness and anterior, posterior, and lateral curvature of the spine. Perform a standing flexion test and evaluate for pelvic side shift. Athletes may develop unique postures brought on by their particular sport, especially if they are using one arm or one leg repeatedly. Runners may have a vari­ ety of lower extremity problems. For example, structural examination may reveal that a patient with an asymmetric dropped arch has a short leg syndrome. Always look

at

levelness of the iliac crests, the greater trochanters, and pelvic side shift, as

these findings may indicate unequal leg length. (See Chapters 3 and 26.) It is fairly common to find significant paravertebral muscle development on the side of the patient'S dominant hand. This must be differentiated from a scoliotic curve. Flattened thoracic kyphosis may indicate an extended Fryette's type II somatic dysfunction. These are clinically painful and produce many symptoms in the upper back, neck, and upper extremity.9

The Seated Examination The seated examination includes an examination of the following regions: •

Head, eyes, ears, nose, throat

•

Neurologic examination Cardiac examination

•

142

• •

Section II • Patient Populations

Pulmonary examination Musculoskeletal examination (See Chapter 3) •

Thoracic spine

•

Ribs

•

Neck (active range of motion, passive range of motion, Spurling's sign)

•

Knee, ankle, and foot

•

Seated flexion test for sacral dysfunction

Supine Examination The supine examination includes examination of the following regions: •

Abdomen

•

Pelvis (ilium motion tender points, pubic symphysis)

•

Hip, knee

•

Lower extremity

• • •

Pulses, sensations Straight leg raising sign Ankle and foot

•

Cervical spine

•

Cranial strain pattern assessment

Prone Examination The prone examination includes the following examination of each of the follow­ ing regions: •

Lumbar spine

•

Hip extension

•

Sacral motion

•

Quadriceps muscle tension

•

Hamstring muscle tenderness and tone

•

Soft tissue diagnosis of somatic dysfunction Palpation and motion testing in the clinical examination are integrated. It is

very important that the osteopathic examination not be a separate examination. The integration of the diagnosis of somatic dysfunction with the standard physical examination helps the clinician make the link between somatic dysfunction and abnormalities in the general physical examination or orthopedic examination.

The Functional (Dynamic) Examination Many times it is beneficial to examine an athlete performing a certain movement or exercise. A physician can palpate various tissues or muscles for activation, weakness, or tightness. This approach also evaluates motions used in the swing, throw, block shot, or tackle. Digital video recording also can be very useful, because motion, gait, and speed when they throw or swing can be analyzed. This also can be sped up or slowed down to evaluate the various component parts of the motion in the search for faults or defects . It is important to differentiate orthopedic pathology from functional conditions: Remember, every patient has certain musculoskeletal compensations that allow them to adapt to their injury. Sometimes compensations become abnormal and are themselves a problem.? In considering the dynamic

Chapter 11

•

The Athlete

143

examination, one must consider the ground reaction force, the patient's center of gravity, the muscle firing patterns, and the postural findings on the structural examination. Then these factors are evaluated and integrated into their treatment plan. When a clinician adds balance and proprioception to this list and when these factors are addressed in the treatment plan, the patient's entire kinetic system is evaluated.

CLINICAL PROBLEM SOLVING Is there a somatic component to the patient's chief complaint, injury or illness? How d o the palpatory findings relate to the condition? Is there a general postural pattern contributing to this situation? Are viscerosomatic reflexes causing facilitation of a specific spinal region? How does the patient respond to osteopathic manipulative treatment (OMT), and does OMT improve orthopedic testing? Keeping these issues in mind determines what is to be treated first. Acute injuries may not tolerate pal­ pation, motion testing, or OMT. In this situation, begin by working in distant yet related anatomic areas until the tissue texture and sensitivity improves. Chronic conditions require chronic treatment. Look for the most significant area of tissue texture change and motion restriction, the key somatic dysfunction. Use exercises not only to stabilize areas of the spine or extremity that are hyper­ mo bile but also to mobilize restricted tissues and joints. Tissue injury needs time to heal; sometimes rehabilitation and/or exercises are added too soon, before suf­ ficient healing occurs. This is commonly seen in rotator cuff tendonitis. Rest and relative rest is important. Athletes need to participate actively in their healing and rehabilitation. Determine a timeline and treatment plan; discuss it with the patient, and stick to it. Support the host, especially with OMT, as it sets the stage for this healing to begin. OMT will improve tissue perfusion and facilitate lymphatic drainage from an area. Another important aspect is deciding when to mobilize an injured area. If there is instability due to ligamentous sprain or fracture, obviously it is necessary to immobilize it with a splint or cast appropriately; also, sometimes casting is neces­ sary to protect patients from themselves. Many athletes use an injured extremity against medical advice. In this situation, applying a cast may be the most appro­ priate thing to do. The primary care physician also must decide what aspects of physical therapy will benefit the patient. There is a right time and a wrong time to send a patient to physical therapy. Communicating with the physical therapist on a regular basis is critical for the patient's wellbeing. Also decide how much rest and how l ong. Be very specific with athletes about what they may and must not do. Provide specific instructions on when to use ice or heat or contrasting baths, when to use compression or traction to the area, exactly when to take their med­ ication. Such instruction will foster an improved treatment plan. Always consider what will be gained from a referral to another specialist and how this will fit into the patient's overall therapeutic scheme. Patients should always be an active par­ ticipant in their health care as the primary care physician educates them and guides them down the path of wellness. Allow patients to decide which way they would like to go with their healing process. Providing a patient with a graded return to activity is important. For example, with runners, determine the total number of miles they are to run per week; consider frequency and duration. It may be important to adjust their mileage and time, for example, by decreasing their mileage by 50% and slowing their pace. As the athlete heals and the injury improves, the guidelines can be

144

Section II • Patient Populations

altered according to their symptoms. Provide them with a timeline extending per­ haps over 4 weeks that lists exactly how much they should run and at what pace. Each week increase their time and/or duration based as their symptoms allow. Recommend what to do if their symptoms recur or worsen as their mileage increases; this may be instructions to increase medication, use ice, adjust warm-up or cool-down activities, walking, or stretching. Also tell them that if they tolerate their graded progression back to exercise, it is not wise to increase activities over the recommendations that have been made. While injured structures are healing, it is also important to maintain cardiac conditioning. Athletes may cross-train with bicycle, pool, or other modalities to maintain their cardiovascular fitness. Encouraging the athlete to do more of these activities instead of the activity in which they were injured usually is beneficial.

Commonly Seen Athletic Conditions in Family Medicine

The Patient with an Acute Ankle Sprain Ankle sprains are the most common athletic injury seen by sports medicine prac­ titioners. Inversion sprains make up of 75% of ankle sprains.1o Most ankle injuries occur in plantar flexion , because plantar flexion decreases the stability of the ankle joint. In plantar flexion, the anterior aspect of the talus is no longer wedged between the malleoli, which increases the mobility of the joint. Upon initial presentation after an acute inversion sprain, it is common to have bruising along the lower aspect of the lateral side of the foot and tenderness over the peroneal tendons. The injured structures are typically anterior talofibular, cal­ caneofibular, and posterior talofibular ligaments. Diffuse swelling typically sur­ rounds the lateral malleolus, ankle, and dorsum of the foot. Bony point tenderness may indicate a fracture. Pain to vibration over any bony structure may also signify fracture. Radiographs with comparative views are generally taken in children due to the potential for growth plate injuries. T he Ottawa Ankle Rules (Table 11.1) were developed to guide clinicians in deciding when to obtain a radiograph of an athlete who sustains an ankle sprain.11 Associated somatic dysfunction is common in ankle sprains and should be treated as soon as possible. An anterior lateral malleolus dysfunction is seen in typical ankle inversion. Muscle energy treatment of this dysfunction is

quick and efficient.

Myofascial restrictions due to muscle splinting and local swelling are common.

Ottawa Ankle Rules: Decision Rule for Radiography in Acute Adult Ankle Inj uries Is the patient Unable to bear weight immediately and in the emergency departmenP Tender on the tip or posterior aspect of the la teral malleolus) Tender on the tip or posterior aspect of the medial malleolus) Any affirmative answer indicates that a radiograph should be obtained. StielilG, Greenberg GH, tvkNight RD. et at. Decision prospective validation.

lAMA 1993;269:1127-1132.

rules for the

use of radiography

in

acute ankle injuries: Refinement and

Chapter 1 1 • The Athlete

145

Removal of myofascial restrictions can help with lymphatic drainage of a swollen, tender ankle. Changes in gait, the use of crutches, and limping contribute to dys­ function of the innominate, sacrum, and lumbar spine. Use OMT in these areas to produce a negative seated flexion test and equalize pelvic side shift.

Anterior Knee Pain Anterior knee pain is a common finding in the athletic population, especially among females. Because many orthopedic terms are grouped into this category, there is a consensus that a detailed history and physical examination are critical in making the diagnosis.12 The most common diagnosis is chondromalacia of the patella. Other terminology includes patellofemoral pain syndrome, miserable malalignment syndrome, and patellar tracking abnormality. It is a painful condi­ tion that usually starts as repetitive overuse and tends to occur in the patient who develops tight hamstrings and weakness in the medial aspect in the quadriceps muscle. As the process continues, malalignment of the patella causes abnormal tracking along the femoral groove. Over time this causes the cartilage of the patella to soften and roughen. Patients complain of pain around the patella, a variable amount of swelling, and difficulty negotiating stairs or hills. The patella may feel like it locks or catches if they sit with their knees crossed for long; this is the classic

' movie goer s sign.

The osteopathic examination includes palpation for restriction of patellar motion with an evaluation of the ability of the vastus medialis muscle to contract. Atrophy and/or flaccidity of this muscle is a common finding, as is tightness of the hamstring muscles and iliotibial band. Counterstrain and other indirect procedures for the hamstring and calf muscles are beneficial. It is also common to find fibular motion restrictions and dysfunction of the ipsilateral innominate. Tightness and tender points along the iliotibial band are common. OMT should be applied to the axial skeletal component in the lumbar spine and to any innominate sacroiliac dys­ function. Indirect myofascial release of the patella and anterior knee is beneficial for an acute condition. It is also important to improve fibular motion through an articulatory or muscle energy procedure. Following OMT, it is important to give the patient flexibility exercises for the hamstring and calf muscles and open- and closed-chain kinetic exercises for the vastus medialis oblique muscle. Closed-chain exercises, such as mini-squats against a wall or extension of the knee against a resistance extension lockout, help facilitate a more functional return to activity. Always treat the lumbar and innominate dysfunction prior to giving the patient static or dynamic flexibility exercises for the hamstrings. If lumbar dys­ function is not treated, hamstring tension tends to recur. It is also important to control swelling of the knee. As little as 5 mL of effusion can stimulate the ham­ string to tighten and the vastus medialis to weaken or become flaccid .

Hamstring Strain Hamstring strains are common, unfortunate, and recurrent. They typically occur in sports that require sudden bursts of speed, like football, track, and rugby.13 The predisposing factors include fatigue, cramping, improper warm-ups, and muscle tension. The athlete may have superficial bruising, a palpable defect or rent in the muscle, a local intramuscular hematoma, or an avulsion of the ischial tuberosity. In milder injuries, there is local tension with multiple tender points in the ham­ string group of muscles. Occasionally there is a tear (or epiphyseal injury) off the ischium rather than in the belly of the muscle. The mechanism of injury is typically simultaneous abrupt hip flexion and knee extension. Somatic dysfunction of the ilium (especially an

146

Section II • Patient Populations

anterior ilium dysfunction) can predispose the athlete to a hamstring strain. Spasms of the biceps femoris may be related to the dysfunction of the fibula as well. Treating dysfunction of the tibia and fibula and using the indirect procedures for the hamstrings facilitates muscle healing. Always look at the patient's feet, espe­ cially for signs of overpronation and malalignment of the patellar femoral joint. Hamstring strains are usually secondary to other biomechanical factors of the feet, knees, or ankles and can be avoided through proper warm-up and cool-down exer­ cises and static or dynamic flexibility programs. Following an acute injury on the playing field, move the patient to the sidelines or the training room for proper evaluation and treatment. Indirect manipulative procedures that place the injured part in a position of ease are the most appropri­ ate. Subsequent treatment should address any segmental dysfunction in the upper lumbar and low thoracic region, as this would maintain sympathetic tone to the lower extremity, maintaining hamstring tightness. The next components addressed should be the ilium and the sacroiliac joint, as proper motion of this joint will also allow more normal motion of the pelvis during gait. Gentle seated dynamic range­ of-motion exercises for the hamstring muscles also help facilitate moving lymphatic fluid from the area and improving range of motion. Always finish the manual treatment by applying the RICEM principle: rest, ice, compression, elevation, and medication for pain control.

Rotator Cuff Tendonitis: Impingement Syndrome Rotator cuff tendonitis and subacromial bursitis typically occur together and are probably the most common sports medicine diagnoses of the shoulder. Patients have pain, weakness, and limited shoulder mobility overhead. With a complete tear, patients may develop pain near the deltoid insertion, which occurs at night, along with difficulty reaching the arm overhead. The rotator cuff is composed of four mus­ cles: the supraspinatus, infraspinatus, teres minor, and subscapularis. The supraspina­

tus tendon is torn in approximately 90% of cases of rotator cuff tendonitis. There are four proposed mechanisms of injury in repetitive overuse (micro­

trauma).14 Primary impingement occurs with repetitive overhead motion as the supraspinatus tendon impinges under the inferior portion of the acromion. The shape and slope of the acromion are important. A congenitally hooked acromion or perhaps an arthritic spur can aggravate the supraspinatus tendon. Secondary impingement occurs with glenohumeral laxity and instability of the shoulder. In this situation, cephalad migration of the humeral head and undersurface tears may occur. Tensile failure during throwing may fatigue the cuff muscles and develop a tear with eccen­ tric loading. Overhead throwing may also cause an internal (posterosuperior glenoid impingement). In this situation the inferior aspect of the supraspinatus is trapped between the greater tuberosity of the humerus and the posterior superior labrum. Patient apprehension resulting from external rotation of the shoulder (at

90 degrees

of abduction) indicates glenohumeral instability and is another cause of tendonitis. Physical examination reveals tenderness in the subacromial space; instability testing (e. g., apprehension and relocation tests, sulcus sign) may reveal laxity. Resistance testing of the supraspinatus is done with the arms internally rotated and abducted 90 degrees in the scapular plane. Inability to resist the examiner's down­ ward force indicates supraspinatus weakness. The impingement sign of Neer

involves injecting 10 ml of 1 % lidocaine hydrochloride into the subacromial space and repeating the resistance test of the supraspinarus.14 Pain relief confirms impingement. Occasionally cervical neuropathy, such as C5 to C6, C6 to C7, can

cause rotator cuff muscle weakness and pain to the shoulder that would mimic

Chapter 11 • The Athlete

147

rotator cuff tendonitis. This possibility always must be ruled Ollt in a patient with rotator cuff tendinopathy

.

There is usually significant structural somatic dysfunction of the upper thoracic

spine and ribs. An extended ( Fryette s type II) dysfunction is commonly found. '

Treatment of this dysfunction with an epigastric high-veloci ty, low amplitude (HVLA) -

thrust is beneficial, because the procedure allows some upward traction as well as the right amount of spinal flexion Rotator cuff patients tend to .

"hike" their shoulder

causing scalene hypertonicity, upper trapezius muscle tender points, and segmental lower cervical dysfunction . It is fairly common to find an elevated first rib as well, partly due to dysfunction at the Tl segment as well as anterior scalene hypertonicity. Tenderness and tightness of the ipsilateral pectora lis minor muscle are common, as is ropy tissue texture change of the infraspinatus and posterior axillary fold. A Jones tender pointlS in the subscapularis muscle

(in the axilla) is also an indicative finding.

Rotator cuff injuries may be associated with other orthopedic problems, depending on the

type and duration of trauma. Plain radiographs may reveal

a

com pression fracture of the humeral head (Hill-Sachs deformity), dislocations

,

arthritic changes, and calcific deposits. When these situations occur simultane­ ously with rotator cuff tear, orthopedic consultation is warranted. Manipulative treatment of these areas should

start with the upper thoracic

sp in e and ribs and the cervical spine and then should move into the shoulder, elbow, wrist, and hand Myofascial or muscle energy procedures that involve the .

shoulder should stay away from painful arcs

of motion and work with tissues in

an i ndirect position ( positi on of ease) until range of motion im proves The corner­ .

stone of improving rotator cuff tendinopathy and impingement syndrome is posture-based work. Patients must improve their core abdominal strength initially, then progress to scapular stab ilizati on and retraction exercises. When patients have reeducated their lower rhomboids and lower trapezius muscles, more-specific strengthening of th e rotator cuff muscles themselves can begin. Patients shou ld not aggressively exercise the shoulder without first addressing core muscle strength imbalances and lower scapular muscle inhibitions.

Heel Pain and Plantar Fasciitis Heel pain is problematic and persistent. Plantar fasciitis (heel spur syndrome ) is one of the most common causes. It is a condition of repetitive i mpact loading and microtrauma. It produces local heel pain

at the medial plantar insertion on the cal­

caneus. Runners, basketball players, and volleyball players are at the highest risk. T he first few steps in the morning are painful, and there is tenderness near the medial plantar fascia insertion on the calcaneus. Tenderness along the sidewall of tbe calcaneus in tbe adult athlete may indicate a calcaneus stress fracture instead of plantar fasciitis. Radiographs may show a calcaneal heel spur. Tbese are generally not clinically significant as they may be seen in patients witbout fasciitis as well. ,

Tbe clinician should look for intri nsic and extrinsic causes. Always look at the six 5's of running injmies: shoes, surface, s peed, stretch ing strength, and structure.9 ,

From

a

biomechanical approach, one should look for tension in the iliopsoas,

hamstring, gastrocnemius, and soleus muscles. Tender points along the plantar fas­ cia may be treated with Jones counterstrain.1S Moreover, muscular tension along the tender points may occur in the calves and hamstring muscle groups. Release procedures, such as counterstrain, are effective for these areas. OMT for the patient

with heel pain should start with the axial component in the lumbar spine and then

proceed to the sacrum, pelvis, and distally to the hamstrings, calf, and finally the foot. Always treat

with the objective to obtain both a negative seated flexion test

148

Section II • Patient Populations

and a negative pelvic side - sh ift test. If there is a leg length inequality, use a heel lift to level the sacral base. (See Cha pt er 26.) Use of ge l heel cups with act iv ity mod ifi­ cation and stret ch i n g of the calves and hamstrings may be bene fi ci a l as well.

Integration of OMT into Conservative and Surgical Management

Conservative Management OMT provides beneficial support to the host through healing of a variety of ath­ letic injuries. Recall that there are specific phases of healing. The patient's body must progress through these phases for proper healing to take pl ace. It is fa i r ly com­ mon to see patie n ts start aggressive strength e ni n g programs in physical therapy before the in fl am matory phase of the process i s complete . That is why it is impor­ ta n t to have a pro per amoun t of rest initially. Relative rest is considered to be rest­ ing the injured part while still maintaining activity with the rest of the bod y. For exa mpl e , a patient with a leg fracture who is in a cast may sit on an exercise bike moving the arms back and forth. This allows the patient to receive a cardiovascu­ lar workout while the legs remain stat i o n a ry . It is possible for a patient who has a wrist or elbow i njury to use a s ta ti o n ary or recumbent b ike or walk on a tr ac k or a tre adm ill for aerobic training. Relative rest is i mpor t a n t for maintaining athletes' cardiovascular status as they heal. It is also important for the sports medici ne prac­ titioner to pr act i ce aggressive conservatism, ma k in g patient-athletes an active and integral part of their heal ing process. This may include cross-training with other activities to maintain cardiovascular f unc t ion , contrasting baths, and the use of medications, OMT, static or dynamic flexibili ty exercises, relaxation techniques, and p sycholo gic a l techniques, such as mental imagery. The multifactorial approach is the p referred manner in which aggressive conservatism is used in treatment. OMT sets the stage for exercises to work. For example, if significant lumbar somatic dysfunct i o n s are n o t tre a te d a n d a patient tries to strengthen core abdom­ inal muscles doing a simple cur l - up exercise, the spine will not move in a seg­ mented fashion and wi l l skip over the restricted areas. Some areas of the spine will be overworked whi l e oth ers are skipped over altogether. OMT ten d s to decrease local swelling and to i mprove pain tolerance. It supports the innate healing power of the pa tien t and impro ves fluid transfer and medication distribution. OMT may also decrease dependence on medica tio n in patients with chronic p a i n . A mult i d is­ ciplinary approach also improves the a b ili t y to compensate for injury. Consider patients who hav e been using a cast and crutches. They transfer abnormal stresses to the lumbar spine and pelvis. OMT to t ho se regions can decrease pain and im pr ove fu n c tion , esp eci ally when the athletes return to their sport. Conservative treatment of athletic i n j ur y includes the RlCEM a nd PRICEM principles. These acronyms, pad (or protect io n) , along with rest, ice, compression, elevation, and medication, as mentioned earlier, are commonly u s e d i n sports med ­ icin e . Besides applying these principles, it is critical to determine whether an area should be immo b ilized. For an acute ligamentous sprain, immob ilization with a cast or splint is i n d icated. OMT, h o wever, may also be indicated for areas di s tant or related. Consider, for example, a patient with a lumbar s prain at the L5 to S1 region. Such an athlete may h ave some reactive muscle spasm of the erector spinae muscle mass and tig h te ning of the iliopsoas. OMT ap plied to these regions, which are distant yet related sites, may unload these muscles and he lp the injured area heal. It is also critical to pa y attention to the area o f inj ury from a standpoint of what n e eds to be pad ded or protected when the patient returns t o play. I t i s impor­ tan t someti mes to shift forces away from the injured area. This is commonl y done

C h a pter 1 1

• T h e Ath lete

1 49

w i t h fo o t i n j u ri e s . F o r e x a m p l e , fo r t h e p a ti e n t who has a meta t a r s a l s p r a i n o r sesa m o i d i t i s , speci fic metatarsa l p a d s a re p l a c e d i n t h e s h o e s to red u c e p r es s u re o n t h e i n j u r e d a re a s a n d red i rect fo rces from the p a i n f u l s i te s t o o t h e r s t r u c t u res . C o n s e rva tive m a na g e m e n t a l s o i n c l u d e s u se o f ice, h e a t , c o n t r a s t i n g b a t h s , u l t r a so u n d , m u sc l e s ti m u l a t i o n , i o nt o p hore s i s , a n d/or p h o n o p h o re s i s . I c e t h e r a p y,

good fo r acute i nj u ries a n d a c u te i n fl a m m a t i o n s , is u s u a l l y k e p t in p l a c e for 1 5 to

20 m i n u te s . Ice m a s s a ge is a l s o u s e f u l fo r tendo n i t i s a n d ca n be u s e d fo r s h o r t e r t i m e s . C o n tra s t i ng b a t h s , a l te r n a t i n g u s e o f ice a n d hea t ( a l w a y s e n d w i t h ice ) , a l s o h e l p s e xerc i s e , a n d i t p u m p s t h e lympha tic fl u i d fro m the i n j u r e d a r e a by stim u l a t­ ing v a s o c o n s t r i c t i o n a n d v a s o d i l a t i o n . For deep m u scle s p a s m , u l tra s o u nd m a y be us e d . U l tras o u n d a p p l i e s d eep h e a t to a m u s c u l a r a rea a n d ca u ses v a s o d i l a ti o n .

T l l i s ca u s e s r e l a x a t i o n a n d i m p roves reg i o n a l b l o o d fl o w. M u sc l e s t i m u l a t i o n , m o s t co m m o n l y i n t e r fe r e n tia l cu rre n t , i s u sefu l f o r c o n tro l l i ng a n d m o d u l a ti n g p a i n a nd a l s o p ro m o t i n g v a s od i l a t i o n a n d the m o v e m e n t o f fl u i d s fro m a ll a re a .

I o n t o p h o res i s is u s e of i n t e r fe re n t i a l c u rrent w i t h a p p l i c a t i o n of a s t e r o i d gel to t h e s k i n . The e l e c t r i c c u rr e n t helps the s ter o i d permea te i n to t h e s o ft t i s s u e s . P h o n o p h o r e s i s i s use o f

u ltr

a s o u n d w i t h a ste r o i d gel t o h e l p t h e s teroi d p e r m e a te

i n t o t h e s o ft t i s s u e s a n d d ecrease pa i n . C o m b i n a t i o n s of t h e s e n u m e r o u s m o d a l i ­ t i e s a re u se d o n a d a i l y b a s i s by a th letic t ra i ne r s i n t h e t ra i n i ng ro o m .

T h r o u g h o u t the c o n s e r v a t i v e m a n a ge m e nt of the a t h l e te , p hys i c i a n s , p h y s i c a l

the ra p i st s , a n d a t h l e t i c t r a i n e r s w o r k to i m prove free range of m o t i o n , s t r engt h , p o s t u re, a n d p r o p r i o c e p t i o n wh i l e m i tiga t i n g p a i n as the tre a t m e n t p rocee d s . I n c o n serv a ti v e m a n agement, it i s i mporta n t to c o n s i d e r the d o s age a n d sequence o f reha b i l i ta t i o n . T h i s incl u d e s t h e d o s a ge and seq uence of O MT to v a r i o u s reg i o n s a nd d o s age o f o t h e r m o d a l i t i e s , s uc h a s electr i c a l m u sc l e s t i m u l a t i o n , u l t r a s o u n d , i c e , a n d h e a t . S o m e a t h l e tes rece i v e t hese tre a t m e nts d a i l y i n h opes o f acceler ati n g he a li n g . S o m e t i m e s t h e p a t i e n t i s o v erd osed-too m u c h o f a g o o d t h i ng. Overuse of t hese conservative m ea s u res c a n wo rsen t h e p a t i e n t'S cond i ti o n . T ile p h y s i c i a n m u s t be m i n d fu l o f t h i s c i r c u m s t a n ce . Surgical Managemen t An i m p o r ta n t part of s u rgica l m a nageme n t o f a t h letic i nj u ry is prehab, or reha bi l i ­

ta t i o n prior to s u rgery. T h i s i s t r u e especi a l l y for a p a t i e n t w i th a knee i nj u ry who is going to h a v e art h ro s co p y o r a n ter i o r cr u c i a t e l i ga me n t reconstructi o n . I n th i s exam­

p le, i t is cri tica l that the pa tient u n d ergo some reha bilita t i o n before s u rgery to l e a r n

how to fi re the v a s t u s med i a l i s o b l i q u e musc l e , stretch a nd strengthen the ha m­

stri ngs, and s trengthen the core a bd o m i n a l a n d pe lv ic m u sc l e s . Reha b i l i ta t i o n exer­ c i ses c a n be d o ne isome trica l l y s o a s not to aggra v a te the i n j u red a re a . T h is w i l l fos ter a fa ster recovery from the s u r g e ry a nd a fa ste r r e t u r n to sport. Pres u rgical

O MT i s a l so u s e f u l , n o t o n l y to c o n tr o l p a i n a nd d ecre ase s w e l l i ng but also to i m p rove fu n c t i o n and motion o f restricted tissue a nd i m p r o v e a na to m ic re l a tion­ s h i ps . Posto perative l y, O M T is d i rected a t th e remova l or red uction of func t i o n a l i m p ed i me n t , to a s s is t p a t ients' a b i lity to m o u n t a rec u perative response. Speci fica l l y, trea ting s o m a t i c d y s f u nc t i o n reduces postoperat ive c o m p l i ca tions, s u c h as a te l ecta­ sis a nd i l e u s . I t a l so m a kes the patient m o re comfo r t a b l e . En h a n c i ng the thoracic cage moti o n preoperatively i s c r i t ica l beca use most p a t i e n ts need genera l a n e sth etics . Even if a s pi n a l a nesthetic i s u s e d , the p a ti e n t w i l l be l y i n g for l o n g p e riod s . I m p r o v i n g thoracic cage m o b i l i ty with OMT h e l p s re d u ce l y m p h a tic co nges tion p o s t ope r a t i v e l y, a s weJl a s dec re a s i ng the incid ence o f p u l m o n a r y a telecta s i s . OMT d ecreases s y m pa the t i c to n e p o stope r a t i ve l y, a n d t h i s improves bowel func t i o n , decrea s i n g postope ra t i v e i l e u s . Co m m o n m a n i p u l a t i v e proce d u res used p o s t o p e r a ­ ti ve l y a r e p a ras p i na I i n h i bition, l y m ph at i c p u m p , a n d r i b r a is i ng .

150

Secti on I I • P a t i e n t Populations

The surgica l pa tient may a lso develop viscerosomatic refl exes as a resu l t of surgery, i n j ury, a nd prolonged medication use. Usua l l y pa tients who elect to have su rgery h a ve a severe i nj u ry and are taking a significa nt amount of nonsteroidal a nti­ i n flamma tory d rugs. Often they d evelop upper t horacic v isceroso matic reflexes, ind i ­ c a t i ng s u b c l i nic a l gastro i n testi n a l i rrita tion from these med ica tions. Such reflexes can be a d d ressed with OMT. It i s importa nt to decrease these m u scu l oskeleta l responses to i n fl a m m a tory viscera l pa t hology as we l l as to m a k e a p propria te cha nges in prescri bed medication . Earl y ra nge-of-m otion e x e rcises a fter s u rgery a re u s u a l l y reco m mended, d e p e n d i ng o n the a natomic structures trea ted . For most postope rative k n ee a rt hro­ scopies, the p a t i e n t can go home the fo l lowi ng d a y a n d atte m p t to bea r we i g h t . M o r e extensive c a s e s m a y necess i t a te u s e of a conti n u o u s p a s s i ve m o t i o n ma ch i n e . O M T h e l p s t o i mprove function a s these p a t i e n ts h e a l a n d m a y perm i t d ecreased use of opi o i d pain medica tio n . I t i m p roves fu nction o f t h e i [ new a na t o m i c re l a ­ tionships a n d n e w s t r u c t u r e . Retu rn -to- Play Considerations

A p h ys i c i a n must c o n s i d e r t h e lev e l of th e a t h lete a n d t h e pa rtic i p a t i o n g u id e l i nes that were d eter m ined i n i ti a l l y. The d u ra t i o n o f the patient'S con d i t i o n m u s t be t a k e n i n to a cco u n t along with the severity. Ath letes may h a ve comorbid cond i­ t i o n s , espec i a l l y if they a re o l d e r; th ese m u s t be t a k en i n to account. How p a t ients respond to reha b i lita tion, w h a t prior inj u ries they h a v e h a d , a n d how those prior i n j u r ies were reha b i l i ta te d w i l l a lso h e l p g u i de the physician in d ete rm i n i ng retu rn­ to-play considerati o n s . There a re specific return-to - p l a y considera tions for some conditions, such a s concussi o n . Since these g u i d e l i nes a re controvers i a l and tend to cha nge frequently, it is important to consult the most rece nt medica l l i te r a t u r e . Every a th l e te has a unique re h a b i lita tion poten ti a l . Some o f t h i s i s d e termi ned fro m pr ior i n j u ry h i story a n d some is fo u n d d u ring the c u rren t re h a b i l itation. T h e p h ysic i a n m a y n o tice that a n a t hlete wi ll respon d more q u ic k l y to o n e therapeutic mod a l ity than to others . Sometimes m o d a li ties h a v e to be rotated to o bta i n m a x i ­ m u m ga i n fro m e a c h mod a l ity. T h e r e h a bilitation p l a n for e a c h p a tient m ust ta ke i n to account the t i m e l i ne, the tea m 's l e v e l of p l a y, a n d press u res from coac hes a nd the tea m to h a ve the a t h lete ret u r n . Once a decision is m a d e by a trea ting physi­ cian, i t is rec o m mended that t h e physician stick to the d ecision and not s u c c u m b to t h e s e extern a l pressures. A l wa y s provide a d equate com m u n ica tion and a release for m for the a th l e te, especia l l y a s t u d e n t a t h lete. Prevention. Patient E d u cation . and Pe rformance Enha nceme nt

Prevention is an i n tegra l pa rt of c a r i n g for a t h letes . OMT p l a y s a signific a n t role in p reve n t i n g a t h letic inj u ry, as much as if not more than proper warm-up and cooli ng dow n . Pa tients who h a ve a fu l l pa i n-free active ra nge o f motion a nd know w he n t hey a r e d eve lopi n g a specific pain or p ro b l e m tend to come to t h e o ffice sooner a n d a v o i d exace r ba t i n g a n i n j u ry. If s o m a tic d ysfu nction goes u n d iagn osed or untrea ted, its severity can increase in s u c h a way th a t a pa tie n t can deve l o p a n i n j ury secon d a ry t o compe nsation fro m t h e soma tic d ysfu ncti o n . I t i s a lso im por­ t a n t tha t a t hl etes h a v e proper gear fo r t h e i r acti v i ty a nd proper access to tra in i n g s e r v i c e s . Often a patient k n ows enough t o r e s t a n i n j u re d a rea o [ t o cross-tra i n to un l o a d tissue stresses appl ied by repetitive overu s e . [ n t h i s situ a t i o n , the patient may be a ble to prevent o r reduce the severity o f a n i n j u ry. Patient e d u cation is a critica l a spect of a th lete care. Ha n d o u ts a n d demonstra­ tions of stretches a nd exer c ises by the phys icia n , therapist, or tra i ner a re impo rta nt.

Chapter 1 1

• The Athlete

1 51

It al so is a good practice to have additional vis ual aids (still pictures, videotapes, D VDs) available for the patient. Occasionally it is necessary to film a patient's throwing or swinging mechanics. This film can be used to find biomechanical errors and to educate the patient. It is important to educate the coach and the relatives of the athl ete as the athlete goes t hrough the stages of rehabilitation. Education is not only an important part of the treatment of athletic in jury; it is also an important part of prevention of the use of anabolic steroids, creatine, sti mulants, and other over-the-counter drugs and banned substances. Patients who have completed a rehabilitation program and have returned to their sport and athletes who have noticed a decline in their performance may need performance enhancement. OMT can help by removing hindrances to compensations from older inj uries and by improving biomechanical funcrion. Performance can also be enhanced by use of appropriate gear and work with spe­ cialized coaches, such as batting coaches , golf swing coaches, throwing coaches, and shooting coaches. Finding patients' functional deficits is important. There may be a deficit in their form that is not noticed initially. Sometimes this can be found if film footage is taken of an athlete's motion and then slowed down and evaluated. Another critical component of performance enhancement is patients' state of m i nd and emotional factors regarding their own performance, their relationsh ip with the coach and other players, and where they fit on the team. Many times an emotional issue is the primary problem or functional deficit in an athl ete, and the muscu l oskeletal findings are only a distant effect. Psychotherapy, relaxation tech­ niques, and mental imagery can be useful for working through a slump in athletic performance. Abrupt cessation of a sport because of athletic injury may lead to poor sleep and be the initiating event in the development of fibromyalgia. Osteopathic physicians believe the mind, body, and spirit are integrally lin ked. T he emotional component of the athlete's injury should never be u n d erestimated. Athletes can q ui c k ly become very d epressed if their per formance fall s off. Thi s sit­ uation often promotes a higher rate of medication usage and the use of nutritional supplements, recreational drugs , and ergogenic aids.

CONCLUSION Osteopathic primary care physicians who use OMT and their structural medicine skills have a un ique advantage in helping athletic patients who are inj ured. The treat­ ment of somatic dysfunction with OMT sets the stage for proper healing to begin. It improves the function of therapeutic exercises , decreases pain, decreases complica­ tions after su rgery, and improves function. Osteopathic physicians who use OMT in sports medicine are highly sought after for treatment of athletic injuries. T hey make significant differences in the l ives and performance of the athletic patients.

Procedures Please note: The procedu res that follow are examples of manipulative treatment that you may wish to employ. The actual choice of p rocedures used should be determined by the unique circumstances of each individual patient.

Anterior Lateral Malleolus (Muscle Energy) (Fig. 1 1 . 1) Consider the dysfunction of a left anterior lateral malleolus. The obj ective is to improve posterior movement of the lateral malleolus. An anterior lateral malleo­ lus is associated with a posterior prox i mal fibula. Patient position: s upine. P h ysician position : standing at the foot of the table.

1 52

Sect i o n II • Pat i ent Popu lations

FIG U R E 1 1 . 1

M u s c l e e n e rgy, a n t e r i o r left l at e ra l m a l l e o l us.

Proce d u re

1.

C u p t h e p a t i e n t 's l eft h e e l in the pa l m of yo u r r i g h t h a n d . P l a ce yo u r ri g h t t h u m b over t h e a n t e r i o r a s pect o f t h e l a t e r a l m a l l eo l u s , w i t h t h e re m a i n i n g f i n gers o f yo u r r i g h t h a n d p roj ec t i n g d ownward a n d a ro u n d t h e poste r i o r a s p ect of t h e ca l ca n e u s . P l a ce y o u r l eft t h u m b o v e r y o u r r i g h t t h u m b (rei nforce m e nt), w i t h t h e rema i n i n g f i n g e r s o f y o u r l eft h a n d e n c i rc l i n g t h e m ed i a l a s p e ct o f t h e a n k l e .

2.

C o ntact the s o l e o f t h e patient's foot with you r a b d o m e n , a n d wh i l e lea n i n g forwa rd , use you r body to positi on the pati e nt's foot i n d o rsiflexi o n . M a i n ta i n a p oster iorly d i rected force ove r the a nt e r i o r a s pect of the l atera l m a l l e o l u s with your t h u m bs .

3.

C o r rective m ove m e n t : I n st r u ct t h e p a t i e n t to g e n t l y p u s h t h e foot i n to p l a n t a r flex­ ion w h i l e rest r i ct i n g t h i s m ot i o n with yo u r body ( m a i n ta i n d o r s i f l e x i o n )

M a i n ta i n

t h e poste r i o r l y d i rected fo rce w i t h yo u r t h u m b s . H a ve t h e p a t i e n t h o l d t h e contrac­ t i o n for 3 to 5 seco n d s .

4.

I n st r u ct t h e p a t i e n t t o re l a x . Wa i t 2 seconds, t h e n e n g a g e t h e n e w b a r r i e r b y mov­ ing t h e p a t i e n t 's foot f u rt h e r i n to d o r s i f l ex i o n w h i l e m ovi n g the l a te r a l m a l l e o l u s poster i o r l y w i t h y o u r t h u m b s .

5.

R e peat two o r t h ree t i m e s o r u n t i l m o t i o n i m p rove s .

6.

W h e n t h e p ro ce d u re i s c o m p l et e , reassess poste r i o r m otion o f t h e l a tera l m a l l e o l u s .

Indirect Hamstring Release (Myo fascial Release) (Fig. 1 1.2)

Consider the dysfu nction of a hypertonic left h a mstri ng. The o bjective is to dec rease h a m string h y pertonici ty. The principles of c o u n terstra i n can be a p plied to tre a t dysfunction between agonist and a n tagonist m u scle gro ups. A speci fic tender p o i n t i s not necessa r i l y present. The physic i a n l o a d s the a n tagonist a n d un loads the agonist. This may be considered a d i rect myofascial release to t h e a ntagonist or an indirect proced ure to the agonist. 1 5

Chapter 1 1

FIGURE 1 1 . 2

• The Ath lete

1 53

I n d i rect myofa s c i a l r e l ease of t h e l eft h a m st r i n g m u s c l e s .

Pa tient pos i t i o n : prone. P h y si c i a n pos i t i o n : sta n d i n g on the side of th e d) sfun c ­ tiona I hamsrring. ,

Procedure

1.

Pa l pate for an a rea of i n c reased t e n s i o n of t h e h a m st r i n g with both h a n d s . M o n i to r t h i s a rea w i t h yo u r l eft h a n d . A t e n d e r p o i n t i s n ot n ecess a ry.

2.

W i t h yo u r r i g h t h a n d , g ra s p t h e a n k l e a n d f l ex t h e k n e e s l ow l y u n t i l t h e p a t i e n t b e g i n s t o f e e l t e n s i o n i n t h e q u a d r i ce p s m u s c l e . A t t h i s p o i n t t e n s i o n of t h e h a m ­ string s h o u l d be m i n i m a l .

3. 4.

U n l o a d t h e h a m st r i n g ( a g o n i st) a n d l o a d t h e q u a d r i c eps ( a n t a go n i st)

If t h e p a t i e n t h a s p a i n in t h e low b a c k with k n e e f l e x i o n , do n ot f l ex as f a r or c h oose a n o t h e r p roced u re .

S.

F i n e-tu n i n g m a y b e a c h i eved b y i n te r n a l l y o r exte r n a l ly ro tati n g t h e t i b i a to a c h i eve t h e l e a s t a m o u n t of ten s i o n in t h e h a m stri n g .

6.

F i n e - t u n i n g m a y a l s o b e a c h i eved b y t ra n s l a t i n g t h e h a m s t r i n g g ro u p m e d i a l l y o r l a t e ra l l y w i t h yo u r l e ft h a n d t o a c h i ev e t h e l e a s t a m o u n t o f t e n s i o n i n t h e h a mstri n g .

7.

After a seve ra l seco n d s , t h e h a m st r i n g w i l l soft e n o r r e l e a s e . P a l pate for t h i s re l ea s e ( o r softe n i n g) o f t h e h a m s t r i n g g ro u p .

8.

S l owly retu r n t h e l e g d own t o t h e ta b l e .

9.

W h e n t h e p roce d u re i s co m p l ete, reassess t h e dysf u n ct i o n a l m u s c l e f o r t e n s i o n .

Knee (Indirect Myofascial Release) (Fig. 1 1. 3) Consider the dysfunction of a myofascia I restriction of the knee. T he objective is to remove the fa sc i a l restriction and improve knee functi on. Patient position : supine. Physician position: standing a t the side of the patient.

1 54

Section II • Pat ient Populations

FIGURE 1 1 .3

I n d i rect myofasc i a l r e l e a s e of t h e r i g ht k n e e .

Proce d u re 1.

P l ace yo u r k n e e u n d e r t h e p a t i e n t 's k n e e to g i ve a s l i g h t a m o u n t of f l ex i o n . P l a ce yo u r l eft h a n d a b ove t h e pate l l a on t h e d i sta l t h i g h a n d yo u r r i g h t h a n d b e l o w t h e pate l l a o n t h e ti b i a .

2.

C o n d u ct a m o t i o n test t o f i n d t h e d i rect i o n o f e a s e o f t h e m yofa s c i a l t i s s u e s . T h i s w i l l i n c l u d e a s i d e-to- s i d e (t r a n s l a t o ry) m ot i o n , a n i n te r n a l a n d exte r n a l rotat i o n , a n d a c o m p ress i o n a n d d i stract i o n of t h e t i s s u e s .

3.

For a n i n d i rect r e l e a s e , unload a n d follow. T h a t i s , m ove t h e t i s s u e s i n t h e d i rect i o n of f r e e r m ot i o n , ta k i n g i n to acco u n t a l l a s pects of t r a n s l a t i o n , i n t e r n a l a n d exte r n a l rot a t i o n , a n d e i t h e r co m p ress i o n o r d i stract i o n .

4.

H o l d t h i s p o s it i o n a n d w a i t for a n i n h e re n t r e l e a s e or softe n i n g of t i s s u e te n s i o n .

5.

W h e n t h e p roced u re is co m p l ete, reassess t h e dysf u n ct i o n a l a re a .

Anterior Innominate Dysfunction (Muscle Energy) (See Fig. 9.9) Consider t he dysfunction of an anterior left innominate. T h e obj ective is to i m prove motion of the d ysfu nctiona l i nnominate into t h e restric tive barrier. In treating the anterior innominate , a mod ifica tion includes grasping the isc h ium on the dysfuncti onal side to help a u gment posterior rotation of the innom i nate. P a tient positi on: sup i n e . Physician posi tion: sta n d ing at t he side of the patient's dysfunctional innom i nate bone. Proce d u re 1.

F l e x t h e pat i e n t 's a ffected k n e e a n d h i p u n t i l t h e rest r i ctive b a r r i e r is e n g a g e d .

2.

A p p l y yo u r s h o u l d e r or a x i l l a to t h e p a t i e n t 's k n e e , u s i n g both h a n d s to g rasp t h e s i d e s o f t h e t a b l e . F i r m l y h o l d t h e h i p a n d k n e e i n t h i s flexed p o s i t i o n .

Chapter 1 1 3.

• T h e At h l et e

1 55

I n st r u ct t h e pat i e n t to press t h e k n ee i n to yo u r s h o u l d e r a re a (exten d i n g t h e h i p) a g a i nst yo u r h o l d i n g force, sta rti n g with m i n i m a l fo rce a n d i n c re a s i n g t h e a m o u n t o f force o n l y a t yo u r r e q u est . I n st r u ct t h e p a t i e n t t o m a i n ta i n t h e force f o r 3 t o

5 seco n d s . 4.

H ave t h e p a t i e n t rest a n d re l a x f o r a f e w seco n d s , t h e n e n g a g e t h e n ew b a r r i e r a n d repeat t h e p rocess; two o r t h re e effo rts a re u s u a l l y s u f f i c i e n t .

5.

W h e n t h e p ro ce d u l-e i s co m p l et e , reassess t h e dysf u n ct i o n a l i n n o m i n a t e .

Plantar Fasciitis (Counterstrain) (Fig. 1 1. 4)

Co n s i d e r poi n t tenderness o f t h e r i g h t pl a n ta r fa scia i n sertion on t h e c a l ca n e u s . o bj ec tive is t o red uce t h i s te n d e r n e s s . Jones l 5 tre a ts t h i s c o n d i t i o n i n a prone pos i t i o n w i t h t h e knee flexed a nd t h e heel p u s he d ro wa rd the fro n t o f the p l a n ta r­ flexed foo t . Pa tient pos i t i o n : s u pine. Physicia n position: sea ted on t h e end of t h e ta b l e , fac i n g t h e p a ti e n t .

The

P r o ce d u re 1.

Locate t h e reg i o n of t h e p l a n t a r f a s c i a i n s e r t i o n o n t h e i n fe r i o r a n d a n t e r i o r s u rface of t h e r i g h t c a l ca n e u s . P a l pate f o r a s i g n i f i c a n t te n d e r poi n t .

2.

M o n i t o r t h a t t e n d e r p o i nt w i t h o n e t h u m b , a n d w i t h t h e o t h e r h a n d p l a n ta r-f l e x t h e a n k l e a n d f l ex t h e t o e s u n t i l te n s i o n o r l o a d i n g of t h e t i b i a l i s a n t e r i o r m u s c l e i s a c h i eved . Yo u r r i g h t t h u m b a cts a s a f u l cr u m to f l e x a ro u n d .

3.

S u p i n at i o n o r p r o n a t i o n o f t h e foot m a y b e req u i re d t o f i n e -t u n e w h i l e o bta i n i n g a

4.

T h e t i b i a l i s a n teri o r is l o a d e d ; t h e g a st ro c n e m i u s a n d s o l e u s a re u n l o a d e d .

5.

H o l d t h i s pos i t i o n f o r 9 0 seco n d s o r u n t i l a p a l p a b l e s ofte n i n g o f t h e t i s s u e s occ u rs .

p o s i t i o n of sympto m a t i c re l i ef ( n o t e n d e r n ess) .

F I G U R E 1 1 .4

C o u n t e rstra i n f o r p l a nt a r fasc i it i s of t h e r i g ht foot_

1 56

S ect ion I I • Patie nt Po p u l ati ons

6.

S l ow l y ret u r n t h e foot to its n o r m a l posi t i o n . Yo u r m o n i t ori n g f i n g e r s h o u l d not

7.

W h e n t h e p roc e d u re i s co m p l et e , r e a s s e s s t h e d ysfu n ct i o n a l p l a n t a r f a s c i a f o r

l eave the p o i n t t e n d e r n ess.

Epigastric Thrust (HVLA) (Fig. 1 1 . 5)

The o b j ective of left side be n d i n g , and l e ft rota­

Consider the d y s fu n c t i o n T6 fl exed , rotated r i g h t s i d e - b e n t r i g h t . ,

th i s p r o ce d u re i s to restore motion in ex te n s i o n t i o n . Th i s proce d u re m a y be u s e d

on

,

mid thoracic d y s functio n s . T h e b a r r i er i s pri­

mari l y engaged with l a te r a l tra n s l a t i o n . K e ep i n g yo u r k n ee o n the ta b l e hel ps sta­ b i l ize your forces so y o u d o n o t h u r t your o w n ba c k

.

P a t i e n t p o s i t i o n : sea ted . P h y s i c i a n p o s i t i o n : s t a n d i n g

be h i n d the p a t i e n t w i t h

t h e r i g h t k n e e o n t h e ta b l e o n t h e s i d e o f t h e p o s te r i o r c o m po n e n t . P r o ced u re 1.

I n st r u ct t h e p a t i e n t to s i t comforta b l y on t h e ta b l e a n d c l a s p t h e h a n d s be h i n d t h e n ec k .

2.

F o l d a s m a l l p i l l ow i n h a lf, p l a ce it i n d i rect c o n t a ct w i t h t h e l eft tra nsverse p rocesses of T7 in a h o r i zo n ta l p o s i t i o n , a n d h o l d i t t h e re f i r m l y with yo u r e p i g a st r i u m .

3.

Pass yo u r left h a n d u n d e r t h e pati e n t 's l eft a x i l l a a n d g r a s p t h e b a c k of t h e p a t i e n t 's l eft forea r m . Pass yo u r r i g h t h a n d u n d e r t h e p a t i e n t's r i g h t a x i l l a a n d g ra s p t h e b a c k of t h e pati e n t 's r i g h t forea r m .

4.

Exte n d t h e p a t i e nt's u p p e r t h o r a c i c a re a d ow n t o a n d i n c l u d i n g T 6 . K e e p t h e p a t i e n t's u p p e r to rso c e n t e r e d ove r t h e p e l v i s d u r i n g t h i s p roced u re .

5.

Tra n s l a te t h e p a t i e n t 's t r u n k to t h e r i g h t a bove T7 to i n t rod uce s i d e b e n d i n g t o t h e l eft o f T 6 u p o n T7 .

FIGURE 1 1 . 5

H V L A e p i g a s t r i c t h r u st f o r t h o r a c i c type I I dysfu n ct i o n , T6 f l e x e d , rotated r i g ht, s i d e bent r i g h t .

C h a pter 1 1 6.

• T h e At h l ete

1 57

Rotate t h e u p pe r t h o r a c i c a re a to t h e l eft, m a k i n g s u re y o u l o ca l i ze fo rces down to T6 u po n n .

7.

T h e f i n a l c o r rective force i s t h ro u g h t h e p i l l ow a n d a b d o m e n a g a i n s t t h e e n g a g e d b a r r i e r. I t

IS

a n acce n t u a t i o n of t h e a c c u m u l a t e d m ot i o n s . Rot a t i o n i s n o t a s i g n i f i ­

ca n t c o m p o n e n t .

8.

W h e n t h e proce d u re i s c o m p l et e , rea ssess t h e dysfu nct i o n a l a rea .

CO N S I D E RAT I O N F o r exte n d e d dysfu ncti o n s , fo l l ow t h e p rev i o u s p roced u re ; h oweve r, h ave t h e p a t i e n t f l e x forwa rd by s l u m p i n g w h i l e b r i n g i n g t h e s h o u l d e r s poste r i o r i n a t r a n s l at o ry m ove­ m e n t . T h e f i n a l c o r rect ive fo rce i s a q u i c k t h rust with s h o rt f o rwa rd a n d lateral m o t i o n

of

t h e p i l l ow a n d e p i g a st r i u m coord i n a ted w i t h a n I n c re a s e i n t h e a m o u n t of t r a ct i o n

t h ro u g h t h e p a t i e n t 's a x i l l a e .

Biceps, Long Head (Counterstrain) (Fig. 1 1 . 6) C o n s i d e r a te n d e r p o i n t i n the ten d o n of the right long hea d of the biceps m u sc l e n ea r the b i c i p i t a l g r o o v e . The o bj ective i s t o a llevia te a m ild

stretc h

the tender p o i n t b y i n i tiating

to t h e a n ta g o n i s t m u sc l e g ro u p ( tr iceps ) .

Pa t i e n t p os i t i o n : s ta n d i n g . P h y s i c i a n p os i t i o n : s ta n d i ng b e h in d the

pat ient.

Proce d u re 1

Loca te t h e b i c e p s te n d e r p o i n t n e a r t h e d i sta l te n d o n i n s e rt i o n .

2.

M o n i t o r t h e te n d e r p o i n t w i t h t h e m i d d l e o r i n d ex f i n g e r o f yo u r l eft h a n d . (Yo u w i l l m o n i t o r t h e te n d e r p o i n t for t h e w h o l e p ro c e d u re . )

3.

U s e yo u r r i g h t h a n d t o f l e x t h e e l bow a n d s h o u l d e r. A m i l d stretch i s p l a c e d o n t h e t r i ceps as t h e b i ce p s i s s h o rte n ed . Try to a c h ieve a p o s i t i o n t h a t m a x i m a l l y d e c re a ses

FIG U R E 1 1 . 6

C o u n terst r a i n f o r a t e n d e r p o i n t in t h e l o n g h e a d of t h e r i g ht b i ce p s .

1 58

Sect i o n II • P at i e n t Po p u l at i o n s t e n s i o n u n d e r yo u r m o n ito r i n g f i n g e r. S u p i n a t i o n o f t h e forea r m i s u s u a l l y neces­ s a ry as w e l l .

4.

H o l d t h e a r m i n t h i s posi t i o n f o r 9 0 s e co n d s . A s re l e a s e occ u rs , you w i l l feel a d ecrease i n te n s i o n u n d e r yo u r m o n i t o r i n g f i n g e r.

5.

S l ow l y ret u r n t h e a rm to the n e u t ra l p o s i t i o n . ( D o not l et the p a t i e n t a s s i st yo u . )

6.

W h e n t h e p roced u re i s c o m p l ete, reassess t h e te n d e r po i nt .

N o te : C o u n ters rra in ca n be u s e d fo r a ny te n d e r p o i n t .

Refe re n ces 1. Wa l t e r G W. T h e F i rs t Sc h o o l o f O s te o p a t h i c M e d i c i n e . K i r ks v i l l e , MO: T h o m a s J e ffe r s o n U n ive rs i t y, 1 9 2 4 ( re p r i n t e d 1 9 9 2 } : 3 9-4 5 . 2 . S t i l l C E J r. Fro n t i e r D o c t o r-M ed ica l P i o n e e r : The L i fe a n d Ti m e s o f A . T. St i l l a n d H i s Fa m i ly. K i r k s v i l l e , M O : T h o m a s Je ffers o n U n i v e r s i ty, 1 9 0 7 ( re p r i n re d 1 9 9 1 , Tru m a n S t a te U n i v e r s i t y } : 2 0 5 -2 1 6 .

3 . P a t r i c k K , S a l l i s J F, Lon g B , e t a l . A n e w t o o l fo r e n co u r a g i n g d c t i v i t y : P roj ect P A C E . P h y s S p o r t s M e d 1 9 9 4 ; 2 2 : 4 5 -5 2 . 4 . Scu d e r i G R , M c C <1 n n P O , Br u n o PJ, e d s . S p o ns Med i c i n e : P r i n c i p l e s o f P r i m a r y C a r e . S t . Louis: Mo s b y, 1 9 9 7 . 5 . S t r a u s s R H . Ca r d i o v a sc u l a r.- b e n e f i ts d nd r i s k s o f e x e r c i s e : t h e s c i e n tific e v i d e n c e . I n : W ic k l a n d E H J r, ed . Spo rtS M e d i c i n e . 2 n d ed . P h i la d e lp h i a : S 3 u n d e rs , 1 9 9 1 ;72-g 0 . 6 . Wa r·d RC. G e r i a t r i c s . I n : Wa r d RC, e d . Fo u n d a t i o ns fo r O s teo pa t h i c M e d i c i n e . 2 n d ed . P h i l a d e l p h i a : L i p p i ncott Wi l l i a m s & W i l k i ns, 2 0 0 2 ; 3 2 7-3 3 7 . 7 . B r o l i n s o n P G , H e i n k ir rg KP, K o z a r AJ . A n osteo p a t b ic a p p ro a c h t o s p o rrs m e d i c i n e . I n : Wa rd R C , ed . Fo u n d a ti o n s fo r Osteo p a t h i c M e d i c i n e . 2nd ed. P h i l a d e l p h i a : L i p p i n c o t t W i l l i a m s & W i l k i n s , 2 0 0 2 ; 5 3 4 -5 5 0 . 8 . M i tc h e l l F L . S t r u ct u r a l p e l v i c f u n c t i on . I n : 1 9 5 8 Ye a r bo o k . I n d i a n a p o l i s : A m e r i c a n Academy of O s te o p a t h y, J 9 5 8 : 7 1 - 9 0 . 9 . He i n k i n g K P. T h e ger i a t r i c a dl l e r e . I n : K a ra gea n e s SJ , e d . P r i n ci p l e s o f Ma n u a l o f S p o r ts

Med i c i n e . P h i l a d e l p h i a : L i p p in c o t t Wi l l i a m s & W i l k i n s , 2 0 0 5 : 6 2 9-6 4 0 . 1 0 . Brenn a n a n

F H J r, C a m p a gna K, Fe l d n e r W. F o o t a nd a n k l e co m m o n c o n d i r i o n s . I n :

K a ragea n e s , 5J , e d . P r i nc i p l es o f M a n u a l S p o rt s Me d i c i n e . P h i l a d e l p h i a : Li p p i n c o tt W i l l i a ms

& W i lki n s , 2 0 0 5 ; 4 2 4 -4 4 1 .

J 1 . S t i e ll [ G , G re e n berg G H , McN i g h t R D , e t a l . D e c i s i o n r u l e s for t b e u s e o f rad i o g ra p h y i n a c u t e a n k le i n j u ri e s : R e f i n e m e n t a n d p ro s pect i ve va l i d a t i o n . J A M A 1 9 9 3 ; 2 6 9 : 1 1 2 7-1 1 3 2 . 1 2 . C u t b i l l J W, La d l y K O , B r a y R C , et a l . A n te ri o r k n e e p a i n : A rev i e w. CJ i n J S p o rt tvl ed 1 9 9 7; 7 : 4 0-4 5 .

1 3 . Best TM, G a r r e t t W E . H a m s t r i n g stra i n s : Ex ped i t i ng r e t u r n t o p l a y. P h y s i c i a n S po r ts Med 1 9 9 6 ; 2 4 ( 8 } : 3 7-4 4 . 1 4 . Wol i n P M , Ta r bet j A . R o t a t o r cu ff i nj u ry : A d d ress i n g o v e r h e a d o v e r l l s e . P h y s i c i a n S p o rts

Med 1 9 9 7 ; 2 5 : 5 4 -74 . a nd C O ll n rers tra i n . Newa r k , O H : A me r i c a n Aca d e m y of O s teopa r h y, 1 9 8 1 .

1 5 . J o n e s L H . S t ra i n

The Geriatric Patient Kenneth E. Nelson, Ann l. Habenicht, and Nicette Sergueef ]

INTRODUCTION Osteopathic practitioners ack nowledge that the body has the inherent ability to heal itself.

If this is so, why isn't everyone healthy, and why don't we live forever? The

answer to this question is obviously that this self-healing

m echa n is m

varies in

efficacy from individual to individual and to a great extent is a manifestation of the individual's ability to compensate for stress. As the individual ages, the ability to compensate for stress decreases , while physiologic sources of stress increase. An indi­ vidual s age can therefore be considered in '

the contexts of both physiology and time.

A person may be old in years and yet remain young physiologically. Conversely, a much younger patient with a chronic illness will be physiologically aged. Eventually, however, every individual who is fortunate enough not to die young is subject to

the

cumulative effects of age. This chap te r focuses upon helping the patient to compensate for the inevitable decompensation brought on by aging. Preventive medicine is extremely important in this context; thus, nutrition and the function of the musculoskeletal system are

two areas where preventive practices are readily applicable.

1 59

1 60

Section II • Pat i e nt Po p u l at i o n s

DIET AND NUTRITION Nu trition is a s u bject u n to i tse l f a n d i s beyond the scope of this cha p ter, b u t it s h o u l d be p a rr of the trea tmen t of a l l p a tie nts . D ie te tics for o l d er p a t ients must take into acco u nt severa l things . Cultural h a b its are formed. People learn their e a t ­ ing ha b i ts i n ea rl y l i fe, a nd these pa tients h a v e had many years to esta blish b a d d ie t e t i c h a b its t h a t l ike every t h i ng else wi l l h a v e the i r grea test nega tive impact i n t h e later years o f l i fe . Getting a pa tie n t to cha n ge a l ifet i me of eat i n g h a b i ts c a n b e d iffic u l t, p a r tic u l a r l y i n o l d age, when gusta tory p l e a s ure m a y be o n e of t h e few enj oy m e n ts still a va i l a ble . F u r t h e r, the p a t i e n t may avoid e a t i ng eve n w hen a de­ q u a te food is ava i l a b l e , sim p l y because mea l prepara tion requ ires too muc h effort o r they do no t like to e a t a lone . Physic a l mo b ility m a y be i mpa ired, further inter­ fering with food b u y i ng and p re p a r a tion. Energy expenditure is d ecreased, w h ich decrea ses c a lo r ic req u i r e m e n ts altho u g h the p a t ient'S req u i r e m ents for m icronu t r i ­ e n ts r e m ai n c o nstant. The f o o d the patient d o e s e a t i s f r eque n t l y poorly a s s imi­ la ted. Poor den ta l healt h , h yposecre t i on o f the gastr i c m u c o s a , and senescen t decrea se in the p r o d u c t i on of e n ter i c e n z y m e s a l l interfere wit h t h e a bsorptio n of n u trien ts . As a p e r s o n gro ws o l d er, financ i a l resources o ft e n diminish, and less money is a va i l a ble for food. Therefore, the phys icia n must c o ns i d er pa tients' d ietary nee d s from a l l d irectio n s , a task t h a t i s by no m e a ns simp l e .

MUSCULOSKELETAL FUNCTION AND SOMATIC DYSFUNCTION Aging brings wit h it d is t i n c t cha nges in t he ne u r o m uscu l o s k e l etal system . S o m a tic dysf un c ti o n is by d efini t i o n an imped iment of f u nc t i o n of the m u sc u l o s keleta l sys­ tem t h a t a ffects the pa tient m e c h anic a l l y and thr o u g h i ts effect u p o n a ssociated v

a sc u l a r and n e u ro l ogic struc tures.1 T h e ind i v i d ua l m u s t a c t ive l y compe n s a te for

the res u l ting impa i rm e n t . Soma t i c d ys fu n c t i o n is assoc i a ted wit h i r r i ta bility of the seg me n ta l l y rela ted n e rvous s y s tem tha t in itself may c o n tri b u te to d isease through direct s o m atov i sceral a n d gene r a l syste m i c i m pa ct 2 S o m a t i c d ysfu n c t i on c a n be .

fou n d in pa t i e n t s of all a ges. It is a reve rs i ble fu nctio n a l i m pa ir m e n t that is

r ea

d ily

a m e n a b l e to oste o p a t h i c manip u l a tive tre a t m e n t ( OMT) . As the i n d ivid u a l ages a n d begins to l o s e muscle mass, s t rengt h a nd stamina d im i n ish, w i t h a res u lt a n t l oss of fu n c tion a l capa city. The more efficiently pa ti e n ts function, t h e m ore t h e y c a n c o m p e n s a te for t h e i ne v i t a b l e stresses of a ging. As m e n tio n e d

e a rlier, if th e pa t i e n t has a n o p t i m a l die t, pa r ticu l ar l y as rega rding cal­

c i u m a nd vi tamin D, a ug men ted by an effective exercise p rogra m , this progress i o n m a y b e a tt e n u a t e d , i f n o t a r rested . It is common knowledge tha t diet coupled w i t h e xercise ma y be e m pl o yed to improve m u sc l e tone a n d m a s s , prevent osteoporosis, reduce hy perlipidem i a , m a i n ­ ta i n c a rd iova scular hea l th, a n d enhance t h e efficacy of med ical the r a p ies for disease p rocesses like diabetes. Thus, most older in d i v id u a ls have been told to exercise as p a r t o f thei r therapeu tic regi m en . These p a tients o ften work ext remely ha rd to m an­ age the i r diet a nd to increase t heir l eve l of p h y s i c a l a c t i v i ty. E xe r c i se p rograms like wa l k i ng low- i m pa c t a ero bics, and ta i c h i a re weight- bearing activi ties . S u c h activi­ ties, a l though highly d e s ira ble, paradoxica lly can c ont r i b u te to postura l decompen­ ,

sa tion. More t h a n h a l f of the general p o pula tio n d emonstrate anatomic inequality of leg l engt h of one-qua rte r inch or more.3 Thi s imbala nce res u lts in pelvic unleveling with compensatory type I group lateral c u rve spin a l mecha n ics above the pelvis . Gr o u p spina l mecha nics a re not onl y a ssoc i a t ed with dysfunctional spinal side bend­ ing, they a lso inc rea s e the normal anteroposterior s p i n a l c u rves. Thus , the pa tie n t is

Chapter 12 • T h e Ge riat r i c Patie n t

16 1

apt to dec o m pensate d u e to weig h t- bea ri ng stress i n both the co r o n a l a nd sagitta l p l a n e s . The inci dence of t h i s deco m pe ns a t i o n increases with age as the patient loses the a b i l i ty to accommoda te for the asymmetric l a tera l a nd a ltered a n teroposter i o r weight-bea r i n g s tresses . Most commonl y th i s ma nifests a s l u m bosacra l o r sa cro­ pelv i c pa i n .3 Thus, the exercise prescribed to benefit the pa tient may res u l t in postura l deco m pensa t i o n a n d m u sculoskeleta l p a in. These issues may o ften be v ery s imp ly a d d ressed with l ift the r a p y, core m u s c u l a r s trengthe n i ng, and if necessa ry, a n a n tero­ poster i or o r thotic ( Levi tor) device in

a ssoci a t i o n

w i t h a ppropri a te l y a p p l ied OMT.

( See Chapters 26 a n d 27.) Postura l i m b a l a nce a n d gait i nsta b i lity are p a r t ic u l a r issues with ger iatric pa tien ts . Per i p h e ra l sensory i n p u t significa n t ly p rovides fo r t h e ma i nte n a nce of u pright pos­ ture. Aging is associa ted w i th

a

decrease in postural b a l a nce t h a t i nc reases the r i s k

of falling.4 When p a t i e nts fa ll, they tend to f a l l to the side, c om m o n ly fract u ring t h e h i p . A s the ind ivid u a l ages, visua l , la byri n t h i ne, a n d s o m a tose nsory i n p u t c h a nge the i r c o n tri b u tion to t he dyna m i c m a i n te n a nce of s ta n d i ng pos t u re . Pres byop i a , cataract forma t i o n , cha n ges i n the vi treo u s hu m or, a nd oth e r o phthalmologic d is ­ eases o f agi ng decrease v i su a l a c uiry a n d consequent ly the i n d ivid u a l's abi l i ty to rely upon v i s i o n for postu ral ba la nce. Impaired vi s u a l a cuiry increa ses the chances of fa l l i ng.s Th us, with loss of v i sio n , the p a t ie n t beg i n s to rely more upon l a by r i n th i n e a n d so m a tosensory i n p u t

.

Upper t h o r a c i c f l e x i o n a n d d ec rea sed cervico-occipi tal extension a ffect hea d posit i o n , l o wer i n g the v i s u a l field fro m the horizo n a nd s h i fti ng the neu t r a l p os i ­ tion o f t he vesti b u l a r a p pa r a tus. T h e hea d-flexed p o s i tion s ignifi c a n t ly i ncreases postura l insta b i J ity.6 When patients c a n n ot re ly u pon visua l cues fo r postur a l ba l­ a nce, they tend to c o mpensa te by s tiffen i n g the m u scles in the i r l o wer legs d ur i n g upright s tan d i ng.4 T h e l o s s o f m u s c le m a s s a nd strength i mpa i rs t h e efficacy of this compe nsa t i o n. S u ch pa tients ca n be tre a te d by a d d ress i n g s o m a tic dysf u n c t i o n o f t h e u pper thorac ic, cervica l , a n d cer v i co-occ i pita l regio n s , partic u l arly flexion dys­ functio ns, and by provid i n g exercises directed a t strengthe n i n g the lower extre m i ­ ties a nd enhancing freedo m of a nkle flexi on and extensio n.

Evaluation of the Patient Although t he foc u s of this c h a pter is u po n the d iagn o s i s a n d trea tmen t of s o m a t i c dys func t i o n , i t i s neces s a ry to trea t t h e e n tire i n d i v i d ual, n o t just the m us c u l o skele­ tal system . An acc urate d iagnosis m u s t o b v i o u sly be pred i cated u po n a t h o r o u g h histo ry a n d p h y s i c a l exa m i na tion, i nclusive o f a l l sys t e m s a n d reg i o n s o f the b ody. Viscero s o m a t i c ref lexes o ften provi d e c l ues to u n d erlyi ng occult v iscera l patho l

­

ogy. (See Ch apter 5.) Trea tment, be it OMT, pharm a c o t h e ra py, d iet, or exercise i s predica ted u po n proper d i a g n o s is The geria tric p a t i e n t i s s u bject to a ll o f the m a l­ a d ies t h a t a ffec t younger patien ts. Therefore, t he d iagnosis a n d trea t men t of soma tic .

dysfu ncti o n fo r ger i a t r ic patients w i t h e a r, nose, a nd throat ( see C h a pter 16); p ulm onary (see C h a p te r 17); cardi ova scula r ( see Cha p ters 18 a nd 19) ; a nd g a s ­ tro i n test i n a l (see C h a p ter 20) p r o blems a re essenti ally the s ame a s d e s c r i bed else­ where i n t h i s text. Geri a t r i c p a t ients a re partic u l a rly l ikely to present w i t h mu lti ple chro n i c degen era tive c ondi t i o n s tha t they may or m a y n o t be a wa re of. It is for these c o n d iti ons in this po pula t i o n th a t the p rinciples of osteo p a th i c med i c i ne, which foc u s upon d i a g n o s i n g rever s i ble soma tic d ysf unction a nd treating it with OMT to o ptimize fu n c t i o n , poss ibly o ffer the g rea tes t impac t. As i n d i v i d u a l s age, they bec o m e resigned to t heir dimi nished resil ience and increa sed

m u sc u l oske let a l

d i sc o m fo r t .

Chr o nic

p r ogressive c o n d i t i o n s

like

162

Section II • Pat i e n t Populat i ons

h y p e r t e n sion, d i a bete s , and c h r o n ic rena l fail ure c a n b e presen t fo r exte n d e d peri­ ods wi thout t h e p a t ie n t k n ow i ng it. P h y sical sympto m s that t h e y might h a v e fo und u na ccepta ble in t h eir you n ger d a ys become n o r m a t ive, s o they d o not c o m p l a i n a bo u t t h e m . Chro nic l o w e r urina ry trac t i n fections, l ow-gra d e upper respira tory infe c t i o n s, and d e ntal sep s i s can res u l t i n m a l a ise tha t does n o t n ecessa ri l y m a n i ­ fest a s a spec i fica ll y l oc a lized co m p l a int. Occ ult h y p o t h y ro i d i s m ma y b e m is i n ter­ pre ted a s n ormal l o s s o f vita l i ty w i t h age. Be n ign c o n d i ti o n s can pres e n t as pe rplex i n g c o m p l a i n ts. Ceru m e n i mpaction , thro u g h i rr i ta tion of the a uric u l a r b r a n c h o f t h e v a g u s nerve, c a n prese n t a s a persistent nonpro d u ctive cough . Or s i m p l y bec a u s e of d iminis h e d h e a r ing, cerumen i m p a c t i o n may c a use t h e pa tient to a pp e a r wit h d r a w n a n d u n res pons i v e . Patients w i t h a n a c ute onse t o f m uscu l oskel eta l p a in, no matter how vague or see m in gly t ri v i a l, s h o u ld have a th o ro u g h p hysica l examinatio n to r u l e out under­ l y ing med i c a l a n d o rt h o pe d i c d isord e r s . S u boccip ital h e a d a c h e may be ca used by upp e r cervic a l s o m a tic d y sfuncti on, o r it may be the result o f eyestrain or a v i s ­ cerosoma t ic reflex fro m the upper resp ira tory trac t or from any o f t h e v i scera in nerva ted by the vagu s . OMT may b e u sed to e x ert a positive effect upon segmen­ ta lly rela ted viscera thro u g h s o m a toviscera l p h ysiology, but the d efi n i tive treat­ m e n t of a v i sc e r o s o matic reflex is t h e speci fic treatme n t of t h e u n d er l y i n g visceral p a t h o l ogy. Ide n t i fica tion of s p i n a l s o m atic d ysfu n c tion necessitates t h a t path o l ogy be rule d o u t in segmen tall y rela ted v iscera . Rib or th oracic s pine pain tba t begins following a n e p i s o d e of c o ughing m a y we ll be the result of s o m a t i c d y s fu nc t i o n of the t h o ra c i c v e r t e b r a e o r r i b, b u t in a n i ndiv i d u a l w i t h osteo p o ro s i s , it m a y be a posttu ssive frac ture . OMT is e m p l o yed to trea t s o m a t i c d ysfu n ct i o n , the f u n c t i o n a l reduc t i o n o f m o tion, a n d a s such i s c o ntra i n d ica ted i f i ns t a bility i s a possib i l i ty. T h e pa t i e n t'S chie f compl a i n t often dicta tes where to beg i n t h e muscu los k e l eta l exa m i n a tio n . If postural d ec ompens a ti on is s uspected , a comp lete str u c tura l exa m­ i n a t i on should be p e rformed a s for a n y o t h e r pa tient. From behind, w i th t h e patient s ta n d i n g, o bserve s y mmetrica l a n a tomic l a n d m a r ks that i ndica te t he pos t u ra l asym­ metry o f s h o r t leg m echanic s . Compare the levels o f t h e posterior superior iliac s pines ( PSIS), sacral dimples, the most lateral aspect o f the iliac crests, and t h e tops of the gre a t e r troc h a n ters. Typ i c a Jly, a l l of t hese a re l o w on the s id e of the short leg. Next, check fo r c o m pe nsa tory spinal la teral c u rves . Ha v e the p a tient bend forward and o bserve for a s y m m e tric a l p a raverteb ral p rominence, the resu l t of the rotation a l c o m p o n ent o f type I m ec h a n ics. The typ i c a l accomm o d a t i o n to a s h o rt leg results in a compensa tory c u rve that is c onvex Oil the sid e of the s h ort leg. Further, o bserve for s y m metry of ana tomic lan d marks a bo v e the p elvis (i. e . , scapulae , a cromi on processes, a n d ma stoi d p rocesses) and o f a n a to mic landma rks of the lower extrem­ i t y ( i .e . , p o p l i te a l creases a n d m e d i a l m a l le o l i). Fina l l y, check fo r p e l v i c side s h i ft. Sta bilize the u pper torso b y hold ing the sho u l der with one hand and p u s h media l ly over the late r a l a s pect o f the opposite side o f the p e l v i s with the other hand . The test i s po s i tive when the pelvi s moves fre e l y i n one direc t i o n but res ists m o v e ment in t h e opp o s i te d irection. A pos i tive pelv i c s i d e shift i s d e s ig n a ted as e i ther l eft or right a s an i ndica t i o n of the d i re c t i o n o f un restr i c ted pelvic mot i o n . Ineq u a lity of leg length i s a ssocia ted with pelvic s i d e s h ift towa rd the l ong leg, or the sh ift m a y be the res u lt o f a symmetric p s o a s major tens ion, w i th the res ultant s i d e s h i ft away fro m t h e c o n tracted musc l e . The d ia g n o s i s o f s h ort leg sy ndrome i s ba sed u p o n a cons tellat i o n o f m u sc u l oske l e tal and genera l body s y m ptoms a n d u pon p h y s i c a l fin d ings t h a t m a y be c o n f i r m e d by ra d i ogra p h y. ( S e e C h a p ter 26.) The m u sc u l oske l eta l exa mina tio n c a n be co n t i n ued by system atica l ly scre e n ing for regio n a l and segmenta l soma tic d ysfu nction. Palpa tion o f a n o lder person

Chapter 12 • Th e Ge r i atric Pat i e n t

1 63

reveals rea d i l y o bserva b l e t i ss u e text ure cha nges and motion restricti o n o f soma tic d y s f u nc tion But the examination also r e v e als a d d itio n a l i n fo rma tio n to the d i s ­ cerning touc h . Chro n i c disease states a r e a c c o m p ani e d b y gen e r a l s u bc utaneous tissue texture change. The m y x ed e mato u s feel of c hro ni c h y p o t h y r o i dis m i s an obvious example. Diabetes has a similar feel that is t h e res u l t of fluid s h ift from t h e intracellular to the ext race llu l ar compartment and a s s u ch i s d irectly p ropor­ t i onate to the severity of hyperglycemia.7,s The d e g r ee o f skin a nd muscle tone, the texture and a m o u n t of s u bcuta n eo u s fat, the range a n d free d o m o f m o v e me nt of joints, the presence or absence o f cre p i t a t i on are important i n dicators of phys i o­ l ogi c age . Signs of ag ing are also noticeable in muscle po\ve r, circu la tio n , c o o rdi­ na tion, and POStLI reo This diffe r e n t i a t i on is sign ific a n t bec a use 0 MT is ad m i n i stered to patients a s dictated b y physiologic age to a far g r ea t er extent than c h ronol ogi cal a ge. (See C h a p te r 4.) .

Treating the Patient The initial foc u s o f any t h e rape u tic reg i me n is d ictated b y t h e patie nt's p r o bl e m s . Once d iagn ose s have been made, appropr i a te tre a t ments can be i n i t i a ted . S pec i fic therapies fo r the m y ria d o f d is or d e rs, ac ute a n d c h ronic, that a ffect the ger i atric pa tient are ava ila ble in general me d i ca l texts . OMT sho u l d , o f c o u rse, be employed a s wel l . The treatment o f s omatic d ysfu n ct i o n as it rela tes to specific c lin i c a l conditions is covered elsewhere in thi s text . This app r o a ch is, howeve r, d i s­ ease oriented, w h il e os te o p a thic med icine is s a id to be focu sed u pon the p a t i ent, not t he disease. So th e clinician who is initia ting d is ease-fo c u s e d treatme nt, be it O MT or the use of med ic a tion, m u s t ap p r o a c h the p a t i ent globally as well, con­ sidering not just a h o l i s t i c a ppro a c h to the body but also the mind a n d s p i r it. Th i s as pect o f trea t me n t should b e initiated a t t h e s a m e time a s d isease- fo c u sed t h era ­ pies. It is here also that pre ve n tiv e in te rve ntions s h o u l d be g i n . Consider the imp act of somatic d y s fu n ctio n upon the in d i v i d u a l and ap pl y the appropri a te d ose of OMT. Id entify and add ress s pec i fic nutritional requirements. Define functional c ap aci t y and provide a realistic exerci s e progra m to e n h a nce capa bilities . Establish interpersonal co m m u n i cat i o n and patients will te l l you i n their own way w h a t t h eir fee l i n gs and needs are. ,

Somatic Dysfunction In

formulating

a

treatment plan and deciding for what p urpose to empl o y OMT,

i t is useful to answer the fol low ing questi ons: How does d y s f un c ti o n of the m u s ­ cu l os k el eta l system mec han i c a l ly affec t the patient? What a re the effects o f a l tered a utonomi c nervo u s a c tivi ty (sym p a t h etic a nd pa r a s ympa thetic) re s u lti ng from soma tic d y s f u nc t i o n ? How does s o matic dysf un cti o n a f fect t h e pa t i e nt S peripheral '

car d io vasc u l a r, a rteria l, venous, and lymphatic systems? Answers to t h e se ques­ tions he l p t h e clinician to d ete r m i n e the d es i red the ra pe u t i c effect of OMT. The clinician s ho u l d also attempt to d ecid e what com po nen t of t h e m u scu­ l os kel e tal system is p re d o minan tl y r es p o n sibl e for t h e d y sfu n cti o n . Is the r e articu­ lar res triction, m u sc l e spasm, o r d ysfu nc t i o nal fa scia l ten s i o n? Recog n i ti o n of the s e conditions can help to determine the a ppr o pr i at e type o f OMT. If the d ys ­ function results from art icu l a r restriction, a p ro c e d ur e that is directed at a rt i cular mechanics shou l d be employed. Examples are hig h -ve l o city, l o w -a m plitud e (HVLA) tec hn i q u e a n d l o w - v e l o c i ty, mod erate- to h ig h - am p l i t u d e a rti c u l a t i o n pro­ ced ures. If the dysfunction resu l t s from s o ft ti s s u e ten sion, a procedure that is intend ed to affect s o ft ti ssue (mu s c l e energy, soft tissue st r etch i ng myofa scia l ,

Section II • Pat i ent Po p u l at i ons

164

release) is a pp r o p ria te. If t h e dysfun c t i o n is best ad d re ssed by attempting to reduce neur a l reflex activity, counterstrain and fa ci li t ate d p ositio n al release may prove to

be the proc e du re s of c ho i c e . S o m a t i c dysfunc t i o n res u l t i n g from viscerosomatic reflex activity s h ould be addressed by tr e a ti ng the u n d e r l y i n g v isceral p a t h o l ogy; h owever, trea tment o f the

p a t h ology ma y be augmented b u t not repl ace d by m a n ipu l a t in g the s o matic com­ p o n e n t ( s o matovisceral refl ex). T h e pr oced ure or p roced ures c hosen under these c i rc u m stances s h o uld res u l t in soma t i c re l a xa tio n with minima l stimulation. Once the v i sc e r a l c omponent ha s been e ffect iv ely trea ted, residua l som ati c dys fu nc ti o n may be trea ted with a pp r o pri at e l y sel ected OMT. Patients m a y ha v e a r e bound r ea c ti o n to OMT and s h o u l d be cautioned a bo u t i t . These reactions may r a n ge from a slight fee l ing of fa tigue to a n increase in pain a t t h e s ite of the chi e f c om p la int or e l s ewh ere . The elderly patient'S res ponse to OMT is s l ower than tha t of y o u nger i n divid u a l s . The typic a l re bound for these patie nts c a n l a st 12 to 48 hours. It i s the resu l t o f t h e amo unt of s o ft tissue irrita­ tion present and the amount of OMT a p p l ied . S o ft tissue p rocedures a re p a rti cu ­ la r ly l i k el y to p ro duce such rebo und reacti ons . Re bound resp o n ses occ u r most fre q ue n t l y after the first or second treatmen t. A rea ction tha t la sts no more than 4 8 h ours and tha t is fo l lowed by ame l i or a t i o n o f symptoms is accepta b l e. If the p a tient has a more severe r e a c tio n, pro b a b l y too m u c h OMT has been adm i n is­

tered

a t one

t i me. The patient should be g i v e n 3 d a y s to 2 weeks between in terven­

t i o n s and the m a n ipul a tion a djusted a cco rd i n g to the response. A pat i e n t w h o

remains u nres p o n s i v e to i n tel ligen tly a ppl i e d mani pu l a t i on a fter t h e s e c o n d o r t h i rd trea tme n t s h o uld be reevaluated, and the poss i b i l ity of a n unrecognized v i sc ero s o m a t ic e t i o l ogy s h o u ld b e c o n si d e r ed . T h e geri a t r ic patien t normally has a relatively strong respo nse to relatively l itt l e stress a nd often with symptoms d i s t a n t from the s i te o f t h e chief comp l a in t or the r a py. Patie nts with c h ro n i c d i seases, s u ch as rheum atoid a rthritis, may require the very gentl e s t of ma n ip u lative attenti o n to prev e n t a n a cute exacer b a rion of symptoms . Osteoa rthri t i s is o fte n an i n d ication of a n attempt by t h e body to com­ pe n s a te for insta bility. As a c o n seque n ce, a djac e n t areas o f p r i m ary m o tion restric­ tio n s h o u ld be s o u ght out a nd t r e a te d to reduce stress upon t h e unstable osteoa rthritic a re a . The patient with o s teoporosis can benef i t from manipulation, but this must be a p propria te ly gent l e. Procedure s a pplying force downward u p on the thoracic cage of the pro n e or s u p i n e pa tient put p o te n tia l l y tra uma tic force

upon the costochond ral, costove rte b r a l, and mid shaft areas of the ribs a n d s hou l d be used o n l y with t h e gre a te s t c a u tio n . Stress caused b y t h e pso a s m a j o r muscle

the neck of the femur m a y be en o u g h to ca u se spontaneous fra ctu re, which is b l amed u p o n t h e ens u ing fall. The paravertebral musc l es of the low b a ck s h ou l d ha ve prop h yl a cti c a tt e n t i o n to p revent c h r o n ic fibrocytic s h o rte n in g and t h e con­

across

sequenr stresses upo n the lumbar and sacral s p i nes, t h e hip,

an

d the femoral neck.

Pati e n ts must be comforta ble durin g OMT if they are to give maximum cooper­ a t i o n . Indirect types of OMT may be cons idered i ni ti al ly because t h ey a re gentle

and n o t threa tening to the p a tien t . The p hysi ci a n m u s t be relaxed to avoid convey­ ing a feel i n g of uncerta i n ty to the p atient. All move ments s hould be slow, comb i n ­ ing control l ed force wit h skil l ful applicat ion . The the rapeut i c forces of direct procedu res need n o t be bruta l, a n d t h e pr ov er b i a l crack fol l o wi n g t h e a p pl ica ti on of th e corrective force is not the sine qua n o n of thera py. Ger i a t r i c pa tie nts often do not demonstrate as full a ra nge of a rtic u l a r moti o n as yo u nger pa tie n ts , a nd estah­ lishment of a f u l l motion range i s not a l ways d e sired. Procedu res may be modified

final c o rrec tive force, or if a force­ ful procedure i s required, the corrective force is ofte n most e ffic i e nt when applied

to employ the patient'S respirato ry m o tion as a

Ch apter 1 2 • The Geriatric Patient

1 65

as the patient exhales. Direct ma ni pul a tive proced ur es applied to the cervica l spine should be slow and gent le a v oiding abrupt rotary forces. The dysfunctional bar rier ,

must be clearl y diagnosed and s pecif i ca ll y engaged before any corrective force is

applied. W h eneve r possible, indirect procedures should be employed. For treatment of l ate r a l compensatory weight-bearing c urves of the older

patient with demonstrable ine qu ality of leg length, s p ecif i c OMT c o u pled with exercise directed at s tre n gthe ni ng the core m u sc u l ature sho u l d be e m ployed before any attempt at lift t h erapy. These p at ie n ts have had years to adap t to their balance pattern and may not require lift therapy. The objective is functional balance of the patient s sacral b as e to eliminate the propensity for chronic engagement of either '

the right or left oblique axis and to reduce the s tress of asymmetric we i ght bear­ ing in the spine above. If OMT and exercise alone do not accomplish this, lift ther­

apy m ay be employed.9 A heel pad typically no larger than one-e i g hth inch should be p la ced in the patient'S shoe on the side of the Sllort leg and adjusted upwa rd

,

if

necessar y, in increments of one-eighth inch every 2 to 4 weeks. As long as the sacral oblique axis remains engaged on the side of the long leg (anterior sacrum on the side of the short leg or posterior sacrum on the side of the long leg), it is appro­

p ria t e to i n c rease the thic kness of the heel pad When the sacral mechanics reverse eng aged on the side that is being lifted, that is, the .

so that the ob l iq u e axis is

s ac rum becomes anterior on the side opposite the anatomic short leg, you h ave cre­

ated an artificial lo ng leg and should reduce the size of the h eel pad to the previ­

ous thickness. For older patients, an esti m ate of how much lift will pro bab ly be

required may be calculated by dividing the inequality of leg length, as measured on

the postural radiography in half. W h en treating leg length inequality of recent ,

o nset (i.e., fracture or hip surge r y ) it is appropriate to attempt to co rrect most of the difference i mm ed ia tely and then determine the ultimate size of the heel pad ,

using the p ri nci p les described herein.

Placing a heel pad in a pat i ent

'

S

shoe n ecessita tes t h a t the p a tient shift the pat­

tern of accommodation according ly. This shift in accom m odat i on may be fa cilitated b y sp e cific a lly treating all existent somatic dysfunction before initiating

lift therapy

or when m aking chan ges in the size of the heel pad. During a dj ustment to the pos­ t ural changes induced by heel pads, pat ients will have new areas of physic a l discom­ fort and

should be informed of it, so that they realize it is part of the accommodation

process. Additional areas of the musculoskeletal system that it is appro priate to address p r op hylact i ca ll y include the following: The craniocervical j u n ctio n is i mportant

for po s tur a l

b alance. Mec h anical pert u r bation , head flexed (tilted from the erect)

position has been shown to increase postural instability.s Upper th orac i c flexion contributes to the head-flexed position and n ecessita tes low to mid cervical com­

extension, placing stress on an area of the spine that is fre q uently unsta­ o s teo a rt hritic. The th oracic cage (thoracic inlet, ribs, vertebrae, and

pensatory ble and

thoracoabdominal diaphragm) can be treated for efficie n cy of respiratory function

and the reru rn of venous blood and lymph to the heart. The lu m bar pel vic and

a bdomina l areas can be treated to promote lower g a strointesti n al r egul a tion

.

Exercise

As individuals age, they undergo s u btly progressive loss of function. on, can

there is be

a

From middle age

strong tendency for loss of muscle mass. By age 80 an active individual

e x pect e d to have lost up to

20%

of gastrocnemius mass.lO Loss of muscle

mass in turn af fects functional capacity. Although these changes may be i n evita b le preventive

measures

,

can retard the progression and maintain optimal functional

status for as lo n g as possible. Exercise can modify risk factors for disabling diseases

.

166

Section II • Patient Populations

It can alter the expression or consequences of diseases that are already present and indirectly affect other modifiers of disability, such as psychosocial functioning. Exercise may actually retard biologic aging. I I Active and passive exercises may be pre­ scribed to mobilize, stabilize, and strengthen the musculoskeletal system; to enhance balance; to develop and maintain physical fitness and increase endurance; and ro improve body chemistry. Therapeutic exercise should begin with identification of functional impediments that can prevent the patient from otherwise performing effectively. Problem areas of the musculoskeletal system should be identified and treated. Areas of hypermo­ bility and instability are frequently found adjacent to and as compensation for areas of motion restriction. Therefo re, motion impediment due ro somatic dys­ function adjacent to areas of hypermobility should be sought out and treated before sta bilization exercises begin. Short leg with pelvic unleveling and dysfunc­ tional anteroposterior mechanics that will interfere with weight-bearing exercises must be addressed before the patient can take full advantage of these activities. Exercise intended to mobilize, stabilize, and strengthen may be employed gener­ ally and may be expected to affect much,

if not all, of the musculoskeletal system

and to exert a positive cardiovascular effect. Swimming is an example of such an activity that has the added advantage of being non-weight bearing. Stretching exer­ cises , such as yoga, may be employed to enhance range of motion but are probably most effective when performed under the supervision of an experienced teacher. Progressive resistance and isometric exercises may be prescri bed to provide sta­ bility and strength and to affect specific anatomic areas or in a total- body pro­ gram. Free weights may be used only

with caution. Compared to progressive

resistance devices, free weights are hard to control and have the potential to exert traumatic stress if control is lost.

If progressive resistance or free weights are used,

low weights should be employed, and the focus of activity should be upon graclu­ ally increasing the number of repetitions. These exercises should be performed 2 or 3 times a week

in

2 to 3 sets of 8 to 12 repetitions using 8 tOlO major muscle

groups. Each repetition should be performed slowly over a bout 10 seconds, and ballistic movements should be avoided. The patient should be encouraged to take at least one day of rest between exercise sessions.ll After addressing the motion restriction of upper thoracic somatic dysfunction, cervical isometric exercises (discussed later in the chapter) may be employed to sta­ bilize and strengthen the mid to low cervical spine and to stretch contracted ante­ rior muscles. Similarly, lumbosacral instability can be reduced by treating upper lumbar flexion dysfunction, stretching the prevertebral iliopsoas muscles, leveling the pelvis, addressing stressful anteroposterior pelvic mechanics, and strengthen­ ing core, abdominal, and lumbar paravertebral musculature (discussed later in the chapter). To stabilize the sacroiliac joints, dysfunctional mechanics should be addressed as already described for the lumbosacral junction

and exercise employed to

strengthen the gluteal muscle group. A simple pelvic tilt (discussed later in the chapter) can be modified to strengthen the gluteal muscles if the patient tonically contracts the buttocks while tilting the pelvis. Slow squats are also effective for this purpose but must be employed with caution because they also stress the knees. Exercises to enhance balance should stimulate the central neurologic control of equilibrium and posture by

prog ressively narrowing the body's base of support, while removing visual,

displacing its center of g ravi ty to the limits of tolerance

vestibular, and proprioceptive inputs.11 Four independent fall-related predictors of hip fracture have been identified. They include slow gait, difficulty performing

Chapter 12 • T h e G e riatri c Patient

167

ta n d e m ( hee l - to - toe) w a l k, red uced v i s u a l a c u ity, a n d s m all c a lf c i r c u mferen c e . 12 The risk a s s o c i a ted wit h three o f these m a y be reduced by exercise . As l ong a s d ysfunctional postu ral mechanics ha ve been adeq u a te l y a d d ressed, t he simplest exercise to e n h a nce b a l a nce a n d reduce the risk of fa lling is wa lki ng. Patients can narrow the base of s u pport and practice heel-to-toe walking. Unsta ble patients can emp l o y a cane for security but sho uld be encouraged to a ttempt tne exerc i se whi l e keepi ng t h e c a n e off the ground a n d using i t o n ly i f they begin t o lose b a l a nce. To a d d ress d i m i n i s h e d c a l f c i r c u mference, p a t ients sho uld strengthen t h e gas­ troc n e m i u s m u s c l e s . W h i le s ta n d ing w i t h their weig h t o n botn fee t , they s h oul d shift their weig h t o n t o the b a l l s of the ir fee t and s t a n d on t heir toes. Pe l v i c sta b i ­ liza t i on i n the coron a l pl ane i s a ls o i mp o r tant. Indivi duals w h o fa l l a n d s u s t a i n a hip fractu re are like l y to h a v e fa llen s i d ew a y s . J3 Reinforcement of the g l u t e u s med ius m us c l es to e n c ourage l a te r a l pel vic s t r e n g t h ening sno u l d be add ressed. The proced u r e is to s t a n d , a bd u c t o n e leg, a n d r e t u r n to t h e i n i tia l position, t h e n do t h e s a m e thing w i th t h e o tne r l eg. The intensity of t hese a ctivi ties m a y be i n creased by na rrow i n g the base of support. Patients should progress from sta nding on two feet w h i l e h old ing o n to t h e back of a c h a i r or the wall to s ta n d i ng on one foo t with no h a n d s u p port. Wh i l e performing t h e exercises, i f flexi bi l i ty per m i ts, they c a n c ha l l e nge vest i bu l a r sensation b y turn i ng their hea d , neck, and u pper torso to one side a n d t h e n to the other. T hey can reduce sen­ sory cues by closing the i r eyes or by standing u p o n a soft surface, such a s a foa m pil ­ l ow. Sh ifting o f the bod y's center of gravity a d d s cha llenge. T h i s can be acco m p lished by having patients hold a heavy o bject o u t to one sid e whi l e ma i nta i n i n g bala nce. They can stand upon one leg wh i l e l i ftin g the other leg out behind the body, a s with the sta n d i ng psoas stretch, or they can lean forward a s far as possible without fa l l i ng or moving their feet. T h i s exercise a ffects main ly the glu te u s maximus. O t her exa m p les of b a l a nce-en h a ncing a cti v ities inc l u d e stepp i n g over o bjec ts, climbing slow l y up a nd d o w n sta i rs, wa lki n g on a soft s u rface s uch as a foa m m a t­ tress, ta i c hi, sta n d ing yoga , ba ll e t exercises, a n d m a i n t a i n i n g balance w hile s t a n d ­ ing o n a moving v ehicle, s u ch a s a b u s. Bala nce-enha n c i ng exercise m a y be performed on a weekly to d a i l y b a s i s. Exercises sho u ld consist of 1 or 2 repe titi ons of 4 to 10 d ifferen t exerci s es t h a t emp h a s ize d y n a m i c ra ther than static posture. P a t i e n ts s h o u l d progress in d ifficulty as tol erated a n d s h o u l d be cautioned n o t to progress too ra p i d l y b u t ra ther to i n c rease t h e d ifficulty of the exercise gradually as competence d eve lops. The activi­ ties shou l d be performed i n a safe e nvironm ent, a nd i d ea l ly someone else i s a v a i l ab l e t o monitor the activity. II Total-body activ i t ies, i nclud i n g walking, bicycl i ng, swimming, a n d d a ncing, c a n b e

e m p l oyed t o e n h a nce card iovascu l a r status a n d t o strengthen m us c l e s a n d e n h a nce ba l a nce among the e l d er l y.14 Regula r p h ysica l activ ity red uces myocard ia l oxygen d ema nd a n d i ncreases exercise capacity, both of which a re associa ted with l o wer levels of coro nary risk.ls In conjunction with other l ifesty le consid erations, such a s smoking cessation a n d d iet, regular exercise sho uld b e the fi rst therapeu tic mod a l i ty emp loyed i n the trea tment of hypertens i o n .16 As patients exercise, rega rdless of the type of activ ity, they wi l l begi n to develop a nd mainta i n ph ysical fitness and increase endura nce. They sho uld be enco u raged to select a form of activity tha t they find enjoya ble . No m atter what form of exercise they select, they shou. ld be encouraged to a ttempt to perfor m i t to the opti m u m limits of their a b i lity. Reg u l a r exe rcise h a s been demons trated to i ncrease s e r u m hig h - d e n s i ty lipopro­ tein c o n ce n tra t i ons a n d reduce l ow-de nsity l i p o prote ins a nd t r i g l yc er i d e s .17 Als o , exe rcise i n creases i n s ul i n sen s i tivity.18

168

Section II • P a t i e n t Po p u l at i o n s

These a c ti v i ti e s m a y be perfo r m e d for 2 0 to 6 0 m in u te s 3 t o 7 t i m e s a wee k . They s h o u l d b e low- i m p a c t weight- bearing a c t i v i ty i f poss i ble, a n d t h e w o r k l o a d s h o u ld i n c r e a s e p rogress i v e l y to m a i n t a i n the re l a t i v e i ntens ity o f t h e exercise a s determined by heart ra te . Ta rget h e a r t ra te i s 4 5 t o 8 0 % o f m a x i m u m h e a rt ra te fo r the i n d i v id u a l . l l Ma x i m u m h e a r t rate c a n be ca l c u l a ted by s u b t r a c t i n g t h e p a t i e n t'S a ge f r o m 2 2 0 . 1 9 Even the gentlest o f a c t i v i ties c a n prove benefic i a l i f the patient i s fra gi le. Deep­ brea thing exercises that actively move the thoracoa bdom i n a l d ia phragm not o n l y fac i l i tate efficiency o f respira tio n a n d m a i n ta in m o b i l ity o f t h e thora cic cage; they a lso promote bowel activity a n d l y m p h a tic d ra i nage.2o Deep-brea t h i ng exerc ises per­ formed s l owly, at 5 to 7 brea ths per m i n u te, have been demonstra ted to a ffect the l ow­ fre q u ency Tra u be-Hering-Ma yer fl u c t u a t i o n s i n a u tO n o m i c tone.2J Such res p i ra tory activity has been s hown to enha nce heart ra te varia b i l i ry a nd i n crease barore flex sen­ sitiv i ty, both l ong-term i n d i c a tors of fa vora ble prognosis i n cardiac patients . 22,23 A gentle form o f exercise based u pon the princip l es o f i n d i rect OMT, a u tOgen ic functi o n a l ba l a n c i ng, has been d emonstrated to affect ba rore fl e x sensitivity s i m i l a r l y.24 T h i s activiry a l so may be emp l oyed to i m p rove m u scu loske leta l motion i n a ma n ner that is respectfu l o f the tissues, prese nting no risk o f overdoing it. This type o f activity ca n be a d j u sted to accommod a te anybody, wha tever the level of fitness.

Nutritional Considerations P a t i e n ts sho u l d be e n c o u raged to follow a l ow-fa t d i e t t h a t p r o v i d e s fa tty a c i d s i n a h i g h r a t i o of unsa t u r a ted t o s a t u r a ted fa ts. T h e y s h o u l d a void refined c a r bohy­ dra tes a s much a s poss i b l e and inste a d c o ns u m e i n c rea sed q u a n t i t i e s o f cerea l s , fr u i ts , vegeta b l e s , a n d l eg u m e s . P rote i n c o n s u m p t i o n m u s t be a d eq u a te to ens u re m a i n t e n a n c e o f m u sc l e m a s s . Th e i ngest i o n of m e a ts a n d d a iry prod u cts, h owever, a re a ls o best l im i ted to p r o v i d e no m ore t h a n 5 0 % of d a i l y prote i n c o n s u m pt i o n ( tOta l c o n s u m p t i o n : 0 . 8 g o f p r o te i n per k i l ogra m o f b o d y w e i g ht ) . 25 Sod i u m i n t a k e s h o u l d be l i m i ted . A l t ho u g h l ow-s a l t m e a l s m a y i n i t i a l l y be per­ ceived a s b l a n d , the p a tien t'S a p p rec i a t i o n for sa lty fla v o r i s b l u n ted by s a l t in the d ie t . A fter severa l weeks the i n d i v i d u a l 's p a l a te w i l l a c c o m m o d a te , a n d p r e v i o u s l ev e l s o f d ie tary s o d i u m wiJi s e e m to be excessive. H e r b s a n d s p i ces m a y be su bsti­ t u ted a s fla vor enha ncers. Wine u s e d i n c oo k i n g conta i n s fl a v o r-e n h a n c i ng q ua l i ­ t i e s a n d p r o v i d e s micro n u tr i e n ts , y e t t h e coo k i n g h e a t u s u a ll y bo i l s o ff t h e a lcoho l . I f o t herwise tOl e ra ted , t h e m od e ra te ( o n e t o two d r i n ks

a

day) consumption of

a lcohol, particularl y i n the form o f r e d wine, i s poss i b l y b e n e f i c i a l to ca rd i o v a s c u ­

lar h e a l t h o 2 6 P a t i e n ts s h o u l d be e n c o u raged to c o n s u m e 1 2 00 to 1 5 0 0 mL ( five to s ix 8 - o z g la s s e s ) o f water d a i l y. A l th o u g h t h e y m a y prefe r o t h e r beverages, a d eq u a te i n take o f wa ter m us t be e m p h a s i z e d . I t may prove a d v a ntage o u s to s uggest that p a t i e n ts c o n s i d er the w a te r to be a m e d i c a ti o n a n d as s u c h c o n s u m e a fu l l g l a s s seve r a l t i mes d a i l y. The sense of t h i rs t i s o fte n d i m i n i s hed w i th age , a n d d e hydra t i o n c a n e a s i l y res u l t . A l so , m a ny o l d e r i n d i v i du a ls h a v e xerosto m i a d u e to reduced s a l i va prod u c t i o n t h a t c a n res u l t in d ecre a s e d food i nta k e Y O t her d ietary s u p p l e m e n ts t h a t s h o u l d be p r o v i d e d i ncl u d e m i n era l s a nd v i t a ­ m i n s . A s i n g l e m u l ti v i ta m i n m a y prov e s u ffic ient, b u t it s h o u l d i n c l u d e a t l e a s t v i t a ­ m i n B c o m p lex, v i t a m i n D , c a lci u m , iron, z i n c , a nd c o p per. Vita m i n D a n d c a lc i u m a re pa rtic ula r l y i m porta n t fo r m us c u l o s ke l eta l h e a l t h . T h e s i g n i fica n c e o f these n u trients for the prevention o f osteoporosi s is read i l y a p p a re n t, b u t they a re a lso i mporta n t in the m a i n tenance of body m u sc l e mass. D u ring n o rm a l agi ng, there i s a progressive loss of m u s c l e mass tha t in the extreme progresses to sa rc o pe n i a , with

16 9

C hapte r 12 • T h e Ge r i a t r i c Pat i e nt

a res u lta n t l oss of function a l c a p a c i ty. 2 8 T h i s c o n d i t i o n is a ssoc i a ted w i t h l ow l e v e l s of v i ta m i n D a n d e l e v a ted p a ra thyroid h o rmone l e v e l s . 2 9 A n o t h e r degen e r a t i v e a n d fu n c t ion a l l y l i m i t i ng process of a g i ng, o s te o a r t h r i t i s , p a r t i c u l a rl y o f t h e we i g h t - b e a r i n g j o i nts, i s properl y a d d ressed by w e i g h t red u c ­ t i o n . 3 o Ad d i t i o n a l l y, g l ucosa m i n e a n d c ho n d r o i t i n s u l fa t e h a ve b e e n s u ggested a s n u tr i t i on a l s upp leme n ts fo r t h i s c o n d i t i o n . A l t h o ugh these compo u n d s s h o w e ffi­ cacy i n red u c i ng s y m p t o m s , n e i t h e r has been s h ow n to a rres t p r ogres s i o n of the d isease o r rege nerate d a m a ged c a r t i l a ge . 3 1 O be s i t y h a s rea c h e d ep i d e m i c proporti o n s in t h e U n i te d S t a t e s . B o d y m a s s i ndex (BMI), t h e r a t i o between wei g h t a n d h e i g h t , m a y be c a l c u l a ted a s fol l o w s :

BMI

=

[ ( w e i g h t i n poun d s )/ ( h e ight i n i n c h es ) 2] X 703 .

T h e res u l ting i nd ic a t i o n of bod y fa t c o n t e n t is c la ss i fied i n Ta b l e 1 2 . l . A q u ic k a n d s i m p l e m e t h o d for determ i n i n g a n i n d i vi d u a l 's opti m a l b o d y

w e i g h t i s to a s s u m e t h a t a fem a l e w h o is 5 fee t ta l l s h o u l d weigh 100 p o u n d s a n d t h e n t o a d d 5 p o u n d s fo r e a c h i nch of h e i g h t a bo v e 5 fee t . S i m i l a r l y, a m a l e w h o i s 5 fee t tall should weigh 1 06 p o u n d s , a n d 6 p o u n d s s h o u l d b e a d de d for e a c h i n c h o f h e ight a bove 5 feet . T h e r e fore, t h e op t i m a l w e i g h t for a fem a le w h o i s 5 feet 6 i nc hes t a .l l i s [ 1 0 0 + (6 X 5 ) ] 1 3 0 I b ( BM I 2 1 ) , a n d t h e optimal weight for a m a l e of t h e s a m e h e i g h t w o u ld be [ 1 06 + (6 X 6 ) J 142 l b (BMI 23 ) . =

=

=

=

W h e n c a l c u l a ti ng opti m a l w e i g h t fo r ge r i a t r i c p a t i e n ts , i t is appropri a te to inc l u d e a n a d d i t i o n a l 1 0 to 15 p o u n d s o f rese rve b o d y fa t t o pro v i d e c a l o r i c s u pport i n t h e e v e n t o f ca t a s tro p h i c i l l n e s s . O be s i ty i s u n q u e s t i o n a b l y d e t r i me n ta l , yet i t is a re v e rs i b l e stressor. Exerc i s e m a y b e e m p l oyed to a ug m e n t we igh t red u c t i o n , b u t i f p a ti e n ts d o n o t restrict c a l oric i n ta k e a s they exercise, they c o m p e n s a te by e a t i n g m o r e . T h e i n d i v i d ua l whose w e ig h t ca uses p h y s i c a l d is tress may be una b l e to tolera te the stress of exerc i s e . T h u s , a n e ffective w e i g h t red u c t i on progra m m ust p r o v i d e a n effect i v e a d m i x t u r e o f ca l o ric restr i ct io n a nd p hys i c a l a c t i v i ty. A ll too m a ny p a t ie n ts feel p o w e r less to a d d ress the i r w e i g h t pro b l e m . Pro v i d ing p a t ie n ts with a h ighly s t r u c t u r e d program, if they a re s u ff i c i e n tly m o t i v a te d , c a n be e m poweri n g . There i s a s i m p l e m e t h o d t h a t w i l l a l l o w p a t i en ts t o identi fy t h e i r own c a l o ric req u i re m e n t s . Before i n i ti a t i n g a n y w e i g h t red uction progra m, b a se l i ne l a bora tory i n formation s h o u ld be o b ta i ne d . Th i s should include a com p l ete blood cou n t a nd a m u l tich a n n el chemistry profi l e w i t h s e r u m gl ucose, rena l a n d hepatic fu nction p a r a meters, l ip i d

Body Mass I ndex Weight Category U n d e rweig h t

BMI

Range

<1 8.5

Normal we i g h t

1 8 . 5-2 4 . 9

Overweight

2 5 . 0-2 9 . 9

Obese

>30 . 0

1 70

Section II • Pat i e n t P o p ulat i o n s

profile, a nd a t least t l1yroid-stimulati ng 11 0rmone level. The incidence o f occult hypothyroidism increa ses s ignifica ntly w ith age, ma king th is last rest very i m portant.

To beg i n the process, patients n eed one or more calorie cou nter reference book s If the i r weight is s ta b l e , t l1ey sho u l d begi n by eat ing as t l1ey n o r m a l l y

a nd a diary.

do for 2 wee k s , recordi ng in the d i ary t h e t o t a l caloric con tent o f everyth i ng they eat. After 2 wee ks, they should a d d up the d a ily calor ic totals a nd d i vide by 1 4 to

lb of d a i ly

deter m i n e their ave r a ge daily caloric inta ke for t h e pe riod . The y i e ld of 1 body fa t i s a pproximately 3 5 0 0 calo r i es. T herefore, red u ction of tl1e a ve r a ge ca loric i ntake by 5 0 0 to 1 0 0 0 c a l o r i es ( 5 0 0 X 7

=

3 5 0 0 ) results in a loss of 1 to

2 I b a wee k. This process is sim i l ar to what most i n d ivid u a ls d o to kee p their

checkboo k bala nced , a nd the analogy often wor k s well as a n expl a n atio n , exce p t t h a t t o lose weight, patients m u st write daily o verdrafts so that they a re forced t o withdraw fro m their ad ipose sa vings accou nts. Pa tients must compensate for t he inevita ble d ecrease in basa l meta bolic rate that

Fu rther,

accompa nies caloric restr iction with an exercise program as out lined ea rlier.

they should be cautioned not to attempt to lose more than 2 po unds weekly lest they place undue physiologic stress on their

bod y and risk depletion of m u scle ma ss.

Min d and Spirit

Existen t i a l a n x iety at some poi nt in l i fe

is a l most u n iversal. The very fact that one

exists c a rries with it the unpleasant k n owledge that sooner or la ter that e x i ste n ce as the i n d ividu a l k n ows it wil l cea se and t h a t cherished relationshi ps w il l be sev­ ered . O n l y individ u a ls w i th the very strongest spirit u a l bel i e f systems

do

no

t fi nd

these thoughts t roubling. In you th, l ife stretches before the indiv idual with w h a t

In old a g e , the i nevita ble i s u ndenia b l y f rag ile and intermittent state, a n d p a i n a n d function a l l im­ ita t ions a re constant . Add to t h is tha t l i fe's goals may h a ve go n e u n met a n d that often appe a rs to b e end less possi b ilities .

near. Health often i s a

cherished relation shi ps have been l ost, a n d it is a won der the elderly a re n o t a ll d e p ress ed . The physic ian-patient rela t ions hip in t h i s e n viro nment is an ex tre mely

powerful one because the ph ysici a n k nows how to re lieve s u ffe r i n g a nd even pro­ long l i fe Possibly the m ost i m p o rt a n t thera peutic agent i n the tre a t ment of m a ny .

o l d e r patien ts i s the personal interest of t he i r physi c i a n .

O ften the mere atten t i o n

o f t he physicia n activates t h e pat i ent 'S m i n d a nd stim ulates interest i n l i fe . Here the fundamental principle of osteop ath ic p h i l oso p hy, that the bod y possesses the in herent ability to hea l itself, becomes n o t o n l y prom isi ng to the patient but reas­

suring to the ph y sic i a n . Con fronted by chronic illness that can only progress u n to

death a nd by p h a rmaceutica l therapies wit h sequelae that a re o n occasion wo rse t h a n what they tre a t , it is com forting to know t hat soma t ic d ysfunction is not per­ m a nent, that it responds, often ra p i d l y, to OMT a nd that OMT is vi rtua l ly without untow a rd side e ffects. And re V. G i b a J d i once said that the re a re two procedures by

and o f an abscess a nd O M T. The fact t h a t a hea d ache m a y b e elimin a ted w ith

whic h a physician ca n prov ide a pat ient with instant relief, I & D (i ncision d ra in age )

so meth i ng a s si m p le a s s u bocci p ita l myofascia l release, t h a t dysp nea may be red uced by

m o b i l iza tion of the thoracic cage a n d dia phragm, t h a t consti p ation may be

relieved by stimulating the gastrointestina l tract through the a bdom i nal wall , and that col ic can be dimin ished by the a p propriate applicatio n of the para vertebral m usculature

is astound ing.

On more t h a n one occasion, a patient whose

in h i bitory p ress u re

to

pain wa s rel ieved by O M T has

become incensed beca u se a p h ys i c i a n seen prev i o u s l y s a id that there wa s n o t h ing wrong. The i rony o f t h is is that that p h ys ic i a n w a s in o n e

sense correct. Somatic

d ys fu n c t i o n is n ot d i s e a s e ; therefore, i n the allopat h ic p aradigm , noth i n g is w rong:

U n fo rtu na tely,

in tha t pa rad igm i t fo l lows that n o t h i n g can be d o n e .

C h a pter 12 • T h e G er i at ric Patient

17 1

One of t h e o b v i o u s d i ffe rences, th ere fore, b e t w e e n d o c t o rs of me d ic i ne a n d d oc ­ t o r s of oste o p a t h y i s t h e u s e o f OMT. It h a s b e e n a r g u ed by ind i vi d u a l s w h o d o n o t u s e OMT a n d w h o c o n s e q u e n t l y d o n o t k n o w w h a t t h e y a re t a l k i ng a bo u t t h a t t h e b e n e fit obta ined t h ro u g h ma n u a l t h era p y i s p s y c h o l o g i c a l . Even if t h a t were

wrong with t h a t ? I t h a s healing touch ha s a p o s i t i v e effect o n both p h y s i o l og i ca l

the o n l y w a y i n w h i c h OMT a ffected the p a ti e n t w h a t i s ,

b e e n d e m o n st r a ted th a t

a n d psyc h ol og i ca l v a r i a bles . 3 3 Thera p e u ti c t o u c h h a s b e e n s u ggested to promote c o m fo r t and red uce a n x ie ty. 3 4 Are th e s e n o t d es ira ble trea t m e n t goa ls ? On the a ve rage, a pati e n t v i s i t in which soma tic dysfunct i o n is d i a gn o s ed a n d O MT

is empl oyed l a sts lo nger tha n a reg u la r medica l visit. This extra time, com b i n e d with the hea l i n g to u c h , a l lows patients to spea k a bo u t their l i fe, to descri b e l i ttle bits

of

of t h e patien t's

l i fe

i n formation tha t might be va lua b l e for the physicia n . Th i s ph ysical co ntact b u i l d s a

stronger p h y s i c i a n-pa tient rel a t i onship . The physic i a n becomes part

in a very physica l sense. This a l lows for truly h o l istic medic i n e , i n which patients are

ca red fo r a nd that c a re becomes pa rt of their gl o b a l environment. Bur t h e osteopa t h ic a pproach i s more t han OMT. Pa tients a re part

of their treat­

ment protocol. They are em powered and given the opp o rt u n ity a re e n c o u raged to

pa rtic i p a te a c t i v e l y in self hea l i ng ( See Chapter 1 . ) T h i s i n c l u s i o n a l lev i a tes the sense of p ow e r l e s snes s that so o fte n a ccompa n ies the existe n t i a l a n xiety o f the e l d e r l y. -

.

CONCLUSION The trea tmen t o f ge riatric pa tients is o n e of the best examp l es of w ho l e b ody med i ­ -

cine. It

offers

sig n i fica n t opportu n i ty t o practice osteopathically d i s t i n ctive h e a l t h

c a r e . W e must t r e a t t h e p a t i e n t's chief compla i n t .

We

m u st look a t u n derl y i n g i l l nesses .

We m u s t closel y exa m i n e t h e pati e n t'S n u tritiona l s t a t u s . The recogn i t i o n o f s o m a t ic d ysfu n c ti o n as it l i n k s seem i ng l y u n rel a ted s ystems through v iscerosom a tic a n d s o m a ­ toviscera l mec h a n i s m s provides a u n i q u e l y h olistic s ystem

of c l in i c a l problem solving.

The d i agnosis and trea tment o f reve rs i b l e soma tic d ys fu nction o ffe rs patie nts re l i e f in a time in th e i r l i fe when

m os t

every t h i n g see ms to be l i n ked to unavo i d a b l e dec l i n e .

B u t p ro b a b l y m o s t i m port a n t we must s t i m u la te p a t ients' interest i n l i v i ng a n d e m p o w e r them w ith methods by w h i c h they ca n pa rticipa te i n t h e i r o w n healing ,

before we can e v er beg i n to s ucce s sful l y treat t h e m .

P roce d u res Cervical Treatmen t (C2- Cl), Pa tient Supin e (Still Technique) (Fig. 12. 1)

right s i d e e r ror i n th i s p r oc e d u re i s fa i l u re to m a i n ­

T h i s p roce d u re i s e m ployed to i m prove exte n s i o n , r i g h t rota t i o n , a n d b e n d i n g a t C3 to C4 . T h e m o s t c o m m o n

ta i n c o m p ress i o n o r t h e d i stra ction v e c t o r to t h e i n v o l v e d segme n t t h r o u gh o u t the p roced u re . T h i s p roced u re req u i re s l o c a l i z a t i o n of m o t i o n

to

the a ffe cted segment.

Pa t i e n t p os i t i o n : s u p i ne . P h y s i c i a n posi tion : sea ted at t h e head

of t h e t a b l e .

P roced u re ( E xa m p l e: C3 o n C4 F lex e d [ Fo rwa rd Bent ] , S i de B ent Left, Rotated Left [Tissue Texture C h a nge, M ot i on Rest r i ct i on, a n d Tenderness on t h e Left ] , Posterior C3 Left)

1.

P l a ce yo u r r i g h t i n d e x f i n g e r on t h e poste r i o r co m po n e n t of t h e dysf u n ct i o n w i t h yo u r t h u m b o n t h e ot h e r s i d e .

2.

P l a c e yo u r l eft h a n d on t o p of t h e p a t i e n t 's h e a d .

3.

W i t h yo u r left h a n d . a p p l y g e n t l e co m p ress i o n a n d i n t rod uce f l ex i o n down to t h e i n vo l ved seg m e n t .

172

Sect ion I I • Patient Po p u l at i o n s

F I G U R E 1 2. 1

Sti l l proce d u re f o r a type I I cervi ca l dysf u n ct i o n , ( 3 o n (4, f l e x e d , s i d e b e n t l e ft a n d rotate d l eft .

4.

Positi o n t h e dysf u nct i o n a l seg m e n t i n t h e d i recti o n of freer motio n , i n vo l v i n g a l l th ree p l a n e s o f m o t i o n t o a p o i n t o f ba l a n ce . Tra n s l a t i o n r i g ht w i l l h e l p l eft s i d e be n d i n g .

5.

W h i l e m a i n ta i n i n g t h e vector fo rce, q u i c k l y t u r n t h e seg m e n t i n t h e o p posite d i rec­ t i o n , toward and even t u a l ly t h ro u g h t h e rest r i ctive b a r r i e r

6.

As y o u m ove t h e s e g m e n t towa rd t h e rest r i ctive b a r r i e r, you w i l l n ote t h at t h e ba r­

7.

W h e n t h e p roced u re i s co m p l ete , reassess t h e dysf u n ct i o n a l a rea .

rier n o l o n g e r exits a n d the seg m e n t has free m ot i o n .

Cervical Trea tment (C2-Cl), Patient Seated (Still Technique) (Fig. 12.2) T h i s p r oced u r e i s e m p l o ye d to i m p ro v e f l e x i o n , r i ght r o t a t i o n a n d r i g h t s i d e bendi ng a t C 3 to C4 . T h e m o s t c o m m o n e r r o r i n t h i s p ro ce d u re i s f a i l u r e to ,

m a i n t a i n c o mpress i o n or t h e d i s tr a c t i o n vector to the involv ed segm e n t t h ro u g h ­

o u t t h e proce d u re . Th i s p roced u r e req u i res loca l i z a ti o n o f m o t i o n to t h e a ffected seg m e n t . P a t i e n t pos i ti o n : seated . P h ys i c i a n p o s i t i on : sta nd i ng i n fro n t o f t h e pa t i en t .

P roced u re ( E xa m p l e : C3 o n C4 E xte n d ed [ B a ckward B e nt ] , Side B e n t Left, R otated Left [Tiss u e Textu re C h a n g e, M o t i o n Rest r i ct i o n , a n d Te n d e rness o n t h e Left], Poste r i o r C3 Left) 1.

P l ace y o u r l eft i n d ex f i n g e r (se n s i n g h a n d ) o n the poste r i o r co m p o n e n t of the dys­ f u n c t i o n , w i t h the re m a i n d e r of the h a n d c o m f o rta b l y a ro u n d the b a c k of the n e c k a s a s u p p o rt a n d f u l c r u m .

2.

P l a c e yo u r o p e rat i n g ( r i g h t) h a n d o n t h e top of t h e p a t i e n t 's h e a d .

3.

T i l t t h e h e a d b a c k , ext e n d i n g t h e s e g m e n t .

4.

S i d e b e n d a n d rotate t h e h e a d l eft u n t i l a l l t i s s u e stra i n s a re re m oved f r o m t h e affected s e g m e n t . T h i s p o s it i o n wi l l b e a n exa g g e ra t i o n of t h e s e g m e n t 's rest posit i o n .

C hapter 12 • T h e G e ri a t r i c P a t i e n t

FIGURE 1 2 .2

5.

1 73

St i l l p r o ce d u re for a t y p e I I cerv i c a l dysf u n ct i o n (3 o n ( 4 , ext e n d e d , s i d e b e n t l eft a n d rotated l e ft .

I n t ro d u ce a g e n t l e c o m p ress i o n vecto r f o rce d o w n t o t h e dysf u n ct i o n a l seg m e n t using the operati n g h a n d .

6.

Rotate t h e h e a d to t h e r i g h t t h ro u g h n e utral i n to a r i g h t rota t i o n w i t h s i m u lt a n eo u s f l e x i o n a n d s i d e b e n d i n g to t h e r i g ht towa rd t h e re strictive b a r r i e r.

7.

As y o u t a k e t h e h e a d a n d n e c k t h ro u g h t h e ra n g e of m o t i o n , y o u m a y f e e l a r e l e a s e t h ro u g h t h e a rt i c u l a r p i l la r.

8.

R e l e a s e t h e com p re ss i o n a n d ret u r n to n e u t ra l .

9.

W h e n t h e p ro ced u re i s co m p l et e , reassess t h e dysfu n ct i o n a l a re a .

Thoracic Dysfunction (Still Technique) (Fig. 12.3) T h i s p r oced u re is usefu l for t h o racic s o matic dysfunction s . It is e m p l oyed to i mp rove fl e x ion , side bendi ng l e ft , a n d r o tation l eft of T5 on T6 . It is a gen t le tho­ r a c ic p roced u re tha t req u i res prec ise loca l i zation . Patient pos i tio n : sea ted . Physi cia n posi tion: sta n d i n g beh i nd the patient to the left.

Proce d u re ( E xa m p l e : T5 on T6, Exte n d e d , S i d e B e n t R i g ht a n d Rotated R i g ht) 1.

P l a c e yo u r left arm a c ro s s the p a t i e n t 's a n t e r i o r c h e s t so t h a t yo u r l eft arm i s d r a p e d o v e r t h e p a t i e n t 's l ef t s h o u l d e r a n d yo u r l e f t h a n d i s o n t h e p a t i e n t 's r i g h t s h o u l d e r.

2.

P l a c e yo u r r i g h t s e n s i n g f i n g e r ove r t h e r i g h t t r a n sverse p rocess of T 5 .

3.

G e ntly i n t ro d u ce exte n s i o n , r i g h t rotati o n , a n d r i g h t s i d e b e n d i n g u n t i l a l l t h ree forces loca l i ze at T5 and t h e path o l o g i c n e utral i s e n g a ged (abse nce of tiss u e te n s i o n )

1 74

Sect i o n I I • P a t i e n t Po p u l at i o n s

F I G U R E 1 2.3

4.

St i l l proce d u re fo r a type I I t h o ra c i c dysf u n c t i o n T 5 o n T6, exte n d e d , s i d e b e nt r i g ht a n d rotated r i g h t .

I n t ro d u ce a vector f o rce i n t h e s h a p e of a V by p ressu re t h ro u g h t h e p a t i e n t 's s h o u l ­ d e r s w i t h y o u r l eft a r m u n t i l t h e vector i s l o c a l i z e d at T5 r i g ht .

5.

M a i n t a i n i n g t h e vector force, q u i c k ly f l ex, s i d e b e n d l eft, a n d rotate l eft t h e T 5 seg­ m e n t . A s t h e seg m e n t T 5 o n T6 i s about to reach t h e rest r i c t i ve b a r r i e r, t h e b a r r i e r w i l l m e l t away.

6.

R e t u r n the seg m e n t to n e u t ra l .

7.

W h e n t h e p ro ce d u re i s co m p l ete, reassess t h e dysfu ncti o n a l a r e a .

L umbar Dysfunction (Still Technique) (Fig. 12.4)

Th is proced u re is u se f u l for lum bar somatic d ysfu nction s . It is e mployed to im p rove flexio n , sid e b end i n g left, a nd rota t i o n l e ft o f L2 on L 3 . It i s a gen d e l u m ­ bar p r oced u re t hat req u ires p recise l ocal izat ion . Patien t position: seated . Physician positio n : stand ing beh ind the p a t i e n t to the left. P roce d u re ( Ex a m p l e : L2 o n L3, E xte n d e d , S i d e Bent R i g ht a n d Rotated R i g ht)

1.

P l ace yo u r l eft a r m a c ross t h e p a t i e n t 's a n t e r i o r c h e s t (or s h o u l d e r s as in F i g .

1 2 4)

so t h a t yo u r l eft a r m is d ra p e d over t h e p a t i e n t 's l eft s h o u l d e r a n d yo u r left h a n d i s on t h e p a t i e n t 's r i g h t s h o u l d e r.

2. 3.

P l ace yo u r r i g h t s e n s i n g f i n g e r ove r t h e r i g h t tra n sverse p rocess of L2 . G e n t l y i ntrod uce exte n s i o n , r i g h t rotati o n , a n d r i g h t s i d e b e n d i n g u n t i l a l l t h ree forces loca l ize at L2 and the patholog i c n e utra l i s e n g a g e d (absence of t i s s u e te n s i o n )

4.

I n t ro d u c e a vector f o rce i n t h e s h a p e of a V by p re ss u re t h ro u g h t h e p a t i e n t 's s h o u l ­ d e rs w i t h yo u r l e ft a r m u n t i l t h e vec t o r i s l o ca l i zed a t L2 r i g h t

5.

M a i n ta i n i n g t h e vecto r fo rce , w i t h a m o d e ra t e - s p e e d f l ex , s i d e b e n d l eft a n d rota te l eft the L2 seg m e n t . A s the s e g m e n t L2 on L3 i s a b o u t to rea c h the rest r i c t ive b a r ­ r i e r, t h e b a r r i e r w i l l m e l t away.

C h a pter 1 2 • The G e r i at r i c Patie nt

FIGURE 1 2.4

175

Sti l l p roced u r e f o r l u m ba r t y p e I I dysf u n ct i o n L2 o n L3, ext e n d e d , s i d e b e n t r i g h t a n d rotated r i g h t .

6.

Retu r n t h e s e g m e n t t o n e u tra l .

7.

W h e n t h e p roce d u re is co m p l ete, reassess t h e dysf u n c t i o n a l a re a .

Sacrum (Facilitated Positional Release) L5 ( UP5L) a n d lower p o l e L5 ( LP5L) . The UP5L p o i n t i s m e d i a l to t h e PSIS a t the u p pe r p o l e o f the s a cr u m , a n d the LP5L is a pprox i ma t e l y 2 e m ca u d a l to UP5L ( F i g . 1 2 . 5) . T h i s p roce d u r e i s u sefu l i n rel iev i n g sacr o i l i a c p a i n .

Te n d e r p o i n ts a re located a l o n g t h e s a c r o i l i a c j o i n t, s p e c i fica l l y u p per p o l e

T h is p roced u re a l l ow s b o t h t e n d e r p o i n ts to b e treated w i th t h e s a m e s t a r t p o s i ­ t i o n w i t h m i n i m u m m o d i fica t i o n s . T h e s a c r a l base w i l l m o v e p o s teri o r l y w h e n t h e s a c r u m i s fli l l y b a c k w a rd be n t a n d w h e n the p e l v i s i s fu l l y fo rwa rd b e n t . Beca u s e o f t h i s fi nd i ng, i t i s poss i ble to trea t t h e s e poste r i o r te n d e r po i n ts by p la c i n g the hip a n d s u bseq u e nt l y the s a c ro i l i a c j o in t i n to f l e x i o n to a l lo w the sacrum to e x te n d . I t is a ge n t l e p roced u re t h a t req u i re s p recise l o ca l i z a t i o n . P a ti e n t pos i t i o n : s u p i ne . P h y s i c i a n p o s i t i o n : s ta n d ing on the a ffected s i d e .

Proced u re ( Exa m p l e : U P L5 Left Te n d e r P o i nt [ F i g . 1 2 . 6 ] )

1.

P l a ce y o u r r i g h t h a n d o n t h e U P L 5 t e n d e r p o i n t to m o n i t o r.

2.

W i t h yo u r l e ft h a n d , g e n t l y f l e x t h e p a t i e n t 's k n e e a n d h i p u n t i l m o t i o n is n oted a t t h e te n d e r p o i n t .

3.

N ow g e n t l y exte r n a l l y rotate t h e h i p u n t i l te n d e r n ess a t t h e U P 5 L p o i n t i s m i n i ­

m i zed to

a

l evel of

0

to 3 on a p a i n sca l e

(1 0

=

start pos i t i o n a n d m o st p a i n f u l ,

0

=

no pa i n ) . If necessa ry, f i n e-t u n e t h e te n d e r p o i n t p o s i t i o n w i t h a dj u st m e n t of t h e l e g p o s i ti o n .

1 76

Sect i o n

F I G U R E 1 2. 5

4.

II • P at i e n t Po p u l at i o n s

Te n d e r p o i nts a l o n g t h e S I j o i nt s p e c i f i c a l l y, u p p e r p o l e pole L5 (LP5L).

LS (U PSL)

a n d l ower

W i t h yo u r l eft h a n d , p l a c e a g e n t l e vect o r f o r c e t h o u g h t h e fe m u r i nto t h e h i p t o fa c i l i tate t h e re l ea s e .

5.

A re l e a s e wi l l b e pe rceived i n 3 to 5 seco n d s .

6.

R e t u r n t h e pati e n t to t h e n e u t r a l posit i o n .

7.

W h e n t h e p roced u re is c o m p l ete, reassess t h e dysf u n c t i o n a l a re a .

Simple Cervical Isometrics (Exercise) Th i s exerc ise is i nt e n d e d to s t r e ngthen cervi c o t h o r a c i c p a ra verte bra l m u s c u l a t u r e . Conseq u en tl y, i t m a y be employed to begin s ta b i l i z i n g m i d to l o w cervi c a l

FIGURE 1 2.6

F a c i l itated p o s i t i o n a l re l ease of a l e ft s a c ro i l i a c dysf u n ct i o n .

C h a pter 1 2 • The G e r i at r i c Pat i e nt

117

h y p e r m o b i l i ty a n d to red uce u pper t h o ra c i c fl exi o n . I t s h o u l d be perfo r m e d a t l ea s t o n c e d a i l y t o t o l e r a n ce a n d m a y be perfo r m e d a t n i g h t b efo re t h e p a t i e n t g o e s t o s leep a n d i n t h e m o r n i n g u pon a w a kening. T h e patient l ies s u pi n e i n bed w i t h t h e h e a d o n the p i l l ow. For p a t i e n ts who c a n ­ not l i e f l a t , t h i s p r oced u re c a n b e m od i fied to be p e r fo r m e d seated . ( See C e r v i c a l I s o m e t r i c s b e l ow. )

Proced u re Pa l pate t h e poste r i o r p a ravert e b ra l m u scu l a t u re of t h e cerv i c a l sp i n e w i t h t h e p a d s of t h e f i n g e rs of both h a n d s . T h i s h a n d p l a c e m e n t l ets t h e p a t i e n t m o n i t o r t h e i nt e n s i ty of t h e m u s c u l a r c o n t racti o n t h a t fo l l ows .

2.

Tu ck t h e c h i n , i n h a l e , a n d p ress t h e b a c k of t h e h e a d i n to t h e p i l low f o r 3 to 5 sec­ o n d s . T h e m u sc u l a r contract i o n s h o u l d be f i r m but s h o u l d n ot res u l t i n c e rv i ca l p a i n o r o t h e r s i g n i f i c a n t d i s c o m f o rt

3.

E x h a l e a n d re l a x .

4.

T h i s process m a y b e repeated 5 to

10

t i m es . T h e i n t e n s ity w i t h w h i c h t h e p a t i e n t

p u s h es t h e h e a d i n to t h e p i l l ow d e te r m i n e s t h e l evel of t h e s p i n e t h a t i s affected . G e n t l e p ressu re wi l l stre n g t h e n t h e cervical reg i o n , w h i l e p u s h i n g with g re a t e r fo rce w i l l affect the u p p e r t h o r a c i c sp i n e .

Cervica/ /sometrics (Exercise) (Fig. 12. 7) Th i s e x e rc i se is p e rfo r m e d as 1 0 i s o m e t r i c contra ctio ns a t e a c h o f 1 0 p o i nts o f the hea d . The o p p o s i ng a r rows in F i g u re 1 2 . 7 i n d icate the co n tact p o i n t s ( w i t h t h e exce p t i o n of p o i nts 9 a nd 10, o n t h e l e ft a n d r i g h t c h e e ks respecti v e l y ) a n d a pp l i e d d i re c t i o n s o f t h e i s o m e t r i c c o n t r a c t i o n s . Th i s exerc i s e i s e m ployed to pro v i d e c e r v i c a l sta b i l i ty b y strengt h en i ng a nd b a l ­ a n c i n g a l l o f the cerv i c a l m u sc l e s . I t m a y b e u s e d b y p a ti e nts w i t h degene r a t i v e

FIGURE 1 2.7

Cerv i c a l i s o m e t r i c e x e r c i s e .

1 78

Section \I • P a t i e n t P o p u l at i o n s

j o i n t d i se a s e o r herniated n uc l e u s p u l p o s u s . I t s h o u l d b e p er fo rm ed a t least o n ce

d a i l y to t o l er anc e .

P a t ient p o si t i o n : sea ted . P r o ced u re

1.

P l ace the t i ps of the i n dex a n d m i d d l e f i n g e rs of one h a n d on the m i d l i n e of t h e fore h e a d j u st a b ove th e b row r i d g e ( F i g . 1 2 . 7 , pos i t i o n 1 ) .

2.

S i m u lta n e o u s l y p u s h t h e f o re h e a d i n to t h e f i n g e r t i p s w h i le a p p ly i n g a n e q u a l a m o u n t of res i sta n ce w i t h t h e h a n d . H o l d t h i s i s o m e t r i c contract i o n f o r 1 t o 3 sec­ o n d s , a n d t h e n re l ease the p ress u re .

3.

Repeat t h i s p roced u re 1 0 t i mes for p o s i t i o n 1 .

4.

C o n t i n u e t h e exercise a s a bove for positio n s 2 to 8 accord i n g to F i g u re 1 2 . 7 . A l t h o u g h it d o e s not matter w h i c h of t h e p o i n ts of contact i s f i rst i n the seq u e n ce o f t h e exer­ cise, it is i m p o rta nt that the poi nts of contact a lways a lternate . That is, if the forehead i s the fi rst point of contact, t h e back of t h e head s h o u l d be the seco n d point of contact

5.

P o i n t s 9 a n d 1 0 d i ffer s l i g h t l y i n t h e i r a p p l i ca t i o n ( F i g . 1 2 7 ) . P l a ce o n e h a n d i n c o n ­ t a ct w i t h t h e s i d e of t h e face a n d i s o m etr i ca l l y atte m pt to rotate t h e h e a d i n t h a t d i rect i o n , a l te r n a t e l y c o n t r a ct i n g a n d re l a x i n g , a s i n s t e p 2 , f o r 1 0 repet i t i o n s .

6.

R e p e a t t h i s rotati o n a l p o rt i o n of t h e exercise i n t h e op posite d i rect i o n .

Simple Calf S trengthening to Stabilize Gait (Exercise) This exercise is intended to increase ga i t sta bi l i ty. It should be em p l oyed by individ u ­ a l s whose ga i t i s n o t sta ble enough t o p er fo rm the sta n d i n g exerc ise d escri bed l a ter. P a t i e n t p osi ti o n : seated on a c ha i r. A stra ight-ba cked c h a i r is p r e fera ble . P roced u re 1 .

2.

S i t w i t h t h e b a c k stra i g h t a n d t h e feet a bo u t 1 2 i n c h es a p a rt f l a t u p o n t h e f l o o r. P l a ce t h e h a n d s u p o n t h e k n ees a n d l e a n t h e torso forwa rd . T h e m o re you l e a n fo r­ ward, t h e m o re weight you ca n p l a ce u po n t h e k n e e s .

3.

C o ntract t h e g a st roc n e m i u s m u s c l e s , p l a n t a r f l e x i n g t h e a n k les a n d ra i s i n g s l owly

4.

S l owly ret u r n to t h e f l a tfooted pos i t i o n a n d rest for 3 to 5 seco n d s .

5.

T h e y n o w cont ract t h e p reti b i a l m u s c l e s , d o r s i f l e x i n g t h e a n k l es s l owly u n t i l o n l y t h e

6.

S l owly ret u r n t o t h e f l a tfooted p o s i t i o n a n d rest f o r 3 t o 5 s e co n d s . R e p e a t 5 to

u p o nto the b a l l s of t h e feet Hold this pos i t i o n for 3 to 5 seco n d s .

h e e l s a re contact i n g t h e f l o o r. H o l d t h i s pos i t i o n f o r 3 t o 5 seco n d s .

1 0 times. Calf Strengthening t o Stabilize Gait (Exercise) T h i s exerc ise is i n te n d e d to increase ga i t sta b i l i ty. It d oes s o by strength e n i n g the gastroc n e m i u s m u sc les, m a i n ta i n i ng a n kle m o b i l i t y and stimu l a ting the ves t i b u l a r

a p paratus. Patient p o s i t i o n : stan d i ng w hi l e h o ld i n g o n t o the b a c k o f a c h a i r o r t h e wall fo r sta b i lity. With increa s i n g a d ep tn ess , the p a t i e n t c a n p r ogress to d o i n g the m free­ h a nd but s h o u l d a l w a y s rem a i n w i t h i n r e a c h of a su p p o rt. Proce d u re

1 . Sta n d with t h e b a c k stra i g h t a n d t h e feet f l a t on t h e f l o o r, a b o u t 1 2 i n c h es a p a rt . G ra s p t h e b a c k o f a c h a i r o r t h e wa l l t o e n s u re sta b i l i ty. For a n y o f t h e fo l l ow i n g v a r i a t i o n s of t h i s exercise, re l e a s i n g the h o l d o n t h e ch a i r or wa l l i n creases d iff i c u lty

2.

C o ntract the gastrocn e m i u s m u scles, p l a n t a r- f l ex i n g the a n k l es a n d r i s i n g s l owly up onto the b a l l s of the feet to sta n d on the toes . H o l d t h i s p o s i t i o n for 3 to 5 seco n d s .

C h a pte r 1 2 • T h e G e r i a t r i c Pat i e n t

1 79

3.

S lowly ret u r n to t h e f l a tfooted pos i t i o n a n d rest for 3 to 5 seco n d s . R e p e a t 5 t o

4.

W h e n com forta b l e perfo r m i n g t h i s e x e rc i s e , p l a c e t h e feet c l ose t o g et h e r, n a r row­

5.

W h e n c o m f o rta b l e p e rfo r m i n g t h is exercise, re p e a t ste p s 1 to 3 wh i l e sta n d i n g

1 0 t i m es . i n g t h e b a s e of s u p p o rt, a n d r e p e a t ste ps 1 to 3 . u po n o n e foot, fu rth e r n a rrow i n g t h e base o f s u p po r t . A l te r n ate sta n d i n g o n o n e l e g a n d t h e n o n t h e ot h e r f o r 5 t o 1 0 repetit i o n s e a c h .

6.

F i n a l ly, i f f l e x i b i l ity p e r m its, c h a l l e n g e vest i b u l a r s e n s a t i o n w h i l e p e rfo r m i n g t h e exercises b y t u r n i n g t h e h e a d , r, e c k , a n d u p p e r t o r s o to o n e s i d e a n d t h e n t o t h e ot h e r, a n d re d u ce s e n s o ry cues by c l o s i n g t h e e y e s o r by sta n d i n g u p o n a s oft s u rface, s u c h a s a f o a m p i l l ow.

Gluteal Strengthening to Stabilize Gait (Exercise) P e l v i c sta b i l i t y i n the c o ro n a l p l a ne is a l s o i mporta n t . I n d i v i d u a l s w h o fa l l a n d s u s ­ ta i n a h i p fra c t u re a re l i ke l y to h a v e fa l le n s i d e w a y s . R e i n forcement of t h e g l u te u s m u s c l es to e n c o u r a ge l a te r a l p el v i c s t rengt h e n i n g s h o u l d b e a d d resse d .

Pa tient p o s i t i o n : sta n d i ng w h i l e h old i n g o n t o t h e b a c k o f a c h a i r o r th e w a ll for s ta b i l i ty. W i t h i n c r e a s i n g a d e p tn ess, the p a t i e n t c a n p rogress t o d o i ng them free ­ h a n d b u t s h o u l d a l wa y s r.·ema i n w i th i n reach of a s u pport. P r o c e d u re 1.

S t a n d w i t h t h e b a c k stra i g h t a n d w i t h t h e we i g h t on o n e f o o t .

2.

S l owly a b d u ct t h e ot h e r l e g ; h o l d i t i n a b d u c t i o n for 3 to 5 seco n d s a n d t h e n s l owly

3.

A l te r n ate sta n d i n g on o n e l e g a n d t h e n on t h e o t h e r for 5 to 1 0 re peti t i o n s e a c h .

4.

W h i l e p e rfo r m i n g t h i s exercise, i f f l exi b i l ity perm its, ch a l le n g e vesti b u l a r s e n s a t i o n

ret u r n to the i n it i a l p o s i t i o n

by t u r n i n g t h e h e a d , n e c k , a n d u p p e r torso to o n e s i d e a n d t h e n to t h e o t h e r. Red u ce s e n s o ry c u e s by c l o s i n g t h e eyes or by sta n d i n g u p o n a soft s u rfa ce, l i ke a foam p i l l ow.

5.

R e l e a s i n g t h e h o l d on the ch a i r o r wa l l a d d s d i ff i c u lty.

Refe re nces 1 . Gl o s s a r y o f o s t e o p a t h i c t e r m i n o l o g y . I n : Wa rd RC, ed . F o un d a t i o n s f o r O s te o pa t h ic M e d i c i n e . 2 n d ed . P h i l a d e l p h i a : Li p p in c o t t Wi l l i a m s & W i l k i n s , 2 0 0 2 ; 1 2 4 9 . 2 . Korr 11YI . S u s t a i n e d s y m pa t h i cotonia a s a factor i n d i sea s e . I n : K o rr 1 M , ed . The Neu robiologic Mec h a n i s ms i n Ma n i p u l a t i v e Thera py. New Yor k , Lo ndon : Plen u m , 1 9 7 8 ;229-2 6 8 . 3 . N e l s on K E. . T h e rna n ;] ge m e n t o f

low

b a ck pa i n . A A O J 1 9 9 9 ; 9 ( 1 ) : 3 3 -3 9 .

4 . Ben j u )'a N , M e l z e r I , K a p l a n s k i J . Aging- i n d uced s h i fts from

a re l ia nce o n sensor), i n p u t t o m u s ­ stan d i n g . J G e r o n t o l A B i o i Sci M e d Sci 2 0 0 4 ; 5 9 : 1 66-1 7 1 . 5 . Lee H K , S c u d d s RJ . Compa r i s o n o f b a l a nce in o l d e r p e o p l e w i th and w i t h o u t v i s u a l i m p a i r­ m e n t . A ge Age i n g 2 0 0 3 ; 3 2 : 6 4 3-64 9 . 6 . B u c k l e y J G , A n a n d V, S c a l l y A , E l l i o tt D B . Does h e a d e x te n s i o n a n d fl e x i on i n c re a se p o s t u ra l

c l e coco n t r a c t i o n d u r i ng b a l a nced

i n sta b i l i t y

in

e l d e r l y s u b j ects when v i s u a l

i n fo r m a t i o n i s

kept consta nr?

Gait

Pos t u re

2005 ; 2 1 : 5 9-6 4 . 7 . Ta rr R , N e lson K E , Va rt R , R i c h a rd s o n D . P a l p a t ory fi n d i ngs a s s oc i a t ed A O N N O F Resea rch Co n fe r e n ce Proceed i n gs . J

with

t h e d i a b e t i c state.

A m O s t e o pa t h Assoc 1 9 8 5 ; 8 5 : 6 0 4 [ a bstracr] .

8 . M n a b h i A, N e l s o n K E , G l o n e k T. Q u a n t i fy i n g t h e s u bj e c t i v e a ssessment of tiss u e tex t u re c h a n g e : C o m p a r i s o n of osteo p a t h i c pa l p a to ry fi n d i ngs w i rh r a n d o m b l ood s u g a r i n d i a betic pa t ients. J A m O s t eo pa rh Assoc 2 0 0 1 ; 1 0 1 : 4 7 2 [a bstract] . 9 . Hei l i g D. P r i n c i p les of l i ft thera py. J A m Osteop a t h Assoc 1 9 7 8 ; 7 7 : 4 6 6 -4 7 2 . R e p r i n te d i n

Peterson B , ed . P o s tu ra l B a l a nce a n d I m b a l a n c e . Newa r k , O H : A m e r i c a n Aca d e m y o f Osteo p a t h y, 1 9 8 3 ; 1 1 3 - 1 1 8 .

1 80

Sect i o n II • Pat i ent Popul ati ons

10. Narici

M V, M a ga n a r is CN, Reeves NO, Ca p o d a g l i o P. E f fect of a g i n g o n h u ma n m u scle

arch i tect u re .

J 1. Singh

MA.

J

A p p l P h ysio] 2 0 0 3 ; 9 5 : 2 2 2 9-2 2 3 4 .

Ex e rc i s e

to

prevent

and

t re a t

fu n c t i o n a l

d i s a b i l i t y.

Cl i n

G e r i a tr

Med

2 0 0 2 ; 1 8 : 4 3 1 -4 6 2 , v i-vi i .

1 2 . Da tgcn t - Mo l i n a P, F a v i e r F, Gra n d j e a n H , e t a l . F a l l -rel a ted b ctors a n d r i s k or h i p fra ctu r e : T h e E P I D O S p r o s pective s t u d y. L a n cet 1 9 9 6 ; 3 4 8 : 1 4 5 - 1 4 9 .

ER, K i e l DP, e t a l . Fa l l d i re c t i o n , b o n e m i n e r a l d e n s i t y, a n d f u n c t i o n :

1 3 . G ree n s p a n S L , M ye rs

R i sk factors f o r h i p fra c t u r e i n fra i l n u rs i n g h o m e e l d e rly. A m J M e d I 9 9 8 ; 1 04 : 5 3 9-54 5 .

A , E l h o WJ . Effect o f a n e x e r c i s e progra m o n f u n c t i o n a l p e r fo r m a n c e

1 4 . D e C a rva l h o B a s t o n e

o f i n s t i t u t i on a l i zed e l d e r l y.

J

R e h a b i ] Res D e v 2 0 0 4 ;4 1 : 6 5 9-6 6 8 .

1 5 . F l etc h e r G F, B l a i r S N , B l u m e n th a l J , et a l . S t a t e m e n t on e x erc i s e : B e n e fi ts

a n ci reco m m e n d a ­

t i o n s for p h y s i c a l a c t i v i ty progra m s fo r a l l A m e r i c a n s . A s t a te me n t fo r h e a l th p r o fess i o n a l s b y t h e Comm i ttee on E x e r c i s e a n d C a rd ia c R e h a b i l i ta t i o n o f t h e Co u n cil o n C l i n i c a l C a r d i o l ogy, Amer i c a n Hea r t Assoc i a t i o n . Circu l a t i o n 1 9 9 2 ; 8 6 : 3 4 0-3 4 4 . 1 6 . K o k k i nos

P F, N a r a y a n 1', P a p a d e m e t r i o u V. E x e r c i s e as h y p e r te ns i o n thera p y. C a r d i o l C l i n

20 0 1 ; 1 9 : 5 0 7-5 1 6 . 1 7 . K re i s berg R A , O b e r m a n

A . M e d i c ,1 1 m a n a g e m e n t o f h y p e r l i p i d e m i a /d y s l i p idem ia . J C l i n

E n d o c t i n o l M e ta b 2 0 0 3 ; 8 8 : 2 4 4 5-2 4 6 l . 1 8 . M a y e r-D a v i s

EJ ,

D ' Agos t i n o R J r, K a rter

AJ ,

e t a l . f n t e n s i t y a n d a m o u n t o f p h y s i c a l a c t i v ity

in rel a t i o n to i n s u l i n s e n s i t i v ity: T h e I n s u l i n Resista nce A t h e rosc l e ro s i s S t u d y. .l A M A 1 9 9 8 ; 2 79 : 6 6 9 -6 7 4 .

1 9 . Froe l ic h e r V I.:; M y e r s I N . Exercise a n d the H e a r t . 4 t h e d . P h i l a d e l p h i a : S a u n d e r s , 200 0 ; 1 0 0- 1 1 2 . 2 0 . A b u - H i j l e h M F, H a b b a l O A , Moq a r r a s h S T. T h e ro l e o f t h e d i a p h ra g m i n l y m p h a t i c a b s o r p ­ t i o n from t h e p e r i to n e a l c a v i t y. J A n a t 1 9 9 5 ; 1 8 6 ( p t 3 } :4 5 3 -4 6 7 . 2 1 . A h m e d A K , H a rness

J B,

M e a r n s AJ . R e s p i r a tory c o n t r o l o f h e a rt ,·a te . Eu r

J

A p p l P h ys i o l

Occ u p P h y s i o l 1 9 8 2 ; 5 0 : 9 5-1 0 4 . 2 2 . Berna r d i L , S l e i g h t P, B a n d i n e l l i G , e r a l . Effe c t of r o s a r y p r a yer a n d yoga m a n t r a s o n a u to­ nomic c a r d i o v a sc u l a r r h y t h m s : Compa r a t i v e s t u ci y. BM] 200 1 ; 3 2 3 : 1 4 4 6 - 1 4 4 9 . 2 3 . Be r n a rd i

L, Spa d a c i n i G , Be l l wo n J , e t a l . E ffec t o f b r ea t h i n g r a te o n o xygen sa t u ra t i o n a n d

e x e r c i s e p e rfo r m a nce i n c h r o n i c h e a r t fa i l u r e . L a n c e t 1 9 9 8 ; 3 5 1 : 1 3 0 8 - 1 3 1 1 .

N , Ne l s on KE, G lo n e k T. The e ffec t o f l i g h t exercise u p o n b l o od f l o w ve l o c i t y deter­ J IvIed Eng Technol 2 0 0 4 ; 2 8 ( 4 } : 1 4 3- J 5 0 . 2 5 . W i J l i a m s S R . Nutri t i o n a n d D i e t T h e r a py. 6 t h ed . S r . Lo u i s : T i m e s M i rror/N!os b y C o l lege.

2 4 . Sergueef

mined b y l a s e r- D o p p ler f l o w m e t r y.

1 9 8 9 ; 5 1 8 -5 3 7 . 2 6 . K l a t s k y A L , A rm strong M A , F r i e d m a n G O . R e d w i n e, w h i te w i n e , l i q u o r, bee t, a nd r i s k fo r

coro n a r y a r tery d is e a s e h o s p i t a l i za t i o n . Am J C a rd i o l 1 9 9 7; 8 0 : 4 1 6 -4 2 0 . 27. Sree bny

LM,

Va l d i n i

M.

X e ro s t o m i a :

A

n egl ected

sym ptom .

A rc h

Intern

N! e d

1 9 8 7; 14 7 : 1 3 3 3 -1 3 3 7 .

M , G oodpaster B H , K titchevs k y S B , e t a l . Muscle m a s s , m u s c l e s t re n g t h , a n d m u s c l e f a t i n f i l t r a t i on a s pted i c t o r s o f i n c i d e n t m o b i l i t y lim i t a t i o n s i n w e l l - fu n c t i o n i n g o l d e r p e r s o n s . J G e r o n t o l A B i o i Sci M e d Sci 2 0 0 5 ; 6 0 : 3 24-3 3 3 . 2 9 . Visser M , Deeg DJ , Lips P. L o w v i ta m i n 0 a n d h i g.h p a r a t h y ro i d h o r m o n e l e v e l s a s d e te r m i ­

2 8 . Visser

n a n t s of l o ss o f m u sc l e s t re n g t h a n d m u sc l e m a s s ( sarcop e n i a ) : The Longi t u d i n a l Aging 5 [U d y A ms t e rd a m . J C l i n E n d oc r i n o l M e t a b 2 0 0 3 ; 8 8 : 5 7 6 6-5 7 7 2 . 3 0 . K a r l s o n EW, Ma n d l L A , A rweth GN, e t a l . Tot a l h i p r e p l a c e m e n t d u e to osteoa r r h r i t i s : T h e

i m p o rta nce o f a g e , obe s i t y, a n d o t h e r m o d i fi a ble risk fa c to r s . Am J Med 2 0 0 3 ; 1 1 4 : 9 3-9 8 . 3 1 . Mo r e l li V, N a q u i n C , Wea v e r V. A l t e r n a t i v e t h e ra p i es fo r t r a d i t i o n a l d i se a s e s t a res: Osteoart hri t i s . A m Fam P h y s i ci a n 2 0 0 3 ; 6 7 : 3 3 9 -3 4 4 . 3 2 . Ca l c u late your bod y mass i n dex . N a t i o n a l Hea rt, L u ng, a n d B l ood I n s t i tute, N a t i o n a l I n s t i t u tes

of Hea lth. Avai l a b l e a t h rtp :l/n h l bisu p port.com/b m i /bm ic a l c . htm. A ccessed Ma y 2 8 , 2 0 0 5 . 3 3 . Peters

R M . T h e e ffec t i v e n e s s of t h e r a p e u t i c to u c h : a m e t a - a n a l y t i c review. N Ul" ' Sci Q

1 9 9 9 ; 1 2 : 5 2-6 1 . 3 4 . Cox C L , H a ye s JA . Red u c i ng a n x i e ty : T h e e m p l o y m e n t o f t h e r a p e u t i c t o u c h a s a n u rs I n g

i n terVen t i o n . Co m p l e m e n t T h e r N u rs M i d W Ifery 1 9 9 7 ; 3 ( 6 } : 1 6 3-1 6 7 .

CHAPTER

13

The Patient at the End of Life Alice J. Zal

INTRODUCTION In th e not-roo-distant past, people died , on average, much younger than today, often of i n fect i ous diseases. Contemporary medicine has greatly limited the toll that infections take upon the population. Chronic illnesses and malignancies are now the leading causes o f death in t h e United States. I A d v a nc i n g medical technology p rovides support to the terminally ill, but often with

a

dehumaniz­

ing effect. Physici ans expend great efforts to assist pa ti e n t s to return to health.

Yet, in spite of the greatest efforts, every patient even tually dies. Medical care can slow the course of the most devastating illnesses, but p h ysic i a n s must also protect and whenever possible improve the quality of life. Death is inevitable, and when the patient reaches the final phase of dying, osteopathic physicians must ask t h e m s el v es what they

can distinctively offer patients in th e final days

of life. The holistic approach of the osteopathic philosophy of practice incorporates all systems of t h e human body inco an integ rated therapeutic protocol.2 It addresses n ot just the disease process; rather, it embraces the patient and extended

family. It is in this conte x t that the osteo pathic physician treats patients from to live until they die. It also enables the family physician to play an integral part, as the leader of the patient's birth to death. This approach empowers patients

181

182

health

Section II • Patient Populations

care team,

coordinating

multiple consultants and conducting the

sy m p h o n y that concludes with a dignified death. Just as there is an art of living, there is an art of dying. Thirty-five years ago at The University of Chicago School of Medicine, Elisabeth Kubler-Ross initiated open consideration of the need to support dying patients and to provide them with the means to live theif final days to the fullest. She stressed the importance of the primary care physician stating: "We have long controversial discussions about whether patients should be told the truth. A

question that rarel y arises when the dyi n g person is tended by the family physi­ cian who has known him from delivery to death and who knows the weaknesses and strengths of each member of the family."} She described the d y ing patient as be in g in a fluid state of five emotional stages. These stages are not stagnant, and

the emotions of the patient and of their significant others can fluctuate from one stage to another and back again in a random sequence. Ideally, however, they

should eventually progress to stage 5. The stages include

(1) denial and isolation,

(2) anger, (3) bargaining, (4) depression, and (5) acceptance. The recognition of

this emotional sequence assists the attending physician to provide support to dy ing individuals although they may be belligerent and even accusatory. The views expressed by Kubler-Ross incorporate a holistic approach that mir­ rors osteopathic physicians' approach to their patients. This system

of support their

allows patients to die with dignity and with the health care team respecting

wishes. Her philosophy gives emotional support ro dying patients, while we as osteopathic physicians give ph y s ical support and nurturing ro patients and their circle of care. It is fundamental ro osteopathic philosophy that the body possesses the inherent ability to heal itself. This holds true even as patients lie d y i ng. Function can be optimized and discomfort reduced. The processes employed to treat terminally ill patients, including osteopathic manipulative treatment

(OMT), life.

are no different from those employed to treat patients at any other stage of

The intensity of the intervention is, of course, variable and is dictated by the

patient's level of physical tolerance. It takes a team of health care providers to meet the needs of JUSt one terminal patient. End-of-life issues pose a unique constellation of challenges to the physician. The terminally ill patient's physiology is stressed to its limits. Multiple dysfunctions affect the patient in a domino effect. Previously healthy systems become disrupted not because they are diseased but because they are incapable of continuing to func­ tion in the presence of the allostasis that is overwhelming rlle patient. These chal­ lenges demand that physicians use all of their knowledge of somatic dysfunction,

disease e n t i tie s, and systemic interactions-incorporate their osteopathic manipula­

tive skills-and be the health facilitator for the patient. Physicians have to coordi­ nate this care such that there is not an overlapping

of care but rather a smooth

concerted effort for the optimal level of support for patients. In this chaotic envi­

to identi fy dys fun c t ion and to optimize function ca n provide relief and even comfort, possibly reducing patients' need for, and conseq uently the a U o st a tiC contri bution of, analgesics , seda tives, laxa tives, diuretics, and the like. Some of the problems for end-of-life care that can be a d d r esse d and alleviated include the following: ronment, osteopathic physicians' ability

• • •

Pain Gastrointestinal dysfunction, including nausea, vomiting, ileus, and constipation Cardiopulmonary problems, incl u ding shortness of breath and central and peripheral edema

Chapter 13 • The Patient at the End of Life

183

MUSCULOSKELETAL AND VISCERAL PAIN Pain can come from numerous sources, including bone, muscles, fascia, or viscera. Visceral dysfunction and pathology can initiaiJy manifest as vaguely l ocalized pain. Viscerosomatic and Chapman's reflexes4 can be used to elucidate the source of pain d uring patients' final d ays of life. Often terminaiJy ill patients demonstrate organ dysfunction in systems not immediately related to their primary disease process. Osteopathic physicians use the musculoskeletal system to offer diagnostic clues through viscerosomatic reflexes. The reflexes as described in Chapter 5 are mediated by general visceral afferent neurons that travel with either sympathetic or parasympathetic neurons from the d ysfunctional or diseased viscera to the dermatomes and myotomes of the corresponding level of the spinal cord. Tissue texture abnormalities are palpable in the paravertebral tissue areas corresponding to the underlying visceral abnormality. These changes are located at the level from which the primary cell bodies of the respective sympathetic and parasympathetic efferent neurons originate. The intensity of the palpable tissue texture a bnormal­ ity offers an indication of the severity and the source of the visceral pathology responsible for the reflex. Viscerosomatic r eflexes are segmentally predictable dermatomal and myotomal responses to inflammatory visceral pathology. The exact location of the reaction or increased tonicity of the overlying paravertebral muscles identifies the involved organ most of the time. General visceral a fferent nociceptive neurons return to the spinal cord in the same nerve root bundles that carry the efferent autonomic fibers. The reflexes conducted by these neurons lateralize to the paravertebral soft tissues on the same side of the body as the viscus. Midline organs, hence, produce bilateral reflex reactions. Treatment of the somatic dysfunction is usualJy temporary, as the underlying organ must be treated to allay the discomfort in the soft tissues inner­ vated by the viscerosomatic reflex. Tumors, whether benign or mal ignant, that d o not in themselves have innervation consequently do not directly produce visceroso­ matic reflexes. In this case, any response will result from direct irritation of adja­ cent innervated tissues exerted by the rumor. Most patients as they enter their final phase of life equate death with the fear of pain. The main goal of the physician is to allow patients to live their last days fully. It is important that one live until one dies. The physician is the person who can make this possible through the use of appropriate OMT, medications, nerve blocks, neurostimulation, biofeedback, and physical therapy to alleviate discomfort. There are no upper limits to the dosage of pain medications, as long as the physician grad­ ually increases the dose to match the increase in pain. Psychostimulants can be employed to antagonize the sedation produced by many opioids. With the use of psychostimulants, knocking out the pain does not mean knocking out the patient. In this arena, osteopathic physicians have an add itional therapeutic modality to offer their patients to alIeviate the pain of somatic dysfunction, which may in rum reduce patients' need for opioids. Along with medication, the use of OMT (soft tissue stretching, gentle articulatory procedures, rib raising, counterstrain, and lym­ phatic pump, to mention a few procedures) can be employed. Osteopathic physi­ cians can help make pain more tolerable and enhance the homeostasis of the patient's body. Osteopathic physicians have a unique armamentarium for diagnosis and treat­ ment of these problems. Having taken an extensive history and physically examined the patient, including palpation for primary somatic dysfunction and visceroso­ matic and Chapman's reflexes,4 the physician can move on to choose the osteo­ pathic procedure that is most appropriate for this patient.

184

Section II • Patient Populations

Often, as patients become less mobile as a res u l t o f deteriorating physica l he a l t h , they get multiple mu sc u l a r contractio ns causing myofasci a l a nd bony a rtic­ ula r dysfu nction . These dysfun ctio n a l cha nges are often coupled with osteoporotic weakening of the skeleta l stru cture. Osteopo rosis can a rise from l a ck of weight­ bea ring activities and poor dieta ry intake of calcium, vitamins, a n d other nu t ri­ e nts. Beca u se of t h e fra gile bone strength of t h ese pa tients, one must be ca u tio us when perfo rming OMT. Physicians ma y ha ve to adjust their ma nipulative proce­ dures to a ccommodate the physic a l n eeds of the individua l p a tient a n d do no h a rm to the already fragile individua l . The le vel o f to l era nce a n d the gen era l health lev el o f the patien t dicta te the level of aggressiveness of the procedure chosen. These procedures inc l ude the fo l l owing: • • • • • • • • •

Artic u lation Soft tissue Direct fasc ia l rel ease Mu scle e nergy Co unters train Fa cilita ted positi onal relea se Indirect fascial release Indirect cra n ial Lympha tic p u mp

High-ve l ocity, low-amplitude (HVLA) procedu res ma y be employed, but only with the u tmost respect for the tolerance of the individu a l pa tien t. When in do u bt, it is best to err in the directio n the less a ggressive p rocedures.

GASTROINTESTINAL PROBLEMS Na usea, vomiting, diminis hed p eristalsis, constipa tion, a nd mala bsorption of nutri­ ents are a ll p roblems that pa tients face at the end of life . As A.T. Stil l p u t it, "The stomach is the mortar box for the retention a nd mixing for other wo rkers."5 The movement of the sma ll in testine is a progressive wave of relaxa tions followed by con­ strictio ns from the pyl o rus to the ileoceca l val ve. According to Bayliss a nd Stariing,6 peristal tic movement is due to "intrinsic nerve a ctivation contained in the Auerbach's plexu s." This i ntrinsic ga stroin testina l component of the a u tonomic nervo us system provides a self-regula tory mecha nism for the gut. Mechanical stimu lation of the gut wall from distension or from the external effect of physical activity, a s occurs with walking and other normal activities of daily living, res u lts in a perista ltic response. The progressive loss of physical mobility, as occ u rs with chronic diseases and i n the terminal stages of illness, resu l ts in decreased mech a n ica l stimulation of the gastroin­ testinal tract. Therefore, direct mechanica l stimula tion of the gut with transa bdomi­ nal OMT may be employed to stimu l a te perista ls is. These procedures should be applied frequ ently and can often be taught to the patient or to a fa mily member. Including the pa tient a nd their fa mily in the process n ot o n l y provides regular a p p l i­ ca tion of the p rocedure b u t also empowers them by providing them with an oppor­ tunity to contribute, often dramatically, to thei r own well being. Passive conges tion of the abdomin al organs may be ad dressed with OMT. The liver and spleen, la rge s u b d ia phragma tic o rgans, are capa ble of sequ estering l a rge volumes of blood a n d lymph. Mechanica l stimula tion of these orga ns m a y be empl oyed to decrea se passive a bdomina l congestio n. The u ndersurface of the tho­ ra coa bdomin al dia phragm is rich in lymphatic vasculatu re. The cistern a chyli is strategic a lly loca ted at the lower end of the thora cic duct in a p p roximati on with the

Chapter 13 • The Patient at the End of Life

185

abdominal aorta between the descending crura of the diaphragm. Not only does ensuring optimal thoracoabdominal diaphragmatic excursion enhance abdominal lymphatic drainage but the slow rhythmic motion of the diaphragm also massages the liver and spleen, augmenting venous return to the heart. Optimal parasympathetic tone to the gastrointestinal tract may be facilitated by treating somatic dysfunction that affects the vagus and pelvic splanchnic nerves through somatovisceral mechanisms. The vagal reflex is the cervical parasympa­ thetic viscerosomatic reflex. These vagal reflexes are located at the occiput, Cl, and C2, with a greater tendency of a right-sided reaction from the pancreas, liver, gallbladder, small intestine , ascending colon, and right side of the transverse colon. The left-sided upper cervical reaction occurs with the esophagus , the stomach, and the duodenum. The sacral parasympathetic reflex (S2 to S4) is associated with con­ ditions involving the left side of the transverse colon, the descending colon, the sig­ moid colon, and the rectum. Food that enters the colon has movement that is a combination of peristalsis and antiperistaltic motion. The forward and backward action slows down the food bolus to allow further digestion and absorption of the intestinal contents. It takes 2 hours for the bolus to move from the cecum to the hepatic flexure and 4 to 5 hours for it to move through the transverse colon. The slow movement of the colon comes from inhibitors in the spinal autonomic system (both in the upper and mid lumbar segments), whereas those supplying the rectum come from the hypogas­ tric nerve, a plexus containing sympathetic (Ll-L3) and parasympathetic (S2-S4) nerve fibers. The neurologic supply to the digestive tract helps the osteopathic physician to locate the areas that require correction to normalize the digestive process. The cor­ rection of the somatic dysfunction causing the gastrointestinal dysfunction can normalize the nerve supply. The correction of the neuronal supply can in turn nor­ malize the blood supply, venous drainage, and lymphatic supply, which in its turn returns normal digestive function. Correcting the underlying somatic dysfunction will improve the efficacy of other medicinal interventions.

CARDIOPUL MONARY PROBLEMS Congestive heart failure and pulmonary failure are common at end of life and often occur in tandem. T he resultant edema, both peripheral and pulmonary, can be treated with lymphatic drainage procedures. "NorrnalJy a contraction of the abdominal diaphragm produces changes in the volume between the abdominal and thoracic cav­ ities. When the diaphragm is well domed, the volume changes produce effective pres­ sure gradients between the thoracic and abdominal cavities. In this way a pump action for lymphatic flow is produced. Flattening of the diaphragm seriously decreases vol­ LIme displacement. This causes decreased lymph flow, which increases congestion of tissues and can decrease cardiac output. Numerous medical and osteopathic research studies have proven that chronic lymphatic congestion with resultant poor oxygena­ tion of cells is associated with increased rates of infection, healing time, fibrosis and scarring, and mortality. "7 Lymphatic pump procedures also add significantly to fluid mobilization and the homeostasis of the patient. OMT, respiratory therapy, and pulmonary toileting all improve the functional level of a patient. Treatment of somatic dysfunction of the thoracic inlet, thoracic spine, ribs, and thoracoabdominal diaphragm will optimize the mechanics of respiration in the otherwise compromised patient. Treatment of somatic dysfunction of C3, C4, and C5 can optimize phrenic nerve function, further improving diaphragm function.s

186

Section II • Patient Populations

CONCLUSION

In general, hands-on treatment of the p a t i en t has a multitude of benefits. It can correct somatic dysfunctions and provide a positive effect on the emotional state of the patient. It ma k es a pa t i ent feel worthwhile and not j ust a burden to those around them as they face their final days of earthly be ing Performing OMT he l p s to decrease pain, improve circulation, and enhance gas­ trointestinal peristalsis an d lymphatic flow. It also says to the patient, "I am here for you, and you are not alone." This hands-on form of medical care makes it so that the inevitable disease process does not have to decrease the quality of any sin g l e human second on Earth. .

Procedures OMT may be employed to reduce dysfunction and alleviate discomfort for the ter­ minally ill patient. Because of the i r compromised condition, these individuals pres­ ent significant OMT dosage issues. (See Chapter 4.) W hen the p atient is fr agi l e or unstable, it is best to employ limited interventions frequently, often mul t i pl e times daily, if tolerated. The amount of OMT will be dictated by the patient's physio­ logic response during t r eat m en t and in the 24-h ou r period following treatment. While treating patients, observe them closely for their response, and stop the intervention as soo n as one is observed. Relaxation of the soft tissues in the area being treated is a good response. Muscle twitching or spasm during the applica­ tion of a procedure is an indication that you have exceeded tolerance and should stop the intervention and select a less a g gress ive procedure. Changes in autonomic nervous activity are also a response. Peripheral vasodilation with redness or increased skin temperature or perspiration indicates it is time to stop. Increased heart or respiratory rate also indicates that you have reached the patient's level of tolerance. If the p a tien t finds the intervention too uncom forta ble stop and choose another approach or wait and try again later. Avoid causing or aggravating pain during OMT. Immediately after the interven­ tion, the p at i ent will often report sympto m reduction. This response is commonly followed briefly by an intensification of the o ri gin a l complaint. Such a rebound reaction should be minimal and should not last more than 24 to 48 h o urs. If it does, the intensity of the following intervention should be app r o pr iately reduced. As the rebound reaction su bsides , a period of resolution typically follows in which the chief complaint is significantly reduced or absent. This period of resolution may last a few hours or longer. Patients shouJd be reev a l uate d 24 to 48 hours after the treatment and treated again as their response dictates. T he f oll owing pr ocedu res are examples of OMT that may be employed in the care of t h e ter m inally ill patient. ,

Cervical Soft Tissue/Articulation

For diagnosis, see C hap t er 3; for treatment procedure, see Chapter

16.

Cervical, Indirect Balancing

For dia gn osis see Cha p te r 3; for treatment procedure, see Chapter 16. ,

These two proced ures are employed to decrease cervica I tissue tension and enhance the symmetric range of motion of t h e cervical spine. They can ease ten­ sion headaches and reduce cervical dysfunction commonly encountered when patients spend long hours propped up with pillows.

Chapter 13 • The Patient at the End of Life

187

Inhibitory Pressure

This procedure is employed to attenuate an effect upon segmentally related viscera by suppressing the somatic component of a somatovisceral reflex. (For treat m ent procedur e, see C h apte r 5.) Thoracic Inlet Myofascial Release

For treatment procedure, see Ch ap ter 19. Rib Raising

For treatment procedure, see Chapter 10 and 17. Thoracoabdominal Diaphragm Release

For treatment p r oc edu r e, see C h apter 17. Significant compromise of respiration may occur in the very ill individual as the result of somatic dysfunction.R The preceding three proced u res are employed to enhance mobility of the entire respiratory mechanism, thereb y i n creasing e ffi cien cy of respiration and ly m phatic and venous return to the heart. Transabdominal Stimulation

For treatment procedure, see Chapter 20. This procedure is employed to treat abdominal somatic dysfunction (ICD 9CM 739.9). It improves bowel function by mechanically stimulating peristalsis, thus increasing gastrointestinal motility whiJe alleviating or pr e venting constipation ([CD 9CM 564). It is useful when treating hospitalized patients or other bedrid­ den individuals. Because it is most effective when applied several ti m es a day, this procedur e may be taught to patients for self-administration if they are sufficiently alert, or it can be taught to a fa m ily m e m b er. Thoracic and Lumbar Counterstrain

Counterstrain points are commonly paire d as posterior and anterior tender points. This is b e c au se they often m ani fest in this paired relationship. If a thoracic or lum­ bar tender point is identified, the segmentally related anterior or posterior poin t should be sought out as well. The two points should then be compared for degree of tissue texture abnormality and tenderness, and the more severe point should be treated first. Following treatment, the treated point should be reassessed, and if it has resolved, the segmentally paired point should be reevaluated. If the paired point is also resolved , the treatment is successful. If the paired point remains tender, it should be treated. Again, following treatment, the second po i nt should be reassessed, and if it has resolv ed, the paired point first treated should be reev al ­ uated. If the first point treated remains resolved, the treatment is successful. If, however, the first point has returned, a third segmentally related point-an ante­ r io r or posterior rib tender point, for example, or an atypical point as described in various countersrrain texts-should be sought our and treated. ANTERIOR THORACIC T END ER POINTS Tl-T6 AND T7-T12 (COUNTERS-mAIN)

These procedures may be employed to reduce pain associated with anterior thoracic tender points. The points ( Fi g. 13.1) may be fo u nd as follows: Tl through T6 are midline points. Tl i s located in the suprasternal notch. T2 to T6 descend

188

Section II • Patient Populations

1"1

-T2

T3 =-_--/T4 �_�r--.T ..,.- 5 ___tt--r-T6 -I,--T7 __-H-T8 T9 T10 --__

_-4-_-1"11 ----1-'T 2

W-lr---L 1 2,3,4 L L e-:--�- 5

f

FIGURE 13.1

Counterstrain anterior thoracic and lumbar tender points.

ste rn u m T7 to L5 are bilaterally paired points. The T7 points are inferior to the costal cartilages on either side of the xiphoid process. T9 and TIO surround the umbilicus. The TIl tender points are midway between TIO and the pubis. The T12 tender po i n ts are upon the iliac crests at the

consecutively down the

.

tender

mid axillary line.9

Patient position: supine. Physician position: standing on the side of point (Figs. 1 3.1 and

FIGURE 13.2

13.2).

the

Counterstrain procedure for an anterior T4 tender point.

tender

Chapter 13 • T he Patient at the End of Life

189

Anterior Thoracic Tender Points T1-T6 (Counterstrain)

Because these a re midline tender points, you may stand on e i t h e r side of the patient as dictated by comfort and/or co n ve ni ence

.

Procedure 1.

Place the index finger of either hand upon the tender point to be treated. T his hand placement must be maintained throughout the procedure.

2.

Assess the degree of tissue texture abnormality and tension associated with the ten­ der point. By increasing the amount of digital pressure applied to the tender point, determine the baseline severity of tenderness. Assign this level of tenderness a value of 100% and inform the patient.

3.

With your other hand, cradle the patient's occiput and posterior cervical spine. Treatment of anterior tender points involves forward bending of the head upon the chest. The patient's arms and hands should rest comfortably at the sides. To fine­ tune the final position, you may have the patient abduct and internally rotate the shoulders. If the patient is lying on a treatment table, this can be accomplished with the arms hanging off the sides of the table. T he lower the tender point, the greater the amount of neck and upper torso flexion required. To obtain enough flexion for T5 and T6, you may have to place a pillow or your knee upon the table or bed beneath the patient's neck or upper back.

4.

Modify the patient's position by adjusting the amount of flexion and adding side bending and/or rotation to obtain maximum reduction of palpable tissue tension and tenderness. It is generally thought that perceived tenderness should be decreased to not more than 30% of the 100% established in step 2.

5.

Hold this position of maximum palpable tissue tension and tenderness reduction for 90 seconds; then slowly return the patient to the original position and reassess. It is important not to remove your monitoring finger during the procedure so that you can be certain that the reduction in tenderness post treatment occurred specifically in the original tender point.

6.

Reassess the point for tenderness.

Anterior T horacic Tender Points Tl-T12 (Counterstrain)

As you progress lower down the spine, it becomes necessary to i n t ro d uce more and more flexion of the torso for the counterstrain proce d ure to be effective. Trea t men t of the lower anterior thoracic dysfunctions, w hic h is basically forward bending of the thoracic spine, is done with the patient supine using pillows or a hospital bed to assist in creating flexion. Eventu al l y it is not p os s i bl e to increase flexion from a bove, and it becomes necessary to provide t h e requisi te positioning by flexing the p a tient S hips and pelv is '

.

Procedure

1.

Begin as for anterior thoracic tender points T1 to T6, steps 1 and 2, by establishing contact with the tender point to be treated while identifying the patient's initial sub­ jective level of tenderness (100%) and objective severity of palpable tissue texture abnormality.

2.

Introduce flexion of the neck and upper torso as described in the previous instruc­ tions. At some point, you will be unable to introduce enough flexion from above to make the procedure effective. At this point additional fleXion can be introduced from below by having the patient flex the hips and knees with the feet flat upon the tabletop or mattress.

190 3.

Section II • Patient Populations For treating T9 to T12, it becomes necessary to introduce flexion to a greater extent from below Place your foot upon the table and rest the patient's calves upon your leg. If the patient is in bed, position the pelvis close to the edge of the mattress, while placing your foot upon the box spring or bed frame beneath the mattress. The patient's leg nearest to you is placed upon your thigh first, and the other leg is lifted and placed so that the ankles are crossed and the calves rest upon your thigh

4.

You can now modify the patient's position by adjusting the amount of flexion and adding side bending (typically toward the side of the dysfunction) and/or rotation from below to obtain maximum reduction of palpable tissue tension and tender­ ness: shift your thigh to increase or decrease flexion of the patient's hips and employ leverage through the patient's legs to side-bend and/or rotate the pelvis. When treating an anterior T12 tender point, more side bending is required than for the other anterior thoracic dysfunctions. It is generally thought that when the patient is properly positioned, perceived tenderness should be decreased to not more than 30% of the 100% established in step 1.

5.

Hold this position of maximum palpable tissue tension and tenderness reduction for

90 seconds; then slowly return the patient to the original position and reassess. It is important not to remove your monitoring finger during the procedure so that you can be certain the reduction in tenderness post treatment occurred specifically in the original tender point

6.

Reassess the point for tenderness.

POST E R I OR THO RACIC T E NDE R POINTS T1 TO T4 ( CO U N T ERST RAIN)

These procedures may be employed

to

tender poims. The points (Fig.

may be found

13.3)

reduce pain associated with posterior thoracic follows: the upper thoracic ten­

der points, Tl to T4, are near the midline upon the lateral aspect of the spinous as

The farther inferior the segment as you descend the tender found more lateral, closer [0 the tip of the transverse process.9

processes.

points may

-T1 6---::::::o._=--T2 . ....-.. �,...T3 ...: �-----1-T 4 �-----JLT5 T6 T7 T8 T9 1"10 T11 T12 L1 L2 L3 L4 L5 UP5L LP5L /\

....� ..

__

FIGURE 13.3

Counterstrain posterior thoracic and lumbar tender points.

be

Chapter 13 • The Patient at the End of Life

1 91

Patient position: lying on the side with the side of the tender point LIp. Physician position:

seated

at the

side of the table, facing the patient.

Posterior Thoracic Tender Points T1-T4 ((ounterstrain) (Figs. 13.3 and 13.4) Procedure (Example: Right-Sided Tender Point)

1

If t h e pat i e n t is ly i n g o n t h e left s ide, u s i n g t h e I ndex f i n g er of yo u r l eft hand, pa l ­ pate t h e te nder poin t o n t h e lateral aspect of t h e upper t h o rac ic spi n o u s process. This hand place m e n t m ust b e main tai n ed t h roug h o u t the procedu re

2.

Assess the degree of tissu e text u re a b n o r mality and tens i on associated with the t e n ­ de r point B y i n creas i n g t h e amo u n t o f dig i tal pressure o n t h e t e n d e r poin t, deter­ min e t h e base l i n e sever i ty of t e n dern ess . Assi g n t his l eve l of te ndern ess a value of

1 0 0% and inform t h e patient. 3.

P l ace your rig h t e l bow upo n the edg e of the tab l e or bed a n d crad l e the l eft s i de of t h e patie n t 's h ead I n t h e pa l m of yo u r rig h t h a n d . Lift t h e patie n t 's h ead so that the ce rvical a n d t h o racic spine is st raig h t

4.

Tra n slate t h e patie n t's h ead a n d c e rv i cal spi n e post e rio r l y w i t h y o u r r i g h t ha n d u n til y o u s e n s e with t h e i n de x f i n g er of y o u r l eft han d t hat you have o b tai n ed maxim u m reductio n of t h e pa lpa b l e tiss u e t e n sio n a n d tendern ess. Add i tio n a l exte n s i o n may b e o btained by havi n g t h e patient b r i n g b o t h arm s a b ove t h e h ead. I t i s g e n e ra l l y t h o u g h t t h at w h en t h e pat i e n t i s proper l y posit i o n ed, per­ c eived te nder n ess sho uld be decreased to n ot m ore t h a n 3 0 % of t h e 100% esta b l i s h ed in step 2.

5

H o l d t h is positio n of m axi m u m pa l pa b l e t i ssue t e n si o n a n d t ende r n ess red ucti o n

9 0 seco nds; t h e n s l ow l y ret u rn t h e pat i e n t t o t h e o r i gi n a l posi t i o n

I t i s i m por­

ta n t n ot to remove yo u r mo n i tori n g fing e r d u ri n g the proced u re so t h at you ca n be ce rtai n the reduct i o n i n t e n de rness post t reat m e n t occu rred specifica l l y in the o ri g i n a l tender poi n t T h e sta n da rd t reatme n t of poste r i or Tl to T4 t e n d e r poi n ts i n v o l ves direct bac k wa rd b e n di n g of the spi n e d o w n to t h e lev e l of dysfu n cti o n , w i th t h e patie n t s u pine a n d t h e p h ys i c i an seated at t h e h ead of t h e t reatme n t ta b l e . T h e m o n i t o ri n g f i n g e r i s p laced b e n eath t h e pat i e n t i n c o n tact wit h t h e poi n t t o b e t reat ed, a n d t h e pat i e n t t h e n s l ides u pward off t h e e n d o f t h e tab l e u n til t h e te n de r po i n t i s b e y ond t h e edge o f t h e ta b l e and t h e pati e n t's h e a d is rest i n g in t h e ph ysicia n 's l ap. Backward be n di n g may be acce n t u ated by l o w e r­ i n g t h e patie n t's h ead b e l o w t h e edge of t h e ta b l e

FIGURE 13.4

Have t h e pat i e n t b ri n g the

COLlnterstrain procedure for a right-side posterior

T4 tender point.

1 92

Sect i o n I I • P a t i e n t Po p u l a t i o n s h a n d s o v e r t h e h e a d a n d p u t t h e m i n yo u r l a p ; a t t h e s a m e t i m e , h ave t h e p a t i e n t d ro p t h e l e g s o ff t h e t a b l e o n e i t h e r s i d e . T h i s p roced u re i s n o t p o ss i b l e if t h e p a t i e n t is bedri d d e n .

6

Reassess t h e p o i n t for t e n d e r n ess.

P O S T E R I O R T H O R A C I C T E N D E R P O I NTS T5-T 1 2 ( C O U N T E RST R A I N )

T h e l ower t e n d e r po i n t s a re p a l p a b l e l a tera l l y fro m between the s p i n o u s a nd t r a ns­ v erse p rocesses to over the tips of t h e respective tra n s verse p rocesses ( F i g . 1 3 . 3 ) . P a t i e n t p o s i ti o n : l a t e r a l l y rec u m bent w i t h t h e s i d e o f t h e te n d e r p o i nt u p .

P h y s i c i a n po s i t i on : s ta n d i n g in f r o n t of th e p a t i e n t t o the s i d e o f t h e ta b l e . Proc ed u re

1.

P l a ce yo u r m o n i t o r i n g f i n g e r u p on t h e t e n d e r p o i n t to be treated . M a i n ta i n t h i s

2.

Assess t h e d e g re e of t i s s u e textu re a b n o r m a l ity a n d t e n s i o n ass o c i ated w i t h t h e te n ­

h a n d p l a ce m e n t t h ro u g h o u t t h e p ro ce d u re . d e r p o i n t . B y i n crea s i n g t h e a m o u nt of d i g it a l p ressu re a p p l i ed t o t h e te n d e r p o i n t , d ete r m i n e t h e b a s e l i n e severity of te n d e r n ess . Ass i g n t h i s l evel of te n d e r n ess a va l u e of 1 0 0 % a n d i n form t h e pat i e n t .

3.

I n t rod u ce exte n s i o n f r o m a b ove by s l i d i n g t h e p a t i e n t 's s h o u l d e rs poste r i o r l y a n d fro m b e l o w b y s l i d i n g t h e p a t i e n t 's h i p s posteri o r l y u n t i l y o u h a v e obta i n ed maxi­ m u m re d u cti o n of p a l p a b l e tissue tension and t e n d e r n ess . A d d i t i o n a l ext e n s i o n m a y be obta i n ed by h avi n g t h e pati e n t b r i n g b o t h a r m s a b ove t h e he a d . It i s g e n ­ e ra l l y t h o u g h t t h a t w h e n t h e p a t i e n t i s p ro p e r l y posi t i o n e d , perceived te n d e r n ess s h o u l d be d e c reased to n o t m o re than 30% of t h e 1 0 0 % esta b l i s h e d i n step 2 .

4.

H o l d t h i s p o s i t i o n o f m a x i m u m p a l p a b l e t i s s u e te n s i o n a n d t e n d e r n ess red u ct i o n for

90 sec o n d s ; then s l owly ret u r n the p a t i e n t to t h e o r i g i n a l positi o n . It is i m p o r t a n t not to re m ove yo u r m o n i t o ri n g f i n g e r d u r i n g t h e p roced u re so that y o u c a n b e certa i n t h e re d u ct i o n i n t e n d e r n ess p o s t trea t m e n t occ u r red specifica l ly i n the o r i g i n a l te n d e r p o i n t .

6.

Rea ssess t h e p o i n t fo r t e n d e r n e s s .

P O S T E R I O R T H O R A C I C T E N D E R P O I NTS, A LT E R N AT I V E P R O C E D U R E T9-T 1 2 (CO U N T E RSTRA I N )

This proce d u re e m p lo y s r o t a t i o n i n stead of exte n s ion .

Pa t i e n t p o s it i o n : s u p i n e P h y s i c i a n pos i t i o n : s t a n d i n g bes i d e the p a t i e n t on t h e .

s i d e o f t h e ten d er p o i n t . Proc e d u re

1.

S l i d e o n e h a n d p a l m u p b e n e a t h t h e p a t i e n t , a n d with yo u r i n dex f i n g e r p a l pate t h e te n d e r p o i n t . M a i n ta i n t h is h a n d p l a c e m e n t t h ro u g h o u t the p roce d u re .

2.

Assess t h e d e g ree of tissue text u re a b n o r m a l ity a n d t e n s i o n associated w i t h the t e n ­ d e r p o i n t . By i n cre as i n g t h e a m o u nt of d i g ita l p ressu re a p p l i e d to t h e te n d e r poi nt, d e t e r m i n e the base l i n e severity of t e n d e r n e s s . Ass i g n t h i s level of te n d e r n ess a va l u e of 1 0 0 % a n d i n fo r m t h e pat i e n t .

3.

W i t h you r oth e r h a n d , g rasp t h e p a t i e n t 's w r i st o n t h e s i d e o p p os i te t h a t of t h e ten­ d e r point a n d p u l l it a c ross t h e p a t i e n t 's ch est u n t i l t h e s e g m e n t you a re m o n itor­ ing i s felt to rotate and you h ave obta i n ed m a x i m u m re d u ct i o n of p a l p a b l e tissue te n s i o n and ten d e r n e s s . It i s g e n e ra l l y t h o u g h t that w h e n the patient is properly p o s i t i o n e d , p e rc e i v e d t e n d e r n ess s h o u l d b e de creased to n o t m o re than 30% of the

1 0 0 % esta b l is h e d i n step 2 . 4.

H o l d t h i s p o s i t i o n o f max i m u m p a l p a b l e t i s s u e te n s i o n a n d te n d e r n e ss re d u ct i o n for

90 seco n d s ; t h e n s l ow l y ret u r n the p a t i e n t to t h e o r i g i n a l positio n . I t is i m p o rtant

C h a pt e r 13 • The Patie nt at the E nd of Life

1 93

n ot to remove yo u r m o n ito ri n g fin g e r d u r i n g t h e p ro c e d u re so t h a t y o u ca n be c e r ­ t a i n t h a t t h e red u ct i o n i n t e n d e r n ess post t re a t m e n t o c c u rred spec i fica l ly in t h e o rigi n a l te n d e r po i nt.

5.

Reassess the po i n t f o r t e n d e r n ess .

A N T E R I O R L U M BA R TE N D ER P O I N TS ( CO U I\J T ERSTR A I I\J ) ( F I G S .

1 3. 1

AND

1 3 .5)

l u m bar shown i n F i g . 1 3 . 1 ) m a y be fo u n d a s fo l l ow s : T he

These proced u res m a y be employed to red u ce pa i n a s s o c i a ted w i t h a n te r i o r te n d e r p o i n t s The p o i n ts (as .

a n ter i o r

tender point for

Ll is e i ther d i rec t l y over or med i a l to t h e a n te r i o r s u pe r i o r

i l i a c s p i ne . The L2 te n d e r point

is o n t h e

i n fe r o m ed i a l s u r face o f the a nterior i n fe ­

r i o r i l i a c spine. T h e L3 t e n d e r p o i n t i s o n the l a te r a l s u rface o f the a nterior i n fe r i o r i l i a c s p i n e T h e L 4 te n d e r p o i n t is o n t h e i nfe r i o r s u r face o f the a n te r i o r .

sp i n e . T h e L S t e n d e r p o i n t i s o n t h e

b o d y o f t h e p u b i c bone. 9

i n ferior i l i a c

Patient position: s u p i n e . Physician posi t i o n : sta n d i ng on the s i d e of the tend er point.

P roced u re

1.

P l a ce t h e index fin g e r of eit h e r h a nd u p o n t h e tender po i n t to be treate d . M aintain t h is h a nd p l a c e m e n t thro u g h o u t the p roced u re .

2.

Assess t h e de g re e of t issu e textu re a b n o r m a l i ty a n d t e n si o n associated w i t h the te n ­ de r p o i n t . B y i n c reasi n g t h e a m o u n t o f digit a l press u re a p p l ied t o t h e t e n d e r point, dete r m i n e the base l i n e seve rity o f te n d e r n ess . Assig n t his l e v e l of t e n de r n ess

a

va l u e of 1 0 0 % a nd inform t h e patie n t.

3.

P l a ce y o u r foot u po n t h e t a b l e a n d rest t he patie n t 's ca l ves u po n y o u r l e g . If t h e p a tie n t i s i n b e d , positio n t h e pe l vis c l ose t o t h e edge o f t h e m a tt ress, a n d p l a c e y o u r f o o t upon the b o x spring o r b e d fra m e b e n e a t h t h e m a tt ress . T h e patie n t 's l e g n e a re r to y o u is p l a c ed u po n y o u r t h i g h first , a n d t h e ot h e r l e g is l ifted a n d p l a ced in s u c h a f a s h i o n t h a t the a n k l es a re c rossed a n d t h e c a l v es rest u p o n yo u r t h ig h .

FIGURE 13. 5

C o u n t e rstra i n p roced u re for a r i g h t -s i d e a n t e r i o r

L1 te n d e r p o i n t .

1 94 4.

Section II • Patient Populat ions Modify the patient's pos ition by adj u sti n g the amou n t of flexion w h i l e adding s ide bendi n g (typically toward the side of the dysf u n dion) and/or rotation from below to obtai n max i m u m redu ction of palpable tissue te n sion and tender n ess shift yo ur thigh to inc rease or decrease flexion of the patie nt's hips and employ leverage th rough the patient's legs to side-b e n d a nd/o r rotate the pelvis. It is g e n erally thought that when the patie n t is properly positio n ed, perceived te nder n ess should be decreased to not more than 3 0 % of the 1 0 0 % establis h ed in step 2 .

5.

Hold this position of m axi m u m palpab l e tis s u e te nsion and te n d e r n ess reduction for

9 0 seconds; the n slowly ret u r n the pat i e n t to the orig inal position . It is important not to remove you r mon itoring fi nger during the procedure so that you can b e certain that the reduct ion i n te n de r n ess post treat m e n t occ ur red specifically i n the original te n der poin t

6.

Reassess t h e poi n t for tende r n e s s .

P O ST E R I O R L U M BA R T E N D E R P O I NTS ( C O U NTE R STRA I N )

These p roced u res m a y be em p l o y e d to red uce pa i n assoc i a ted w i t h poste r i or l u m­ b a r tender points. The points ( a s shown i n Figure 1 3 . 3 ) m a y be fo u n d a s fo l lo w s : The posterior l u m b ar te n d er p o i n ts ( L l t o L5 ) a re o v e r t h e poste r i o r aspects of t h e tra nsve rse processes of t h e respective vertebra l segments. La tera l tend er po i n ts for L3 a n d L4 m a y a l so b e fo u n d in the g l u te a l m u sc u la t u re . 9 The l a tera l tender p o i n t fo r L4 i s i m me d i a tely poste r i o r t o the te nsor fascia la ta a n d 4 c m bel ow t h e i l iac cresr. The te n d e r p o i n t fo r L3 i s hal fw a y betwee n the poster ior s u perior i l i a c s p i n e a nd t h e la tera l te n d e r poi n t for L 4 . There a r e two l a tera l L 5 te n d e r points, a n u pper po le L 5 (UP5L) o n the s u p e r i o r m ed i a l s u rface o f t h e p o s te ri o r superior i l i a c spine a n d a l o w e r p o l e L5 ( LP5L) 2 c m bel o w UP 5 L . 9 F o r trea tment of the tender poi n ts u p o n the poste r i o r as pec ts o f t h e trans v e rse processes, the p a ti e n t l i es supine upon t h e trea tment ta b l e o r bed and the p hysicia n s t a n d s a t the s i d e of t h e p a t i e n t on the s i d e of the tender point (Fig. 1 3 . 6 ) .

FI G U R E 13.6

Cou n terstrain pro cedure for the l eft-side poster i o r l u mbar tender po ints upon the poste r i o r aspects of the l u m bar t ransverse p rocesses.

C h a pt e r 1 3 • The Patient at the E n d of Life

1 95

Proced u re S l i d e o n e h a n d pa l m u p b e n e a t h t h e p a t i e n t . a n d w i t h yo u r i n d e x f i n g e r p a l pate t h e t e n d e r p O i n t . M a i n ta i n th i s h a n d p l a ce m e nt t h ro u g h o u t t h e p roce d u re

2

Assess t h e d e g ree of t i s s u e text u re a b n o r m a l ity a n d te n s i o n a s s o c i ated w i t h t h e t e n ­ d e r p o i n t . By i n c rea s i n g t h e a m o u n t of d i g i t a l p ress u re a p p l i e d to t h e t e n d e r p o i n t . d eterm i n e t h e b a se l i n e seve r i ty of te n d e r n ess . Ass i g n t h i s l evel of t e n d e r n ess a va l u e of 1 0 0 % a n d i nf o r m t h e p a t i e n t .

3.

W i t h yo u r ot h e r h a n d , g ra s p t h e p a t i e n t 's w r i st o n t h e s i d e o p po s i t e t h a t of t h e t e n ­ d e r p o i n t a n d p u l l i t a c ross t h e p a t i e n t 's ch est u n t i l t h e s e g m e n t y o u a re m o n i to r­ i n g is fe l t to rotate a n d y o u h a ve o bta i n ed m a x i m u m red u c t i o n of p a l p a b l e t i s s u e t e n s i o n a n d t e n d e r n e s s . I t i s g e n e ra l ly t h o u g h t t h a t w h e n t h e p a t i e n t i s p ro p e r ly p o s i t i o n e d , p e rc e i ved t e n d e r n ess s h o u l d be d ec re a sed to n o t m o re t h a n 3 0 % of the

1 0 0 % esta b l i s h e d in step 2 4.

H o l d t h i s p o s i t i o n of m a x i m u m pa l pa b l e t i s s u e t e n s i o n a n d t e n d e r n ess red u ct i o n f o r

9 0 seco n d s ; t h e n s l ow l y ret u r n t h e p a t i e n t to t h e o r i g i n a l p o s i t i o n . I t i s i m po rta n t not to rem ove yo u r m o n i to r i n g f i n g e r d u r i n g t h e p roce d u re so t h a t y o u c a n be c e r ­ ta i n t h e re d u c t i o n i n t e n d e r n es s p o s t treat m e n t occu rred s p e c i f i c a l l y i n t h e o r i g i n a l tender point.

5.

Reassess t h e p o i n t f o r t e n d e r n e ss .

LAT E R A L T E N D E R P O I NTS F O R LAT E R A L L3, LAT E R A L L4, A N D U P S L

P a t i e n t p o s i t i o n : p rone. Ph ysi cian position: stand i ng o n t h e s i d e o f t h e te n d e r

poi n t . P roced u re

1.

P l a ce t h e i n dex f i n g e r of e i t h e r h a n d u p o n t h e te n d e r p o i n t to be treated . M a i n ta i n t h i s h a n d p l a c e m e n t t h ro u g h o u t t h e p roce d u re .

2.

Assess t h e d e g ree o f t i s s u e text u re a b n o r m a l ity a n d t e n s i o n a s s o c i a t e d w i t h t h e t e n ­ d e r p o i n t . By i n crea s i n g t h e a m o u n t of d i g i t a l p re s s u re a p p l i e d to t h e t e n d e r p o i n t , determ i n e t h e b a s e l i n e seve r i t y of t e n d e r n ess . As s i g n t h i s l evel of t e n d e r n e s s a va l u e of 1 0 0 % a n d i n form t h e p a t i e n t .

3.

R e a c h a c ross t h e p a t i e n t w i t h yo u r o t h e r h a n d a n d g ra s p t h e p a t i e n t 's a n t e r i o r t h i g h J u st p rox i m a l t o t h e pate l l a T h e p a t i e n t 's k n e e m a y re m a i n st ra i g h t . o r y o u ca n f l ex t h e k n e e to 90 d e g re e s .

4.

L i ft t h e p at i e n t 's k n ee, d ra w i n g i t s l ow l y towa rd yo u , i n t ro d u c i n g exte n s i o n a n d a d d u c t i o n o f t h e h i p u n t i l t h e te n d e r p O i n t d e m o n strates m a x i m u m re d u ct i o n of p a l p a b l e t i s s u e te n s i o n a n d te n d e r n ess . It i s g e n e r a l ly t h o u g h t t h a t w h e n t h e p a t i e n t i s prope rly p o s i t i o n e d , p e rc e i v e d te n d e r n ess s h o u l d b e d ec r e a s e d to n o t m o re t h a n 3 0 % of t h e 1 0 0 % esta b l i s h e d i n s t e p 2 .

5.

H o l d t h i s pos i t i o n o f m a x i m u m p a l p a b l e t i ss u e t e n s i o n a n d te n d e r n ess red u ct i o n f o r

9 0 seco n d s ; t h e n s l owly ret u r n t h e p a t i e n t to t h e o r i g i n a l p o s i t i o n . I t i s i m p o r t a n t not to re m ove yo u r m o n i t o r i n g f i n g e r d u r i n g t h e p roced u re s o t h a t you c a n b e c e r ­ ta i n t h a t t h e red u c t i o n I n te n d e r n es s post t reat m e n t occu r re d s p e c i f i c a l l y i n t h e o r i g i n a l te n d e r p o i n t .

6.

Reassess t h e p o i n t f o r t e n d e r n es s .

LATE R A L R E C U M B E N T T R E AT M E N T O F TH E L P 5 L T E N D E R P O I NT

Pati e n t p os i t io n : l y i ng on t h e s i d e w ith the tender p o i n t u p . P hysicia n posit i o n : s ra n d i ng a t r h e l e v e l o f t h e p a t i e n t 's p e l v i s .

1 96

Sect i o n I I • Pat i e n t Po p u l a t i o n s

Proc ed u re 1.

P l a ce t h e i n d e x f i n g e r of e i t h e r h a n d u p o n t h e poste r i o r s u p e r i o r i l i a c s p i n e t e n d e r p o i n t to be t reated . M a i n t a i n t h i s h a n d p l a c e m e n t t h ro u g h o ut t h e p roced u re .

2.

Assess t h e d e g ree o f t i s s u e textu re a b n o r m a l ity a n d t e n s i o n assoc i a ted with t h e te n ­ d e r p o i nt By i n c rea s i n g t h e a m o u nt of d i g it a l p re s s u re a p p l i e d t o t h e t e n d e r poi nt, d et e r m i n e t h e bas e l i n e severity of t e n d e r n ess . Ass i g n this l evel of te n d e r n ess a va l u e of 1 0 0 % a n d i n fo r m t h e p a t i e n t

3.

W i t h yo u r o t h e r h a n d g ra s p t h e p a t i e n t 's k n e e i p s i l a te ra l to t h e ten d e r p o i n t a n d d raw i t towa rd yo u , s i m u lt a n e o u s l y i n trod u c i n g f l e x i o n t o t h e h i p a n d k n e e .

4.

F l e x t h e h i p to 9 0 d e g rees a n d m o n itor the d e g ree of t i s s u e text u re a b n o r m a l ity a n d te n s i o n associated w i t h t h e t e n d e r p o i n t . Yo u c a n f u rt h e r a dj u st t h e p o s i t i o n b y m i n ­ i m a l l y i n c rea s i n g o r decrea s i n g h i p f l e x i o n a n d a d d i n g h i p a b d u c t i o n o r a d d u ct i o n a n d i n t e r n a l o r exte r n a l rotat i o n , u s i n g t h e p a t i e n t 's fem u r as a lever. F i n a l ly, you may h ave to a p p l y a co m p ressive force a l o n g t h e l e n g t h of the fe m u r toward the p e l v i s u n t i l t h e t e n d e r p o i n t d e m o n strates m a x i m u m red u c t i o n of p a l p a b l e t i s s u e ten s i o n a n d te n d e r n es s . I t

IS

g e n e r a l l y t h o u g h t t h a t w h e n t h e p a t i e n t is properly p o s i t i o n e d ,

percei v e d te n d e r n ess s h o u l d be decreased to not m o re t h a n 3 0 % of t h e 1 00 % esta b l i s h e d i n step 2 .

5.

H o l d t h i s p o s i t i o n o f m a x i m u m p a l p a b l e t i s s u e t e n s i o n a n d t e n d e r n ess re d u ct i o n for

9 0 seco n d s ; t h e n s l ow l y ret u r n t h e p a t i e n t to t h e o r i g i n a l p o s i t i o n . It is i m p o rta n t n o t to remove yo u r m o n i to r i n g f i n g e r d u r i n g t h e p roced u re so t h a t yo u ca n b e cer­ ta i n the re d u ct i o n i n te n d e r n es s post treat m e n t occu r red s p e c i f i ca l l y i n the o r i g i n a l te n d e r p o i nt

6.

Reassess t h e p o i n t f o r te n d e r n es s .

Refere n ces J . S n y d e r L, Q u i l l TE. P h y s i c i a n 's G u i d e to End -of- L i fe Ca re . P h i l a d e l p h j ,l : A m e r i c a n C o l l eg e of P h ys i c i a n s , 2 0 0 1 . 2 . North r u p TL, ed . A c � d c m y o f A p p l i ed O s t e o p a t h y 1 94 5 Yea r b oo k . M a n i p u l a ri v e T h e r a p y

D e m o n s t ra t i o n s . A n n A r b o r

,

M I : E d w a r d s Brothers, 1 9 4 5 . ( N o w a v a i l a b l e t h r o u gh the

A m e r i c a n A c a d e m y o f O s teo p a t h y, I n d i a n a p o l i s . )

3 . K u b l e r-Ross E. O n D e a t h a n d D y i n g . N e w Yo rk : Sc r i b ner, 1 9 6 9 ; 7 . 4. N o r t h u p G W. O s reo p a r h i c Med i c i n e : An A m e r i c a n Reform a t i o n . C h i c a g o : A rn e r i c a n O s re o pa r h i c A s s o c i a t i o n , 1 9 6 6 ; 6 4 .

5 . D e a son J . P h y s i o l o g y : G e n eral a n d O s t e o pa t h ic K i r k s v i l l e , M O : J o u r n a l P r i n t i n g , 1 9 1 3 . 6 . Ba y l i s s W M , S ta r l i ng E H . T h e Ill o ve m e n rs a n d i nnerva t i o n o f the s ma l l i n te s t i n e . J P h y s i o l ( L o n d ) 1 9 0 1 ; 2 6 : 1 25-13 8 . 7 . K u c h e r a M L , K u chc[d WA . O s t e o p a t h i c Con s i d e r a t i o n s i n Syste m i c D y s f u n c t i o n . Col u m b u s , .

O H : G reyden, 1 9 9 4 .

8 . Strcta nski MF, Ka i se r G . O s t eop a t h i c p h i l o s o p h y a n d e m e rge n r rrea r m e n t i n a c u t e res p i rarory fa i l u re . J A m O s te o p a r h Assoc 2 0 0 1 ; 1 0 1 : 4 4 7-4 4 9 . 9 . .l a n e s L H . Srra in a n d Co u nr e rs t r a i n . C o l o r a d o S p r i ng s : A m e r i c a n A c a d e m y o f Osteo p a r h y, 1 98 1 .

SECTION III

Clinical Conditions

The Patient with Otitis Media David B. Fuller

INTRODUCTION Otitis media (infection of the middle ear) is prevalent in children and fairly com­ mon in adults. It is amenable to osteopathic diagnosis and treatment, especially if one

thinks from a structure and function perspective.

Thinking osteopathically allows one to develop hands-on treatment based on an

understanding of each patient's dysfunction and to return that patient to a

state of balanced health. Understanding the normal anatomy and physiology

and how each patient's pathophysio l ogy presents leads one directly to optimal

treatment for each patient. In the case of o titi s media, this is well stated in the American

Osteopathic

Osteopathic

(AOA)

Association

textbook

Foundations

for

Medicine in Chapter 22, "General Pediatrics": "Thus, it is impor­

tant to remember that any infection is

a

resul t of a combination of influences:

degree of virulence and quantity of an infecting agent, along with host suscep­ tibility. The osteopathic approach favors measures that improve host resistance and recovery concurrent with weakening, or eradicating the infecting agent".1 Of course, treatment may involve appropriate use of pharmacologic therapy,

es p ec i al l y targeted antibiotics when indicated. This section focuses on what can be done

from a musculoskeletal perspective to treat patients with otitis media.

197

198

Section III • Clinical Conditions

A model that helps to organize cl inica l diagnosis and treatment is one that addresses dysfunction along the lines of structural, neurologic, and fluid aspects of the individual.

ANATOMY AND PHYSIOLOGY The middle ear is a chamber that sits in side the petrous porti on of the temporal bone, with the lateral wall consisting of the tympanic membrane. It contains the auditory ossicles, which transfer sound waves across the middle ear. P ress u r e is equilibrated with the outside atmosphere via the Eustachian (auditory) tube, which connects anteriorly and i nferiorly to the lateral wall of the nasophary n x

.

The

rato ry tract, is lined with ciliated epithelial cells that move secretions from the middle ear to the nasophary n x . I) Eustachian tube, like the rest of the upper

r e sp i

The ear structures are innervated by a sympathetic supply originating from spinal levels at Tl to T4. These sympathetic nerves generally follow the arterial su pply to per ipheral structures. These same pathways are followed by visceral afferent nerves with i n form ation flo w ing from organs to the spinal cord and central nervous system.3 The parasympathetic nerve supply travels via the facial nerve through the ptery­ gopalatine ganglion to the

mid

dle ear.4

Lymphatic drainage from the ear travels superficially to deep cer v ical ly m p h atics via preauricular and post a u ricula r lymph nodes, then in feriorl y through the thoracic inlet to the thoracic duct and right lymphatic duct, then to the venous circulation.s Other important structural details are the attachments of the sternocleidomas­ toid muscles to mastoid processes of temporal bones. The temporomandibular joint sits immediately anterior to the ear

.

PATHOPHYSIOLOGY Acute otitis media is characterized by sudden onset of inflammation of the middle ear. The most common cause of infection is bacteria, al t ho u gh viral infections are common as well. Otitis media usually causes pain, fever, and congestion. Ph ysic a l examination reveals loss of normal anatomic landmarks (such as the cone of light), inflammation, and b u l ging of the tympanic membrane. Sympathetic facilitation is common, with characteristic changes in the mucosal lining of the upper respiratory tract producing increased mucus th at becomes thick and tenacious. As sympathetic activity continues, the corresponding sp i n al segments, T1

to T4,

become facilitated.6 Sympathetic hy pera c ti v ity is also

believed to be the basis of the Chapman myofascial tender points associated with eye, ear, nose, and t h roat d ysfunction.7 Posterior Chapman tender points for oti­ tis media are found at the posterior aspect of the tip of the transverse process of the first cervical vertebrae (Fig. 14.1). Associated anterior Cha pman tender points

are located on the u pper e dge of the proximal clavicle as it crosses over the first rib.s (See Fig. 5.1.) Dysfunction of the Eustachian tube plays a key role in the development of oti­ tis media. Any structure placing tension on the Eustachian tube will promote dys­ function and obstruction, leading to a p re ssure grad ient in t h e middle ear chamber as well a s fluid accumulation . Hypertonicity of the posterior pharyngeal muscles,

the me dial pterygoid, and the digastric muscles and dysfunction of the hyoid bone

may play an important role in E ustac h ian dysfunction.I,9

Structural factors also include te m poral bone dysfunc tio n and sternocleidomas­

toid hypertonicity. The te mpora l bones move with the cranial rhythmic impulse in a

Chapter 14 • The Patient with Otitis Media

FIGURE 14.1

199

The posterior Chapman myofascial tender points associated with eye, ear, nose, and throat dysfunction.

continuous cycle of internal and external rotation. This motion assists drainage of the ear. Internal rotation dysfunction of the unilateral temporal has been reported in children with otitis media and is also found in adults.!O Sternocleidomastoid hyper­ tonicity facilitates this dysfunctional internal rotation of the temporal bone.! Hypertonia in the cervical myofascial tissues can interfere with lymphatic flow.6 Lymphatic congestion leads to boggy, edematous tissues that can impair home­ ostasis and cause discomfort." The Arnold ear-cough reflex results from stimulation of the auricular branch of the vagus nerve. This is one reason why cough may occur with otitis media, espe­ ciall y when it follows upper respiratory infections. Coughing can aggravate somatic dysfunctions, especially in the upper thoracic, rib and, anterior neck areas . Chronic otitis media with effusion is inflammation of the ear lasting more than 3 months. Examination often shows a retracted tympanic membrane with decreased hearing. The patient may or may not have pain. Environmental allergies and irritants (especially tobacco smoke) may cause chronic irritation to the middle ear and nasopharynx as well.l Chronic irritation leads to long-term sympathetic facilitation and changes in the upper respiratory epithelium. The number of goblet cells increases and vascular elements decrease, causing the mucosa of the nasopharynx to become thick and sticky.7 Chronic otitis media can lead to somatic findings similar to those of acute otitis media, but the character of the findings will be consistent with chronic dys­ functions. (See Chapter 3.) In summary, the pathophysiology of otitis media includes structural dysfunction (Eustachian tube, neck musculature, thoracic and rib), neurologic dysfunction (sympathetic hyperactivity causing mucosal and viscerosomatic changes), and fluid problems (fluid in middle ear, lymphatic congestion of head and neck).

Osteopathic Treatment Paradigm Osteopathic treatment simply flows from the patient'S pathophysiology and specific pattern of somatic dysfunction. Osteopathic manipulative treatment has been shown to be beneficial in treating patients with otitis media.9.!2 Osteopathic treatment should address structural, autonomic, and fluid aspects of the dysfunctional process. A course of treatment should address any significant struc­ tural somatic dysfunction of the rib, thoracic, and cervical areas along with the cranium. Treatment should address any sympathetic component resulting from facil­ itated thoracic dysfunction or manifesting as Chapman's points. Treatment should

200

Section III • Clinical Conditions

improve fluid mechanics by ad d ressing thoracic inlet, cervical, and head lymphatic components,

specifically th e Eustachian tube,

via ear, mand ible,

and cranial

proced ures. One algorithm that works well is to start with occipitoatlantal release, then ad d ress thoracic and r ib dysfunction and move cephalad. Of course, every patient has his or her own pattern of dysfunction and needs to be ad dressed ind ivid ually. The fol lowing is one possible treatment sequence. With the patient seated , d iagnose and treat as follows: 1. Upper thoracic and rib d ysfunction to d ecr ease sympathetic facilitation to head and neck as wel l as impr oving lymphatic d r ainage. Pr ocedures can vary with the ind ivid ual,

such

as myofascial

release;

high-velocity,

low-amplitud e

(HVLA) thrust; muscle energy; and counterstrain. (See Chapter 4.) Move the patient to the supine position, d iagnose, and treat as follows: 1. Occipitoatlantal myofascial r elease (Chapter 16) to add r ess overall tension. 2. Thoracic inlet fascial release (Chapter 19),

any

clavicular d y sfunction

(Chapter 16), and specific upper thoracic and rib d ysfunction. This proced ure will d ecrease sympath etic facilitation and its effect upon the h ead and neck and will improve lymphatic d rainage from these areas. 3. Posterior Chapman's points and specific d ysfunctions at the occipital-C1-C2

complex (discussed later in the chapter ).

4. Cervical spine d ysfunction with appropr iate proced ures. (See Chapters 16, 17, and 22.) This pr oced ure add resses mechanical, sympathetic, and fluid components. 5. Anterior neck d ysfunction, that is, hyoid , sternocleid omastoid , and anterior vertebral d ysfunctions to improve lymphatic d r ainage and d ecrease tension on the Eustachian tubes. (See Chapter 16.)

6. Specific pr oced ures for Eustachian tube d ysfunction, that is, Galbraith's pr o­ ced ure, traction of the pinna (d iscussed later in the chapter). 7. Cranial d ysfunction, especially cranial torsions and temporal bone d ysfunc­

tion (d iscussed later in the chapter ). 8. Other head procedure, that is, sphenopalatine ganglion pr oced ure (d iscussed

later in the chapter) and effleurage. (See Chapter 16.) These techniques improve autonomic and fluid functions.

Case Illustration A 28-year-old patient has ear pain following an upper respiratory infection. After taking a history and performing a physical examination, the physician diagnoses otitis media with accompanying somatic dysfunction that includes

T4, rotated and side bent right, extended, with an elevated fourth rib dorsally accompanied by a Jones tender point at the costovertebral angle; fascial restriction at the thoracic inlet; C2 rotated and side bent right; a right cranial torsion; and a fascial restriction at the occipitoatlantal junction. One appropriate treatment sequence for this patient would be as follows: occipitoatlantal myofascial release, thoracic outlet myofascial release, counter­ strain to T4 and fourth rib followed by the HVLA procedure, specific treatment of choice to (2, balance the cranial torsion, and finish with the Galbraith pro­ cedure. This sequence takes about 5 minutes, leads to significant improvement in the patient's symptoms, and hastens the resolution of the otitis media.

Chapter 14 • The Patient with Otitis Media

201

Procedures Posterior Chapman's Reflexes from Otitis Media

This procedure is employed to treat poste r io r Chapman 's reflexes associated with otitis media. These are small (2-3 mm) nodular masses that are palpable in soft tissue and th a t demonstrate sharp pinpoint nonr adiating tenderness. The posterior points are located upon the pos te rior aspect of tips of transverse processes of C1 ipsilateral ro the side of the otitis (Fig. 14.1). Patient position: supine. Ph y s i ci an posit io n : standing or sitting at the head of the ta ble.

Procedure 1.

Place your index finger on the palpable nodular mass of Chapman's point on the posterior aspect of the tip of transverse processes of C 1, laterally between the angle of the mandible and the tip of the mastoid process.

2.

Apply pressure to the point in a circular fashion, massaging it in an attempt to dis­ sipate it. The amount of pressure necessary will be mildly to moderately uncomfort­ able for the patient.

3.

Apply the therapeutic pressure for approximately 10 to 30 seconds. Cease the treat­ ment when the palpable point resolves or is significantly decreased.

Galbraith's Procedure (Fig.

14.2)

Th is proced ure is emp loyed to improve function of Eustachian t u be and decongest the middle ear. Patient positio n: su pine with the head slightly elevated and turned to the right. Physician p o sitio n: standing at the right side of th e table near head level.

FIGURE 14.2

Galbraith's procedure to improve function of Eustachian tube and decongest the middle ear.

20 2

Section III • Clinical Conditions

Procedure (Example: Left Eustachian Tube Dysfunction)

1.

Stabilize the patient's head by placing the palm of your left hand upon the left side of the patient's head in such a way that your t humb lies superior and anterior to the ear and your index finger lies posterior to the ear on the mastoid process.

2.

3.

Place the pads of the middle three fingers of your right hand so that they hook around the angle of the mandible. Pull rhythmically on the angle of the mandible along the line of the mandibular ramus at a bout 3 cycles per second for 1 minute.

4.

You can easily teach patients to perform this procedure upon themselves or their children at home.

Traction on the Pinna (Fig. 14.3) This pro cedu re is empl oyed to improve f u n c ti on of Eustachian tube and de co ngest the m iddle ear. Be careful when performing this pr oce d ure in acute conditions because it e m pl oys an abrupt applicati o n of fo rce that can be very pa in fu l. This pro ce dure is more appropriate for adults than for children. (Example: L e ft Eustachian tube o r middle ear dysfunction.) Patient positi on : supine with the he a d turned to the right. Physici an position: standing at the head of the tabl e .

Procedure

1.

Stabilize the patient's head by placing the palm of your right hand upon the left side of the face so that your thumb lies superior and anterior to the ear.

2.

With your left hand grasp the superior aspect of the ear between your thumb and index finger. You may wish to grasp the ear with a small gauze pad to facilitate the firmness of your grasp. The ear must be held firmly, but be careful not to contuse it

3.

Firmly apply intermittent traction to the ear directed superiorly, posteriorly, and laterally. The force should be applied as a tug abrupt enough to move the pinna.

An alternative treatment is to apply gentle , steady, continuous traction on the pinna in the same direction without any sudden tug.

FIGURE 14.3

pi nna of the ear to improve function of Eustachian tube and dec o ngest the middle ear.

Tractio n on the

Chapter 14 • The Patient with Otitis Media

FIGURE 14.4

203

Cranial vault hold.

The following two cranial procedures are indirect methods that req ui r e a sensi­ tive light

touch.

Cranial Vault Hold for Spheno-Occipital Synchondrosis Torsion (Figs.

14.4

and

14.5)

The ca rtilaginou s articulation between the sp h e n o id and occiput,

the spheno-occipital or sphenobasilar synchondrosis, remains un fu sed throughout life in som e individuals. In most it does fuse, but not until well i n to the third decade of life.J3 Various dysfunc­ tional patterns, in c l u din g torsion, side-bending rotation, extremes of flexion and

FIGURE 14.5

Placement of fingertips for the vault hold. A. index finger; B, middle finger;

C, ring finger; D, little finger.

204

Section III • Clinical Conditions

extension, horizontal strain, vertical strain, and compression, have been described. Their description is beyond the scope of this text. Torsions are discussed here. S pheno-occipital torsion is, as the name suggests, twisting between the two bones at the synchondrosis. The dysfunction is described in term s of the sphenoid bone relative to the occiput and is named for the side on which the greater wing

of the sphenoid is displaced superiorly, toward the ve r tex of the skull. This area can be palpated with the hand placement referred to as a vault hold. This hand placement allows the physician to palpate the entire cranial base simultaneously. The examiner's hands bilaterally contact the greater wings of the sphenoid, the squamous and petrous ponions of t h e temporal bones, and the occiput. Patient position: supine. Physician position: seated at the head of the table with the forearms resting on the tabletop . Procedure 1.

Place the distal phalangeal pads of your index fingers bilaterally upon the greater wings of the sphenoid (Fig. 14.5, point A)

2.

3.

Place the distal phalangeal pads of your middle fingers bilaterally upon the squa­ mous portion of the temporal bones Just anterior to the ears (Fig. 14.5, point tions of the temporal bones just posterior to the ears (Fig. 1 4.5, point

4.

0

Place the distal phalangeal pads of your little fingers bilaterally upon the lateral aspect of the squamous portion of the occipital bone (Fig. 14.5, point

5. 6.

B)

Place the distal phalangeal pads of your ring fingers bilaterally upon the mastoid por­

D).

Your thumbs should rest comfortably over the vault of the skull. Assess for spheno-occipital synchondrosis torsion left by inducing a gentle motion of the sphenoid in a cephalad anterior direction with your left index finger and in a cau­ dal posterior direction with your right index finger. Compliance is consistent with tor­ sion left, resistance with torsion right.

7.

Assess for spheno-occipital synchondrosis torsion right by inducing a gentle motion of the sphenoid in a cephalad anterior direction with your right index finger and in a cau­ dal posterior direction with your left index finger. Compliance is consistent with torsion right, resistance with torsion left.

8.

Indirect procedure reproduce the pattern of greatest compliance and hold until the amplitude of cranial rhythmic impulse decreases and stops, a still point. When a still point is obtained, release your hold on the mechanism with the next flexion and external rotation phase of the cranial rhythmic impulse.

9.

Reassess spheno-occipital motion.

Temporal Bone Dysfunction (Crania/) This procedure may be employed to treat restriction of motion of the temporal bones as th ey relate to one another and to the midline bones of the base of the skull, the sphenoid, and the occiput. The dysfunction may be unilateral or bilat­ eral. The motion pattern of the midline bones is flexion and extension. The paired temporal bones externally rotate in association with sph eno-occipital flexion and internally rotate with extension. (Readers unacquainted with these mechanics are referred to a basic text on the subject.)J4 This mechani sm demonstrates an inher­ ent rhythmicity, the cranial rhythmic impulse, of 6 to 14 cycles per minute and appears to be linked to baroreflex physiology.15,16 Motion testing is done to iden­ tify compliance or resistance between the bones of the c r a n i a l base in assoc i ation with the cranial rhythmic impulse. Patien t p os i tio n : supine. Physician position: seated at the head of the table with the forearms resting on the tabletop (Figs. 14.6 and 14.7).

Chapter 14 • The Patient with Otitis Media

FIGURE 14.6

205

Treatment of temporal bone dysfunction (cranial).

Readers untrained in cranial manipulation should avoid manipulating the

tem­

poral bones because of the sensitivity of the vestibular apparatus. Procedure 1.

Cradle the patient's head in both hands. Your thenar e minences should be in contact with the posterior portion of the temporal bones behind the patient's ears

(Fig. 1 4 7 point A), and your thumbs should be pointing caudally, contacting the .

,

tips of the mastoid processes (Fig. 14.7, point B) Be certain that you contact the patient's head laterally to the occipitomastoid suture.

2.

With your thumbs, in synchrony with the cranial rhythmic impulse, gently apply medI­ ally directed pressure over the mastoid processes (Fig. 14.7, point

B). Apply this force

as the skull moves into the flexion and external rotation phase of the cranial rhythm.

FIGURE 14.7

Points of contact for han d placement during treatment of temporal bone dysfunction. A is the contact point for the thenar eminence; B is the con­ tact point for the distal thumb.

206

Section III • Clinical Conditions

FIGURE 14.8

Hand placement to decongest the pterygoid fossa and improve the nerve function of sphenopalatine ganglion to promote normal Eustachian tube function.

3.

As the cranial rhythm moves into extension and internal rotation, decrease the pres­ sure with your thumbs while gently a pplying medially directed pressure to the tem­ poral bone with your thenar eminences (Fig. 14.7, point A)

3.

4.

Follow the cranial rhythmic impulse by synchronously alternating steps 2 and

5.

Pay attention to the palpable compliance or resistance of the bones to your appl ied forces. Compare external rotation, thumb pressure, with internal rotation, thenar pressure. Compare the compliance and/or resistance pattern that you feel for the right temporal bone With that of the left temporal bone.

6.

Follow the pattern and gently attempt to amplify it over several cycles of the cra­ nial rhythmic impulse

7.

Reassess temporal bone motion.

Pterygoid Fossa Decongestion, Sphenopalatine Ganglion Procedure (Fig.

14.8)

This p roced ur e is e m p lo yed to indirectly decongest the pterygoid fossa and improve the nerve function of the sphenopalatine ganglion thereby allowing n o r m al function ,

of the Eustachian tube. Relaxation of the medial pterygoid muscle also enables the tensor ve li palatini muscle to functionally open the Eustachian tube.

Patient posicion: supine. P h y sic i a n position: seated at the head of the

table.

Procedure

1.

Place the pad of the distal phalanx of your middle finger inferior to the angle of the mandible on the Side of the otitis.

2.

A pply medially and superiorly directed pressure with your finger to contact the ede­ matous tissue along the inner portion of the mandibular ramus.

3. 4.

Gently pum p the area in a cephalad/caudad direction for 1 minute. Treat the opposite side. This procedure may be taught to the patient for self-treatment twice daily.

Chapter 14 • The Patient with Otitis Media

207

References I. Centers S, Morelli MA, Vallad-Hix C, Seffinger MA. General Pediatrics: Foundarions for Osteopathic Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002;315. 2. Moore KL. Clinically Oriented Anatomy. 2nd ed. Baltimore: Williams & Wilkins, 1985;964. 3. Kuchera M, Kuchera W. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus, OH: Greyden, 1994;2.

4. Moore KL. Clinically Oriented Anatomy. 2nd ed. Baltimore: Williams & Wilkins, 1985;943. 5. Moore KL. Clinically Oriented Anatomy. 2nd ed. Baltimore: Williams & Wilkins, 1985;43 6. Shaw HH, Shaw lvlB. Osteopathic management of ear, nose, and throat disease. Foundations for Osteopathic Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002;372. 7. Kucllera M, Kuchera W. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus, OH: Greyden, 1994;38. 8. Chapman F. An Endocrine Interpretation of Chapman's Reflexes. 2nd ed. Indianapolis: American Academy of Osteopathy, 1937;27. 9. Shaw HH, Shaw MB. Osteopathic management of ear, nose, and throat disease. Foundations for

Osteopathic

Medicine.

2nd ed .

Philadelphia:

Lippincott

Williams

& Wilkins,

2002:378-379. 10. Steele KM. Clinical management of chronic otitis media/eustachian tube dysfunction. Lecture presented at the Annual Convocation of the American Academy of Osteopathy, 2004; Colorado Springs, CO.

11. Kuchera M, Kuchera W. Osteopathic Considerations in Systemic Dysfunction. 2nd ed. Columbus, OH: Greyden , 1994;6. 12. Mills MV, Henley CE, Barnes LL, et al. The use of osteopathic manipulative treatment as adjuvant therapy in children with recurrent acute otitis media. Arch Pediatr Adolesc Med 2003;] 57:861-866. 13. Williams PL, ed. Gray's Anatomy. 38th ed. Edinburgh: Churchill Livingstone, 1995;490. 14. King HH, Lay E. Osteoparhy in the cranial field.

In: Ward RC, ed. Foundations for

Osteopathic Medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2002;985-1001.

15. Nelson KE, Sergueef N, Lipinski CM, Hertng-Mayer oscillation:

et

al. Cranial rhythmic impulse related to the Traube­

Comparing laser-Doppler

flowmetry and palpation. J

Am

Osreopath Assoc 2001;101 :163-173. 16. Sergueef N, Nelson KE, Glonek T. The effect of cranial manipulation upon the Traube­ Hering-Meyer oscillation as measured by laser-Doppler flowmetry. Altern Ther Health Med 2002;8(6}:74-76.

The Patient with Temporomandibular Joint Pain and Dysfunction John McPartland

INTRODUCTION App l ying an o steopathic p ers pect iv e to dysfunct ions involving the tempor o

­

a larg e toolbox with whic h we can help our patients. In contrast, th e sta ndard medical app ro ach to TMJ dys functio n can be mandibular joint (TMJ) provides

quite limite d . I The standard medical appr oach is easily inc o rpo r a ted into the ost eop at hic perspective, as presented in this review.

TMJ dy s function is the most fr e quent source of facial pa in after tootha che criteria divide TMJ dy s func tion into three categories: myofascial pain dys function (MPD) syndrome, internal derangement (lD) inj ury and degen er a tive j oint disease (DJD). MPD sy n dro me is best characterized as a psyc h oph ysi o logi c di sease pr imar i ly involving the muscles of masticati on frequently p rovoked by .

Current d iagnostic

,

­

,

somatic dysfunctions elsewhere in the body.2 ID is de fined as an a b nor mal relation

­

s hip between the articular disc and the mandibular condyle, common examples bei n g acute disc disp lacem ent and chr oni c recurrent dislocations. DJD involves organic deg ener ation of the articular s u r faces within the TMJ. An es timated

10 mil­

lion people in the United States (1 in 25) have TMJ disorder. The greatest incidence is in adults aged 20 to 40 y ears The female-to-male ratio is 4:1.J .

208

Chapter 15 • The Patient with Temporomandibular Joint Pain

209

�

6

Jaw Closed

l ../

��� , ((

Jaw Open

FIGURE

15.1

Time course illustration of TMJ movement: normal position of disc and mandibular condyle during opening and closing of the jaw.

STRUCTURE AND FUNCTION The TMJ has been described as the most complex joint in the body because it not only acts as a hinge joint but also permits a gliding movement, in which the condyle of the mandible slides along the squamous portion of the temporal bone. The articular surface of the temporal bone is similarly complex, consisting of a convex articular eminence anteriorly and a concave articular fossa posteriorly. The condyle and the tem poral bone are separated by an articular disc that divides the joint cavity into two small spaces. The articular disc, also known as the meniscus, is a biconcave fibrocartilaginous structure. It provides a gliding surface for the condyle, resulting in smooth joint movement. The meniscus has three parts, a thick anterior band, a thin intermediate zone, and a thick posterior band. When the mouth is closed, the condyle is separated from the temporal bone by the thick posterior band. When the mouth is open, the condyle is separated from the tem­ poral bone by the thin intermediate zone (Fig. 15.1). Opening the mouth activates the suprahyoid muscles (mylohyoid, geniohyoid, and digastric muscles), which provide the hingelike movement. Anterior condylar glide is provided by the infe­ rior division of the lateral (external) pterygoid muscles. Elevation of the mandible (closing the mouth) is accomplished by the temporalis, masseter, and medial (internal) pterygoid muscles. Lateral displacement (grinding movement) activates the ipsilateral temporalis and the contralateral medial and lateral pterygoids, with some assistance from the ipsilateral or contralateral masseter muscles. Protraction of the mandible activates the suprahyoid muscles, medial and lateral pterygoids, masseters, and sometimes the temporalis muscles.3

ETIOLOGY AND PATHOPHYSIOLOGY OF TMJ SYNDROME MPD is the most common cause of TMJ pain. Its multifactorial etiology includes somatic asymmetries leading to malocclusion, jaw clenching, bruxism, increased pain sensitivity, and personality disorders, such as stress and anxiety. The bottom-line etiological basis of the symptoms (i.e ., pain, tenderness, and spasm of the mastication muscles) is muscular hyperactivity and dysfunction. Whiplash injury and other strains to the neck or upper thoracic spine are frequently overlooked contributors to

210

Section III • Clinical Conditions

MPD-type TMJ syndrome.2 Although a dental procedure may precipitate MPD, apprehension on the part of the patient may be a more significant factor than the pro­ cedure itselF The significance of psychological factors has been recognized during the past few years. Patients with chronic MPD tend to score high on obsessive­ compulsive scales and have elevated levels of disease conviction. I Although MPD usually starts as a functional disorder, it can lead to organic changes in the joint, in the muscles of mastication, and in the dentition.3 ID is caused by a biomechanical problem within the TMJ. Mandibular muscle spasm observed in ID is a response to the d ysfunction, not the cause of the prob­ lem. Anterior disc displacement is the most common cause of ID (Fig. 15.2). The disc d islocation reduces upon opening of the jaw, which causes an opening click. The d isc dislocates again upon closing of the jaw, which causes a closing click. If the condyle cannot overrid e the displaced d isc, jaw locking occurs (described later in the chapter). Disc d isplacement and interposition of the posterior band between the condyle and the eminence can cause pain and jaw noise . Degenerative joint disease is often secondary to microtrauma or macrotrauma of the disc, mandibular condyle, or surrounding connective tissues. Dental proce­ dures are a common source of trauma, particularly work on molar teeth. The other causes of DJD are osteoarthritis, rheumatoid arthritis, ankylosis, infections of the bone or joint, and neoplasia.

Clinical History Patients with TMJ syndrome commonly complain of facial pain, jaw range of motion (ROM) restriction, jaw noise (clicking or popping) , and headaches or neck pain. Earache is fairly common. Many patients report a recent history of jaw trauma (e.g., wisdom tooth extraction) and acute or chronic problems with

FIGURE 15.2

Time course illustration of TMJ movement: anterior disc dislocation that reduces upon opening the jaw and redislocates upon closing the jaw.

Chapter 15 • The Patient with Temporomandibular Joint Pain

211

bruxism or the clenching of teeth. Facial pain is usually periauricular, worsened by chewing. Periauricular pain may

be unilateral or bilateral. In MPD, the pain may TMJ

worsen during periods of increased stress. Headaches may be triggered by

syndrome. In patients who have a history of headaches resistant to treatment, the diagnosis and treatment of

TMJ syndrome should not be overlooked.

Clicking, popping, and snapping sounds may or may not be associated with pain. (Few nociceptors innervate the disc, so pain may be absent.) An isolated click is very common in the general population and is not a risk factor for development of TMJ syndrome. Reduced jaw ROM and locking episodes are common. The lock can be open or closed. Open lock, or inability to close the mouth, is seen when the condyle dislocates anteriorly in front of the articular eminence; if not reduced immediately, it is very painful. Closed lock, or inability to open the mouth more than 10 mm, is seen when the disc remains anteriorly displaced at all times. Closed lock may be caused by pain or disc displacement.

Physical Examination The physical examination can be separated into visual and palpatory components. Visually inspect for facial asymmetry (lateral deviation of the mandible), muscle hypertrophy, malocclusion of teeth, and abnormal dental wear. Inspect mandible ROM; normal vertical jaw opening is 50 than

40

mm

mm

measured between the incisors. Less

is hypomobile, and more than 70 mm is hypermobile. Do not be

fooled by dentures. (Dentures tend to be short, producing false negatives in hypo­ mobile patients.) Normal ROM for lateral mandibular movement is 10 mm on each side of midline. Watch for lateral tracking of the mandible away from midline as the mouth is slowly opened. The tip of the chin or the space between the lower incisors serves as a good landmark for observing midline mandible motion. Lateral tracking may present as deflection (lateral deviation en route that corrects when the jaw is fully opened) or as deviation (lateral deviation at end range). Deflection may express a

C- or S-shaped pattern. While testing ROM, listen for clicking or popping and feel for crepitus. Less obvious sounds can be auscultated with a stethoscope placed over the

TMJ. Visually inspect rotation and side bending of the neck, and check

for unusual spinal curves or shoulder elevation. Palpate the TMJ and surrounding muscles with the patient supine. The TMJ is best palpated directly

below the zygomatic arch,

1 to 2 cm anterior to the tragus.

The posterior aspect of the TMJ can be palpated through the external auditory canal. Feel for lateral deviation as the mouth is slowly opened, with one condyle moving laterally and the other condyle moving medially. Palpate surrounding mus­ cles for spasm and tender points or trigger points. According to Travell and Simons,.l trigger points in the lateral pterygoid, medial pterygoid, and masseter muscles

frequently refer pain to the TMJ. The temporalis, scalene, sternocleido­

mastoid, and suprahyoid muscles should also be examined. To exaggerate any dys­ functions, palpate for tenderness while turning the patient's head and neck to one side and then the other. Watch the patient'S response to palpation, especially flinch­ ing, pain behavior, or lingering pain after palpation.

In a study of 130 TMJ patients, nearly all presented with at least one type of bio­ mechanical cranial dysfunction.4 Compression of condylar parts of the occiput was most common (27% of patients), followed by compression of the sphenobasilar symphysis (18%), articular strain of the frontosphenoid articulation (12%), and nonphysiologic strain patterns, such as vertical or lateral strain (11%). Extracranial

dysfunctions occurred at C3 to C4 (50% of patients), the sacroiliac joints (32%),

212

Section III • Clinical Conditions

lumbosacral junction (29%), C4 to C5 (30%), T2 to T3 (14%), T3 to T4 (14%),

and occipitoatlantal (9%). About 14% of patients had scoliosis.4 Interestingly, dys­ functions of the temporal bones were rarely noted in this study, although the tempo­ ral bone has been cited as a primary problem in other studies.2,5,6 Similarly, the study of 130 TMJ patients made no mention of Cl to C2 dysfunction, whereas another study linked unilateral TMJ pain with an anterior rotational of the atlas on the ipsilateral side.2 Laboratory Studies

Laboratory studies generally are not indicated. Blood work may be required if sys­ temic illness is suspected to be the cause of TMJ syndrome: •

Complete blood count if infection is suspected

•

Calcium, phosphate, and alkaline phosphatase for possible bone disease Uric acid if gout is suspected Serum creatine and creatine phosphokinase, indicators of muscle disease Rheumatoid factor, erythrocyte sedimentation rate, antinuclear antibody panel, and other specific antibodies are checked if rheumatoid arthritis , temporal arteritis, or a connective tissue disorder is suspected.

• • •

Imaging Studies

Imaging studies generally are not indicated. If a fracture or bony erosion (DJD) is suspected, conventional radiography is the most widely used imaging study. It is sim­ ple, evaluates bony structures, and in most cases is sufficient. Real-time ultrasound allows visualization of the structure and function of the articular discs, mandibular condyles, and surrounding muscles. Computed tomography can explore both bony structures and muscular soft tissues. It can be done with contrast material instilled into the joint cavity. Magnetic resonance imaging (MRI), though costly, is the study of choice if (1) articular or meniscal pathology is suspected and an endoscopic or sur­ gical procedure is contemplated and (2) in a case of traumatic TMJ syndrome. Other Studies

Dental tapes and dental casts can be used to analyze occlusal strain and stress. Orthodontic strain analysis can diagnose static and kinematic occlusal patterns by detecting bite prematurities and interferences.6 Arthroscopy is an acute diagnostic approach. It should be reserved for patients with internal TMJ derangements resistant to conservative treatments. A good MRI study should be obtained before contemplating arthroscopy.

Differential Diagnosis of • • • • • •

TMJ

Syndrome

Dental infections, mandibular fractures Gout, pseudogout, rheumatoid arthritis Tension headaches, migraine headaches Otitis media, sinusitis Temporal arteritis Trigeminal neuralgia, postherpetic neuralgia

Treatment TMJ dysfunction from trauma (e.g., tooth extraction or other dental work) is often self-limiting and responds to simple treatment: osteopathic manipulative treatment

Chapter 15 • The Patient with Temporomandibular Joint Pain

213

(OMT) and patient education. OMT approaches include soft tissue massage, myofas­ cial release, muscle energy, counterstrain, functional methods, and osteopathy in the cranial field (OCF). Effective OCF methods are described in the procedures section later in the chapter. (See also Chapters 8, 10, and 25.) Patient education includes teachi ng self-massage , mindfulness while eating, and other forms of self­ rehabilitation. Self-massage includes skin pinching, roJling skin between finge rs, and stripping massage. The patient should perform self-massage several times per day. Soft tissue massage helps inactivate muscle trigger points and disrupts fibrous adhesions. Moist heat packs are helpful during acute episodes, used not longer than 15 minutes per application. Alternating hot and cold packs may be helpful. Acute TMJ

Pain

Acute TMJ pain from muscle clenching may be relieved by slightly stretching (gap­ pi n g) the joint capsule, which promotes relaxation of hypertonic muscles. This can be performed by the patient or the practitioner. With the finger pads, apply light caudad traction upon the ramllS of the mandible. Alternatively, stretch the joint capsule using a dental appliance. A temporary dental appliance can be fashioned by rolling gauze cotton around the ends of two wood spatulas or tongue blades. Ask the patient to open the mouth about 20 mm, and posi tion the cotton rolls between the molars. Ask the patient to gently close the mouth. The cotton rolls act as fulcra to disengage the TMJs. In the author's opinion, the fulcra also improve temporal bone move m e n t during the inhalation phase (flexion, external rotation) of cranial motion. Nonsteroidal anti-inflammatory analgesics can be used on a short-term basis (ibuprofen and naproxen are commonly used). Severe muscle spasm may benefit from prescribed muscle relaxants (benzodiazepines, or cyclobenzaprine in patients unable to tolerate benzodiazepines) . Chronic TMJ

Syndrome

TMJ syndrome is another kettle of fish. Its treatment can be difficult. Some experts recommend management by a team approach, with rhe team consisting of an osteopathic physician with good OMT and pharmacologic skills, a dentist, a psy­

chologist, and in a small number of cases, a surgeon. (Surgical indications include internal derangements, adhesions, fibrosis, and DJD. ) Benzodiazepines and codeine have no place in chronic TMJ syndrome. Counsel patients that chronic pain cannot be resolved in the presence of benzodiazepines or opioid pain medications. Relaxation-inducing herbs, such as hops or valerian, may be substituted. Bedtime doses of calcium and magnesium (500 mg each) pro­ vide muscle relaxant activity. Tricyclic antidepressants (e.g., amitriptyline and nor­ triptyline) in low doses have been used effectively for chronic painful conditions. They act by inhibiting pain transmission, by improving axoplasmic flow in nerve fibers, and by reducing nighttime bruxism. Gabapentin (Neurontin) and its new analog pregabalin (Lyrica) have been prescribed for chronic TMJ syndrome. Avoid caffeine, which increases muscle tension, and alcohol, which increases bruxism. Educate patients about bruxism and the need to avoid clenching and grinding teeth. The key to relaxing jaw muscles is keeping the teeth slightly apart. Prescribe a soft diet for patients with ch e w ing pain, and advise patients to chew more slowly and take smaller bites. Encourage patients to stay away from large, firm food, such as carrots, apples, and stale bagels. Instruct them not to chew gum and to avoid opening the mouth wide while yawning. Teach self-massage (discllssed earlier in the chapter), jaw mobilization exercises, and proper posture . The Alexander tech­ nique is a good approach for postural reeducation.? Other home exercises include

214

Section III • Clinical Conditions

passive jaw opening with finger assist, passive jaw stretching with wooden tongue blades, and active ROM exercises. Exercise sheets and other resources can be obtained online from The TMJ Association (www.tmj.org). Exercises should be taught in the office and repeated at home in front of a mirror. Trigger point injec­ tions or spray-and-stretch of the lateral pterygoid, medial pterygoid, and masseter muscles may be useful; the reader is directed to Travell and Simons."' Preexisting anxiety, depression, and obsessive-compulsive disorders must be addressed. Any chronic painful condition, such as TMJ syndrome, will worsen any preexisting anxiety or depression. The psychologic component of TMJ can be engaged with cognitive-behavioral treatment.1 Teach stress reduction strategies and behavior modification. In appropriate settings, psychological counseling may provide benefit. Relaxation training using electromyographic (EMG) biofeedback is helpful if a referral can be found locally. Occlusal splints (mouth orthotics) are controversial.8 There are two types of splints. Night guards (also known as bruxism appliances or mouth orthotics) are worn at night. They reduce muscle tension by preventing grinding and clenching of teeth. Repositioning appliances (auto-repositional splints) are worn 24 hours a day. They realign the jaw, usually by anterior repositioning. Splints must be fitted precisely by a dentist; advise against buying ready-made versions sold in drug­ stores. Significant bite correction may require orthodontic braces or restorative work (e.g., crowns, occlusal adjustments, bridges). Osteopathic considerations aim at stabilizing the joint and restoring its mobil­ ity, strength, endurance, and function. Manipulative treatment should be gIven before and after fitting for occlusal splints and before and after restorative den­ tistry. Normalize function of the temporal bone, since the squamous portion of that bone directly affects articular function of the TMJ. Treat sphenobasilar syn­ chondrosis (SBS) compression and nonphysiologic strain patterns. Check the neck, thoracic spine, and the sacroiliac.9 Do not forget abollt the causes of scoliosis, such as short leg.Io (See Chapter 26.)

Procedures TMJ pain responds best to gentle OMT interventions. Muscle hypertoniciry can be treated with counterstrain or indirect myofascial release. Articular dysfunctions in the cervical and thoracic spine respond well to muscle energy procedures. Articular dys­ functions of the cranium should be treated with indirect OCF procedures. Extension of the fourth ventricle (EVA), perhaps the most indirect procedure available, is described later in the chapter. Indirect OCF may be subtle but may nevertheless pro­ duce acute and sometimes unexpected changes, such as ocular alterations.11 Avoid using intraoral OCF procedures directed at the sphenoid because they frequently cause further problemsY In cases of TMJ lock, two direct-action OCF procedures the Strachan procedures, described later in the chapter, are particularly useful. EV-4 Procedure

(Crania/)

Expansion of the fourth ventricle (Fig. 15.3) is the biodynamic counterpart to the CVA (compression of the fourth ventricle) procedure developed by Sutherland.13 (See Chapter 10.) The EVA is an indirect procedure that hypothetically works upon the fluid body rather than just ventricular fluids (think globally, not locally). A quick review of indirect OCF procedure may be useful: Pull out some pennies or nickels and place a coin in each palm and on each fingertip. Develop a sense for that amount of pressure. You should never feel more pressure when you apply your hands to

Chapter 15 • The Patient with Temporomandibular Joint Pain

FIGURE 15.3

215

EV-4.

someone's head using indirect OCF procedures. With the patient supine, sit at the head of the table in a comfortable position, with the seat and the treatment table at correct heights. The patient's head should lie upon the table away from the edge, per­ mitting you to rest your forearms on the table while holding the head. Con sider stretching your forearm flexor myofascia to make a light handhold easier to accom­ plish. Before taking hold of the patient's head, you should be centered--calm, men­ tally focused upon the moment, breathing from the respiratory diaphragm, seated squarely on the ischial tuberosities, with relaxed hands, arms, shoulders, and neck. With the patient supine and the practitioner seated at the head of the table, apply the Becker hold. The Becker hold, developed by Rollin Becker is a relaxed alternative to the standard vault hold.H Cup your hands, holding the patient's head like a bowl of water. As the weight of the patient's head settles, allow your hands to separate somewhat, so the bottom of the patient'S occiput rests upon the padded table. The primary objective is to apply a handhold that is totally unob­ trusive to the

patient. Imagine that your hands are two water balloons and the

head you are holding is another water balloon YOLl are trying to gently balance between your hands. When the Becker hold is properly applied, your thumbs should rest against the patient'S sphenoid bones. This facilitates your ability to sense the patient's cranial rhythmic impulse (CRT). The Becker hold also enables the perception of rhythms that are slower and deeper than the CRI, such as the slow wave (the

2- to 3-cycle wave), which moves at 2 to

3 cycles per minute.13,14

During the patient'S inhalation phase (flexion, external rotation) of cranial motion, your intention is to subtly augment a widening of the transverse diameter of the cranium. After several cycles, you may observe a prolonged inhalation phase in your subject or come to a still point, that is, neutral. After time, the rhythm returns and you can disengage during the inhalation phase. When the procedure is com­

plete, reassess the cranial motion pattern and the amplitude of the CRI.

216

Section III • Clinical Conditions

Jaw Lock Corrections

At the other end of the OCF spectrum from the EVA procedure are Strachan's pro­ cedures for correcting open lock and close lock. The procedures are described and illustrated in Fryette's classic text. IS

Jaw Lock Open Lock Correction (Example: Right-sided Open Lock)

Strachan caJled open lock (see Clinical History, earlier in the chapter) an anterior lesion, characterized by an uneven and painful forward glide on the affected side, chin deviation toward the contralateral side, and ina bility to close the mouth. Patient position: supine. Physician position: standing or sitting at the

end of the

table. Procedure

1.

Place your left hand on the left side of the patient's face such that the hypothenar eminence lies against the zygomatic arch and the fingertips extend beyond the chin. The hypothenar eminence stabilizes the patient's head throughout the proce­ dure and prevents it from rolling to the left.

2.

Place your right hand on the right side of the patient's face so the fingers wrap around the ramus of the mandible, with two fingers above the angle and two fin­ gers below the angle (Fig

3.

154A)

The first phase of the procedure is an indirect (exaggeration) procedure. As the patient relaxes, open the mouth further by applying traction with the fingers of the left hand to depress the chin while the right-hand ring finger and little finger exert forward pres­ sure on the right ramus. This passive movement relaxes the lateral pterygoid muscle.

4.

The second phase begins when maximum forward glide has been reached. With the index and middle fingers of the right hand, apply gentle cephalad pressure against the ramus. This presses the condyle into the articular surface of the temporal bone and impinges the disc at its thin central section; maintain the cephalad pressure until the

5.

procedure is complete to ensure posterior replacement of the disc. Close the jaw with the fingers of your left hand on the chin. The left hand simulta­ neously exerts pressure from left to right to cause complete posterior gliding of the right condyle and the impinged disc.

6.

When the procedure is complete, reassess the motion of the dysfunctional TMJ.

Jaw Lock Closed Lock Correction (Example: Right-sided Closed Lock)

Strachan called closed lock (see Clinical History, earlier in the chapter) a posterior lesion. IS

A FIGURE

15.4

8 TMJ: Strachan's procedures for correcting open lock (A) and close lock (8). (Reprinted with permission from Fryette HH. Principles of Osteopathic Technic. Indianapolis: American Academy of Osteopathy,

1954, 1980.)

Chapter 15 • The Patient with Temporomandibular Joint Pain

217

Patient position: supine. Physician position: standing at the s i d e of the table fac­ ing the end of the table. Procedure

1.

Instruct the patient to open the mouth enough to permit placement of your thumbs on the occlusal surfaces of the lower molars. Grasp the rami and body of the mandible (Fig.

2.

15 48)

With the left thumb, apply sufficient pressure on the right molars to gap the TMJ and stretch the restraining tissues. While maintaining this caudad pressure, use the finger grasping the right ramus to exert a forward pull to overcome the resistance of the lesion. Repeat if necessary.

3.

Assess the freedom of forward glide on the right and left sides without changing the position of the hands. With some ingenuity, this procedure can be turned into

4.

a muscle energy procedure. 16 When the procedure is complete, reassess the motion of the dysfunctional TMJ.

References 1. C ha udhary A, Appelbaum updated June 30,

2004.

J

Temporom a n dib ul a r j oint sy ndrome. Emedicine web page. Last Available

at

http : //www. emedicine. com/ neu roltopi c366. h t m .

Accesse d Ap r il 10,2005. 2. L a rso n

NJ.

Osteopathic manipulative co n trib ut ion to treatment of TMJ

syndrome.

Osteopathic M edic ine 1978;10(8):16-26. 3. Travell JG, Simons DG. Myofascial Pain and D y sfunction : The Trigger Point Manual. Vol 1. Baltimore: Williams

& Wilkins, 1999.

4. Blood SD. The craniosacral mechanism and the tempotomandibular joint.

J

Am Os teopa t h

Assoc 1986;86:512-519.

5. Magoun HI Sr. The temporal bone: rrouble maker in the head. J Am Os teopath Assoc 1974;73:825-835. 6. Royder JO. Structural influences in temporomandibular joint pain and d ysfun ction . J Am

Os teopa t h Assoc 1981 ;80:460-467.

7. B rock ban k N. Alexander Technique self di sco v ery. Alexander Tech n iq ue web page. Last u pd at ed 2004. Available at http://www.alexandertechnique.com/articles/brockbank. Accesse d

April 10,2005. 8. McArdle WD, G ol d ste in LB, L a st FC, er al. Temporom a n d ibu l a r joinr repositioning and exer­ cise p erform a nce : A do u ble- b lin d trial. Med Sci Sports Exerc 1984;16:228-233.

9. Hruby RJ The tot a l body approach to the osteopathic managemenr of remporomandibular

joinr dy sfuncti on . J Am Osteopat h Assoc 1985;85:502-510. 10. Feely RA, Marotz JE. Myofasc i a l pain dysf un c t ion and sh or t - leg sy n d rome : A retrospective

study. JAm Osteopnth Assoc 1985;85:663.

11. Weiner LB, Gra nt LA, Grant AH. Monitoring ocular changes that may accompany use of den­ tal appliances an d/or osteopathic c r an ios ac ral man i pul at ions in t h e treatmenr of TMJ and

relared problems. Cranio 1985;5 :278-285. 12. McPartland JM. Side effects from cranial-sacral treatment: Case reports and commenrary.

J Bo dyw ork Movement T hera p 1996;10 ):2-5. 13. Jealo u s JS. Emergence of Originality: a B io d y na mic view of Osteopathy in the Cr a nial Field.

2nd ed. Farmington, ME: Biodynamics/Sargent, 2001. McPartland JM, S kinner E. The bio dyna mic model of osteopathy in the cranial field. In: Liem T, ed. C ra nia l Osteopathy: P rincip l es and Practice. 2nd ed. Edinburgh: E lse v ie r Churchill Li v ings tone , 2004:653-674. 15. Fryette H H. P rin ciples of Osteopathic Techn ic. Indianapolis: American Academy of 14.

Osteopathy, 1954, 1980. 16. Freshwater Z, Gosling CM. The effect of a specific isometric muscle energy tec hniq ue on range

of opening of the temporom a ndib u lar joint: 36 [meet ing a b stract] .

a

pilot study. J Osteopath Med 2003;6(1):

CHAPTER

16

The Patient with an Upper Respiratory Infection Kenneth E. Nelson

INTRODUCTION For problems of the upper respiratory tract , osteopathic medicine offers several advantages. Diagnostic palpation reveals tissue texture change, altered structural position, restriction of motion, and tenderness indicative of somatic dysfunction. Somatic dysfunction of t he upper thoracic, cervical, and cranial regions can be wholly responsible for functional symptoms and/or pain complaints referable to

the upper respiratory tract. Deep facial pain, which may be interpreted as a symptom of chronic sinusitis, may result from high cervical somatic d ysfunction. Anterior occiput dysfunction and anterior atlas dysfunction produce ipsilateral pain in the region of the ear and behind the eye respectively. Upper respiratory symptoms may result from dysfunc­ tion involving the base of the skull and face. Tissue text ure change and tenderness without distinct alteration of structural position or restriction of motion are palpated in association with somatic d ysfunc­ tion of reflex origin, viscerosomatic reflexes. Viscerosomatic reflexes offer useful diagnostic information. A viscerosomatic pattern from the upper respiratory tract corroborates the d iagnosis of an upper respiratory tract problem. While visceroso­ matic reflexes from the upper gastrointestinal, cardiovascular, or pulmonary system may be associated with musculoskeletal complaints resembling upper respiratory pathology, their presence l eads the clinician to inquire a bout and examine areas in 218

Chapter 16 • The Patient with an Upper Respiratory Infection

219

greater depth that might otherwise be given ooly cursory consideration during evaluation of what appears to be an upper respiratory complaint. T he intensity of tissue texture change of a viscerosomatic reflex mirrors the severity of the visceral pathology responsible for it, thereby offering additional diagnostic information. Primary spinal somatic dysfunction is associated with neurologic hyperirritabil­ ity, facilitation that can affect the upper respiratory tract. Somatovisceral reflexes have their effect through the autonomic nervous system, resulting in exaggerated reactions mediated by the sympathetic or parasympathetic nervous system. Osteopathic manipulative treatment (OMT) may be employed to alleviate symptoms of somatic dysfunction that resemble those of upper respiratory com­ plaints. When treating upper respiratory infections, OMT, employed to eliminate somatovisceral activity, modulates the patient's physiology, enhancing recupera­ tion and augmenting the efficacy of any other necessary therapies. 1,2 The use of OMT to reduce the intensity and duration of illness has been repeat­ edly documented.3-6 To understand the osteopathic contribution to the diagnosis and treatment of the upper respiratory tract, it is appropriate to begin with an overview of the anatomy and physiology of the region and the effect of somatic dysfunction upon it.

Structure and Function (and Dysfunction) The upper respiratory tract is lined with ciliated pseudostratified columnar epithe­ lium, interspersed with goblet cells, columnar cells with microvilli but without cilia, and basal cells. Beneath the epithelium lie groups of serous and mucous glands. Secretions from these glands keep the epithelial surface from desiccating, humidify inspired air, and function as a first line of defense against infections. This protective coat has two layers, an outer mucous layer and an inner serous layer. The sticky mucous layer is intended to entrap particulate marter, including microorganisms . It contains immunoglobulins and the bactericides lysozyme and lactoferrin. The more fluid serous layer allows the cilia of the epithelium to sweep the secretions antero­ posteriorly through the nose. This action normally occurs at about 6 mm per minute.7 As the secretions are swept posteriorly from the nose and sinuses into the nasopharynx, they are imperceptibly swallowed. Typically, 1000 mL of mucus trav­ erses the upper respiratory tract daily.8 The nasal mucosa contains cavernous vascular tissue with large venous sinuses that under autonomic control can shrink or swell to affect the size of the nasal pas­ sages. As air traverses the nose, the nasal turbinates create turbulence and the air is cleaned, humidified, and warmed. The efficient function of the upper respiratory tract as a conduit, humidifier, conditioner, and primary defeose against infection can be impaired by somatic dys­ function. This impairmenr predisposes the region to disease and retards recupera­ tion. Somatic dysfunction does this mechanically and through its effect on the nervous system. The mechanical impact of somatic dysfunction may be direer, from altered functional relationships of the face , calvaria, upper spine, thoracic cage, and asso­ ciated soft tissues. The mechanical impact may be indirect, through the effect of musculoskeletal dysfunction upon the venous and lymphatic drainage from the head and neck. Somatic dysfunction results in increased activity within the autonomic nervous system.9 Efficient function of the upper respiratory tract is predicated upon a dynamic state of balance between sympathetic and parasympathetic control.

220

Section III • Cl inica l Conditions

Disruption of this balance results in functional symptoms with impaired efficiency of the upper respiratory tract. This chapter reviews the functional musculoskeletal anatomy, lymphatic d rainage, and innervation of the upper respiratory tract and ad dresses the effect of somatic dysfunction upon upper respiratory physiology.

The Mechanical Impact of Somatic Dysfunction The upper respiratory tract lies between the anterior bones of the cranium (basioc­ ciput, sphenoid, and frontal) and the bones of the face. The posteroinferior portion of the upper respiratory tract, the pharynx, is suspended from the base of the cranium (basioccip ut , sphenoid, and temporal bones) and the anterior aspect of the cervical spine through the precervical fascia. M echan i cal d ysf unction of the cranial base can result in cranial nerve entrapment. Resultant functional alteration of the facial and vagus nerves affects the upper respiratory tract through altered parasympa­ thetic and pharyngeal motor activity. Dysfunction of the cranial base and facial bones can have a mechanical affect directly upon the upper respiratory tract. to Manipulation of these dysfunctions is particularly effective for, although not limited to, the treat

­

ment of upper respiratory problems in infants and children. (See Chapter 8.) The lymphatic vasculature from the nose, sinuses, and pharynx dr a i n s predom­ inantly to the s u bmand ibu l ar and retropharyngeal nodes and f rom there through the d eep cervical lymphatic vessels to return to the venous circulation. Drainage of lymph from t he upper respiratory tract may be encumbered by tension from somatic d ysfunction within the precer v i ca l muscles and fascia

.

Alternating, positive-negative intrathoracic pressure associated with respiration draws lymph centrally into the venous circulation. This mechanism of Jow-pressure fluid return is an important component of the bod y's response to the soft tissue con­ gestion often encountered in upper respiratory pathology. Lymphatic drainage of the upper respiratory tract may be impaired when respiratory excursion is reduced by somatic dysfunction effecting t he thoracic inlet, thoracic spine ribs, or thora­ ,

coabdominal diaphragm. The degree of the intrathoracic pressure gradient may also be affected by increased cervical lordosis as the result of upper thoracic flexion or occipitocervi­ cal extension. Increased cervical lordosis pl aces traction upon the soft tissues of the anterior neck. This facilitates a shift from nasal to mouth breathing, with unto­ ward affect u pon t he upper respiratory tract and the patient's total physiology. T he resistance to the passage of air through the nose determines to a great extent the gradient of intrathoracic pressure during the respiratory cycle. Because mouth breathing is associated with significantly less resistance than nasal breathing, the intrathoracic respiratory pressure gradient is decreased. M outh breathing has been shown to result in decreased thoracic cage movement leading to d ecreased vital capacity, hypoventilation, decreased pulmonary circulation, and a tendency to develop respiratory acidosis. II

Nasal congestion resulting from an upper

respiratory infection

initially

increases turbulence of inspired and ex pi red air and the intrathoracic respiratory pressure gradient. This facilitates t he cleansing and conditioning of inspired air and lymphatic drainage of the upper respiratory tract, respectively; however, as nasal congestion progresses to relative obstruction, the patient shifts from nasal to mouth breathing . The cleansing and cond itioning effect of nasal respiration is lost, and lymphatic drainage of the already congested tissues is red uced. As desc r ibed previously, somatic d ysfunction can ad d to the pathophysiology of this condition.

Chapter 16 • The Patient with an Upper Respiratory Infection

221

Based u pon the premise t hat the functionally unencumbered individual pos­ sesses the physiologic basis to reestablish health in the presence of disease, the osteopathic physician works to assist the patiem toward optimal functional status. The importance of efficiem cardiovascular circulation has been stressed since the beginning of osteopathic medicine. Tn 1910, Andrew Taylor Still stared, "As you are well versed in anatomy and physiology, I feel a little timid a bout insisting on the perfect freedom of the arteries that supply and the veins that drain the glandu­

lar system of the neck. But the demand for their freedom is absolute and we must be governed accordingly. A sore tongue, sore eyes, sore nose, running ears, the nasal air passages and all the membranes r apid ly heal when you have secured per­ fect drainage. "12 The importance of t he mobilization of passive congestion was reiterated in 1923 by Miller,1.l who described lymphatic p ump procedure. He stated that the bod y develops "auto-anti-toxins" when lym phat ic circulation is enhanced. " . . . the body

simply absorbed the bacterial toxins which were present and set up a defense against them. This procedure was done regardless of the ir names or the number of kinds present. The toxins stim ulated the defensive mechanism, which in turn pro­ duced tbe auto-ami-toxin. This was the specific cure made directly against the prod ­ uctS absorbed. The cure was made, not by any drugs administered, but rather, dur­ ing the time of the (osteopathic manipulative) treatment. " The use of lymphatic

pump procedure to stimulate an antibod y response has since been documented. 2

The significance of Miller's statement can be fully ap p reciated when taken in the context of osteopathic outcomes statistics from the influenza epidemic of 191 8, in which he actively practiced. The overall fatality rate fro m influenza in the United States was conservatively between 5 and 7%. Among 110,120 i n f lue n z a patients reported as receiving osteopathic care, 257 died, a fatality rate of 0.25%, or less

than 5% of the national fatality rate. 3

The Neurologic Impact of Somatic Dysfunction Somatic dysfunction must be considered in the broader context of dysfunction of the neuromusculoskeletal system and not merely as mechanical kinks. Somatic dysfunction may reflexively result from u pper respiratory pathology and as a vis­ cerosomatic reflex provide diagnostic insight. Alternatively, primary somatic dys­ function may exert untoward sympathetic or parasympathetic effects upon the upper respiratory tract as a somatovisceral reflex. A viscerosomatic reflex results from a peripheral focus of irritation, in th i s case from the

up

per respiratory tract, that activates nociceptive general visceral affer­

ent neurons. The ongoing afferent stimulation results in establishment of a state o f irritability (facilitation) within the central nervous system. Additional afferent activity from any source results in a response to significantly less stimulus than would normally be re quire d The response may be parasympathetic, sympathetic, .

or somatomotor, depen d ing upon the area of the centra l nervous system affected.14 Viscerosomatic reflex tissue texture change and tenderness from upper respira­ tory pathology is demonstrable in the temporalis muscles. Somatosensory input from the upper respiratory tract is communicated to the central nervous system via the trigeminal nerve. Thus, it is reasonable to find viscerosomatic reflex activity in the muscles that are innervated by the trigeminal nerve. Tissue texture change and tenderness of the upper cervica l paravertebral soft tissues have also bee n described as a viscerosomatic reflex from the upper respira­ tory tract. Low-threshold afferent neurons from mechanoreceptors in the facial

222

Section III • Clinical Conditions

skin constitute a principal trigeminal i nput to induce the reflex disc harges in t he upper cervical nerves that innervate the posteri o r neck muscles. The amount of reflex cervical mu scle spasm d epe nds not only on d isplacemen t but also o n veloc­

ity of mechanical stimulation. Identified n eu rons were found to be in the m a gno ­ cel lular l ayer (lamina V) of the trigeminal nucleus caudal i s .15 It ca n therefore be

inferred that neurons in the trigeminal nucleus caud a lis , whether from the facial skin or the mucus m e mbra nes of the nose and sinuses, project m onosynapt ically to the upper cervical motor neu rons and can be involved in producti on of the up per cervical viscerosomatic reflex fro m the upper resp iratory tract The autonomic nervous system is typically th oug h t of as co n sisting of effere n t neurons. Both para sympathetic and sym pathetic n erves, h owever, contain afferent fibers. The cells of origin of these per ipheral fibers are unip olar neurons found in th e i r respective cranial and dorsa l root ganglia. T hes e sensory neurons travel with their r espect i v e parasym pat hetic and sympathet ic ne rves. 16

Parasympathetic in ne rvation of the upper res piratory tract comes from the facial n er ve . Prega nglio n ic fibers synapse in the pterygopa l atine gan glion . They reac h their d estina t ion through t he pal atine, n a sal, and pharyngeal nerves in the d istri bu tion of the trigeminal nerve. Pa rasympathetic hyperact i vity results in thin­ ning of nasal secretions and rhinorrhea. The sympath et ic innervation of the uppe r respiratory tract comes from the upper f ive (predomina ntly upper three) segments of the thoracic spinal cord. The prega n gl i on ic fibers synapse in the superio r ce rvica l ganglion. The po stgangl ion ic fibers form the carotid plexus. From th ere, they foll ow the vascular su pply or tra­

verse the pterygopa latine gan gl io n to reac h the upper respira tory tract with bran c hes of the trigeminal nerve. Somatic d ysfuncti o n of the upper thoracic spine is assoc i a ted with sp inal segmental facilitation and increased sympath etic tone to

the head and neck. A so m atov isceral reflex will result in vasospasm and thick, tenac i ous nasal secretions, impairing the topical

cleans ing of the nose and

paranasal sinuses.

TREATMENT In contempo r a ry allo p ath ic medicine upper respiratory i n fec ti ons are specifically treated o n ly once the i nfecting organ ism has been identified, and then only when the in fection is bacterial. Viral infections are treated su ppo rtively, with symptom ­ suppress ing pharmaceuticals. Bacterial infections, when recogniz ed, are typically treated empirically. The site of in fection, patient's age, and presence or absence of

concomitant illness are all taken into account, and t h e antibiotic with the h ig hest probab il ity of effectively treating the disease is prescr ibed . T h e spec i fic infectious

agent, its sensitivity, and its resistance come into cons ide rat io n only when the ini­ tial empir i c al prescr i ption proves to be ineffective. This approach to tr eat ment, spec i fic al ly desi gnated by the disease process, d iffe rs from t he approach of classi­ cal osteo pat h ic m edi c ine . As described earl ier, t h e d i st inc tive osteopa th ic appr o ac h considers the di sease to be an effect of fun cti onal compromise of the patient. lt is therefore t he osteo­ pat hic app roac h to identify and treat the causes of the functional com p ro m ise . The use of OMT to treat so matic d ys f unc ti on should enh a nce the effectiveness of the antibiotic when it is necessary and reduce or eliminate the need for symptom­ sup pressing pharmace uticals. As in all other aspects of medicine, the s p eci fic use of OMT is predica ted upon the specific diagnosis of so matic d ysfu nction. The initial examination and ma ni p ulative

Chapter 16 • The Patient with an U p per Res piratory Infection

treat m ent

a

223

re perfor med with the patient seated. This can be efficiently integrated

into the physical examination of head, eyes, ear, nose, throat (HEENT),

h ea rt, and

lungs. The thoracic spine, ribs, and clavicles should be examined for somatic dys­ function and appropriately treated. F l e x i on dys f u nction of the upper thoracic spine

results in increased cervical lordosis and a propensity for mouth breat h i ng .

Upper thoracic, upper rib, and clavicular dysfunctions can compromise lymphati c return thr o u gh the thoracic inlet.13,17,IS This adds to upper respiratory passive congestion. General restriction of motion of the thoracic spine and ribs reduces thoracic excursion, further impedes the return of and possibl y impairs the immune response.2

lymph to the general circulation,

Upper thoracic somatic dysfunction with associated spi na l facilitation results in a somatovisceral reflex with increased s y mpathet i c tone to the upper respiratory tract. The result is arteriolar co n striction

and thickening of nasal secret ions.

With the patient supine, the cervical region and c rania l mechanism may be examined and treated. Additional examination and treatment of the th or a cic inlet may also be done, and t r i ge m inal nerve stimulation and lymphatic procedures may be performed. 1 7-19 The trigeminal nerve, the sensory innervation of the upper respiratory tract, also carries sympa thetic and parasympathetic postganglionic

fibers to the upper

res pirato ry tract. Stimulation of the trigeminal nerve (as first described by B ailey in

19222°) in a s socia tio n with cervical and thoracic OMT has been demonstrated minutes to several hours

to red u c e nasal congestion and increase secretions for 30 post treatment.21

p rocedures can be used to facilitate lymphatic communication from N. J. La rso n , Chicago College of Osteopathic Medicine, Chicago, Illinois, 1971). They can be done in association with thoracic l y mphatic pump procedures. The efficient retu rn of lymph to the venous system is predicated upon unrestricted mobility of the thoracic inlet, clavicles, thoracic spine, ribs, and thoracoabdominal diaph ragm . All thoracic lymphatic pump procedu res employ this mobility to augment the intrathoracic pressure gradient b e tween inhalation a nd exhalation. A proposed sequence for the diagnosis of somatic dysfunction and the use of Anterior cervical soft tissue

drainage of the upper respiratory tract (personal

OMT when treating a patient with an upper respiratory infection is as follows:

Patient seated, diagnose and treat: 1. Upper thoracic dysfunction 2. Upper rib dysfunction 3.

Clav icular dysfunction

Patient supine, diagnose and treat: 1. Cr an i a l dysfunction 2. Cervical dy sfuncti on

Use these p r oced ur e s :

1. Suboccipital myofascial re l ease 2. Trigeminal nerve procedures 3. A n te rior neck soft tissue procedures 4. Thoracic lymphatic pump

This sequence has proved to be effective for me, but it is certainly open to mod­ ificat ion, depending upon the needs and tolerances of the patient and th e pre fer

ences of the indiv id ual practitioner.

­

Section III • C l inic a l Conditions

224

CONCLUSION The p h a rmacologic trea tme nt of co mmon n on bacte rial upper resp i r a tory com­ p laints is d i rected for the most part at suppo rtive symptom s uppressi o n , in t h e bel i ef that i f left t o their na tural course most o f these conditi ons w i ll reso l ve. T h a t is, t h e body possesse s the inh erent a b i lity t o h e a l i tself. Oste o p a t h ic m edic i n e h a s l o n g recogn ized th i s a nd o ffers specific method s to identify a nd a llev i a te d ysfunc­ t i o n th a t reta rd s t h e s e lf- h e a l i n g p roce ss. Osteop a t h ic medic i n e has much t o offer for diagnos i s a nd t reatment of the p a t i ent w i th a co mplaint refera ble to the upper respira tory tract. T h e first question is whether the compl aint is truly upper respira tory in o rigin or is a soma tic d ys­ function prod ucing symp toms refe r a b l e to the uppe r respiratory tract. Pai n com­ plaints resembli ng t h o s e of upper re spiratory pa thology m a y immediately resolve when soma tic dysfunction of the upper thora cic reg i o n , u p p e r ce rvical region, a nd head is

properly trea ted.

Soma tic dysfunct i o n m u s t, howe ver, b e consid ered in the broad er context of dysf unction of the neuromusculoskeleta l s ystem a nd not me rely as mec h a n ical ki nks. Such mechanica l impediments do h a ve significa n t effects upon the patient, b u t the u ntoward effect of soma tic dysfu nction is ofte n a l tered ne urologic activity in the pa ra sympa the tic a nd sympa the tic supply to the a re a affected by illne s s . F u r t h er, general visceral a fferent hyperactivity m a y establish and maintain cent ral dysfunctiona l areas. Th u s, s o m a tic dysfu nct i on res u l ti ng from a n upper respira ­ tory infection may result in altered physiology th a t maintains the o r i gina l problem. This chicken-and-egg d ilemma is frequ e n tly encountered in o s teopa thic medicine. Although it may initially appe a r to be pro blema t i c, it allows the clinician to employ seemingly un rela ted therap i es to address a s i ngle clinical problem. Circula tory dysfunction sho uld also be identified and tre ated . Ma n i p u l a tion of the thoracic a nd ce r v ical regions, coupled with t h e trigemin a l proced ures of Ba i ley a nd the l ympha tic pump proced u re of Miller can b e employed to facilitate the pa tient'S response to the il lness. Co u pled with a l l other availa b l e me t h o d s o f ther­ a py,

OMT o ffe rs a d ecid ed thera p e u tic adva ntage .

As d e scri bed pre v i o u sly, t h e dis tinctive o s teopa thic a pp r o a ch consid ers t h e dis e a s e to b e an e ffect of f u nctio n a l compromise o f t h e pa tient. I t is the refore the o s teopa t h ic a ppro a ch to i d e n tify a nd tre a t the ca u s e s of the functional com­ p r omis e . The use of OMT t o tre a t s o matic dysfunc t i o n in the p a t i ent with an upper r e spira t ory complaint sho u ld r e d uce or elimin a te the need for symptom­ s u ppressing pharmaceut i c a l s a nd enha nce the effectiv e ness of antibiotics when they a re nece s s a ry.

Procedures Upper Thoracic Spine (Muscle Energy) (Fig. 16.1) This procedure is employed to treat Fryette type II dysf u nction, either flexed or exte nded, in t h e uppe r thoracic spine. (For d i agnosis, see C h a p ter

3.)

Pa tient positi on: sea ted upon the sid e of the trea tment ta ble. Physician p o s i tion: standing be hind the p a tie n t.

Procedure (Examp l e: T3 F l exed, Side Bent Left, and Rotated Left U pon T4) 1.

Place the fingers of your right hand on the patient's right shoulder such that the tip of your thumb lies in contact with the right side of the spinous process of 13.

2.

Place your left hand on top of the patient's head.

Chapter 16 • The Patient with an U p per Respiratory I nfection

FIGURE 16.1

225

Muscle energy. u pp e r t h o racic spine T3 fl exed, sid e bent l eft, and rotated l eft u p o n T4.

3. With your left hand introduce side bending and rotation of the patient's head, neck, and upper thoracic spine down to your right thumb, contacting T3. This can be accomplished by positioning the head so the patient appears to be looking at the right shoulder. 4. While maintaining the side-bending rotation force against your right thumb, intro­ duce extension down to the level of 13 with your left hand by moving the patient's head so he or she appears to be looking at the ceiling (If the dysfunction is extended, you can introduce flexion in a similar way by having the patient look at the floor.) 5. With the palm of your left hand against the left posterolateral aspect of the patient's head, instruct the patient to push the head into your hand, and apply a counterforce equal to the patient's force so that you feel pressure of the spinous process of T3 against your right thumb. Experiment by moving the point of contact of your left hand, and you can subtly change the degree of side bending and rota­ tional forces applied to 13. (If the dysfunction IS extended, your left hand should contact the left anterolateral aspect of the patient's head.) 6. Have the patient maintain the contraction for 3 to 5 seconds. 7. Instruct the patient to relax while simultaneously ceasing your counterforce and wait 1 to 2 seconds for the patient's muscles to relax. 8. Engage the new barrier by further side bending right, rotating right. and extending as described previously. 9. Repeat steps 5 to 8 until the best possible increase of motion is obtained. 10. Reassess the motion between T3 and T4. Upper Rib Diagnosis and Treatment

DIA G N OSIS OF ELEVATED FIRS T A N D SECOND RIBS The upper ribs, 1 and 2, tend to demonstrate restricted bucket handle motion as their dysfunctional mechanics. That is, their anterior, or sternocostal, articulation and their posterior, or costovertebral, articulations remain relatively fixed, while the lateral por­ tion of the rib body moves up and down like a bucket handle. Upper rib dysfunctions are often positioned as elevated bucket handle mechanics. The poste ro l a te r a l aspect

226

Section III • Clinical Conditions

of the d ysf u nc ti o n al rib is in a slight ly cep h a l ad p osition and resi sts downward

pressure. It may be diagnosed as follows. P at ie n t positio n : seated upon the side of the treatment table. Physician position: standing behind the patient.

Procedure 1.

2.

3. 4. 5.

Begin by examining the upper thoracic spine for somatic dysfunction. (See Chapter 3) Segmentally related spinal dysfunction should be treated before any attempt to treat rib dysfunction. Palpate the scalene muscles laterally at the base of the neck in the triangular space superior to the clavicle, posterior to the sternocleidomastoid, and anterior to the trapezius. Spasm of the anterior and middle scalenes will elevate the first rib. The scalenes should be stretched before treatment of an elevated first or second rib. Palpate the lateral aspect of the first rib at the base of the neck. Apply downward force to the rib. An elevated first rib resists this motion. Palpate the angle of the second rib just above the superior border of the scapula. Again, apply downward force over angle of the second rib. An elevated second rib resists this motion.

F I RST RIB (HVLA) (FIG. 16.2) This pr o ced ure is employed to restore normal respiratory ex c u rs i on of the first rib to establish physiol ogic range of motion to the TlIri b 1 costovertebral joi nt Patient position: seated. Ph y sician position: sta ndi n g behind the p atien t .

.

Procedure (Example: Elevated First Rib on the Right)

The posterolateral portion of the rib is elevated and resists downward motion from above with surrounding tissue texture change and tenderness. 1. 2.

Put your left foot upon the table just to the left of the patient's pelvis. Rest the patient's left arm upon your knee. You may wish to place a pillow between the patient's axilla and your knee.

FIGUR E 16.2

Elevated first r i b

on

the r i g h t, HVLA.

Chapter 16 • The Patient with an Upper Respiratory Infection 3.

227

Place your right hand a t the base o f the patient's n eck o n the right over t h e elevated first rib such that your index finger is directed anteriorly and your thumb is directed posteriorly.

4.

Place your left forearm and hand against the left side of the patient's head and neck to splin t the cervical spine.

5.

With your left hand, use the patient's head and neck as a lever to rotate and side­ bend the cervical spine to the right down to the level of Tl and the first rib.

6. 7.

With your right, hand apply downward pressure to rib 1 on the right. Holding the patient's chest between your right han d an d left knee , translate the torso to the left to increase right side bending of the cervicothoracic Junction

8.

Instruct the patient to inhale deeply and exhale and increase the downward pres­ sure over the first rib with your right han d during the exhalation .

9.

The final corrective force is a HVLA thrust directed downward, medially, an d ante­ riorly through your right hand against the dysfunctional first rib.

10. Reassess first fib motion. SECOND R IB

(HVLA) (FIG. 16.3)

This procedure is employed to restore normal respiratory excursion of the second

joint of rib 2. behind t he patient.

rib to establish physiologic range of motion to the costotransverse Patient position: seated. Physician position: sranding Procedure (Example: Second Rib on the Right)

There is tissue texture change surrounding the angle of rib 2 on the right, which is higher than rib 2 on the left.

1 2.

Put your left foot upon the table just to the left of the patient's pelvis. Rest the patient's left arm upon your knee. You may wish to place a pillow between the patient's axilla and your knee.

3.

Place your right hand over the patient's right shoulder, with your thumb contacting the angle of rib 2. You may fin d it easier to do this if you pull the patient's right arm to the left across the patient's chest. ThiS protracts the shoulder and draws the scapula to the side.

FIGURE 16.3

Elevated second rib on the right, HVLA.

228 4.

5. 6. 7. 8.

9. 10. 11.

Section III • Clinical Conditions

Place your left elbow in front of the patient's left shoulder, with your forearm touch­ ing the left side of the neck and face. Your left hand should be holding the top of the patient's head. This arm and hand placement allows you to splint the patient's cervical spine with your left forearm With your left hand, slowly rotate the patient's head and neck to the left, disen­ gaging the rib head from the hemifacet as T1 rotates away from it. With your left hand, and forearm side bend the patient's neck to the right down to the level of rib 2. With your right hand, apply downward pressure to the angle of rib 2. With your left hand, introduce slightly more right rotation of the patient's head and neck while exerting downward pressure on the second rib with your right hand. This further disengages the rib head from the hemifacets. Stop the rotation when you sense that the rib exhibits less resistance to the downward pressure from your right hand. Instruct the patient inhale deeply and exhale and increase the downward pressure over the first rib with your right hand during the exhalation. The final corrective force is an HVLA thrust directed downward, medially, and ante­ riorly through your right hand against the angle of the dysfunctional second rib. Reassess second rib motion.

Acromioclavicular Dysfunction

ACROMIOCLAVICULAR, ANTERIOR CLAVICLE (HVLA) This procedure is e mp loyed to restore functional motion of the acromioclavicular joint. The patient often complains of shoulder pai n Upon examination, flexion of .

the g leno h u mera l joint is limited by discomfort, and the superior surface of the clavicle is rotated a n teriorly as opposed to its usual more horizontal position rela­ tive to the acromion. The po s te rior edge o f the clavicle is palpably prominent. Patient position: seated. Physician position: standing behind the patient to the

side of the dysfun ct i o n al c l avic l e

.

Procedure (Example: Anterior Clavicle on the Right) Grasp the patient's right elbow with your right hand, and using the humerus as a lever, move the elbow anteriorly, flexing the glenohumeral joint This rotates the acromion process and the superior surface of the clavicle posteriorly (Fig. 164) 2. Place your left hand with your fingers directed anteriorly over the patient's clavicle and apply downward force, holding it in the somewhat posteriorly directed position obtained in step 1. 3. Hold the clavicle with your left hand, and with your right hand, draw the patient's elbow posteriorly in an arc that incorporates shoulder abduction and extension, using the arm as a lever to align the acromion and clavicle (Fig. 16 5) 4. Reassess acromioclavicular motion. 1.

ACROMIOCLAVICULAR, POSTERIOR CLAVICLE (HVLA) This procedure is employed to restore functional motion of the acromioclavicular joint. Many patients c om pl a i n of shoulder pain. Upon examination, extension of the glenohumeral j o i nt is found to be limited by discomfort, and the superior surface of the clavicle is rotated posterio rly as opposed to its usual more horizontal position relative to the acromion. The anterior edge of the clavicle is palpably prominent. Patient position: seated. Physician position: stan ding behind the patient to the side of the dysfunctional clavicle.

Chapter 16 • The Patient wit h an U p per Respiratory Infection

FIGURE 16.4

229

St a rtin g position for a nterior clavic l e and fina l position for posterio r c l a vic l e.

Procedure ( E xamp le: Posterior C l avic l e on the Right) 1.

Grasp the patient's right elbow with y our right hand, and using the humerus as a lever, move the elbow posteriorly, extending the glenohumeral joint This rotates the acromion process and the superior surface of the clavicle anteriorly (Fig.

2.

16.5)

Place your left hand with your fingers directed anteriorly over the patient's clavicle and apply a downward force, thus holding it in the somewhat anteriorly directed position obtained in step 1.

FIGURE 16.5

Sta rtin g position for posterior clavic l e and final position for anterior c l avic l e.

Sect i o n III • C l i n i c a l Conditio n s

230 3.

H old the clavicle wit h y o u r left hand, and with y our r i ght hand draw the patient 's e l b ow anteriorly in an a rc that incorporates shoulder abd uctio n and f lexion, u si n g the arm as a lever to align the acromion and clav icle

(Fi g . 1 6 . 4)

4. Reassess acromioclavicular motion.

C E RVICAL (S O FT T I S S U E/ART I C U LAT I O N ) (S E E F I G . 1 0-2)

the s ym ­ 3.) Pa tient p o s iti o n : s u p i n e . P h ysician posit i o n : sea ted at t h e head o f t h e trea t m e n t

This proced ure is e mp l o yed to d ecrease cervical tiss u e ten s i o n and enhance metric range of motion of t h e cervical spi n e. ( For d iagnosis, see Cha p t e r ta b l e .

Procedu re 1.

With both hands, p lace t h e pads of y o u r fi n g ers over the cerv ical paraspinal tissues at the level of maximal palpable paravertebral tension.

2.

A p ply bilateral pressu re directed in an anterior and cephalad direction until y ou sense stretch of the cervical paras pinal soft tissues . A p plying more press u re will pro ­ duce a r t i c ular motion.

3.

H old the p ositi on w i th t h is degree of ap plied force un til the t issues relax .

4. 5.

Slowly release the holding fo rce, exerting care not to unload the muscles too rapid ly. Reassess availa ble cervical motion and soft tissue tension.

Repeat steps 2

t h ro u g h 4 several times, work ing u p and down the cervical spine until the desired d ecrease in p a raspinal tens i o n is achieved . As y ou become p roficient with this procedure, y o u will learn to f ocus specifically u p on asy m m etric areas of p a rasp i nal tension.

C E RVICAL (I N D I R E CT B A LA N C I N G) (FI G . 1 6 . 6)

a n d enhance the s ym ­ the cerv ica l spine. ( Fo r d i agnosis, see Cha pter 3 . ) Pat i ent p o s i t i o n : s upine . Phys i c ian p o sitio n : s e a ted a t the hea d o f the trea t m e n t

T h is proced u re is e mployed to d ecrease cervical tis s u e te n s i o n metric range of motion of table.

FIG U R E 1 6 . 6

Cervica l ind i rect ba l ancing t o decrease cerv i c a l tiss u e tensio n a n d en h a nce t h e sy m m et r i c a l range of m o t i on .

Chapter 1 6 • T h e Pat i e n t w i t h a n U p per R e s p i rato ry I n fect i o n

23 1

Proced u re (Exa m p l e : C4 Ext e n d ed, Rotated, a n d S i d e B e n t R i g h t u p o n C5)

1.

With both h a n d s , p l ace t h e p a d s of your fi n g e rs ove r t h e cerv i c a l p a ra sp i n a l t i s s u e s

2.

Al l ow

posterior a n d l a t e r a l to the l a t e r a l m a sses of C 4 . t h e p a t i e n t 's h e a d to rest u p o n t h e t a b l e , a n d w i t h both h a n d s a p p l y a nt e r i o r

fo rce to t h e poste r i o r a spects of t h e t r a n sverse p rocesses of C 4 to i n t ro d u ce exte n ­ s i o n of C 4 re lat ive to C 5 . 3.

T h ro u g h you r r i g h t h a n d , a p p l y latera l f o rce t o t h e l eft a g a i nst t h e r i g h t l a t e r a l m a ss

4.

With y o u r l eft h a n d , a p p l y a n t e r i o r fo rce a g a i nst t h e poste r i o r as pect o f t h e l eft

of C4 to i n t ro d u ce r i g h t s i d e b e n d i n g of C4 re l a t ive to C 5 . tra n sverse p rocess of C4 t o i n trod uce r i g h t rotat i o n

5.

of C4 relative to C 5 .

S e n se g e n e r a l te n s i o n b etween C 4 a n d C 5 a n d a dj u st yo u r h o l d i n g fo rce u n t i l you find t h e p o s i t i o n w h e re t h e i n terverteb ra l tissue tension in a l l p l a n es i s o p t i m a l l y red uced .

6.

H o l d t h i s p o s i t i o n u n t i l you perceive a release,

a

d ec rease of soft t i s s u e te n s i o n

between C 4 a n d C 5 .

7 . As t h e t i s s u e s release, you m a y sense that t h e C 4 seems to move b a c k i n t h e d i rec­ tion of the o r i g i n a l b a r r i e r. Yo u m a y fo l lo w t h i s s e n s at i o n , ta k i n g C4 t h ro u g h a fu l l r a n g e o f moti o n .

8.

Rea ssess m o t i o n between C 4 a n d C 5 .

C E RV I CA L POSTE R I O R ( H V LA)

(FIG . 1 6 .7)

This proced u re is e m p l oy e d to trea t articu l a r som a t i c dysfu n ction o f t h e typ ica l cerv ica l verte brae, C2 u p o n C3 to C7 u p o n Tl . The example, po s ter ior C5 right, consists of CS upon C6, fl exed ( fo rw a r d bent), rotated r ight, s i d e b e n t right ( re s t r ic te d exte n s i o n , r o t a t i o n l e ft a n d side bending left ) . Te n d e rness and t i ss u e tex­ ture c h a n ge wil l be p resent in the a rea of the right tra nsverse p rocess of C S . The i ntent of this mani pulation is to reesta blish CS e xte n s i o n , rota t ion l e ft, a n d s i d e ben d i n g left. ( For diagnosis , see Chap te r 3 . ) -

FIGURE 1 6.7

Ce rvica l : post e r i o r HVLA to treat t y p e I I a rt i c u l a r s o m a t i c dysf u n ct i o n o f the typica l c e rvica l ve rte b r a e .

232

Sect i o n III • C l i n ica l Conditio n s

T h e p a t i e n t l i es s u p i ne u p o n t h e tre a t m e n t ta b l e , a n d t h e p h y s i c i a n stands or sits at the head of the t a b l e .

Procedure

1. C ra d l e t h e p a t i e n t 's h e a d a n d n e c k w i t h both of y o u r h a n d s . C o ntact t h e poste­

2.

3. 4.

5.

6.

rior c o m p o n e n t of C 5 o n the r i g h t with t h e l ate ra l a s pect of t h e p rox i m a l p h a ­ l a n x of yo u r r i g h t i n dex f i n g e r. W i t h t h e f i n g e rt i ps o f yo u r l eft h a n d , contact the a rea of t h e a nte r i o r c o m p o n e n t l a tera l ly over the t i p of t h e l eft t r a n sverse p rocess of C 5 . U s i n g you r ri g ht I n dex fi nger a s a f u l c r u m , i n tro d u ce exte n s i o n of the cervica l spi ne between C5 and C6. T h i s exte n s i o n b rea k m u st b e m a i nta i ned t h ro u g h o u t the rem a i n d er of t h e p roce d u re . With both h a n d s , i n trod u c e l eft s i d e b e n d i n g of ( 5 u po n C 6 t r a n s l a t i n g C 5 t o t h e right. Rotate the h e a d a n d n e c k to t h e l eft d o w n to a n d i n cl u d i n g C 5 u n t i l te n s i o n is f e l t to a c c u m u late between C 5 a n d C 6 a n d t h e rotat i o n a l b a r r i e r i s reached . The f i n a l corrective fo rce is a q u i c k , gentle, s h o rt rotati o n a l movement t h ro u g h yo u r r i g h t i n dex f i n g e r, d i rected i n a n a n te ros u pe r i o r d i rection towa rd t h e patient's r i g h t eye a l o n g t h e p l a n e o f t h e a rti c u l a r fa cets between C 5 a n d C 6 . Reassess m oti o n between C 5 a n d C 6 .

ATLAS POSTE R I O R (M U SC L E E N E RGY) ( F I G . 1 6. 8)

to treat a rtic u l a r s o m a t ic d ysfu n c t ion of C l , the a t l a s , the a x i s to esta blish symmetric rota t i o n o f t h e a t l a s u po n the a x i s . ( F o r d i agnosis s e e C h a pter 3 . ) T h e patient l i es s u p i n e u p o n t h e tre a t m e n t ta b l e , a n d t h e p hys i ci a n s ta n d s o r s i ts a t t b e head of tbe ta b l e .

T h i s proced ure is e m p l oyed re la tive to C 2 ,

,

FIGURE 16.8

M us c l e e n e r g y f o r poste r i o r a t l a s o n t h e r i g h t .

Cha pter 1 6 • The Patient with an Up per Res p iratory Infection

233

P rocedure (Exa m ple: Posterior Atlas R i g ht, Cons i sts of the Atlas Being Rotated to the Right, Restricted Rotation to the Left u pon the Ax is) Tend ern ess a n d tiss u e tex ture chan ge wil l be present in the s u boccipital regio n o n the ri ght. The i nten t of thi s m an ip u l atio n is to rees tablis h atl as rotation to the l eft. 1 . B egin by cra dli n g the patient's occipu t and u pper cervica l spine in yo u r rig ht ha n d, with yo u r fingers poin ti n g toward the left a n d yo u r thu m b in con ta ct with the right s i de of t he pati ent's head p o i n ting toward the patient's cheek . 2. The la teral aspect of you r right index finger shou l d co n tac t the posterio r ri ght trans­ verse process of the atl as a nd mu st remai n in this positio n thro u ghou t the rem ain­ der of the procedu re. 3 . Ho l d the l eft si d e of the patien t's head in yo u r left ha nd w ith yo u r f in gers exten ded downw ard o ver the l eft side of the neck s u c h th at yo u r f in gerti ps can p alpate the a rea betw een the atl as a n d axi s . 4 . L ift the head an d n eck sli ghtly from th e table an d intro du ce a sma l l a mo u nt o f exten­ sion between the atlas a n d axis u sing the I nd ex fin ger of yo u r ri ght hand as a f u lcru m. S. With both ha n ds , ro ta te th e pa tient's head a nd atl as to the l ef t u pon the axi s to engage the ro tatio n al ba rrier. 6 . M ain ta in ten s ion a gai n s t th e d ysfu nctiona l barrier and i nstru ct the pa ti en t to gen tly rota te the h ea d ba c k tow ard the righ t agai n s t yo u r ho lding fo rce fo r 3 to S s eco nds . 7. Pause for 1 t o 2 s econds, a n d then rota te the hea d fu rt her to the l eft t o en gage t he n ew ba rrier. 8. R eassess a tl a n toax ial motio n . Re peat s teps 6 a n d 7 un til the b es t possible in crea s e o f mo ti o n is obtain ed.

ATLAS ANTERIOR ( H VLA) ( FIG . 1 6 .9) Th is p roced u re i s e m p l oyed to trea t a r tic u l a r som a tic d ys function of C l , the a t las, re l a t i ve to C2, the a xis , to esta b l ish sym m e tric rota tion of the a t l a s upon the a x i s . The p a t i ent m a y compl a i n of p a i n b e h i n d t h e eye o n the d ysf u n c tio n a l si d e . ( For diagnos i s , see Chapter 3 . ) P a t ie n t pos i tion : s u p i n e . P h ys i c i a n pos i tion: s ta n d i ng or sea ted a t the head of the ta b l e .

F I G U R E 1 6. 9

HVlA f o r a n t e r i o r a t l a s o n t h e l e ft .

234

Sect i o n III • C l i n i ca l Cond itions

Proce d u re ( E xa m p l e : Anterior At las Left)

The a t l a s is rotated to t h e rig ht, restricted rota t i o n to t h e l eft, u p o n the a x i s . Ten d e r n ess a n d tissue text u re c h a n g e w i l l b e p resent i n the s u bocc i p i t a l reg i o n on t h e l eft . 1.

2. 3. 4.

5.

C ra d l e t h e p a t i e n t's h e a d with both of yo u r ha nds s u c h t h a t t h e t i p s of yo u r i n dex a n d m i d d l e f i n g e rs exte n d ca u d a l l y b e n eath the occ i p ut to conta ct the t r a n sverse p rocesses of the atlas b i l atera l l y. The i n dex f i n g e r of each h a n d s h o u l d be positioned to c o n tact J ust a nt e r i o r a n d t h e m i d d l e f i n g e r j u st poste r i o r to the tip of the trans­ ve rse p rocesses of the atlas. The t r a n sverse p rocesses of the a t l a s a re p a l p a b l e b i l at­ e ra l ly J u st poste r i o r and s l i g h t l y ce p h a l a d to t h e a n g l e s of the m a n d i b l e . W i t h t h i s h a n d p l a ce m e n t , a p p ly tract i o n w i t h y o u r f i n g e rt i p s s o t h a t you ca n h o l d t h e a t l a s u p a g a i nst t h e occi p u t , a n d t h e two w i l l m ove a s a s i n g l e u n it . W i t h both h a n d s rotate t h e p a t i e n t 's occ i p u t a n d a t l a s t o t h e l eft t o e n g a g e t h e dys­ f u n ct i o n a l rotatio n a l b a r r i e r between t h e a t l a s a n d a x i s . U s i n g yo u r l eft h a n d , a p p ly a poste r i o r (rota t i o n l eft) h i g h -ve l ocity, low-a m p l i tu d e t h rust t h ro u g h t h e t i p of yo u r i n dex fi n g e r a g a i nst t h e a nte r i o r aspect o f t h e l eft t ra n sverse p rocess of t h e atl a s to rotate the atlas to t h e l eft u pon the a x i s . W h e n the p roced u re is co m p l ete, reassess t h e m o t i o n between the a t l a s a n d a x i s .

O C C I P U T POSTE R I O R ( M U SCLE E N E R G Y ) ( F I G . 1 6 . 1 0) This p rocedu re is employed to tre a t artic u la r s o ma tic d ysfu n c tion of t h e o cc i p u t re l a ti ve t o C l , the a t l a s , t o esta b l i s h symmetric m o t i o n be tween t h e occ ipu t a nd the a tl a s . (For d iagnosis, see Chapter 3 . ) P a t i e n t position: s u p i n e . Physicia n p o s i t i o n : s ta n d ing o r s e a ted a t t he hea d o f the ta b l e . Proce d u re ( Ex a m p l e : Occi put Post e r i o r on t h e R i g ht)

T h e occ i p u t i s rotated to the r i g h t a n d side-bent to the l eft u pon the atlas, with tissue text u re c h a n g e and t e n d e r n ess i n t h e s u bocci p i ta l reg ion o n the r i g h t . 1.

C ra d l e t h e p a t i e n t 's h e a d i n yo u r r i g h t h a n d w i t h yo u r f i n g ers p o i n t i n g towa rd t h e l eft a n d yo u r t h u m b i n contact with the r i g h t s i d e o f t h e patient's f a c e p o i n t i n g towa rd t h e c h e e k .

FIGURE 1 6 . 1 0

M u sc l e energy fo r poste rior occiput o n t h e r i g h t .

Chapter 1 6 • The Patie nt with an U p per Res pirato ry I n fectio n 2.

235

P l a ce the metacarpop h a l a n ge a l j o i n t of t h e i n dex f i n g e r of yo u r r i g h t h a n d i n c o n ­ tact w i t h t h e postero l a t e r a l a s p e ct of t h e p a t i e n t 's occ i p u t a n d exte n d t h e o cc i p u t over yo u r i n dex f i n g e r T h i s esta b l i s h es a n exte n s i o n b re a k between t h e occi p u t a n d t h e a t l a s a n d h e l p s l oca l i ze t h e s i d e - b e n d i n g a n d rotati o n a l f o rces i n t ro d uced t o t h a t a re a d u r i n g t h e rest o f t h e p roced u re . T h i s exte n s i o n b rea k m u st be m a i n ta i n e d t h ro u g h o ut re m a i n d e r o f t h e p roced u re .

3.

W i t h yo u r left h a n d , cra d l e t h e left s i d e o f t h e p a t i e n t 's fa c e .

4.

W i t h both h a n d s , rotate t h e p a t i e n t 's h e a d to t h e l eft u n t i l t h e rota t i o n a l b a r r i e r is e n g aged betwe e n t h e occ i p u t and the a t l a s .

5.

I nt r o d u c e s i d e b en d i n g t o t h e r i g h t betwe e n t h e occ i p u t a n d t h e a t l a s by s l i g h t l y l i ft i n g t h e p a t i e n t's h e a d fro m t h e t a b l e a n d a p p l y i n g a m i l d l atera l tra n s l a to ry f o rce downwa rd (to t h e p a t i e n t 's l eft) t h ro u g h yo u r right i n d ex f i n g e r.

6.

M a i nt a i n t e n s i o n a g a i n st t h e dysf u n cti o n a l b a r r i e r a n d i n s t r u ct t h e p a t i e n t to g e n ­ t l y rotate t h e h e a d b a c k t o t h e r i g h t a g a i nst yo u r h o l d i n g fo rce f o r 3 t o 5 seco n d s .

7.

Pa use f o r 1 to 2 sec o n d s a n d t h e n rot ate t h e h e a d f u rt h e r t o t h e l eft a n d s i d e - b e n d to t h e r i g h t ( l at e r a l t ra n s l a t i o n to t h e l e ft) t o e n g a g e t h e new b a r r i e r.

8.

Re assess occ i p itoa t l a n t a l moti o n . R e p e a t steps 6 a n d 7 u n t i l t h e best possi b l e i n crease o f m o t i o n

IS

o b ta i n e d .

OCC I PUT ANTE R I O R (M U S C LE E N E RG Y) (F I G . 1 6 . 1 1 ) T h i s p roced u re i s e m p l o y e d to tre a t a rti c u la r s o m a t i c dysfu ncti on o f the occip u t re l a t i v e to C l , the a tl a s , to esta blish s y m m e t r i c m o t i o n between t h e occ i p u t a n d t h e a t l a s . ( F or d i a g n os i s , see C h a pter 3 . )

Pati e n t p o s i ti o n : s u p i n e . Phys i c i a n p ositi o n : sta n d ing o r sea ted a t t h e head o f t h e ta bl e .

Proced ure (E xample: Occ i p u t A nterior o n the R i g ht) The occi p u t is rotated to the l eft and s i d e - b e n t to t h e r i g h t upon the atlas, w i t h t i s s u e text u re c h a n g e a n d t e n d e r n e ss i n t h e s u b o c c i p ita l reg i o n o n t h e r i g h t .

1.

G r asp t h e r i g h t s i d e of t h e p a t i e n t 's f a c e i n yo u r r i g h t h a n d i n s u c h a w a y t h a t t h e c h e e k rests i n yo u r p a l m a n d yo u r f i n g e rs c u p t h e p a t i e n t 's c h i n .

FIGURE 1 6 . 1 1

Muscle energy for anter i o r o cc i p u t on t h e r i g h t .

236 2.

Section I I I • Clinical Condit ions P l a ce yo u r l eft h a n d tra n sverse ly ben eath t h e patient's cervico-occ i p ita l J u n ction so that you r i n dex f i n g e r is over t h e tip of t h e transverse p rocess of t h e atlas on t h e right and you r t h u m b is over t h e t i p of the t r a n sverse p rocess of t h e atlas o n the left . The m etaca rpo p h a l a n g e a l J o i n t of yo u r l eft i n d ex f i n g e r s h o u l d be touch i n g t h e atlas on the right side of the m i d l i n e . This h a n d p l a ce m e n t wi l l a l l ow you to hold the atlas so t h at yo u can move t h e occ i p u t from a b ove with force a p p l ied t h ro u g h yo u r r i g h t h a n d .

3.

W i t h b o t h h a n d s i n p o s i t i o n , rota te t h e p a t i e n t's h e a d a n d c e rv i c a l s p i n e to t h e r i g h t so t h a t t h e dysf u n ct i o n a l r i g h t occ i p itoat l a n t a l a rt i c u l a t i o n is pos i t i o n e d towa rd t h e s u rface of t h e t reat m e n t t a b l e .

4.

I n t rod uce a s l i g ht a m o u n t o f o c c i p itoatl a nt a l exte n s i o n w i t h yo u r r i g h t h a n d b y h o r­ i z o n t a l ly t ra n s l a t i n g t h e p a t i e n t 's h e a d p oste r i o r l y a g a i n st t h e h o l d i n g fo rce of yo u r l eft h a n d . T h i s w i l l i n c rease a rt i c u l a r t e n s i o n a n d loca l i ze t h e p roced u re to t h e occi p­ i t oa t l a n t a l a rt i c u l a t i o n . T h e a sy m m e t r i c p l a ce m e n t of yo u r r i g h t h a n d upon the r i g h t s i d e o f t h e p a t i e n t 's face a n d t h e metaca r p o p h a l a n g e a l j o i n t of yo u r l eft i n d ex f i n ­ g e r c o n tacti n g t h e a t l a s o n t h e r i g h t w i l l a l so i n t ro d u ce rota t i o n o f t h e occi p u t to the r i g h t u p o n t h e a t l a s .

5.

I n t ro d u ce s i d e b e n d i n g t o t h e l eft betwe e n t h e occi p u t a n d a t l a s b y a p p l y i n g a l a t ­ e r a l t r a n s l a t i o n t o t h e r i g h t with you r l e f t h a n d wh i l e a p p l y i n g t r a ct i o n i n a c e p h a ­ l a d d i rect i o n w i t h yo u r r i g h t h a n d . Th i S ste p , I n com b i n at i o n w i t h s t e p 4 , wi l l e n g a g e t h e dysf u n ct i o n a l b a r r i e r between t h e oc c i p u t a n d a t l a s .

6.

H a ve t h e p a t i e n t f l e x t h e occ i p u t u p o n t h e a t l a s by p u l l i n g t h e c h i n toward t h e c h est for 3 to 5 sec o n d s . T h i s is a p p l i e d as an i s o m e t r i c c o n t ract i o n a g a i nst t h e h o l d i n g fo rce o f yo u r l eft h a n d u p o n t h e atl a s .

7.

P a u s e f o r 1 t o 2 sec o n d s , a n d t h e n rotate the h e a d f u rt h e r t o t h e r i g h t a n d s i d e ­

8.

Rea ssess occi p i t o a t l a n t a l m ot i o n a n d rep e a t steps 6 a n d 7 u n t i l the best poss i b l e

b e n d to t h e l eft, as i n steps 5 a n d 6 to e n g a g e t h e n ew b a r ri e r. i n c rease of m o t i o n is obta i n e d .

Occipitoa tlantal (Myofascial Release, Direct) (Fig.

1 6. 12)

This proced ure is e m pl oye d for genera l trea tment of arti c u l a r a n d soft tissue m y o fa s c i a l somatic d y s fu n ct i o n of the occ i p u t relative to C l , the a t l a s , to r e d u c e myofa sci a l te n s i o n a n d esta bl i s h symmetric m o t i o n between t h e occ i p u t a n d t h e a t l a s . ( F o r d i a g n o s i s , s e e Ch a p ter 3 . )

FIGU RE 16. 12

Occ i p itoat l a ntal d i r ect myofasc i a l r e l e a s e to treat a rt i c u l a r a n d soft tissue a n d myofas c i a l a n d so m a t i c dysfu n ct i o n a n d to esta b l i s h sy m m etric mot i o n between t h e occ i p u t a n d a t l a s .

C h a pter 1 6 • The Patie nt with an U pper Res pirato ry I n fect io n

237

Pa tient p o s i ti o n : s u p i n e . P h y s i c i a n positi o n : sta nd i ng o r s e a t e d a t t h e h e a d o f the table.

Pro cedure 1.

C ra d l e t h e p a t i e n t 's h e a d with both of yo u r h a n ds s u c h t h a t t h e t i p s of yo u r f i n g e rs a re at t h e level of t h e ce rv i co-occ i p i t a l j u n cti o n .

2.

Flex you r f i n g e rs so t h at yo u r f i n g e rt i ps a re d i rected a n t e r i o r l y a n d cep h a l a d between t h e p a t i e n t 's occi p u t a n d a t l a s . Th i s i s t h e h o l d i n g p o s i t i o n f o r t h e re m a i n ­ d e r o f t h e p roce d u re . I n t h i s p o s i t i o n yo u r f i n g e rs w i l l p rov i d e a f u l c r u m betwe e n t h e p a t i e n t 's occi p u t a n d a t l a s a n d p rov i d e u pw a r d tract i o n a g a i n s t t h e occi p u t .

3.

A l l ow t h e wei g ht of t h e p a t i e n t 's h e a d to rest u p o n t h e t i p s o f yo u r flexed f i n g e r s .

4.

A s t h e s u b o cc i p ita l t i s s u e re l axes. y o u m a y a lt e r t h e d i rect i o n of t h e a p p l i e d p res­ s u re a g a i nst a reas of persi ste nt t i s s u e te n s i o n .

5.

Reassess. The p roced u re i s f i n i s h e d w h e n the s u bocci p i t a l soft t i s s u e s a re re l a x e d a n d occi p i toat l a n tal a rti c u l a t i o n h a s u n rest r i cted mot i o n .

Trigeminal Nerve Procedure of Bailey20 (Figs.

1 6. 13- 1 6. 1 5)

T h i s proced u re e m p l o y s c o u n t e r i r r i t a t i o n to open the n a s a l p a s s a ge s a n d produce d r a i n a ge o f t h e s i n u s e s . D ig i t a l p ressure a p p lied over the cutaneous, s u pra or b i t a l , i n fr a o r b ita l , a n d m e nta l b r a n c h e s o f t h e trigemi na l ne rve p r o d u c es r e flex v a socon­ s t r i ct i o n in the m u co us m e m b ra n e s o f the u p pe r res p i r a t o ry tract. This w i l l res u l t i n tra n s i e n t d ec o n ge s t i o n o f t h e n a s a l mucosa wi t h res u l ta n t openi ng o f the o r i fices of the para n a s a I s i n u se s . P a t i e n t positio n : s u p i n e . P h y s i c i a n po s i t i on : sta n d i ng or s e a te d a t the h e a d of the ta b l e .

Procedure 1.

P l a c e t h e p a d s of yo u r i n dex fi n g e rs b i l ate ra l ly over o n e of t h e t h ree pa i red b r a n c hes of t h e t r i g e m i n a l n e rve . Sta rt with t h e s u p ra o r b i t a l n e rves and prog ress to t h e i n fra­ o r b ita l and mental b r a n c h e s .

FIG U R E 1 6 . 1 3

D i g i ta l press u re over t h e s u p ra o r b ita l b r a n c h e s o f t h e t r i ge m i n a l n e rv e t o p r o d u c e a r e f l e x vasoconstrict i o n i n t h e m u c o u s m e m b r a n e s of t h e u p p e r res p i ratory t r a ct .

238

Secti on I I I • C l i n i c a l C o n d i t i o n s

FIGURE 1 6 . 1 4

D i g it a l press u re o v e r t h e i n fra o r bita l b r a n c h es o f t h e t r i g e m i n a l n e rve to p r o d uce ref l e x v a s o c o n st r i ct i o n i n the m u c o u s m e m b ra n es of the u p p e r r e s p i r a t o ry t r a c t .

Apply grad u ally in cr easing gentle pressu re. When maxi mu m pressu re is appli ed , h ol d it f or 3 0 sec on d s an d sl owly release . Acute tissu e textu re c hange is pa lpable ove r the su praorbital and maxil lary nerves in the presenc e of frontal and maxillary sinu sit is, respect ively. 3 . Percu ss over t h e fronta l a nd maxillar y si nu ses. Percu ssing over the sin u ses can pro­ d u ce abr u pt d r ain age of a m u c u s-fil led sinu s if the orifice has been opened It c a n b e likened to hi ttin g the bott om o f a cat su p bott le. C onseq u e n t l y, t h e pati ent shou ld be warned that they might su d d enly experien ce a copiou s am ou n t of post ­ nasal mu cu s. 2.

FIGURE 1 6 . 1 5

D i g i ta l press u re over t h e m e nta l b r a n c h e s of t h e t r i g e m i n a l n e rv e t o p r o d uce ref l e x v a s o c o n st r i ct i o n i n t h e m u c o u s m e m b r a n e s of t h e u p p e r res p i ratory t r a c t .

Cha pte r 1 6 • The Pat i ent with an Upper Re s p i ratory Infect i o n

FIGURE 1 6 . 1 6

239

F a c i a l eff l e u r a g e t o red u ce co n g est i o n o f t h e s u p e rf i c i a l soft t i ss u e s a n d e n h a nce l y m p h at i c d r a i n a g e o f t h e f a c e .

FAC I A L E F FLEURAG E ( FIG .

1 6 . 1 6)

T h i s proced u re is e m p l oy e d to red uce congesti o n of the s u pe r fi c i a l s o ft tis s u es a n d e n h a nce l y m p h a tic d r a in a ge of t h e fa c e . The stro k i ng p roce d u r e m a y a ls o be i n c or­

p o r a ted i n to t h e t r i ge m i n a l sin u s p r oc ed u r e of B a i l e y

descri bed previ o u s l y.

P a t i e n t p os i t i on : s u p ine . P h y s i c i a n po s i t i o n : sta n d i n g or s e a t e d a t the h e a d of

the

ta b l e .

Proced ure

f o r eh e a d

1.

P l a ce the pads of you r i n d ex f i n gers b i l a t e r a l ly over the p a ti e n t s

2.

A p p ly m e d i a l to l a t e r a l p ress u re d s tr ok i n g. T h i s is i n t e n d e d to m ove interstit ia l fluid

3.

of the soft tissu es of t he face i n to the s u p e rf i c i a l ly m p h at i c d ra i n a ge R e p e a t steps 1 a n d 2 over t h e c h e e k s a n d chi n

'

.

.

.

S U BMA N DIB ULAR P ERCU SSION (FIG . 1 6 . 1 7)

T h i s proced u r e is e m p l oyed to reduce congestion of the s u p e rfi ci a l soft t i ss u e s a n d l y m p h a ti c d r a i nage o f t h e fac e . P a t i e n t p o s i t i o n : s u p i n e . P h ys i c i a n positi o n : s t a n d i n g or s e a t e d a t the h e a d o f

en hance

t h e ta b l e .

Proced u re H o l d the p a t i e n t 's c h i n wit h y o u r l eft h a n d , a p p ly i n g u p wa rd p ress u re b ein g s u re t h e patient's u p p e r a n d lower t eeth a re in c ontact to avo i d chip p i n g them. 2 . P l a c e t h e t i p s of the f i n gers of y ou r ri ght h a nd so t h a t they con ta ct th e s k i n over t he s u bmen tal reg i on j ust med i a l to t h e b ody of the ma n d i b le on t he right . 3 W i t h yo u r r i g h t f ingertip s, a p p l y a ra p i d ly osci l la t i n g p e rcu ss i ve force a ga ins t t h e s u b m enta l s oft ti s s u e s 4. R epea t s t e p s 1 t h r ou gh 3 on the lef t s id e

1.

.

.

A N TERIOR N E CK SOFT TISSUE, LY M PH ATI C P R OCE DURE T h i s p r oce d u r e is e m ployed to reduce congestion of t h e soft t i s s u es a nd e n ha nce

lym phatic d r a i n a g e o f the n ec k . T h e fa s c i a o f the neck m a y be c o n s i d ered as an

240

Section III • C l i n i ca l Co n d i t i o n s

FI G U R E 1 6 .1 7

S u b m a n d i b u l a r p e r c u ss i o n to red u c e c o n g e st i o n of t h e s u p e rf i c i a l soh t i s s u e s and e n h a n c e l y m p h a t i c d r a i n a g e of t h e face.

external c y linder t hat sp l its to enclose the ste r nocleidomastoid and trapezius m us­ cles and surrounds the d eep fascia that invests the d e eper struct u r es of t he neck and fills the space between them. The superfic ial lymphatic drainage of the head lies outside the external fasc ial c yl i nde r and must pass through it to d rain into the d eep cervical lymphatic vessels. Th e first part of t his proced ur e is d irected at mov­ ing ly mph from the supe rficial to the d eep lymphatic v essels. The second part of this procedure is d i rected at the deep structures. Patient position: sup i n e . Physician position : stand i ng or sea ted at the head of the table . Proce d u re Mo vin g Lymph from th e Supe rficia l to th e Deep Lympha tic Vessels

1.

G ra s p t h e pat i e n t s u c h t h a t both of yo u r h a n d s t o u c h t h e poste r i o r a n d l a tera l

2.

A p p l y ce p h a l a d tract i o n a n d rota t i o n of t h e n e c k a lte r n ately with y o u r h a n d s s u c h

asp ects of t h e i r h e a d a n d n e c k b i latera l l y. t h a t you stretch t h e m ost s u p e rf i c i a l t i s s u e s of t h e n e c k . Decon gesting th e Deep Cervica l Structures (Fig. 1 6. 1 8)

1.

G ra s p t h e p a t i e n t 's hyo i d b o n e betwe e n t h e t h u m b a n d i n dex f i n g e r of yo u r d o m ­

2.

A p p l y g e n t l e a l t e r n a t i n g l a t e r a l f o rces t o d i s p l ace t h e hyo i d t o t h e l eft a n d r i g h t of

inant h a n d . the m i d l i n e . Avo i d co m p ress i n g the ca rot i d a rte r i e s .

3.

M ove y o u r h a n d i n ferio rly, g rasp t h e thyro i d ca rt i l a g e of t h e l a ry n x , a n d repeat t h e a l t e r n a t i n g l a tera l fo rces i n s t e p 2 . The p a t i e n t m a y b e sta rt l e d by n o ise p rod uced a s t h e poste r i o r c a rt i l a g es of t h e l a ry n x m ove o v e r st ructu res post e r i o r to t h e m . Do n o t a p p l y t h i s p roce d u re to t h e c r i c o i d c a rt i l a g e o r t r a c h ea . It wi l l i n i t i a t e a co u g h ref l e x .

4.

R e a ssess a n t e r i o r c e rv i c a l soft t i s s u e t e n s i o n .

Thoracic Lymphatic Pump (Fig. 1 6. 19) This procedure is employed to facilitate lymphatic a nd venous return to the heart and reduce pulmonary congestion through the introduction of abrupt negative intratho­ racic pressure and improved thorac ic cage mobility. It is important to be certain that

C h a pter 1 6 • The Pat ient wit h a n U p per Res p i ratory I nfect i o n

FIG U R E 1 6. 1 8

241

A n te r i o r n e c k soft t i ss u e t o d e c o n g est t h e d e e p c e rv i ca l st r u ctu res.

the patient d oes not have a nyth i ng l o ose in the mo uth ( e . g . , food , gum, d e n tu r e s) to

p r e ve n t a s p i r a t i on as a resu lt o f t h i s proced u re . This procedure i s i na p propria te for obstructive p u l m o n a ry d i sease, such as asthma o r e m p hy se m a , i n w h ic h t h e exp i ra t o ry phase o f resp i r a t i o n is co m p romised . F o r a p r o c ed u r e t o tre a t these ind i v i d u a l s , s e e Ly mphatic P u m p : O s c i l l a t o r y Mod i fication, Cha pter 1 9 . P a t i e n t p o s i t i o n : s u p i n e . Physic i a n po s i t i o n : s t a n d i n g a t the h e a d of the t a b l e . p a tients with c h r o n i c

Procedure 1.

2.

P l a ce yo u r h a n d s p a l m down u po n t h e patient's a nt e r i o r ch est wa l l over the ste r­ n u m and pectora l m uscles . For fem a l e p a t i e n ts, the h a n d s s h o u l d be p laced between t h e breasts. S t r a i g hten yo u r arms and lock yo u r e l bows .

FIG U R E 1 6 . 1 9

Tho r a c i c l y m p h a t i c p u m p to fa c i l itate l y m p h a t i c a n d v e n o u s ret u r n to the h e a rt and red uce p u l m o n a ry c o n g e st i o n by i ntrod u ct i o n of a b r u pt n eg a t i ve i nt r a t h o r a c i c p r e ss u re a n d i m proved t h o r a c i c ca g e m o b i l ity.

242

Section III • C l i n i c a l Co n d i t i o n s

3.

I n struct t h e pat i e n t to e x h a l e i n a re laxed fa s h i o n t h ro u g h t h e o p e n m o u t h .

4.

Lea n u p o n t h e a nte r i o r thora c i c cage with yo u r h a n d s a n d fo l l ow the c h est i nto exha­ l at i o n . Towa rd t h e e n d of exh a l at i o n , q u i c k l y rem ove yo u r hands from the c h est wa l l .

A resu lta n t i n s p i rato ry gasp w i l l occ u r a s a res u l t o f t h e reco i l o f t h e t h o racic cage. 5.

Repeat seve r a l t i m es accord i n g to p a t i e n t to l e r a n ce .

Refe rences 1 . W h i ti n g CA . I n ve s t i g a t i o n of the P h a gocytic Index. B u l letin 1. A . T. S t i l l Resea rc h I n s t i t u t e . C i n c i n n a t i , O H : M o n fo rd , 1 9 1 0 ; 6 1 -6 3 . 2 . Measel J W Jr. T h e e ffec t o f t h e l y m ph a ti c p u m p u p on t h e i m m une response: I. P re l i mi na r y stud ies on t h e an t i b o d y response to p n e u m ococca l pol ysacch a r i d e as s a y e d by bacter i a l a gg l u t i n a t i o n a nd passive hemagg l u t in a t i o n . J Am Oste o p a t h Assoc 1 9 8 2 ; 8 2 ( 1 ) : 2 8 -3 1 . 3 . S m i t h R K . O n e h un dre d t h o u s a n d cases o f i n fluenza w ith a d e a t h r a te o f o ne -fortieth o f t h a t o ffic i a l l y re porte d u n d e r conven t i o n a l medica l t r e a t m e n t : 1 9 1 9 . J A m O ste o p a t h Assoc ­

2 0 0 0 ; 1 00 : 3 20-3 2 3 . 4 . Pea r so n W M , Hines N H , P o l ovich C A , e t a l . S y m p os i u m on resp i r a r o r y d i seases: Et i o l o gy, pa t h o l o gy, d i agn o s is, a n d trea t m e n t . J Am O s te o pa t h As soc 1 9 3 8 ; 3 6 : 3 0 7-3 3 1 . 5. Purse F M .

C l i n ic a l e va l u a t i o n

of o ste o pa th i c m a n i pu l a t i ve therapy in

m e a s l e s . J Am

Ost eo pa t h Assoc 1 9 6 1 ; 6 1 : 2 74-2 76. 6 . Sch m idt Ie. O ste o p a t h i c ma n i p u l a t i v e th e ra py a s a pri ma r y fa cror i n the m a n ag em en t o f u ppe r, m i d d le, a n d p a ra re sp i ra t o ry i n fect i o n s . J A m O sr e o pa r h A s s o c 1 9 8 2 ; 8 1 : 3 8 2-3 8 8 . 7 . W i l l i a m s PL, e d . G ra y 's A n a to m y. 3 8 th e d . E d i n b u rg h : Ch u rch i l l L i v i n g stone , 1 9 9 5 ; 1 6 3 4 . 8 . Pr oc r o r O F. P h y s i o l ogy o f the u pper a i rw a y. I n : F e n n W O , R a h n H , e d s . H a n d book of P h y s i o l ogy. Sec. 3 , Respira t i o n , v o l L Wa sh i ng r o n : America n P h y s i o l ogica l Soc i e ty, 1 9 6 4 . 9 . Patterson M M , Wu r ster ED . N e u ro p h y s i o l ogic syste m : I n tegra t i o n a n d d i s i n teg ra ti o n . In:

Wa rd R C , e d . F o u n d a t i o n s f o r O s te o p a t h i c Medicine. Balti more: Wil l i a m s & Wi l k in s , 1 9 9 7 ; 1 3 7-1 5 1 . 1 0 . M a g ou n H I . O s te op a t h y i n the Cra n i a l F i e l d . 2 n d e d . K i r k s v i l l e , M O : J o u r n a l P r i n t i ng, 1 9 6 6 ; 2 8 9-2 9 L 1 1 . O g u ra

ing:

JH,

Togawa K , D a m m k o e h l e r R , e t a l . N a s a l obstruction a n d the mec h a n ics o f breat h ­

P h y s i o l og i c

re l a t i o n s h i p s

and

e ffec t s

of

n a sa l

s u rgery.

A rch

O r o l a r y n go l

1 966;8 3 : 1 35-150. 1 2 . S t i l l A T. Resea r c h a n d Practice. K i r k s v i l l e , M O : A u t h o r. 1 9 1 0 . Repri n te d Seattle, WA : Ea s t l a n d , 1 9 9 2 ; 4 7 . 1 3 . M i l l e r CEo T h e mec h a n ics o f ly m ph a t i c c i rc u l a ti o n : Lym p h h e a r t s . J A m O ste o p a t h Assoc 1 92 3 ; 2 2 : 3 9 7-3 9 8 , 4 1 5-4 1 6 .

1 4 . B ea l M . Vis c er o s o m a t ic reflexes: A re v i ew. J A m O s te o p a th Assoc 1 9 8 5 ; 8 5 : 7 8 6- 8 0 L 1 5 . S u m i n o R , N o za k i S, K a to M . Cen tra l p ar h wa y of tri g e m i n o - ne c k reflex. I n : O r a l - F a c i a l Se n s o r y a n d M o r o r Functions. Intern a tio n a l Sympos i u m , Ra pp ong i , Tokyo. O r a l P h y s i o l 1 9 8 0 ; 2 8 [ a bstract] . 1 6 . W i l l i a m s PL, ed . G r a y 's A n a tomy. 3 8 t h e d . Ed i n b u rgh : C h u rch i l l Li v i n gs ton e , 1 9 9 5 ; 1 2 9 3 . 1 7 . R u m n ey I e . Oste o p a th i c m a n ip u l a tive t re at men t o f i n fec t i o u s d i se ase s . O s t e o pa th A n n 1 9 74 ; 2 : 2 9-3 3 . 1 8 . B l ood H A . I n fec ti o ns o f t h e e a r, nose a n d t h roat. Oste o pa th A n n 1 9 7 8 ; 6 : 4 6 5 -4 6 9 . 1 9 . H ara k a l J H . M a n i pu l a ti ve trea t m e n t f o r a c u te u p p e r respira tory d isease. Os t e o p a th A n n 1 9 8 1 ; 9 : 2 5 3-2 5 7 . 2 0 . Ba i le y

JH.

O s teo p a th i c treatment of t h e e y e , e a r, n o s e a n d thro a t i n h a y fe ver, a s t h m a , bron­

c h i t i s, catarr h a l d e a fness a n d a l l ied c o n d i t i o n s . Lectu re 1 3 . O s teo p a th i c trea tment o f h a y fever. P h i l a d e l p h i a : A u t h or, 1 9 2 2 . 2 1 . K a l uza CL, Sherbin M . T he p h y s i o l ogic response of t h e n o s e to os t eo p a thic m a n i p u l a ti v e

tre a t m e n t : P re l i m in ar y repo rt. J A m O ste o pa th A s s o c 1 9 8 3 ; 8 2 : 6 54-6 6 0 .

The Patient with a Lower Respiratory Tract Infection Zachary J. Comeaux

INTRODUCTION Clearly the introduction of antibiotics in medical ca re h a s beco m e the mainsta y of reducing morbidity due to pulm onary infections of ma ny types . Recent guid elines for trea t ment of community -acqu ired

pneumonia,

published

by the British

Thoracic Society I in 2001 with a 2004 u pd ate, still ho l d empiric a ntibiotic ch o i ce and deci s i o n ab out hospitalization to be the key qu estions in treating the cond i­ tio n . The Cleveland Clinic Intensive Review of Internal Medicine2 lists the s a m e b u t a d d s prevention, citing v a ccin ation a n d a v erting a spiration a s prima ry p reven­ tion strategies. Foundations for Osteopathic Medicine3 m irrors this a p proa ch. Review of the state hea lth department record s fro m the great flu and pneu m o ­ nia epidemic o f

1918, h o wever, reflects a significan t red u ction in morbidity and

mortality in p a tients attended by

an

osteopathic p h ysician.4 The threat of infec­

tio u s diseases, such as influenza a nd severe a c u te res pirato r y s y ndro m e (SARS), demonstra tes t h a t es pecially in the case of viral illness, s upportive care still pla ys a significant ro le in reco very fro m res pirato r y infection. Ad d to this the progres ­ sive emergence of organis m s resistant to antibiotics, which h a s led to the request for th e m ore judicio u s u s e of antibiotics a nd to i m plem entation of a progra m of v a ccina tion with newer congregate streptococca l v a ccines.s In this context, the u s e of m a nual treatment is usually seen as a n a lternative

a p proach to pha r m a ceutica l treatment. It m a y, however, be m ore effective and 243

244

Section III • Clinical Conditions

accurate to see these as complementary therapies , contributing in different ways to enabling the body's self-healing mechanism, or host defenses , to resist and eradi­ cate infection. The loss of elderly patients with multisystem disease to a respira­ tory tract infection , despite successive courses of paired antibiotics appropriately chosen from culture and sensitivity testing, repeatedly underscores the importance of optimizing the host response component of healing. What contribution, then, can osteopathic thought and practice make that is rel­ evant to contemporary medical care, especially for the patient with pneumonia?

REVIEW OF PNEUMONIA Despite the spectrum of potential pathogens, both Centers for Disease Control and PreventionS and British Thoracic Society cite

Streptococcus pneumoniae as the pri­

mary pathogen implicated in community-acquired pneumonia. Hospital-acquired pneumonic infection, however, involves a wide spectrum of pathogens, depending on the bacterial climate of the particular institution. In the latter case, attention to supportive organs and systems may be more important. This chapter for the most part addresses uncomplicated streptococcal pneumonia. The lungs are most often viewed as organs of oxygen exchange, depending pri­ marily on their ability to expand and contract to allow alterations in pressures to drive the system. Certainly this aspect is considered in this discussion. However, the lungs also function as a sensitive low-pressure gaseous and liquid interface, and issues of circulation are as important as oxygenation in function and dysfunction of the respiratory system. The precise analysis of these critical parameters is often the point of placement of a central line in distinguishing pulmonary hypertension from primary heart failure. This logic can be factored into goals of osteopathic treatment.

OSTEOPATHIC CORRELATIONS IN PNEUMONIA Classical Considerations Consistent with this idea of the lung's involvement in the circulatory system, Still iden­ tified the primary problem in pneumonia as vascular stasis secondary to decreased neural function.His explanation for effectiveness includes the following description: "I usually find the sixth, seventh and eighth ribs pushed above, below or twisted upon

the transverse processes, thus closing up the intercostal veins by pressure and disturb­ ing the vasomotors to the lungs.... When the ribs are adjusted and the blood and nerve supply freed from pressure, the fever generally goes down and ease will fol­ low. "6 Still wrote in an era when the most advanced science was gross pathology but apparently with positive results from his biomechanical approach to physiology. Charles Hazzard cites Still's attention to ribs but describes a more general treat­ ment, stressing the harmonious coordination of all affected areas and systems.He describes an approach to a supine patient that is compatible with a hospital bed, beginning with cervical treatment (occipitoatlantal area) for vagal release, scalenes as secondary muscles of respiration, ribs and vertebrae, and also release of abdom­ inal tension.? McConnell reiterated the advantage of regional treatment with attention to the thoracoabdominal diaphragm.s Barber, another student of Still's, described a protocol for treating pneumonia beginning with lateral recumbent soft tissue work from cervical to lumbar spine. He followed this with supine cervical articulatory and soft tissue procedure. Next, he performed a variation of rib raising using the arm as a lever in full inspiration.

Chapter 17 • The Patient w i th a Lower Resp i ratory Tract Infect i o n

245

Following this, he applied 2 minutes of thoracic manual vibration before ne fin­ ished lip with suboccipital inhibitory pressure held for 5 minutes.9

Contemporary Considerations Kuchera and Kuchera 01 tive treatment

(OMT) to complement conventional medical care, aimed at increas­ Rib

ing the patient'S comfort and supporting the patient's self-healing potential.

raising coupled with paraspinal muscle stretch is described in detail as a routine initial stage of treatment, treating the thoracic cage as a unit of function. Occipitoatlantal inhibition and compression of the fourth ventricle (CV-4) are rec­ ommended to help control fever. Once the patient is in less distress, the second stage, myofascial release of the fas­ cia associated with the periscapular muscles and the anterior cervical

fascia associ­

ated with secondary respiratory drive, may be app l ied. Additionally, attention is paid to any segmental dysfunction from C7 to T4. The third stage, applied during convalescence, consists of continued rib raising, addition of lymphatic pump proce­ dures, and continued treatment of any incidental vertebral dysfunction. Many of these particulars derive from the respiratory-circulatory model of J. Gordon Zink.11 to review it. For those interested in refining effectiveness, the approach of

J. P. Barral12 rep­

resents an approach to connective tissue release targeting deep tissue. Although presented and taught as a visceral procedure, its application in practice is much broader. Much of it is directed toward diagnosing and treating the cause of a patient's pain. He does not list pneumonia as a treatable condition. But his descrip­ tions of manipulation of the lung and pleura, though not described as treating pneumonia, are of benefit for the pneumonic patient.

Outcome Studies In the current climate fa v ori n g evidence-based choices in medicine, some research supports the use of the osteopathic approach to pneumonia.Smith's \3 report on the osteopathic treatment of influenza patients in 1918, a l though not rigorous by today's scientific

standards, described a 10% mortality rate for patients with pneumonia OMT as compared to 33% for those with standard medical care.

who received

Noll and associates performed a series of pilot and clinical trials with elderly patients hospitalized with pneumonia. The largest trial involved 28 in the treatment group and 30 in the control group (control was a light touch protocol). Treatment included a standardized protocol by second-year osteopathic students followed by a visit from an osteopathic manipulative medicine specialist who performed discre­ tionary individualized treatment according to perceived need. Results demonstrated shorter reliance on intravenous antibiotics in the treatment group (implying quicker clinical response) and an overall shorter hospital stay. This was consistent with results from a previous pilot study with 11 and 10 subjects

in the treatment and

control groups, respectively.41 ,51 Edward Stilesl6 published the

results of a retrospective chart review of 25 patients

and concluded that in patients hospitalized with chronic obstructive pulmonary dis­ ease (COPD), pediatric lower respiratory tract infections, cholecystitis, and hysterec­ tomies, each category had decreased hospital stay with the integration of their care plan.

OMT into

246

Section III • Clinical Conditions

Osteopathic Treatment: Mechanism of Action T here is a tendency in medical practice,

driven by social accountability, to think

in

terms of a mechanism of action in selecti n g any treatment. Used in the field of epi­ demiology, one general concept that many find useful in d ea ling with the pneumo­ nia patient is the host disease model. In this application of the model, the individ­ ual is stratified according to the fisk facto r s. J7 In the individual case, however, this concept may be inverted to emphasize optimization of function of the different homeostatic or health maintenance systems in the body. As implied in the writings of Still cited previously, the inflammatory or immune response to infection or tis­ sue injury is the primary route of healing; however, this pr o cess may be overtaxed or stagnate and benefit from modulation to optimize heal ing. In so m e health circles, the concept of the psychoneuroimmune system has been to describe this complex interrel ated system.l� (See Chapter 6.) To selectively

used

a particular osteopathic p rocedu re, especially for visceral thorax, the following review of interactions may be helpful: poten­

evaluate the usefulness of disease in the

tial elements of somatovisceral dysfunction available for osteopathic inputs to nor­ malize the physiologic function of the body

-

ele m ents of

a

specially focused phys­

ical examination and focused treatment plan based on traditional rationale and theoretical research .3 Neuroreflexive

Sympathetic: Stress, includ i ng that of acute illness, may cause increased pulse, ineffec­ tive tachypnea, and constriction of blood vessels, impedi n g tissue oxygenation and removal of waste. The proximity of the sy m pathet ic chain ganglia to the rib heads presents

an

opportunity for external inhibition of sympathetic hypertonic­

ity. The pneumonia patient is often emotionally a n d physically s tressed . Facilitation: A classical osteopathic concept stating that previously acquired seg­ mental dysfunction may lead to a decreased threshold of reactivity to nocicep­ tion,

resulting in increased myoton ia

,

possibly mediated by sy m pathet ic

hype r arousal ; facilitation may result in somatovisceral or v i sc erosoma tic reflexes described later in the chapter. Viscerosomatic and somatovisceral re flexes: Attributed

to commonalities in

interne ur on al communication in the p oster i or horn of the sp i nal column, these concepts suggest t h at d ysfunction in the visceral organs can cause seg m en tal somatic dysfunction or that somatic dysfunction may demonstrate itself throug h visceral pat h ol ogy The reciprocal relat i o n s hi p s in tile pulmonary .

area involve thoracic segments T2 to

T6.3

Postural reflexes: The pattern of postural reflexes has led some scientists to postu­ late postural p a tter n generators distal to t h e brainstem and cerebellum.19 From the os teopathic point of view, these underscore the importance of eval­ uation and treatmenr of integrate d body regions, not isol a ted parts or articll­ lations. In this context, the importance of optimizing thoracic expansion

IS

descr i bed later in the chapter. Biomechanical

ArtIcuLar: For the thorax to fu n c t ion, the complex of costovertebral contacts and intervertebral face t joints and mobility of the spinal column must function

normally to accommodate lung expansion.2o A d d itionally, the costochondral and chond roste rn al joints must be

flexible. Articulations of the clavicle and

first rib cooperate in m ob i li ty of the dome of the lung.

Chapter 17 • The Patie nt w i th

a

Lower Resp iratory Tract I nfectio n

247

Myofascial: Distensi bility of the horizontal diaphragms, tentorium cere bel lae, tho­

racic inlet, thoracoa bdominal and pelvic floor, and the fascial elements of the accessory muscles of respiration is required for optimal respiration. Vascular Lymphatic: The major route of lymph drainage from the lower body is through the

posterior of the thoracic cavity to return to the left su bclavian vein. Ly mphatic flow is often considered to be passive, totally dependent on the thoracic pres­ sure gradients generated by respiration. This dynamic is i mportant but com­ plements a measurable lymphatic vasomotor oscillation of

0.04 to 0.10 Hz.21

Venous: Much venous return relies on the activities of daily living. Acute illness

suspends these activities. The vena cava, under activation of the thoracoa b­ dominal diaphragm, acts as a low-pressure pump to expedite return of waste­ laden blood to the heart and then the lungs for reoxygenation. The venous sta­ sis of pulmonary disease in conjunction with inactivity from hospitalization may benefit from manipulative assistance. Adjunctive treatments to increase venous return, if not contraindicated in heart failure or pulmonary edema, may assist ho meostatic balance. Interstitial: To clear tissue edema, fluids must find their way to one of the previ­

ously mentioned components of the vascular sy stem. External pressure, including myofascial effleurage, may assist in this process. Pneumatic Respiratory: An unobstructed re spiratory cycle assists bronchial ciliary clearance

of de bris in the mucous layer, resorption of transudates, gas exchange, and the other processes dependent on the alternating positive and negative intratho­ raCic pressu res.

Impact on Evaluation of the Pneumonia Patient Sputum and blood cultures with sensitivity descri be the nature and invasiveness of the pathogen and help select the antibiotic of choice. Chest radiography describes the a mount of pulmonary edema; arterial blood gases describe the compromise to oxygen exchange. O bservation of skin tone and state of consciousness of the patient also add infor mation as to the severity. Si milarly, the quality of thoracic compliance (ri b mobility and spinal symmetry and flexi bility) can help descri be physiologic status, chronic host susceptibility, and degree of physiologic stress. In dividual rib as sess ment and segmental spinal diagnosis can help describe predisposing and o bstructive factors and organ involvement (viscerosomatic and somatovisceral reflexes). The role and effectiveness of diaphragmatic excursion may suggest the amount of potential gain fro m myofascial release. Similarly, but more often to a lesser extent, the thoracic inlet area may offer a point of entry to optimize function. Posture, tissue quality, psoas muscle tone, and a bdominal girth may all suggest aspects of the patient's overall wellness and prognosis. The key to e ffective treat­ ment is to find changea ble features that will promote this patient'S health. It i s often the te mptation t o profile the patient as old o r dia betic o r o bese and there by explain treatment failure. Rather, one should find variables that one can work with. Within the physiology of this patient, what is the rate-li miting step in the return to relative health?

248

Section III • Clinical Conditions

TREATMENT Following the elements and principles described previously, treat what you find. Try to be comprehensive and develop

a

detailed plan with series of discrete

intermediate goals and tissues to be affected. As per Kuchera and Kuchera,lo staging of treatment is important. All OMT is applied by way of prescription. (See Chapter

4.) Diagnosis gives an initial idea of

where to go. And just as antibiotics and oxygen have particular parameters of application and are modified according to certain milestones, so it is with

OMT in

the pneumonic patient. The following are possible effective interventions. Observation and palpation <. Rib raising Rib articulation Paraspinal muscle stretch ,:­ Lymphatic pump Occipitoatlantal release':Cervical paraspinal muscle release Cervical articulatory release Diaphragmatic release':­ Oscillatory release

Observation and Palpation Specific diagnosis is mandatory for effective OMT. Do not start working out of habit. First read the tissues. Start with a broader mental focus than looking for the most restricted articulation. Johnston and Friedman 19 described the sequence of progressive focus in osteopathic diagnosis as "Screen, scan, segmental diagnosis." Begin with a hands-on appreciation of this particular patient. What does the first hand contact tell you about the level of vitality and health of this individual? To the remark, "It's nice to see you," an elderly gentleman once replied, "It is nice to be seen." Tissue behaves in the same way. Attentive and concerned contact assure patients that they are receiving attention and care and encourages them to cooperate in efforts to rekindle their self-healing capacity. T his can contribute to efforts to decrease tone in the sympathetic system. The first step is to determine the quality of the tissue and make a survey of the area of interest. In the thoracic region, how well does the chest wall move in inspi­ ration? Is the whole shape pliable or rigid? Does the sternum rise or sink with inspiration? Do the ribs cooperatively rise and fall? According to experience with patients and knowledge of anatomy, which tissue is most in need of release and remobilization? Is there a protuberant, crowded abdomen whose contents are restricting descent of the diaphragm? Is

a

residuum of old trauma affecting the

diaphragm? These matters will start to give an indication for prognosis and amount of effort required to approach optimal prognosis. Analytic assessment of articulations can follow the methods previously learned. It is recommended to be complete and thorough in the thoracic spine and rib cage. Special attention to the thoracic inlet is helpful. Besides its importance in the respiratory-circulatory model, this area can reflect hypertonicity in the scalene muscles that act as accessory muscles of respiration.

"Recommended treatment choices for first

conract.

The first rib has complex

Chapter 17 • The P at i ent with a Lower Respiratory Tract Infection

249

associatio ns and if restricted can impede the p u m p handle respiratory excursion o f a l l ribs below it. This r i b is em bed ded

in the mi d d le cervical fascia that b l ends with

the d o me of the lung. Checking tens ion in the space between the clavicle and the anterior bord er of the trapezius allows one to affect tension o n the dome of the l u n g . As noted previo u s l y, attention to ci al. Res tri ction here ca n b e

the thoracoabd o m inal diaphragm can be cru ­

a p pro a ched

fro m several va ntage p oin ts. Within the

myofascia l m od el, the d iaphragm ma y be approached

as a critica l horizontal fas­

cial element. In the Barral mod el, restrict i o n of the di aphragm can be the res u lt of visceral pto sis, the d rag fro m sus pended abd ominal viscera. Addition a l ly, a recess in the anterio r chest wa l l j u st above or below the tenth left rib at its costochond r a l insertion m a y i n t h e context o f Robert Fu lford 's a ppro a ch reflect the resid u u m o f emotional traumaY Use o f each of these dim ens i ons o f dia gno sis and treatmen t is relevant, especia l l y in severe or trea tment-res i st a nt cases. They are helpful in ex panding effectiveness and efficiency in ro utine treatment; however, thorough d i scussion of them is beyond the scope of this chapter. 12,22

Other regiona l i nfluences m a y be integrated , depending on the degree of compro­

mise of the patient. The pel vic floor interacts recip roca lly with the thoracoabdomi­ na l diap h ragm in dev e l oping the reversing pressure gradients

that make insuffl a ti o n

of the l ungs possible. Therefore, particular p elvic restriction may contribute to res­ piratory co mpromise. Als o, psoas muscle ten sion or l umbar restriction o f motion ma y contri bute to diaphragma tic excursion through tensio n on the posterior m argin. In the end , the rule is to treat what you find-but you d o not find what y o u do

not look for. Remem ber, pneumonia is not just an infection of the lungs. You are not just treating the disease; y o u are treating the patient as

fu ncti on al unit.

a

co m plete, co m p l ex

Rib Raising Rib rai s i ng can be accompli shed with the p a tient in any of several positio ns; the s u pine pos ition is con sid ered first. It is most u sefu l at bedside with the unconscious or

otherw ise seri o u s l y d ebilitated patient . 3

Rib Raising, Supine

Thi s procedure is d escrib ed i n Chapter 5 and depicted in Fig u re 5.6.

Alternative position : Appro a ch the pa tient from the head of the bed and s l i d e

your hands beneath the pa tient p a ssing beneath each sh o u l d er. Engage r i b angles by apply ing pressure with fingertips below each rib pair. App l y traction by a com­

bination of flex ing the fingers and Jeaning backward . Rib Raising, Seated

Patient position: seated with a rm s crossed in front o f the chest. Phy sici an position: standing facing the patient. The p atient's a r m s are s up p o rted on the ph ysici a n 's chest. The phys ician's hand s reach around the patient to co ntact the patient's rib angles on both sides . Activating force: Lean so that gentl e extension of the patient's thoracic spine

occurs and sim u ltaneo u sly carries the contact wit h the p a tient's ribs , anter iorly and su pe r i o rly. Progres s i on: P u t the han d on the patient 's

rib angles above or below the first site

a n d repeat the proce d u re until a l l of the patient's rib s have b een raised . A focused effort may be placed on any regi on that exhibits increased restrictio n . Alternative po s iti ons: The patient's straightened a rms , with fingers i nterlaced , may be p l aced over either or both of y o u r shoul ders.

250

Section I II • Clinical Conditions

Either method requires some i n ti macy with the potential

to share air. It is rec­

o mmended that you work with held inspirations and slowly exhale, then draw breath over your sho u lder.

Rotation and Rib Raising (Fig. 17.1) The following combination method is powerf u l and convenient. It is used at bed­ side with the seated pat ie n t and with the outpatient examination table or chair. It is a g o od begin ning p lace and is effective in a

busy practice, si nce it can be done in the

time that would other wise be used for discussion with or instruction of the patient. Patient position: seated. Physician position : standing behind and at the left side of the patient. The p a tie n t 'S left hand is placed on the patient'S right shoulder. Reach across with your left hand and stabilize the patien t'S left hand and

right

shoulder. Place your right palm ove r the patient'S right rib cage at the level need­

ing attention. Activa ti ng force: Apply a right translatory force to the ribs with the right hand while stabilizing or leftward rotating the torso wit h the left hand. Development of a r hyth mic repet itio n can both be relaxing and soothing and mechanically effec­ tive in mobil i z in g the r ig h t hemithorax. Progression: Reposition and repeat on the other side. With practice, thoracic vertebral articulation can be i nteg ra ted into t h i s

maneuver

for optimal effect.

Rib Articulation. Seated Rib articulation can be achieved by the positioning mentioned just previously. In max­ imizing articulation, the rhythmic right rotational component in the des c r i bed under­ rotation and rib raising exa mple would be modified or enhanced in the following way. Position: For monitoring purposes the rib or ribs to be articulated are contacted

more specifi cal l y with the base of the thumb or between the thumb and index finger. Activating force: Each r i g h t translation and left rotation alternates with ret u rnin g left translation of the rib and a righ t rotation and

a

side be ndi n g of the

torso. Focused attention is on the mobility of the rib or ribs of interest. Progression: Gentle rhythmic repetition challenges the liga me n to u s tissue, con­

fining rib motion return to reasonable opti m a l mobility within this clinical context.

FIGURE 17.1

Rotation and rib raising, patient seated.

Chapter 17 • The Patient with a Lower Respiratory Tract Infection

251

Paraspinal Muscle Stretch: Lateral Recumbent (Fig. 17.2) Recall this basic soft tis s u e man euver l earned long ago . Jus t as an aspirin is to u ted as aborting a myocardial infarction, simple things d one at the right time can have helpful resu Its . Patien t po sition: lateral recumbe n t . Physician position: standing or seated with finger pad s poised to engage the erector spin a e m u sculature. Activating force: Sta bilize the patie n t if n ecessary and apply la tera l gentle trac­ tion effectin g l a teral cro ss-stretc h to the fascia and muscle tiss u e. Progressi on: Move up a n d down the spinal column both to test for restrictio n an d to add beneficial stretch to soften and relax tense tis sue. Comeaux23-25 d escribes fur­ ther

benefits of repetitive appl ication of force.

Lymphatic Pump Pedal Pump (See Chapter

10,

Thoracic Pump (See Chapter

Procedures and Fig.

16,

10.3)

Procedures and Fig.

16.19)

Occipitoatlantal Release (See Chapter 16, Procedures and Fig. 16.12) The intent is to normal ize tensio n s in t h e vicinity of the jugular foramen and rectus capiti s group

of musc les affecting the vagus n erve, which pro vides

the parasympa­

thetic supply to the lungs and bro n chial tree. Patient po s itio n: su pine. Physician position: sitting at the head of the bed or table

with forearms ge n tly resting on the bed or table, holdi n g the o cciput in

the palms o f the han d s , with fingertips engaged below the inferior o ccipital border. Activating force: Straighten your fingers and p ress the fingertips into the suboc­ cipital muscles.

the hea d to be s u spended and passively for maximal relaxatio n of the muscles, u s u a lly 1 to

Progression: Hold this position, all ow i n g extend into your palms. Al low 2 minutes .

FIGURE 17.2

Paraspinal muscle stretch with the patient in the lateral recumbent position.

252

Section III • Clinical Conditions

Alternative: These principles may be appl ie d at bedside in the uncooperative ( unconscious ) patient from an ante ri or approach. Reachi ng

a rou n d t he nec k place forward pressure ,

your index fingers at the atlanro-occipitaljunction a nd generate by gen tl y lift i ng the neck

forward, allowing the head to extend.

Cervical Paraspinal Muscle Release The

inte nt is to relax so me of the accessory muscles of respi rat ion and to treat dys­

funct i on which may inhibit function of the phren i c nerve ,

.

Patient position : supine. Ph ysic i a n posit ion : st anding at the right

side of the bed hand laid across the patient's fore­ head and the right hand reaching across to grasp the la tera l muscle mass of the left side of the nec k with the finger pads engagi ng t h e posterior border of the stern­

or table facing t he head of the bed with the left ,

ocleidomastoid muscle. Activating

force: Use your left hand to s tabi li ze or roll the head to the left while hand forward, s t re tc h ing the engaged muscles

d r a wing your right

.

P rog ression : Repeat this maneuver rhythmically, gently but effectively until the

musculature softens. Repeat the proce d ur e on the opposite side by reversing stand­ ing and hand positions. Variation: A similar relax a tion of the superior fi bers of the trapezius muscle may be accomplished by placing the right hand over the top of the patient'S

shoulder and stretching by pulli ng your hand and arm clown and forward in a

left way

that bri ngs the patient's elbow nearer to the waist.26

Cervical Articulatory Release (Fig. 17.3) The inte n t

is to achieve general articular mobilization a nd to discover and treat with t he phrenic nerve or other respiratory musculature. dysfunctional cervical segments w hose nerve roots may be involve d

FIGURE 17.3

Cervical articulatory release.

Chapter 17 • The Patient w i th a Lower Res p i ratory Tract Infect i o n

Position: The patient is seated, and diagnosis is made of

a

253

segmen ta l or regional

C4 flexed, side bend left, rotated left for the description); the physician is standing behind and slightly to the right side of the patient facing side bending (presume

the same direction. The physician's left hand is placed acro ss the top of the head, fingers at right angles to midline. The base of the physician's right index finger is placed against the lateral pillars on the right at the level to be treated. Activating force: Guided by the physician's l eft hand, the patient drops the head forward, rolls it (side-bending the neck) to the left, extends it, and then rolls it (side-bent right) forward, hoping for articular release in this latter phase. Progression: Three to four slow, rhythmic repetition s, with the right hand refin­ ing the plane of articular mobilization, may be sufficient. Work up and down the spine to determine whether you have the primary segment or there are also others. Usually this procedure is not repeated on the orher side. Variation: This procedure may be performed with the p hysician at the head of the bed or table if possible. In this position, there is generally more control, with the effect of gravity working with the articulating hand.

Cervical Articulatory Release. Oscillatory Release As described previously, oscillatory release can be integrated into cervical articular treatment.22 Position: The physician stands behind the patient as descri bed for articular treatment.

The right hand (metacarpal head) engages the restrictive barrier.

Activating force: Apply gentle pressure to the dysfunctional segment, using the head and superior segments for leverage; side-bend to the right. Once resistance is engaged, the right hand oscillates with a rotary motion at the wrist at about 150 cpm to enhance release and advance the restrictive barrier. ,

Progression: Several seconds of oscillation is adequate to begin. Then reassess the barrier; three or four cycles of thi s are usually enough to assess whether this approach contributes to release. Variation: The same principles can be applied in the supine patient, with the physician at the head of

the bed or table.

Facilitated oscillatory release is a formulation of ideas and maneuvers, many of which are classical, to be used as elements in eclectic or combined procedures with other applications of force. A key idea is the gentle development of a standing wave according to the natural harmonic properties of the tissue involved. Therefore, it should feel natural and relaxing to the patient.

Diaphragmatic Release Patient position: s u pine Physicia n position: standing facing the side of the patient .

to be treated. Place one hand across the chondral masses of the lower ri bs and the other hand acro ss the posterior lower ri b cage . Activating

force

(direct treatment):

Test the thoracolumbar fascia and

diaphragm for ease and bind in flexion and extension, rotatio n and side bending. ,

Gently move in three dimensions into the directions of restrictions and apply steady force until tissue

give is complete

.

Indirect treatment: Test the thoracolumbar fascia and diaphragm for ease and bind in flexion and extension, rotation, and side bending. Gently move in three dimensions into the directions of easy or balanced tension. Follow the shift in bal­ ance to maintain this neutral tension until the unwinding process ceases.

254

Section III • Clinical Conditions

FIGURE 17.4

Diaphragmatic release.

Diaphragmatic Release Alternative (Doming the Diaphragm) (Fig.

17.4)

Patient position: supine. Physician position: sta n ding at side of the bed facing the

ma rg in of the rib cage, below the tenth rib. Activati ng force: Apply slow, progressive pressure to ga t h e r the fascia of the anterior abdomen and diaphragm by allowing the t humbs to sink in under t h e ribs head. The physician's open palms are placed over the lower

with thumbs l atera l to the sternum an inch

and then press upward.

Progression: Pay attention to t ak i ng up any slack with expirations. Maintain

pressure through several respiratory cycles

until optimal release is ob tained

.

Case Illustrations Integrating procedure: In actual practice, one blends procedures based on experience, skill, diagnostic focus, and intent of intervention, as is illustrated in the following case examples. Additionally, bedside or outpatient protocols can be individualized to patient and practitioner (patient seated, supine, or prone), the physician think­ ing in terms of principles rather than recipes for imitation. In the analytic, mechanistic climate of the modern hospital, soothing human contact in the appropriate professional setting can have significant benefit in recruiting the patient's psyche to contribute to healing. Touch communicates concern and builds rapport between physician and patient. Additionally, the delirium and despair of the chronically ill patient is reachable with the hope instilled by caring contact.

Case 1 History A 67-year-old woman presented to the emergency department with fever and progressive shortness of breath over 2 days. She reported incidental lower

Chapter 1 7 • T h e Pat i e n t w i t h a Lower Resp ira t o ry Tr a ct I n fect i o n

255

t h o ra c i c back pa i n b u t d e n i ed a n y h i st o ry o f t ra u m a . T h e p a t i e nt gave a h i st o ry of hyperte n s i o n , m o d e rate i nt e r m itte nt e p i g ast r i c d i sco mfo rt, a n d b a c k pa i n a n d h a d been seen i n t h e p r i m a ry c a r e sett i n g o n ce eve ry

4

months.

S h e was a wi dow of 4 y e a rs, l i v i n g a l o n e . S h e d e n i e d s m o k i n g a n d a d m itted o n l y occas i o n a l soc i a l a l c o h o l use. H e r u s u a l r o ut i n e was to b e m ostl y sede nta ry with occas i o n a l h o u sewo r k . I n it i a l rad i o g r a p h s s h owed d i ffuse i n fi l t rate w i t h c o n so l i d a t i o n i n t h e r i g ht l owe r l o be, a n d a n oxyg e n sat u rat i o n of i nc l u d ed a t e m perature o f p i rat i o n s at

28

1 03°F

92 % .

Vita l s i g n s u p o n a d m i ss i o n

rect a l , b l oo d pressu re o f

per m i n ute, h e i g ht

5

1 50/92 m m H g , 1 80 l b .

res­

fe et, six i n ch es, a n d we i g ht

S h e was a d m itted b y t h e e m e r g e n cy p hysi c i a n a t

11

P. M .

with telephone

o r d e rs for e m p i r i c cefa zo l i n a n d cu l t u res p e n d i n g . S h e w a s prescr i bed

4

L oxy­

gen per n as a l ca n n u l a . H e r h o m e m e d i c at i o n s were c o nt i n ued, a n d s h e was reeva l u ated o n the fo l l ow i n g m o r n i n g .

Physical Examina tion the Mornin g A fter Emergency A dmission M us c l e tone was g e n e ra l l y p o o r. H e r h e a rt rate was reg u l a r at m i n ute, a n d res p i ra t i o n w a s and m i n i ma l , and

1+

24

84

beats p e r

p e r m i n u t e . H e r a b d o m e n w a s p r ot u be r a n t

b i l ate ra l p ret i b i a l e d e m a w a s p r e s e n t . Te m pe r a t u re t h e

fi rst m o r n i n g aft e r a d m i ss i o n w a s

1 00°F.

S h e h a d b e e n g i ven i b u p rofen u p o n

a d m i ss i o n f o r t h e b a c k p a i n . T h i s a g g ravated h e r e p i g a st r i c d i scomfort, a n d s h e refused a d d it i o n a l d os e s . T h e m uscu loske l eta l exa m i n at i o n , p e rfo r m e d with the p a t i e n t s e a t e d a n d s u p i ne i n bed, reve a l ed s u bo pt i m a l t h o r a c i c c a g e com p l i a n ce w i t h o u t foc a l r i b rest r i cti o n . T h e d i a p h r a g m a n d lower r i bs reve a l ed rest r i ct i o n seco n d a ry t o a b d o m i n a l prot u b e r a n c e . Correspo n d i n g t o t h e p a t i e nt's s i te o f p a i n, t h e r e was te n d e rn e ss with pa l pa t i o n a n d i n creased flexion w i t h o ut rotat i o n of T 1 o . S h e was a l so te n d e r i n t h e r i g h t su bocc i p i t a l a rea w i t h o u t f ra n k rotat i o n o f a n y ce r­ vica l ve rte bra l seg m e nts. Reeva l u a t i o n of t h e a d m itt i n g r a d i o g r a p h s reve a l ed a poss i b l e co m p ress i o n fract u re at

T1 0

t h a t t h e ra d i o l og i st l a t e r confi r m e d a s p r o b a b l y a n o l d i nj u ry.

M o d e rate d e g e n e rative j o i nt c h a n g es were a l so n oted t h r o u g h o u t .

Assessment Loba r p n e u m o n i a Back pa i n S o m a t i c dysfu n ct i o n , t h o r a c i c a n d r i bs, c e rv i c a l a n d a bd om i n a l G a st r i t i s Old

(?)

com p